Cross-Cultural Adaptation, Validation, and Reliability of the

*Corresponding author: Aliaa Khaja, Department of Trauma and orthopedics,

Al Razi Orthopedic Hospital, Kuwait City, Kuwait, Tel: +965 66135777; E-mail:

[email protected]

Citation: Khaja AF, Al-Roudhan M, Hanna SS, Boshahri MO, Al-Awadh M, et

al. (2020) Cross-Cultural Adaptation, Validation, and Reliability of the Michi-

gan Hand Outcomes Questionnaire: Arabic Version. J Surg Curr Trend Innov

4: 037.

Received: May 20, 2020; Accepted: May 23, 2020; Published: May 30, 2020

under the terms of the Creative Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in any medium, provided the

original author and source are credited.

Introduction

The hand is a complex limb consisting of the bones, muscles,

nerves, tendons, arteries, veins, and ligament [1]. It is important that

the upper limbs and the hands be in good form, both structurally and

functionally, to enable an individual perform daily activities with

convenience and without hindrance. Impairments such as muscu-

loskeletal or neurological injuries to the upper limbs and the hands

could have a negative impact on their functioning. Injuries also have

a negative impact on the patient’s life, including leisure, work, and ac-

tivities of daily living. For long, occupational therapy has focused on

the ability to function independently and effectively [2]. Occupational

therapists bear the responsibility of dealing with people experiencing

hand injuries to assist them regain maximum usage and capability of

the hands [3]. As such, it has become necessary to employ important

tools and outcome measures for the assessment of the efcacy of hand

rehabilitation programs [3]. Two major types have been put forward,

namely, self-reported outcome measures and performance-based out-

come measures [3]. Performance-based outcome measures include

the Minnesota Manual Dexterity Test and the Jesben hand Func-

tion test. Both tools require the patient to carry out certain function-

al tasks. Contrastingly, self-reported outcome measures require the

completion of questionnaires by the patient, rating their performance

on a set of predetermined functional tasks [3]. Self-reported outcome

measures employed in hand rehabilitation include the Disabilities of

the Arm, Shoulder and hand (DASH) questionnaire, the Canadian

Occupational Performance Outcome Measure (COPM), as well as

the health-related quality of life-Short Form 36 (SF 36) [3]. With-

out a doubt, the accuracy of performance-based outcome measures

may present a more accurate representation of the patient’s ability,

but then self-reported information by the patient is equally important:

their feelings and thoughts about their hands after sustaining injuries.

By combining the patient’s subjective information on the actual per-

formance, an occupational therapist will have a more holistic view of

the patient with hand injuries. The Michigan Hand Outcomes Ques-

tionnaire (MHQ) is an example of a self-reporting outcome measure

commonly used for the assessment of hand injuries [4]. The MHQ

was developed in 1998 and has become a very essential tool for the

measurement of health status domains, activities of daily living, over-

all hand function, aesthetics, work performance, and satisfaction [4].

The Michigan Hand Outcomes Measure comprises 37 items with rat-

ing scales ranging 1 to 5. Every single domain is scored and convert-

ed to values that range from 0–100 [4]. A high score indicates better

results, with the exception of pain in which a high score indicates a

more intense pain. It can measure the level of impairments on either

side of the hand [5]. The responsiveness and validity of the MHQ has

determined for various hand conditions [4]. It has also been translated

Khaja AF, et al., J Surg Curr Trend Innov 2020, 4: 037

DOI: 10.24966/SCTI-7284/100037

HSOA Journal of

Surgery: Current Trends & Innovations

Research Article

Aliaa F Khaja*, Meshari Al-Roudhan, Sager S Hanna,

Mohammad O Boshahri, Mohammad Al-Awadh and

Awdhah Al-Samhan

Department of Trauma and orthopedics, Al Razi Orthopedic Hospital, Kuwait

City, Kuwait

Cross-Cultural Adaptation,

Validation, and Reliability of

the Michigan Hand Outcomes

Questionnaire: Arabic Version

Abstract

Background: Michigan Hand Outcomes Questionnaire (MHOQ)

is a patient-reported hand-specic questionnaire representing out-

comes.

Objectives: The purpose of this study was to translate the MHSQ

into Arabic and investigate its psychometric properties by testing the

internal consistency, reliability, validity, and oor/ceiling effects.

Materials & Methods: 57 patients participated in this survey. The

internal consistency tests were performed using Cronbach’s alpha.

Spearman’s Correlation was calculated to estimate construct validity

in comparison to DASH. Also, the Bland-Altman Plot was used to

investigate the proportional bias between DASH and Arabic MHSQ.

Results: Arabic MHS had a Cronbach’s alpha of 0.85, which was

very high and reliable. All subscales of MHSQ had an internal con-

sistency higher than 0.70. Furthermore, a strong correlation with

DASH score was observed (r=0.771, p<0.001), which suggests a

good construct validity. DASH had a statistically signicant correla-

tion with all MHSQ subscales.it indicates especially high correlation

with Hand function (r=0.701; p<0.001), activity of daily life (r=0.761;

p<0.001) and pain score (r=-0.620; p<0.001). No relevant ceiling and

oor effect was observed among the responses.

Conclusion: Overall, the Arabic version of MHSQ proved to be

a good and reliable diagnostic tool for patients with hand injuries.

Keywords: Arabic; Michigan Hand Outcomes Questionnaire; Psy-

chometric; Reliability; Validity

Citation: Khaja AF, Al-Roudhan M, Hanna SS, Boshahri MO, Al-Awadh M, et al. (2020) Cross-Cultural Adaptation, Validation, and Reliability of the Michigan

Hand Outcomes Questionnaire: Arabic Version. J Surg Curr Trend Innov 4: 037.

• Page 2 of 6 •

J Surg Curr Trend Innov ISSN: 2578-7284, Open Access Journal

DOI: 10.24966/SCTI-7284/100037

Volume 4 • Issue 3 • 037

into several languages like Dutch, Chinese, Japanese, German, and

Thai [6,7]. The MHQ is yet to be translated to Arabic. And so, to learn

more about Arabic patients with hand injuries, it is the aim of this

study to translate the MHQ into Arabic and investigate its reliability

and validity.

Disabilities of the Arm Shoulder and Hand (DASH)

The DASH questionnaire is made up of 30 unique items, all

self-reported by patients and designed specically for measurement

of symptoms and physical functions in patients experiencing muscu-

loskeletal disorders of the upper limbs [8]. The objective of DASH

is to describe the disability that patients with upper limb disorders

experience and to observe symptom changes as well as changes in

functions over time following treatments [9]. DASH has proven to be

a reliable tool for use by physicians in the investigation of joints in the

upper extremities. Each item has a score ranging from 0 to 4. The total

score is calculated by adding the scores of all rated items (0–120).

Finally, the total DASH is reversed to match the majority of the MHS

subscales.

Materials and Methods

Translation

Translation was done as per recommendations of Guillemin’s

guidelines for validation and cross-cultural adaptation [10] after

permission obtained from the original MHQ copyright holder. Two

Bilingual orthopaedic surgeons were responsible for the conceptual

and literary translation of the original MHQ. Two other versions were

produced by independent translation companies with a background in

scientic English. All the versions produced were similar. Modica-

tions to incorporate from all the versions were made and implemented

in the nal version. A professional Arabic grammar checker reviewed

it. The back-translation came close to the original score. A pilot test

was then conducted on 10 random patients from the hand clinics, after

the Arabic version was approved by the translation committee. Both

the physicians interviewed the patients after completing the question-

naire to address any issues or need for assistance.

Participants

A total of 57 patients with hand disorders participated in this study.

The inclusion criteria were age 18 years or older, the ability to read

and write Arabic with ease, and at least 3-week duration of symptoms.

Patients who were not able to ll out the forms, with major neurologic

disorders or with elbow or shoulder problems were excluded from the

study.

Psychometric Properties and Data Analysis

Internal consistency

The outcome measures of each construct were presented using de-

scriptive analysis. Mean and Standard Deviation (SD) were calculat-

ed. Internal consistency was evaluated by calculating the Cronbach’s

α.Internal consistency determines to what extent different items with-

in one questionnaire measure the same construct of interest [11]. Ac-

cording to the literature, α>0.70 is regarded as acceptable, while it

should not be higher than 0.95, to avoid redundancy [12].

Construct validity

Construct validity reects whether the questionnaire measures

what it was designed to measure. In the case of hand problems, ques-

tions measure the typical complaints following Hand injuries [11].

To test the construct of the Arabic MHS, its relationship to a gold

standard questionnaire like DASH, this had a validated Arabic ver-

sion, needed to be examined. For this purpose, Spearman’s correla-

tion coefcient between Arabic MHS and DASH was calculated. A

higher correlation coefcient would prove the construct validity of

the Arabic MHSQ. Furthermore, the accuracy of the measurement is

determined by calculating the oor and ceiling effects. The oor ef-

fect is the percentage of patients who scored the lowest possible score

(score of 0), and the ceiling effect is the percentage of those with the

highest score (score of 48). If more than 15% of the respondents had

a oor or ceiling effect, the effects would be considered to be relevant

[13].

The calculations were performed using Micorosft Excel 2019,

IBM SPSS v.26, and Graphpad Prism v.8.

Results

57 patients participated in this study and completed the MHS and

DASH questionnaires and agreed to have their data analysed for re-

search purposes. 31 patients (54.4%) were male, while 26 were fe-

males (45.6%). The average age of the participants was 50.65 years,

with a standard deviation of 16.05 years, which means that the major-

ity of the sample was between 35 and 67 years of age. As shown in

table 1, Mean, standard deviations, minimum, maximum, and oor/

ceiling effects were calculated. All subscales of MHSQ seem to have

no more than 2% oor/ceiling effect, which indicates that there is no

problem with the accuracy of the measurement.

Internal consistency

To estimate the reliability of the questionnaire, Internal consisten-

cy was calculated by using overall Cronbach’s alpha which was equal

to 0.859, indicating an overall high degree of internal consistency, the

Cronbach’s alpha of all the subscales were also proved to be higher

than 0.7, which indicate an acceptable to very good reliability (Table

2).

Construct validity

The correlation of different subscales with each other was exam-

ined by calculating the Interclass correlation coefcient. The results,

which are shown in table 3, indicate that there is a relatively high

and signicant association between the subscales. The relationship

of Pain with Hand function (r=-0.814; p<0.05), Work (r=-0.886; p

<0.05) was especially high (reverse association, which means, that

higher pain is associated with worse daily life activity and disrupted

daily work).

For the validity assessment of the Arabic MHOQ, Arabic DASH

is used as the standard instrument that is acceptable in almost all

countries. Table 4 presents the spearman’s correlation coefcients to

measure the level of association between DASH and Arabic MHSQ,

and its construct validity, respectively. As shown in Table 2, Arabic

DASH shows a statistically signicant correlation with all subscales

of Arabic MHSQ. However, it indicates especially high correlation

with Hand function (r=0.701; p<0.001), activity of daily life (r=0.761;

p<0.001) and Pain score (r=-0.620; p<0.001).

Citation: Khaja AF, Al-Roudhan M, Hanna SS, Boshahri MO, Al-Awadh M, et al. (2020) Cross-Cultural Adaptation, Validation, and Reliability of the Michigan

Hand Outcomes Questionnaire: Arabic Version. J Surg Curr Trend Innov 4: 037.

• Page 3 of 6 •

J Surg Curr Trend Innov ISSN: 2578-7284, Open Access Journal

DOI: 10.24966/SCTI-7284/100037

Volume 4 • Issue 3 • 037

Finally, to visualize the agreement between Arabic DASH and

MHSQ, the Bland-Altman plot is used. As shown in gure 1, it seems

to be no proportional bias, because as the mean scores of DASH and

MHS are rising, their difference remains unbiasedly within 95% con-

dence interval.

Discussion

The aim of this study was to translate the MHQ into Arabic and

also validate the MHQ-Arabic version. Translation of the MHQ into

Arabic was done without any signicant changes. Good reliability

and validity results were obtained from the MHQ-Arabic version

when tested.

We were satised with the content validity of the MHQ-Arabic

version. We slightly altered the demographic data collected regarding

patient characteristics. To t into the Arabic contest, adjustments were

made to the income, ethnic background, job, and medical expense

reimbursement plans. We excluded the item on the ethnic background

considering that the Arabic population is a relatively homogenous one

and most f the population is Arab. Additionally, the MHQ-Arabic ver-

sion will be used for patients with the ability to read and speak Arabic.

Variables Mean SD Min Max Range Floor Effect Ceiling Effect

AGE 50.65 16.05 18 79 61 - -

Hand Function 51.23 23.77 0 100 100 2% 2%

ADL 58.19 21.52 59 100 64 2% 2%

Work 56.58 20.54

0 100 100 2% 2%

Pain 46.84 20.21 0 100 100 2% 2%

Appearance 59.21 22.12 0 100 100 2% 0%

Satisfaction 56.58 56.58 57 83 64 2% 2%

MHS Total 55.52 12.01 0 80 80 2% 0%

Table 1: Descriptive analysis of demographic age and the score of the Michigan Hand Score Questionnaire, including oor and ceiling effects.

Cronbach's Alpha

Hand Function 0.864

ADL 0.908

Work 0.7

Pain 0.71

Appearance 0.734

Satisfaction 0.758

MHS Total 0.859

Hand Function ADL Work Pain Aesthetics Satisfaction

Hand Function 1

ADL 0.517 1

Work 0.641 0.619 1

Pain -0.814 -0.635 -0.886 1

Aesthetics 0.315 0.32 0.329 -0.454 1

Satisfaction 0.409 0.415 0.464 -0.528 0.773 1

Hand Function ADL Work Pain Appearance Satisfaction MHSQ TOTAL

DASH (TOTAL) 0.701 0.761 0.551 -0.62 0.265 0.416 0.771

p Value 0 0 0 0 0.0466 0.0013 0

Table 2: Cronbach’s Alpha values for the whole MHSQ and each sub-

scale.

Figure 1: Bland-Altman Plot to visualize the level of agreement between

DASH and MHSQ.

Table 3: Interclass Correlation Coefcients between subscales of MHSQ.

Bold: Highest coefcient in each column

All coefcients are statistically signicant at 0.05 level

Table 4: Spearman’s Correlation Coefcients indicating the validity of Arabic MHSQ.

Citation: Khaja AF, Al-Roudhan M, Hanna SS, Boshahri MO, Al-Awadh M, et al. (2020) Cross-Cultural Adaptation, Validation, and Reliability of the Michigan

Hand Outcomes Questionnaire: Arabic Version. J Surg Curr Trend Innov 4: 037.

• Page 4 of 6 •

J Surg Curr Trend Innov ISSN: 2578-7284, Open Access Journal

DOI: 10.24966/SCTI-7284/100037

Volume 4 • Issue 3 • 037

Thus, we did not consider the ethnic background as necessary. We

changed the choices on income based on the average monthly income

in Kuwait. We added items on family income to the MHQ-Arabic

version to showcase the demographic characteristics of the Arab ex-

tended family. Finally, we added an item to the MHQ-Arabic version

to include questions on medical expense reimbursement plans as we

considered that it may impact treatment continuity.

The respondents were able to answer the questions during the test-

ing phase of the prenal MHQ-Arabic version. Thus, the results of

this study show that the MHQ was cross-adapted into Arabic with

ease, which of course shares similarity to conclusions reached after its

translation to other languages [6]. We also examined the construct va-

lidity of the MHQ-Arabic version. Overall hand function, ADL, work,

pain aesthetics, and satisfaction were major variables considered in

predicting the satisfaction of Arabic patients who had injuries of the

hand. Patients with low pain score and high aesthetic scores tend to

have high satisfaction scores. Also, pain assisted greatly in the predic-

tion of hand function, work, ADL, and overall function. Patients with

high pain scores tend to experience difculty with functioning, work

performance, and ADL. Contrastingly, the correlation of aesthetics

with hand function was low-to-moderate, although it was a signicant

outcome for patients with an injury of the hand. The construct validity

of the MHQ-Arabic version agreed with the original and other trans-

lations of the MHQ [5,14].

An instrument is said to be reliable if the results it produces are

consistent on repeated administration [15]. The Arabic version of

the MHQ achieved a high internal consistency, which agreed with

the original MHQ and other translations [5,14,16,17]. Several trans-

lations retained a high Cronbach’s alpha similar to that obtained by

our study (> 0.7) after cross-cultural adaptation. Every domain main-

tained a high degree of internal consistency with the exception of the

aesthetics domain. The consistency of the aesthetics differs from the

original MHQ [5].The low consistency displayed by the aesthetics

domain may be due to poor interrelatedness between the items in the

aesthetics domain per hand [18].

The Interclass coefcient of the total score of the MHQ-Arabic

version showed high and signicant association between the sub-

scales(r=-0.814; p<0.05), Work (r=-0.886; p<0.05). This is similar to

the result from the original MHQ as well as other translated versions

[5,14,16,17,19,20]. This indicates the high reliability of the domains

in the MHQ-Arabic version in repeated testing.

A strength of this study is that it complied was the large number of

participants that took part in the prenal version of translation. Beaton

et al. suggested that the prenal version of translation should be taken

by at least 30-40 participants [21]. 57 participants were engaged in

our study, their comprehension and interpretation of the questionnaire

were investigated with great care. It is important to note that the study

was designed to test the reliability and validity of the questionnaire.

And even though there is no set guideline to determine the precise

number of sample size for development of the questionnaire, large

sample sizes are preferable to smaller samples. And so, future studies

should employ more participants with varying hand injuries which is

necessary to extend knowledge.

Conclusion

TheMichigan Hand Outcomes Questionnaire was translated and

cross-culturally adapted into Arabic. The Arabic version had a good

performance in both validity and reliability testing, which was similar

to the original questionnaire and other translated versions. Provided

the questionnaire is valid and reliable, it may easily be function as

an outcome measurement for self-perception of hand-injured Arabic

patients.

Declaration

Ethical approval and consent for publication

• Ethical approval was obtained

• Consent of publication was obtained in writing from all partici-

pants

• Name of Ethical Committee: Ministry of Health, Kuwait, Re-

search and publication ofce

• Committee Reference Number: 2019:891

Consent to publish

Consent of participation and publish was obtain with written For-

mat from all participants

Availability of data and material

The data that support the ndings of this study are available from

[ministry of health Al-Razi Orthopedic Hospital, Kuwait] but restric-

tions apply to the availability of these data, which were used under

license for the current study, and so are not publicly available. Data

are however available from the authors upon reasonable request and

with permission of [ministry of health Al-Razi Orthopedic hospital,

Kuwait].

Competing Interests

The authors declare that they have no competing interests

Funding

No funding was supplied in this case report

Authors’ Contributions

The data collection and the writing were done by all the four au-

thors equally.

Acknowledgment

The Authors wish to thank the original authors of the Michigan

Hand Outcomes Questionnaire for making this project possible.

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Citation: Khaja AF, Al-Roudhan M, Hanna SS, Boshahri MO, Al-Awadh M, et al. (2020) Cross-Cultural Adaptation, Validation, and Reliability of the Michigan

Hand Outcomes Questionnaire: Arabic Version. J Surg Curr Trend Innov 4: 037.

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J Surg Curr Trend Innov ISSN: 2578-7284, Open Access Journal

DOI: 10.24966/SCTI-7284/100037

Volume 4 • Issue 3 • 037

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