Rheumatol Int
DOI 10.1007/s00296-013-2796-y
ORIGINAL ARTICLE
Translation and validation of the Turkish version
of the Ankylosing Spondylitis Quality of Life (ASQOL)
questionnaire
M. T. Duruöz • L. Doward • Y. Turan • L. Cerrahoglu • M. Yurtkuran • M. Calis • N. Tas • S. Ozgocmen •
O. Yoleri • B. Durmaz • S. Oncel • T. Tuncer • O. Sendur • M. Birtane • F. Tuzun • U. Bingol • M. Kirnap •
G. Celik Erturk • O. Ardicoglu • A. Memis • F. Atamaz • R. Kizil • C. Kacar • G. Gurer • K. Uzunca • H. Sari
Received: 8 March 2012 / Accepted: 4 June 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract The Ankylosing Spondylitis Quality of Life
(ASQoL) questionnaire is a disease-specific measure of
needs-based quality of life developed in the UK and the
Netherlands. This study describes translation, validation,
and reliability of the scale into Turkish population. The
ASQoL was translated into Turkish using the dual-panel
process. Content validity was assessed via cognitive
debriefing interviews with ankylosing spondylitis (AS)
patients. Patients with AS according to modified New York
criteria were recruited into the study from 12 hospitals of
all part of Turkey. Psychometric and scaling properties
were assessed via a two administration survey involving
the ASQoL, the Nottingham Health Profile (NHP), Bath
M. T. Duruöz
Rheumatology Division, PMR Department, Celal Bayar
University Medical School, Manisa, Turkey
e-mail: tuncayduruoz@gmail.com
M. T. Duruöz
Romatoloji Bilim Dalı Başkanı, Celal Bayar Üniversitesi Tıp
Fakultesi, Manisa, Turkey
L. Doward
Epidemiology Division, Galen Research, Manchester, UK
Y. Turan (&)
O. Sendur
G. Gurer
PMR Department, Adnan Menderes University Medical School,
Aydin, Turkey
e-mail: dryaseminturan@gmail.com
L. Cerrahoglu
PMR Department, Celal Bayar University Medical School,
Manisa, Turkey
M. Yurtkuran
U. Bingol
Rheumatology Division, PMR Department, Uludag University
Medical School, Bursa, Turkey
AS Functional Index (BASFI), and Bath AS Disease
Activity Index (BASDAI). Classical psychometrics asses-
sed reliability, convergent validity (correlation of ASQoL
with NHP, BASFI, and BASDAI) and discriminative
validity (correlation of ASQoL with perceived AS-severity
and general health). Cognitive debriefing showed the new
Turkish ASQoL to be clear, relevant, and comprehensive.
Completed survey questionnaires were received from 277
AS patients (80 % Male, mean age 42.2/SD 11.6, mean AS
duration 9.4 years/SD 9.4). Test–retest reliability was
excellent (0.96), indicating low random measurement error
for the scale. Correlations of ASQoL with NHP sections
were low to moderate (NHP Sleep 0.34; NHP Emotional
M. Calis
M. Kirnap
PMR Department, Erciyes University Medical School,
Kayseri, Turkey
N. Tas
G. Celik Erturk
PMR Department, Gazi University Medical School,
Ankara, Turkey
S. Ozgocmen
Rheumatology Division, PMR Department, Erciyes University
Medical School, Kayseri, Turkey
O. Yoleri
A. Memis
PMR Department, Ataturk Training Hospital, Izmir,
Turkey
B. Durmaz
F. Atamaz
PMR Department, Ege University Medical School,
Izmir, Turkey
S. Oncel
R. Kizil
PMR Department, Dokuz Eylul University Medical School,
Izmir, Turkey
123

Reactions 0.83) suggesting the measures assess related but
distinct constructs. The measure was able to discriminate
between patients based on their perceived disease severity
(p \ 0.0001) and self-reported general health (p \ 0.0001).
The Turkish version of ASQoL has good reliability and
validity properties. It is practical and useful scale to assess the
quality of life in AS patients in Turkish population.
Keywords Ankylosing spondylitis
Quality of life

ASQOL
Introduction
Ankylosing spondylitis (AS) is a chronic inflammatory
disease that evidently involves sacroiliac joints, spinal
column, and occasionally peripheral joints and character-
ized with enthesitis [1, 2]. Population studies report a
prevalence of AS of between 0.5 and 1.6 %, and it is more
commonly found in men than women [3, 4].
There are studies revealing that quality of life has been
negatively affected in the patients with ankylosing spon-
dylitis [5]. However, these studies have been performed
using the scales that measure overall health status including
Nottingham Health Profile, Short Form-36 (SF-36), Health
Assessment Questionnaire for the spondyloarthropathies
(HAQ-S), and EuroQoL [6–11]. Studies have not used
specific quality-of-life scales until the recent times.
Absence of such a scale has been extremely felt in speci-
fying therapy strategies, as well as in evaluating health
status and disability. Recently, Doward et al. [12] devel-
oped Ankylosing Spondylitis Quality of Life (ASQoL)
questionnaire, which measures disease-specific quality of
life. ASQoL is a unidimensional and disease-specific scale
developed in the United Kingdom and the Netherlands
T. Tuncer
PMR Department, Akdeniz University Medical School,
Antalya, Turkey
M. Birtane
K. Uzunca
PMR Department, Trakya University Medical School, Edirne,
Turkey
F. Tuzun
H. Sari
PMR Department, Istanbul University Cerrahpasa Medical
School, Istanbul, Turkey
O. Ardicoglu
PMR Department, Atatürk Training and Research Hospital,
Ankara, Turkey
C. Kacar
Rheumatology Division, PMR Department, Akdeniz University
Medical School, Antalya, Turkey
123
Rheumatol Int
based on the understanding of needs-based quality of life.
This measure adopted the needs-based model that postu-
lates that QoL is dependent on an individual’s ability to
meet his or her needs. It is a fixed-response questionnaire
that asks endorsement (yes/no) of 18 items related to
symptoms, functioning, and disease-related concern. The
ASQoL questionnaire has been validated in the populations
of UK, the Netherlands, Hungary, France, China, Spain,
New Zealand, and Germany [13–17].
Although validity and reliability of ASQoL have been
demonstrated in many languages, validity and reliability of
Turkish version have not been studied yet. Thus, the
present study aimed to investigate validity and reliability of
the Turkish version of ASQoL.
Methods
Patients with ankylosing spondylitis (n = 277) according
to modified New York criteria [18] were recruited into the
study from 12 hospitals of all part of Turkey. Patients with
severe concomitant medical illness were excluded. The
demographic, clinical, functional, laboratory, and radio-
graphic data of the patients were noted. Body mass index
(BMI), disease duration (month), pain at rest and during
activities (visual analog scale; VAS 0–100 mm), and
morning stiffness (minutes), NSAID’s effectiveness were
assessed. Perceived severity of AS within the last week was
evaluated based on the answers ‘‘yes’’ or ‘‘no’’ given by the
patients to the questions ‘‘mild,’’ ‘‘moderate,’’ ‘‘quite severe,’’
or ‘‘severe.’’ Overall health status perceived by the patients
within the last week was evaluated by percentage of the
answers given as ‘‘yes’’ or ‘‘no’’ to the questions ‘‘very well,’’
‘‘well,’’ and ‘‘poor/very poor.’’
Finger-floor distance (forward, right, and left sides),
dorsal Schober’s test, modified lumbar Schober’s test, chest
expansion, menton-sternum, and occiput-wall distances
were assessed in order to measure the spinal movement
limitation in AS patients. Sacroiliitis was scored from 0 to
4 as New York grading system [18].
The disease activity and functional condition of AS
patients were evaluated by Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI) [19] and Bath Anky-
losing Spondylitis Functional Index (BASFI) [20],
respectively. BASDAI and BASFI are indexes studied in
terms of their validity and reliability in the Turkish popu-
lation [21, 22].
Nottingham Health Profile (NHP) [23, 24] and ASQoL
are quality-of-life questionnaires
Nottingham Health Profile was developed in the UK in the
1970s for use in population surveys. It has six dimensions
Rheumatol Int

of health: physical mobility, pain, sleep, energy, social iso- Table 1 Demographic and clinical characteristics of patients
lation, and emotional reactions. Patients were asked whether (n = 277)
or not each item applied to them. Each dimension score ranges Age [year; mean (SD), range] 42.4 (11.6), 34–50
from 0 (optimal) to 100. Higher score indicating more Disease duration [year; mean (SD), range] 9.4 (9.4), 2–14
severely compromised QOL [23]. The Turkish version of the Morning stiffness [min; mean (SD)] 39.1 (54.7), 0.5–60
NHP was obtained after an accurate translation process, which VAS-pain [mm; mean (SD), range] 36.9 (28.3), 0–100
resulted in a conceptually equivalent version [24]. BASDAI [mean (SD), range] 2.2 (1.5), 0–5.6
The ASQOL comprises 18 questions, each with a BASFI [mean (SD), range] 2.4 (2.3), 0–9
dichotomous ‘‘yes/no’’ response format, scored ‘‘1’’ and Chest expansion [cm; mean (SD), range] 3.3 (3.1), 2–4
‘‘0,’’ respectively. Total scores range from 0 to 18, with a NSAID effective [yes, no; n (%)] 224 (80.9), 53 (19.9)
higher score indicating poor quality of life [12]. Perceived severity of AS [mild, moderate, 63 (22.7),134 (48.4),
quite severe, very severe; n (%)] 59 (21.3), 21 (7.6)
Cross-cultural adaptation Overall health [very well, well, poor/very 30 (10.8), 170 (61.4),
poor; n (%)] 77 (27.8)
The ASQoL was translated into Turkish using the dual-
panel process. ASQoL was translated into Turkish by the Reliability
first author. Thereafter, the Turkish version of ASQoL was
confirmed by two authors. Items of the Turkish version of Internal consistency of ASQoL was found 0.89 which was
ASQoL questionnaire are shown in ‘‘Appendix’’. excellent (Table 2). Test–retest reliability of ASQoL was
0.96, which indicated high test–retest reliability.
Reliability
Validity
Internal consistency of ASQoL was evaluated by Cronbach’s
alpha coefficient (a [ 0.70 was considered significant) from Convergent validity (comparison of ASQoL with the other
baseline results of the patients. ASQoL questionnaire was scales used for evaluation of AS) is given in Table 3. There
applied for two times at 1-week interval by the same was a good correlation between ASQoL and overall scales
researcher, and the intraclass correlation coefficient (ICC) compared; the most significant correlation was obtained
method was used to assess test–retest reliability ([0.85 was with NHP Emotional Reactions and NHP Total. Correla-
considered significant). tion of ASQoL with the other subgroups and scales was
relatively similar.
Validity Correlation between ASQoL and physical examination
findings was evaluated for discriminative validity
Content validity was evaluated via ‘‘cognitive debriefing’’ (Table 4). Accordingly, correlation with morning stiffness
method interviewing with 2 authors of this study and 15 was the most significant one. Correlation of ASQoL with
ankylosing spondylitis patients. Psychometric and scaling finger-floor test and chest expansion was good, whereas a
properties were evaluated by applying the ASQoL, BAS- moderate correlation was observed with number of painful
DAI, BASFI, and Nottingham Health Profile (NHP) ques- regions and number of affected regions.
tionnaires. Classical psychometrics assessed convergent It was found that the Turkish version of ASQoL is able
validity (correlation of ASQoL with NHP, BASFI, and to distinguish the difference between perceived severity of
BASDAI) and discriminative validity (correlation of
ASQoL with perceived severity of AS and overall health).
Table 2 Descriptive ASQoL scores
The statistical analysis of the data was performed using
Statistical Package for the Social Sciences (SPSS) for Descriptive scores Internal
consistency
Windows 14 package program. Time 1 Time 2
(n = 277) (n = 277)

Mean (SD) 7.6 (5.8) 7.3 (5.9) 0.89

Results
Median 7 7
Interquartile 2–12 2–12
We recruited 277 participants (222 males, 55 females) into range
the study were male. The mean age of participants was 42.2 Range 0–18 0–18
(S 11.6) years, whereas disease duration was 9.4 (SD 9.4) % minimum 7.9 14.8
years. Demographic and clinical characteristics of the % maximum 1.1 6.5
patients are given in Table 1.

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 Rheumatol Int

Table 3 Comparison (Pearson’s) of ASQoL with other scales study successfully translated ASQoL into Turkish. The
Comparator scale r
Turkish version of ASQoL has been easily understood by
the patients.
NHP energy scale 0.71 Validity and reliability studies of ASQoL questionnaire
NHP pain scale 0.46 in various languages highlighted that it is a practical
NHP emotional reactions 0.83 questionnaire, which could be easily understood and
NHP sleep scale 0.34 completed in a short time by the patients [13–17]. We
NHP physical mobility 0.48 observed that the Turkish version of ASQoL questionnaire
NHP social isolation 0.77 was also easily understood and applied.
NHP total 0.9 The internal consistency of ASQoL questionnaire in
BASDAI total 0.26 various languages, including US English, Canadian Eng-
BASFI total 0.21 lish, Canadian French, French, German, Italian, Spanish,
VAS-pain 0.3 and Swedish, in the study groups consisted of minimum 7
and maximum 102 patients. They found alpha Cronbach’s
coefficient minimum 0.44 and maximum 0.87 in the
baseline evaluation [14]. Jenks et al. [17] reported the
Table 4 Comparison (Pearson’s) of ASQoL with physical exami-
nation findings internal consistency of ASQoL to be 0.85 in 63 spondyl-
oarthritis patients. Our result was higher than that of the
Physical assessment r
other studies in terms of both the number of patients
Morning stiffness 0.24 (n = 277) and the coefficient. Thus, we can say that
Finger-floor test 0.17 internal consistency of the Turkish version of ASQoL is
Finger-floor test right side -0.26 excellent (Cronbach’s a 0.89). Moreover, good test–retest
Finger-floor test left side -0.27 reliability (ICC 0.96) indicates low measurement error for
Modified Schober’s test -0.71 the questionnaire.
Dorsal Schober’s test 0.1 Comparing the Turkish version of ASQoL scale with
Menton-Sternum distance -0.01 NHP, which is another quality-of-life scale, strong corre-
Occiput-wall distance -0.04 lation was found with energy and total score. Likewise, a
Chest expansion 0.16 recent study compared ASQoL with subgroups of NHP and
reported strong correlation with physical mobility, energy,
and pain [10]. A study, which evaluated the quality of life
via Short Form-36, reported a moderate correlation
disease (p \ 0.0001) and self-evaluated overall health between ASQoL and SF-36 [14]. Another study from
(p \ 0.0001) among patients. Turkey emphasized a strong correlation between ASQoL
and SF-36 [25]. Nevertheless, a study, which evaluated
validity and reliability of the Spanish version of ASQoL in
Discussion 54 patients, demonstrated a strong correlation between
physical and mental components of SF-36, pain, vitality
Interest in the investigations concerning quality of life in and role-physical domains of SF-36, and the most of dis-
rheumatic diseases has been extremely increased in last ease-related variables [13]. Based on the results of the
decades. Quality-of-life scales have gained importance in present study, we think that the Turkish version of ASQoL
the patients with AS, which accounts for the number of is able to evaluate energy, pain, physical mobility, sleep,
studies investigating efficacy of newly developed medica- emotional reactions, and social isolation, which are the
tions. One of the objectives to do the cross-cultural vali- most important parameters of quality of life. Thus, we can
dation of the questionnaires is the ‘‘perfect copy’’ of the consider the Turkish version of ASQoL as a questionnaire
original instrument, to facilitate international comparisons that multidimensionally evaluates the quality of life of AS
and multinational studies. patients.
ASQoL questionnaire was developed in 2003 due to A mild-to-moderate correlation was observed between
inadequacy of the scales that specifically evaluate quality the Turkish version of ASQoL and BASDAI, BASFI and
of life [12] and widely accepted in a short time in terms of VAS-pain. However, Pham et al. [16] found a moderate-to-
efficacy of new therapy strategies on AS patients and strong correlation between the French version of ASQoL
identification of perceived health status. Many studies have and the above-mentioned parameters. Moreover, Zhao
been reported concerning validity and reliability of ASQoL et al. [15] found significant correlation between Chinese
questionnaire in various languages [13–17]. The present version of ASQoL and BASFI, VAS-pain and BASDAI

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Rheumatol Int

total, but they emphasized that the correlation was not Evet Hayır
significant in the patients having a BASDAI score over 4.
Additionally, Jenks et al. [17] reported strong correlation 1. Hastalığım gidebileceğim yerleri kısıtlıyor I__I I__I
between ASQoL and BASDAI, BASFI and VAS-pain. A 2. Bazen içimden ağlamak geliyor I__I I__I
strong correlation was observed between ASQoL and 3. Giyinmede zorluk çekiyorum I__I I__I
BASDAI, BASFI in another study performed previously 4. Evdeki işleri yapmakta zorlanıyorum I__I I__I
in Turkey [25]. Results of the present study and the pre- 5. Hastalığımdan dolayı uyumak imkansız I__I I__I
vious studies showed strong correlation with the gold 6. Ailem veya arkadaşlarımla birlikte etkinliklere I__I I__I
standard criteria for clinical evaluation of AS disease and katılmam çok zor oluyor
revealed that ASQoL is a questionnaire that is sensitive to 7. Her zaman yorgunum I__I I__I
different variables, which are the guides for appropriate 8. Bir iş yaparken dinlenmek için sık sık ara I__I I__I
therapy strategies during clinical monitorization of veriyorum
patients. 9. Dayanılmaz ağrım var I__I I__I
Comparing the Turkish version of ASQoL and phys- 10. Sabahları kendimi toparlayıp güne başlamam uzun I__I I__I
süre alıyor
ical examination findings, the most significant correla-
11. Evdeki işleri yapmam imkansız I__I I__I
tion was found with morning stiffness. Whereas,
12. Kolayca yoruluyorum I__I I__I
correlation of ASQoL with finger-floor test and chest
13. Kendimi sık sık engellenmiş ve çaresiz I__I I__I
expansion was good. Previous studies in the literature hissediyorum
have reported strong correlation between ASQoL and
14. Her zaman ağrım var I__I I__I
BASMI [15, 25, 26]; in this case, quality of life worsens
15. Hastalığımdan dolayı çok şey kaçırdığımı I__I I__I
in AS patients as physical disability worsens. In the hissediyorum
present study, the most significant correlation was found 16. Saçımı yıkamakta zorlanıyorum I__I I__I
with morning stiffness. The 10th question of ASQoL ‘‘it 17. Hastalığım moralimi bozuyor I__I I__I
takes long time for me to pick up myself in the morning 18. Hastalığımın başkalarının planlarını bozmasından I__I I__I
and to start the day’’ evaluates the trouble caused by endişe ediyorum
morning stiffness. As is understood, ASQoL is quite Toplam:
specific for AS patients. I__I__I
It was found that the Turkish version of ASQoL was
able to distinguish the difference between perceived
severity of disease (p \ 0.0001) and self-evaluated overall
health status (p \ 0.0001) among patients.
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