Crosscultural Measurement Equivalence of the Health Assessment Questionnaire II


Address correspondence to Martijn A. H. Oude Voshaar, MSc, Institute for Behavioural Research, Faculty of Behavioural Sciences, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. E-mail:



To evaluate the crosscultural measurement equivalence of the US and Dutch Health Assessment Questionnaire II (HAQ-II) in rheumatoid arthritis (RA).


Item response theory (IRT) analyses were performed on US (n = 18,747) and Dutch (n = 1,022) HAQ-II data to evaluate the equivalence of crosscultural item performance. The observed inconsistencies were modeled by assigning country-specific item parameters to biased items. The impact of crosscultural item bias on the comparability of the Dutch and US total scores was analyzed by evaluating the agreement between physical function levels estimated from an IRT model with country-specific item parameters for biased items and physical function levels estimated from the original model that did not account for cultural bias.


Two items showed significant crosscultural bias. However, the agreement in physical function estimates between the respecified and original models was very high, with an intraclass correlation coefficient >0.99 and Bland-Altman limits of agreement ranging from −0.08 to −0.01 on a latent scale with a mean of 0 and an SD of 1.


This study suggests that the Dutch and US HAQ-II produce total scores that can be interpreted interchangeably across countries in RA studies, despite some minor bias at the item level.