Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty

Abstract

Background: Cross cultural validity is of vital importance for international comparisons.

Objective: To investigate the validity of international Dutch-English comparisons when using the Dutch translation of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC).

Patients and methods: The dimensionality, reliability, construct validity, and cross cultural equivalence of the Dutch WOMAC in Dutch and Canadian patients waiting for primary total hip arthroplasty was investigated. Unidimensionality and cross cultural equivalence was quantified by principal component and Rasch analysis. Intratest reliability was quantified with Cronbach's alpha, and test-retest reliability with the intraclass correlation coefficient. Construct validity was quantified by correlating sum scores of the Dutch WOMAC, Arthritis Impact Measurement Scales (Dutch AIMS2), Health Assessment Questionnaire (Dutch HAQ), and Harris Hip Score (Dutch HHS).

Results: The WOMAC was completed by 180 Dutch and 244 English speaking Canadian patients. Unidimensionality of the Dutch WOMAC was confirmed by principal component and Rasch analysis (good fit for 20/22 items). The intratest reliability of the Dutch WOMAC for pain and physical functioning was 0.88 and 0.96, whereas the test-retest reliability was 0.77 and 0.92, respectively. Dutch WOMAC pain sum score correlated 0.69 with Dutch HAQ pain, and 0.39 with Dutch HHS pain. Dutch WOMAC physical functioning sum score correlated 0.46 with Dutch AIMS2 mobility, 0.62 with Dutch AIMS2 walking and bending, 0.67 with Dutch HAQ disability, and 0.49 with Dutch HHS function. Differential item functioning (DIF) was shown for 6/22 Dutch items.

Conclusions: The Dutch WOMAC permits valid international Dutch-English comparisons after correction for DIF.

Figure 1

Pain item calibrations for the Dutch WOMAC and the English WOMAC. English calibrations on the x axis, and Dutch on the y axis. Calibrations are expressed in logits. Negative calibrations indicate easier items. Positive calibrations indicate more difficult items. An identity line is drawn through the origin, with a slope of 1. Statistical control lines (95% CI) are drawn around the identity line (dotted lines). The area between the dotted lines depicts acceptable item deviation. Items outside the control lines demonstrate DIF. The numbers near the data points refer to the WOMAC item numbers. For a full explanation of the items see table 1.

Figure 2

Physical functioning item calibrations for the Dutch WOMAC and the English WOMAC. English calibrations on the x axis, and Dutch on the y axis. Calibrations are expressed in logits. Negative calibrations indicate easier items. Positive calibrations indicate more difficult items. An identity line is drawn through the origin, with a slope of 1. Statistical control lines (95% CI) are drawn around the identity line (dotted lines). The area between the dotted lines depicts acceptable item deviation. Items outside the control lines demonstrate DIF. The numbers near the data points refer to the WOMAC item numbers. For a full explanation of the items see table 1.