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Rheumatology 2001; 40: 555-558
© 2001 British Society for Rheumatology

Original Papers

Evaluation of functional ability of Thai patients with rheumatoid arthritis by the use of a Thai version of the Health Assessment Questionnaire

M. Osiri, U. Deesomchok and P. Tugwell1,

Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand and
1 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Methods. The Health Assessment Questionnaire (HAQ) was translated into Thai and its validity and applicability were assessed in 22 Thai patients with active rheumatoid arthritis (RA) before and after 6 months of treatment with disease-modifying anti-rheumatic drugs (DMARDs). The activities in three subcategories of the Thai HAQ were modified, including Eating, Hygiene and Activities. Two common activities in Thai people were incorporated into the items in the Grip and Arising domains.

Results. Significant improvements in mean HAQ scores and other parameters were observed after DMARD therapy. Mean HAQ scores correlated significantly with tender joint count, patient global and physician global assessments, and grip strength.

Conclusions. The Thai HAQ met validity requirements and can be used in the measurement of functional capacity of Thai RA patients.

KEY WORDS: Rheumatoid arthritis, Health Assessment Questionnaire, Translation, Disability, Disease-modifying anti-rheumatic drugs.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Rheumatoid arthritis (RA), a disease characterized by chronic destructive inflammatory polyarthropathy, is distributed worldwide [1]. Early treatment with disease-modifying anti-rheumatic drugs (DMARDs) has been shown to promote disease responses, delay joint damage and deformity, and improve quality of life [2–4]. The Stanford Health Assessment Questionnaire (HAQ) [5–9] is one of the instruments available for measuring the health status and physical function of RA patients. It is used widely and has been tested extensively for reliability, validity and responsiveness [5–9]. The HAQ has been successfully translated into different languages and validated in these languages in order to adapt the instrument to the culture and lifestyle of patients in different countries [9–14]. This has never been done in Thailand. Thus, this study was conducted to (i) translate the HAQ into Thai and backtranslate it into English to ensure the accuracy of the Thai version of the HAQ; and (ii) assess the responsiveness of the Thai version of the HAQ in the clinical context of treatment with DMARDs and evaluate the correlation between the Thai HAQ and other clinical parameters.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
The original version of the HAQ in English was translated into Thai by one of us (MO). The Thai version of the HAQ was backtranslated by another physician who was blinded to the original English version. Two scoring methods were used to calculate the mean HAQ scores in this study. In the first method, originally used by Fries et al. [5], the highest score for each of the eight domains was summed and divided by 8 to yield a mean HAQ score of 0–3 on a continuous scale. Any activity that required another person's assistance or the use of an assistive device received a score of 2 if rated lower (0 or 1). The second method, introduced by Borg et al. [15], was the average score of all items of the HAQ. In this method of calculation, the score for an item was increased by 1 if a device was used or the patient needed help from another person to perform it.

Patients
Twenty-two new cases of active RA who required second-line therapy and were attending the Rheumatology Outpatient Clinic at King Chulalongkorn Memorial Hospital between December 1996 and October 1997 were included in this study. All patients fulfilled the American College of Rheumatology (ACR) 1987 revised criteria for the diagnosis of RA [16] and had not been treated previously with a DMARD or prednisolone. In addition to the HAQ, other clinical and laboratory parameters described as the ACR core set of disease activity measures [17] were collected before and after 6 months of DMARD therapy. DMARDs prescribed to the patients in this study included methotrexate, chloroquine, hydroxychloroquine, sulphasalazine and combined DMARDs.

Statistical analysis
The outcome measures were tested for normal distribution by the one-sample Kolmogorov–Smirnov test before parametric statistical methods were used. Qualitative variables were compared by the use of the {chi}2 test and quantitative variables with the t-test. Pearson's correlation coefficients were calculated between the HAQ scores and other variables. Data were analysed using SPSS for Windows version 9.0 (SPSS, Chicago, IL, USA).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
The original English version of the HAQ and its modifications are presented in Table 1Go. The Thai version of the HAQ had to be adapted to fit the daily activities of Thai patients. There were six alterations (four changes and the addition of two activities to the items of the original HAQ) in the Thai version of the HAQ that better assessed activities common in Thai culture. The overall questionnaires and aims of assessment were maintained [18].


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  		TABLE 1. Comparison of the original English version of the HAQ and its backtranslation into English

 
Question 11 (‘Are you able to take a tub bath?’ was replaced with ‘Are you able to lift up a water bowl to wash yourself?’, which reflects the Thai tradition of bathing. The other important component measurement of the ‘take a tub bath’ movement requires the patient to sit flat on the tub floor, and was covered by the first additional activity. Many Thai people also sit on the floor in their houses instead of chairs. This activity was incorporated in item 4, ‘Are you able to get in and out of bed?’, and the domain title was also changed from ‘Arising’ to ‘Getting up/down’.

The second extra activity, ‘wring clothes after washing’, was included in order to test the grip strength of both hands of the patients. This activity was included in item 17 ‘turn on and off a faucet’ under the domain ‘Grip’.

Results from the two scoring methods are shown in Table 2Go. Average HAQ scores calculated by the second method were slightly lower than those calculated by the first method, but the difference was not statistically significant. The addition of the two common activities of Thai people to the original HAQ did not change the scoring results.


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  		TABLE 2. Mean and S.D. of the Thai HAQ calculated by two methods and their correlations (n=22)

 
Mean HAQ scores (calculated from the original method) correlated positively with tender joint count (correlation coefficient r=0.557, P=0.007), patient's global assessment (r=0.582, P=0.004) and physician's global assessment (r=0.614, P=0.002). A negative correlation was seen between mean HAQ score and grip strength (r=-0.709, P=0.001).


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
An important problem in the applicability of a questionnaire is the variation in lifestyle and culture among countries. Although Thailand is becoming more westernized, the majority of urban Thai people blend Western culture with Thai lifestyle in their everyday lives. Thai people in some rural areas, however, live in the ‘old Thai style’. This is why we added two items regarding common activities to the Thai version of the HAQ. Another possible approach to the creation of the Thai version of the HAQ would have been to use the method of item generation and reduction, as in the original HAQ [5, 6]. However, this method requires more time and resources, and the activities of daily living of Thai people are not much different from those of Westerners.

The demographic characteristics of the patients we studied was comparable to those in previous studies of functional ability [11–14] (data not shown). Most of the clinical and laboratory variables, as well as the mean HAQ score, improved after 6 months of treatment with DMARDs. Although our study had no control group, we postulate, from the similarity of our results to those of previous studies, in which there was a significant correlation between the HAQ score and many clinical variables, that the Thai version of the HAQ is valid as a parameter for the measurement of functional ability [11–14].

The addition of the two activities commonly performed by Thai people to the items in the original HAQ did not alter the scores of the Thai HAQ. The mean HAQ scores calculated by the two methods correlated significantly with each other. The two extra activities reflected the coordination of several groups of joints and muscles. Both activities remained impaired after the improvement of others, so they may be useful for predicting long-term disability. We recommend the permanent addition of these two questions in the Thai version of the HAQ, because they provide additional information about the functional ability of Thai patients with RA.

Although the average HAQ scores balanced the weights from each activity of the HAQ, the first (original) scoring method showed a larger change in the Thai HAQ scores than the alternative method (Table 2Go). This may be important when one is attempting to detect small differences, as the original scoring method is more sensitive to change (J. F. Fries, personal communication).

The Thai HAQ scores correlated significantly with some clinical variables after 6 months of DMARD treatment, which agrees with the results of other validity studies of the HAQ. This supports the validity of the Thai version of the HAQ, as reported for the previous different language versions of the HAQ [11–14].

In conclusion, the Thai version of the HAQ is a useful instrument for the measurement of the functional capacity of Thai patients with RA. Although there are some modifications and additional questions, the objectives of the questionnaires are well maintained and the scoring results are not altered. It can be self-administered by the patients, has validity and requires no complicated tools. The HAQ can predict the functional outcome of patients with RA [7, 8], so it is also useful in clinical practice to optimize the quality of care of these patients.


   Acknowledgments
 
We would like to thank Dr Saowanin Indrabhakti of the Division of Cardiology, Department of Medicine, Lerdsin Hospital, Bangkok, Thailand for the backtranslation of the Thai version of the HAQ into English; Professor Dr Francis Guillemin of the Clinical Epidemiology and Evaluation Unit, University Hospital of Nancy, France and Professor Dr Pirom Kamolratakul of the Department of Preventive Medicine, Faculty of Medicine, Chulalongkorn University for reviewing the manuscript; Professor Dr James F. Fries and Dr Gurkipal Singh of the Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center for their valuable comments on the Thai HAQ; and Miss Thiwa Krammee for secretarial assistance. This work was supported in part by the Development Grant for New Faculty Researcher, Chulalongkorn University, Bangkok, Thailand.


   Notes
 
Correspondence to: P. Tugwell, Department of Medicine, University of Ottawa and Ottawa Hospital, General Campus, Room LM-12, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6. Back


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Alarcon GS. Epidemiology of rheumatoid arthritis. Rheum Clin North Am1995;21:589–604.
  2. Wolfe F, Hawley DJ, Cathey MA. Clinical and health status measures over time: Prognosis and outcome assessment in rheumatoid arthritis. J Rheumatol1991;18:1290–7.[Medline]
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Submitted 28 April 2000; Accepted 14 November 2000


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