Issues in cross-cultural validity: example from the adaptation, reliability, and validity testing of a Turkish version of the Stanford Health Assessment Questionnaire

Arthritis Rheum. 2004 Feb 15;51(1):14-9. doi: 10.1002/art.20091.


Objective: Guidelines have been established for cross-cultural adaptation of outcome measures. However, invariance across cultures must also be demonstrated through analysis of Differential Item Functioning (DIF). This is tested in the context of a Turkish adaptation of the Health Assessment Questionnaire (HAQ).

Methods: Internal construct validity of the adapted HAQ is assessed by Rasch analysis; reliability, by internal consistency and the intraclass correlation coefficient; external construct validity, by association with impairments and American College of Rheumatology functional stages. Cross-cultural validity is tested through DIF by comparison with data from the UK version of the HAQ.

Results: The adapted version of the HAQ demonstrated good internal construct validity through fit of the data to the Rasch model (mean item fit 0.205; SD 0.998). Reliability was excellent (alpha = 0.97) and external construct validity was confirmed by expected associations. DIF for culture was found in only 1 item.

Conclusions: Cross-cultural validity was found to be sufficient for use in international studies between the UK and Turkey. Future adaptation of instruments should include analysis of DIF at the field testing stage in the adaptation process.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Activities of Daily Living* / classification
  • Arthritis, Rheumatoid / diagnosis*
  • Arthritis, Rheumatoid / physiopathology
  • Cross-Cultural Comparison*
  • Disability Evaluation
  • Female
  • Health Status*
  • Hospitals, University
  • Humans
  • Male
  • Middle Aged
  • Outpatients
  • Reproducibility of Results
  • Severity of Illness Index*
  • Surveys and Questionnaires
  • Turkey