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Keywords:

  • Health status;
  • Outcomes measures;
  • Quality of life;
  • Rheumatoid arthritis;
  • Osteoarthritis;
  • Crosscultural validation

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

Objective

To evaluate the validity, reliability, and cultural relevance of the Arthritis Impact Measurement Scales 2 (AIMS2) as a health assessment tool for Chinese-speaking patients with arthritis.

Methods

The cultural relevance, language equivalency, and content validity of the AIMS2, Chinese version (CAIMS2) were evaluated by an expert panel. Measurement performance was tested on 240 subjects (rheumatoid arthritis = 81, osteoarthritis = 77, healthy = 82). Subjects (n = 175) were retested within 2 weeks for testing of reliability.

Results

Three items were modified and 2 items were added, as suggested by the expert panel. Interitem reliability was satisfactory (intraclass correlation coefficient 0.8552–0.9594). Test–retest reliability of the CAIMS2 subscales ranged from 0.770 to 0.952 in subjects in whom the CAIMS2 was self administered. Significant score differences between patients with arthritis and healthy subjects were found in all 12 subscales, except for the support from family and friends and tension subscales. CAIMS2 subscale scores correlated with clinical and laboratory measures of disease activity and patients' perceived quality of life as measured using the Chinese version of the World Health Organization Quality of Life instrument.

Conclusion

Empirical data support CAIMS2 is a valid and reliable health status measure for Chinese speaking patients with arthritis.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

The Arthritis Impact Measurement Scales (AIMS) have been widely used to assess the health status of people with arthritis in many countries for years (1–9). Extensive testing and refinement have been done to make AIMS a reliable, valid, and sensitive tool for evaluating the health status of individuals with arthritis (1, 10–12). Previous studies evaluating the efficiency and sensitivity of existing health status measures have demonstrated that the AIMS was efficient in assessing patients' mobility, pain level, and global functional impairment (13). In 1992, Meenan et al (14) further revised the measure (AIMS2) to cover aspects of arthritis relevant health status—arm function, work, and support from family and friends—that were not addressed by the previous measure. Three sections were also added to assess the respondents' satisfaction with current level of function, problem areas, and areas in which they wanted improvement. Empirical data supported that the AIMS2 is valid and reliable.

Chinese people make up almost one-quarter of the world's population. Han Chinese made up 93.5% of the population in the People's Republic of China where Mandarin is the official language. Although there are 201 living languages (dialects) in China, the people in China share a unified writing system (Ethnologue.com, 2002). Recently, health status measures, such as the Short Form 36, Health Assessment Questionnaire, and the World Health Organization Quality of Life instrument (WHOQOL–BREF), have been translated and validated for Chinese-speaking patients (15–17). However, these general questionnaires are not as comprehensive, sensitive, or specific as the AIMS2 in detecting health changes in arthritis patients (13). The aim of this study was therefore to translate AIMS2 into Chinese (CAIMS2) and evaluate its validity.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

Stage 1: translation and development of CAIMS2.

An expert panel consisting of 1 rheumatologist, 1 general physician, 1 clinical psychologist, 1 physiotherapist, 1 occupational therapist, and 3 rheumatoid arthritis (RA) patients was recruited to comment on the cultural relevance and content validity of the AIMS2 in Hong Kong. The rheumatologist and the clinical psychologist in the expert panel had more than 20 years' clinical experience. The physiotherapist and occupational therapist had more than 3 years' experience in the rehabilitation of patients with chronic arthritis.

The original AIMS2 was translated into Chinese by one investigator (EMYC) and back-translated into English by an independent bilingual volunteer. No dialect-specific Chinese characters were used in the translation. Language equivalency of the original AIMS2 and the back-translated version of the AIMS2 were studied by 2 of the investigators (EMYC and CSL) and the expert panel. Members of the expert panel were also asked to evaluate the Chinese version of AIMS2 in terms of cultural relevance and content validity as a health status measure for the Chinese population in Hong Kong using a 5-point Likert scale (very poor, poor, fair, good, and very good). The finalized version—CAIMS2—is shown in Appendix 1 (Copy available at the Arthritis Care & Research Web site at http://www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html.)

Performance testing and evaluation of the internal consistency, reliability, and validity of the CAIMS2.

Subjects and questionnaire administration.

Patients with RA and osteoarthritis (OA) attending the specialized outpatient clinics of the University Departments of Medicine and Orthopedics and Traumatology, Queen Mary Hospital, between August 1998 and October 1999 were recruited by convenient sampling to participate in this study. All RA patients fulfilled the American College of Rheumatology (formerly American Rheumatism Association) classification criteria for RA (18). Patients with OA had hip or knee arthritis. Hip OA was diagnosed if the patient complained of hip pain and had at least 2 of the following 3 features: erythrocyte sedimentation rate (ESR) < 20 mm/hour, radiographic femoral or acetabular osteophytes, or radiographic joint space narrowing (superior, axial, or medial). Knee OA was diagnosed if the patient complained of knee pain and had at least 1 of the following 4 features: age > 70 years, morning stiffness < 30 minutes, presence of crepitus on physical examination, radiographic osteophytes or joint space narrowing.

Patients who agreed to participate in the study were asked to refer a family member or friend who had no history of chronic musculoskeletal conditions or other chronic illnesses to participate as a control subject.

All patients were asked to complete the self administered CAIMS2. Two research assistants were trained to interview subjects who had difficulties with the questionnaires. All subjects were asked to complete the CAIMS2 again in 2 weeks and return by mail for test–retest reliability. Subjects who could not complete the CAIMS2 in a self- administered format were contacted for a telephone interview. Altogether, 175 subjects repeated and returned the questionnaire.

Evaluation of quality of life, disease activity, and functional ability.

All subjects were asked to complete the Chinese version of the WHOQOL–BREF (17) once. To evaluate the criterion validity of the CAIMS2, the following parameters were assessed in the RA patients: disease activity (total tender joint count, total swollen joint count, grip strength, ESR, C-reactive protein [CRP]), function (Barthel Index) (19), pain (visual analog scale [VAS]), and fatigue (VAS). All clinical assessments were performed by 1 investigator (EMYC) in the outpatient clinic according to standardized procedures.

Pilot testing.

Five subjects with RA and 5 healthy controls were recruited for a pilot study. All were able to complete the questionnaire with minimal assistance within 25 minutes. A paired t-test was used in the preliminary analysis of the data collected in the pilot study. There were no significant differences in most of the test–retest item scores of the CAIMS2. Correlation between the CAIMS2 physical subscale score (mobility, walking and bending, arm function, and hand function) and the physical domain score of the WHOQOL–BREF was analyzed (r > 0.6).

Field testing.

Eighty-one patients with RA, 77 patients with OA, and 82 healthy subjects were recruited for field testing. Correlations between the CAIMS2 scores and subscale scores with the corresponding quality of life assessment, disease activity, and functional ability tests were made. For reliability testing, 175 subjects were retested.

Statistical analysis.

All the items and scales of the CAIMS2 were scored in such a way that lower scores indicated good health status and higher scores suggested poor health. The reliability of the CAIMS2 was estimated by calculating the internal consistency of scale and the test–retest reliability of the 175 repeated questionnaires. The Cronbach's alpha was used to evaluate if items in each of the subscales of the CAIMS2 were appropriate to measure the respective underlying concept. The internal consistency of each subscale was accepted for group comparison if the Cronbach's alpha coefficient was greater than 0.7. Intraclass correlation was used to evaluate the test–retest reliability and r > 0.7 suggested adequate reliability for a group of patients and r > 0.9 suggested reliability adequate for individual comparisons (20).

A Spearman's rank correlation test was used to assess the correlation between the CAIMS2 scores and other disease activity assessment, functional assessment, and quality of life scores. Total tender joint count, total swollen joint count, ESR, CRP, and pain VAS were used to compare the impact score of the CAIMS2 arthritis pain subscale. Grip strength and Barthel Index scores were compared with hand finger function, arm function, self-care tasks, household tasks, and work subscales of the CAIMS2. Age, sex, and education level were used as facets for comparison to evaluate the convergent/divergent validity of the CAIMS2. The WHOQOL–BREF physical facet was compared with the mobility level, walking and bending, hand and finger function, arm function, and arthritis pain subscales of the CAIMS2. The WHOQOL–BREF psychological facet was compared with the level of tension and mood subscales of the CAIMS2. The WHOQOL–BREF social relationship facet was compared with the social activities and support from family and friends subscales of the CAIMS2. The environment facet of the WHOQOL–BREF was not used for correlation analysis because there is no comparable subscale in the CAIMS2. A summary of the above comparisons is shown in Figure 1. A correlation coefficient of 0.60 or greater was accepted as strong evidence in supporting construct validity (21).

thumbnail image

Figure 1. Comparison of Chinese Arthritis Impact Measurement Scales 2 (CAIMS2) subscales with disease markers, physical assessement, and World Health Organization Quality of Life (WHOQOL) instrument in statistical analysis of the divergent and convergent validity of CAIMS2. ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; VAS = visual analog scale.

Download figure to PowerPoint

An analysis of variance was used to evaluate the differences of the CAIMS2 scores between RA and OA patients and healthy subjects. Significant differences (P < 0.05) in CAIMS2 scores among subject groups further supported the discriminant validity of the instrument.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

Content validity and cultural relevance.

All members of the expert panel agreed that 3 of the 12 subscales (mobility level, self-care tasks, and arthritis pain) were highly relevant components of health status of people with arthritis. Six other subscales (walking and bending, hand and finger function, arm function, household tasks, work, and mood) were rated as relevant. Three subscales (social activities, support from family and friends, and level of tension) were rated as poorly relevant by 1 panel member, but 3 members regarded them as highly relevant in the assessment of health status of arthritis patients. Ratings on the relevance of all 12 subscales of the CAIMS2 are shown in Table 1.

Table 1. Ratings by the expert panel on the relevance of the 12 subscales used in CAIMS2*
 Very good %Good %Fair %Poor %Very poor %
  • *

    CAIMS2 = Chinese Arthritis Impact Measurement Scales 2.

Mobility level5050000
Walking and bending33501700
Hand and finger function33501700
Arm function17661700
Self-care tasks6633000
Household tasks50173300
Social activities331733170
Support from family and friends173333170
Arthritis6633000
Work50331700
Level of tension173333170
Mood33175000

The expert panel rated 53 of the 56 items of the CAIMS2 as culturally relevant for Chinese arthritis patients. Among them, 36 items were rated as very good or good in cultural relevance by all members of the expert panel. Fifteen items were rated as very good or good in cultural relevance by more than 4 of the 8 members of the panel. Four items were rated as fair by more than 4 of the 8 panel members. Items 15, 45, and 55 were rated as poor by 2 of 8 panel members. The panel suggested modification of these questions so that they were more suitable for Hong Kong Chinese culture (Table 2). More than 4 of the 8 members of the expert panel commented that items 25, 30, and 31 in the questionnaire were only fairly relevant to Hong Kong culture. Items 2 and 3 were regarded as redundant in assessing mobility level (Table 3). Although most of the panel members rated the above 3 items as poorly relevant to Hong Kong and that items 2 and 3 were redundant, the investigators decided to keep these 5 items in the questionnaire for field testing. Subsequent analysis took these items into account and assessed whether the content validity could be improved by adding or removing some or all of them from the original questionnaire.

Table 2. Three items rated as poorly relevant by the panel that were modified
Item no.Original questionChanged to
15Could you easily open a new jar of food?Could you easily open a jar of food?
45On the days that you did work, how often did you have to work a shorter day?How often did you have to have sick leave?
55How often did you feel that others would be better off if you were dead?How often did you feel that you would be a burden on others due to arthritis?
Table 3. Items rated as poorly relevant and redundant by the expert panel
Item no.Original questionRationale
25If you had the necessary transportation, could you go shopping for groceries without help?A lot of people in Hong Kong do not require transportation to go shopping
30How often did you have friends or relatives over to your home?People in Hong Kong seldom invite their friends or relatives to their home
31How often did you visit friends or relatives at their homes?People in Hong Kong seldom visit their friends and relatives in their homes

In addition to the questions altered, the expert panel suggested inclusion of 2 items relevant to the Chinese culture. Eating and the use of chopsticks are abilities highly valued by Chinese people. Thus, the following items were added: “Could you easily use chopsticks?” in the hand and finger function and “Did you need help in feeding?” in the self-care tasks.

The final version of CAIMS2 consisted of 59 items. All of the answering scales were rated as either good or very good by the expert panel. Due to the length of the questionnaire, sections on current level of function, problem areas, and areas patients wanted to have improvement were not included in CAIMS2.

Subjects.

Subjects (240 total; RA n = 81, OA n = 77, healthy subjects n = 82) were recruited for field testing. There were 71 men (29.6%) and 169 women (70.4%). The age of the RA subjects ranged from 22 to 72 (mean 48) years; OA subjects 46 to 83 (mean 65) years; and healthy subjects 19 to 82 (mean 36) years. The majority of the healthy subjects had completed 9 years or more formal education but only 69% of the RA subjects and 24% of the OA subjects had achieved such educational level.

Most of the RA and healthy subjects (RA 83%, healthy subjects 94%) could complete the CAIMS2 and the Hong Kong version of the WHOQOL–BREF without assistance. However, only 27% of all OA subjects were able to complete the questionnaire by themselves. The majority of the subjects who needed assistance to complete the questionnaire were illiterate. Of subjects older than 65 years, 72% needed assistance in completing CAIMS2, whereas 22% of the subjects younger than that age needed assistance. The majority of subjects older than 65 years had achieved less than 9 years of education. All the subjects who needed assistance in completing CAIMS2 had achieved less than 11 years of education. Of subjects having achieved 9 or fewer years of education, 66% needed assistance in completing CAIMS2. All the subjects who had achieved more than 11 years of education could complete the questionnaire independently.

The administration time for patients who were able to complete the questionnaire without assistance was 22.85 (SD = 7.96) minutes. This is comparable to the findings of Meenan et al (14).

Internal consistency and reliability.

The internal consistency of the individual subscales was satisfactory (self- administered group α = 0.8552–0.9594; interviewed group α = 0.6521–0.9825). The Cronbach's alphas of each subscale are shown in Table 4. The internal consistency of subscale to total was satisfactory (self-administered group α = 0.8443; interviewed group α= 0.8074). Two weeks after the initial testing, 175 subjects completed the CAIMS2 (self administered n = 125, interviewed n = 50) for the analysis of test–retest reliability. The data collected from questionnaires completed independently were analyzed separately from those who required assistance. All of the intraclass correlation coefficients (ICCs) of the test–retest subscale scores were higher than 0.75, with 50% higher than or close to 0.9 (test-retest correlation coefficients [r] = 0.770–0.952) among those who completed the CAIMS2 by themselves. The ICCs were lower among those who needed assistance in completing the questionnaire (r = 0.526–0.922). Only 75% of the ICCs of the test–retest subscale scores were above 0.75, with the test–retest ICC of only 1 subscale higher than or close to 0.9. The ICC values of each subscale are shown in Table 4. These results support the satisfactory test–retest reliability of the CAIMS2 as a self-administered health status measure.

Table 4. Internal consistency and test–retest relibility of the CAIMS2 subscales*
 Subjects who completed CAIMS2 independentlySubjects who required assistance to complete CAIMS2
Internal consistency (Cronbach alpha) n = 166test–retest relibility (ICC) n = 125Internal consistency (Chronbach alpha) n = 74test–retest relibility (ICC) n = 50
  • *

    CAIMS2 = Chinese Arthritis Impact Measurement Scales 2; ICC = intraclass correlation coefficient.

Mobility0.85520.9150.86180.819
Walking and bending0.89690.9290.82220.922
Hand and finger function0.94940.8000.93810.526
Arm function0.93270.8460.89660.533
Self-care ability0.95940.8020.98250.600
Household tasks0.95080.8210.90830.793
Social activities0.88990.9040.81690.841
Support from family and friends0.89020.8960.86290.839
Arthritis pain0.93560.9520.79020.871
Work0.86860.8320.65120.809
Tension0.89200.7700.84380.793
Mood0.89040.9040.88520.867
Subscales/total score0.8443 0.8074 

Convergent and divergent validity.

There were significant correlations between the CAIMS2 arthritis pain subscale score and the pain VAS (r = 0.566, P = 0.001), total tender joint count (r = 0.311, P = 0.001), and total swollen joint count (r = 0.243, P = 0.001). No significant correlation was found between the CAIMS2 arthritis pain score and disease activity indicators, such as ESR and CRP. However, ESR and serum CRP levels correlated highly with each other (r = 0.527, P = 0.01). Laboratory findings also correlated significantly with total swollen joint count (ESR r = 0.325, P = 0.018; CRP r = 0.346, P = 0.012) and pain VAS score (ESR r = 0.335, P = 0.016). These results supported the validity of using the CAIMS2 to measure pain and severity but not the activity of arthritis.

Comparison of the CAIMS2 score and the functional scores showed significant negative correlations and supported that higher arthritis impact was associated with decreased function. Scores on the Barthel Index correlated highly with the self-care subscale (r = −0.552, P = 0.0001), work subscale (r = −0.399, P = 0.001), and mobility subscale (r = −0.361, P = 0.002) of the CAIMS2. There were also significant negative correlations between the Barthel Index score and mood (r = −0.250, P = 0.035), and grip strength (right hand) and support from family and friends (r = −0.299, P = 0.028). Significant negative correlations were also found between grip strength (right hand) and the CAIMS2 work (r = −0.334, P = 0.025), mobility (r = −0.345, P = 0.011), and hand and finger function (r = −0.276, P = 0.044) subscales; and grip strength (left hand) with work (r = −0.364, P = 0.014) and mobility (r = −0.309, P = 0.023) subscales. These results suggested a significant association between functional status and psychological well being.

Significant correlations were observed between WHOQOL–BREF physical domain scores and all of the CAIMS2 subscale scores, except support from family and friends. WHOQOL–BREF physical health had the highest correlation with the CAIMS2 arthritis pain score (r = −0.667, P = 0.000) and lowest correlation with self-care ability score (r = −0.137, P = 0.46). The WHOQOL–BREF psychological domain score correlated negatively with the CAIMS2 mobility, walking and bending, arm function, social activities, support from family and friends, arthritis pain, work tension, and mood subscale scores. The highest correlation was found between WHOQOL–BREF psychological domain score with tension (r = −0.245, P = 0.000) and mood subscale scores (r = −0.264, P = 0.000). The lowest correlation was found between WHOQOL–BREF psychological domain score with support from family and friends subscale scores (r = −0.159, P = 0.021). The WHOQOL social domain score correlated negatively with the CAIMS2 social activities (r = −0.291, P = 0.000), mood (r = −0.291, P = 0.000), tension (r = −0.263, P = 0.0001), support from family and friends (r = 0.246, P = 0.0001), and arthritis pain (r = −0.223, P = 0.001) subscale scores. Correlations between the CAIMS2 subscales and other disease activity assessment, functional assessment, and quality of life scores are summarized in Table 5.

Table 5. Correlations (r) between CAIMS2 scores and other disease assessments*
 Pain (VAS)Total tender jointsTotal swollen jointsBarthel IndexGrip (R)Grip (L)WHOQOL physicalWHOQOL psychologicalWHOQOL social
  • *

    CAIMS2 = Chinese Arthritis Impact Measurement Scales 2; VAS = visual analog scale; WHOQOL = World Health Organization Quality of Life instrument.

  • P < 0.01.

  • P < 0.05.

Mobility0.1350.0950.042−0.361−0.345−0.309−0.480−0.224−0.093
Walking and bending0.4660.3930.192−0.182−0.163−0.208−0.624−0.189−0.148
Hand and finger function0.2530.0940.072−0.112−0.276−0.205−0.313−0.122−0.170
Arm function0.3410.1410.133−0.161−0.216−0.214−0.379−0.166−0.169
Self-care ability0.1530.1980.127−0.552−0.139−0.171−0.137−0.045−0.075
Household tasks0.3090.1730.215−0.039−0.013−0.058−0.237−0.077−0.076
Social activities0.1560.1170.1130.139−0.192−0.147−0.405−0.218−0.291
Support from family and friends0.0940.1050.1790.084−0.299−0.232−0.104−0.1590.246
Arthritis pain0.5660.3110.243−0.191−0.490.002−0.667−0.204−0.223
Work0.1540.3620.170−0.399−0.334−0.364−0.522−0.204−0.151
Tension0.3610.2760.290−0.114−0.0720.008−0.349−0.245−0.263
Mood0.3610.2220.194−0.250−0.276−0.231−0.512−0.264−0.291

The above results supported the hypothesis that a higher correlation between the instrument score and other assessments that measure the same concepts is expected and that indicators of different health concepts or domains yield a lower correlation.

Discriminant validity.

Significant differences in the CAIMS2 scores (P < 0.05) were found between arthritis subjects (RA and OA) and healthy subjects in all the subscales, except support from family and friends and tension (Table 6).

Table 6. CAIMS2 of healthy subjects and patients with RA or OA*
 Healthy n = 82RA n = 81OA n = 77
  • *

    CAIMS2 = Chinese Arthritis Impact Measurement Scales 2; RA = rheumatoid arthritis; OA = osteoarthritis.

  • Healthy versus RA subjects; P < 0.05.

  • Healthy versus OA subjects; P < 0.05.

  • §

    RA versus OA subjects; P < 0.05.

Mobility0.84 ± 1.231.98 ± 1.832.64 ± 2.86
Walking and bending0.77 ± 1.263.34 ± 2.36§6.01 ± 2.69
Hand and finger function0.22 ± 0.921.87 ± 2.44§0.29 ± 0.86
Arm function0.24 ± 1.182.21 ± 2.52§0.60 ± 1.14
Self-care ability0.18 ± 1.160.59 ± 1.150.57 ± 2.04
Household tasks1.22 ± 2.732.37 ± 2.941.96 ± 2.86
Social activities5.18 ± 1.795.96 ± 1.74§6.95 ± 1.96
Support from family and friends3.84 ± 2.213.72 ± 2.752.75 ± 2.81
Arthritis pain0.73 ± 1.104.51 ± 2.113.91 ± 2.35
Work1.00 ± 1.362.26 ± 2.102.71 ± 2.43
Tension3.23 ± 1.763.82 ± 2.13§2.57 ± 2.47
Mood1.98 ± 1.283.44 ± 2.16§2.23 ± 2.35

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

This is the first attempt to translate the AIMS2 into Chinese and evaluate its validity and reliability in assessing the health status of Chinese arthritis patients. Our results support that the CAIMS2 is a valid and reliable health status assessment tool for Chinese-speaking arthritis patients. The validity of the CAIMS2 was higher for literate subjects who were able to complete the questionnaire independently, and the performance was poorer in illiterate subjects who required assistance to complete the questionnaire.

The item-to-total statistics supported that the internal consistency of each subscale was satisfactory. Because some expert panel members had queried the relevance of 3 subscales (social activities, support from family members and friends, and level of tension), the reliability alpha of the subscale-to-total was calculated with 1 or a combination of these subscales deleted. The reliability alpha of the subscale-to-total increased to 0.8669 if the subscales support from family and friends and level of tension were deleted. It further increased to 0.8715 if the social activities subscale was also deleted. However, the item-to-total coefficient fell from 0.8283 to between 0.6971 and 0.7369 if any single subscale was deleted from the CAIMS2. This suggested that the reliability of the CAIMS2 will not be increased if any single subscale is deleted. On the other hand, the inclusion of the social activities, support from family and friends, and level of tension subscales may not significantly increase the reliability of the instrument.

The CAIMS2 also has high reliability with ICC of the test–retest subscale scores greater than 0.75. The ICC was lower among those who needed assistance in completing the questionnaire. The low ICC of the questionnaires completed with assistance may suggest that the interview format was not as reliable as if the questionnaire was self administered. Because most of the subjects who required assistance were elderly, it may also suggest that the reliability of this tool in the elderly was lower. Additional studies are needed to identify the main cause of decreased reliability so that modifications can be made to improve the reliability of the CAIMS2 in illiterate and elderly patients.

Significant correlations between the CAIMS2 and other clinical assessments of arthritis severity also confirmed the convergent and divergent validity of the scale. However, no significant correlations between the CAIMS2 score and disease activity measures, such as ESR and CRP, were found in this study. This is in accordance with previous studies that demonstrated a weak to moderate correlation between AIMS score and disease activity measures (1, 11–14). Our data suggest that the CAIMS2 is an appropriate tool to measure the severity but not the disease activity of arthritis. In addition to the measurement of pain level at the time of the assessment, the frequency of pain experienced by a patient in a certain period of time is also measured by the CAIMS2. Thus, information on the intensity and frequency of pain can be captured. Further studies are needed to compare the sensitivity of CAIMS2 to measure changes in disease activity.

Significant correlations were observed between the patients' physical and psychological functional status as measured using the Hong Kong version of the WHOQOL–BREF and the CAIMS2 scores. These results support that the CAIMS2 is valid in measuring the physical and psychological aspects of health status. Furthermore, significant differences in the CAIMS2 scores (P < 0.05) were found between arthritis patients (RA and OA) and healthy subjects in all the subscales, except support from family and friends and tension. The validity of the social domain of the CAIMS2 and the subscales on support from family and friends as well as tension needs to be further analyzed.

In conclusion, we have successfully translated AIMS2 into Chinese. Preliminary data showed CAIMS2 is a valid tool for measuring the functional status of Chinese-speaking patients with chronic arthritis. Further evaluations of the construct validity and sensitivity of the CAIMS2 in clinical trials will be carried out. However, we have found in our study that it was difficult to administer the questionnaire, which consists of 59 items, to elderly clients and those with lower education level. A shorter and easier to administer version is needed for clinical use.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information

Thanks are due to members of the expert panel for their contribution in the initial stage of the development of the CAIMS2, and to the volunteer who helped with the back-translation of the questionnaire. We thank Ms Karis Larm for secretarial assistance.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  9. Supporting Information
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suppmat_20.pdf527KSupporting Information file suppmat_20.pdf

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