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Translation and cross-cultural adaptation of the asas health index and the environmental item set into 15 languages

Article type: Published abstract


Background/Purpose: The ASAS Health Index (ASAS HI) is a unidimensional questionnaire measuring health and impairment in functioning in patients with spondyloarthritis (SpA). The ASAS HI is accompanied by a multidimensional item set aiming at measuring environmental factors (EF Item Set). These two disease-specific questionnaires are the first questionnaires which have been developed based on the International classification of functioning, disability and health (ICF). The ASAS HI contains 17 dichotomous items addressing categories of pain, emotional functions, sleep, sexual function, mobility, self care, and community life and the EF Item Set contains 9 dichotomous items addressing categories of support/relationships, attitudes and health services. The objective is to translate and adapt the ASAS HI and the EF Item Set cross-culturally into 15 languages with 17 versions and to field test the new versions in patients with axial SpA (axSpA). Methods: Translation and cross-cultural adaptation was done in 20 countries according to published recommendations (forward-backward procedure) in 5 steps: translation, synthesis of translation, back translation, expert committee review and pre-testing in a field test. The field test was conducted in patients with axSpA to test its applicability in patients with all forms of SpA. Results: The ASAS HI and EF Item Set was translated into Arabic, Chinese, Croatian, Dutch/Flemish, French, German, Greek, Hungarian, Italian, Korean, Portuguese, Russian, Spanish (Colombia, Mexico, Spain), Thai, and Turkish. 206 patients (approximately 10 patients/country, 59.7% male, mean (SD) age 42.4 (13.9) years, mean (SD) BASDAI 3.8 (2.3)) with axSpA underwent qualitative interviews during field testing in 23 countries (19 non-English speaking countries, 4 English-speaking countries). 65% of the patients were diagnosed with AS, 35% with non-radiographic axSpA and 33% of the total sample size suffered from peripheral involvement. Interviews showed the English questionnaire and the translations to be clear, relevant and comprehensive. All versions were accepted with minor modifications. The total sum of the ASAS HI (range 0-17, with a lower score indicating a better health status) was 7.1 ± 4.4 (mean ± SD). Completion times for ASAS HI and for EF Item Set were respectively, 2.6 ± 1.6 and 2.1 ± 1.5 (mean ± SD) minutes. Conclusion: The ASAS HI and the EF Item Set were successfully translated into 15 languages with 17 versions. This study showed the ASAS HI items to be readily adaptable throughout countries, indicating the concepts covered may be meaningful in many cultures. In the other hand, more difficulties were experienced with the contextual factors indicating these concepts may be more culture-dependent. The field test suggested that the English and the non-English versions have high face and content validity. By investigating patients with axSpA with and without peripheral manifestations it could be shown that the ASAS HI and the EF Item Set are valid to be applied in patients with all forms of SpA. Further validation is underway to test the psychometric properties of this new disease-specific questionnaire.

Full citation

Kiltz U, Van Der Heijde D, Boonen A, Bautista - Molano W, Burgos-Vargas R, Chiowchanwisawakit P, et al. Translation and cross-cultural adaptation of the asas health index and the environmental item set into 15 languages. Arthritis and Rheumatology. 2014;6


Methods Condition Gender Age Country Setting Sample size
axial spondyloarthritis 42.4 (13.9) years 10

Number of items

Not available


Measure does not require training

Required time

Less than 5 min

Access measure


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Articles last updated: December 2020