Case and Research Letter
Source of Bias in the Spanish Language Version of the WPAI:PSO (Work Productivity and Activity Impairment—Psoriasis v.2.0) Questionnaire
Sesgo en el Cuestionario de productividad laboral y deterioro de las actividades: psoriasis (WPAI:PSO v2.0) en la población española
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Margarit, A. López-Ferrer, E. Vilarrasa, L. Puig" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Margarit" "email" => array:1 [ 0 => "emargarit@santpau.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "López-Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Vilarrasa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Puig" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Psicología, Universidad Autónoma de Barcelona (UAB), Bellaterra, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sesgo en el Cuestionario de productividad laboral y deterioro de las actividades: psoriasis (WPAI:PSO v2.0) en la población española" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The 6-item Work Productivity and Activity Impairment–Psoriasis questionnaire (the WPAI:PSO)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> has been used in numerous clinical trials and other studies to evaluate the impact of psoriasis. It is supported by the WPAI validation study,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> version 2.0 of the Spanish language adaptation (the WPAI:PSO v.2.0),<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> and a validated adaptation to Spanish of the general health version of the questionnaire (the WPAI:GH).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> This questionnaire, which measures effects on both work and other activities of daily living, includes items to be answered with <span class="elsevierStyleItalic">yes</span> or <span class="elsevierStyleItalic">no</span>, a time estimate in hours, or a choice on a 10-point scale. In our clinical practice in Spain we have detected that patients with psoriasis who are not employed by a company under a so-called indefinite contract—one that does not have a term limit—often do not respond as expected to the question on work status in the WPAI:PSO v.2.0.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We devised an observational, cross-sectional survey to assess the validity of information obtained from the Spanish questionnaire's first item, on work status: “<span class="elsevierStyleItalic">¿Está actualmente empleado (tiene un trabajo a sueldo)?</span>” Back-translated to English, this item would be “Are you currently employed? (Do you have a job with a salary?).” We enrolled 50 patients diagnosed with psoriasis in the dermatology department of Hospital de la Santa Creu i Sant Pau in March and April 2016. Participants had to be over the age of 18 years and give their written informed consent to inclusion before undergoing any part of the study. They then responded to the Spanish WPAI:PSO v.2.0 in a room in our outpatient clinic. After they had completed the questionnaire, we recorded age, sex, and work status. To give us this last information, the patients answered the Spanish question, “<span class="elsevierStyleItalic">¿Realiza actualmente algún tipo de trabajo remunerado?</span>” (“Are you currently doing some type of paid work?”) The respondent was then asked to give specifics about the work situation. Their answers are categorized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">All of the recruited patients agreed to participate. The mean (SD) age was 44.46 (13.69) years, and 60% were men. We detected no significant differences in responses according to sex or age. The correlation between our survey findings and the information from item 1 of the questionnaire was high (<span class="elsevierStyleItalic">α</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.81). All patients with employee status and who received a salary answered the WPAI:PSO question correctly. However, a comparison with the work situations recorded in our survey (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) revealed that 9 of the 10 working patients in the category “other” (18% of the total) responded incorrectly to item 1 of the Spanish WPAI:PSO v.2.0 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The incorrectly responding patients were all freelancers, occasional-contract workers, or persons working without any contract whether legally or not. These 9 patients answered <span class="elsevierStyleItalic">no</span> to the Spanish item 1, which asked specifically if they had a “job with a salary.” We should point out that Spain had 1<span class="elsevierStyleHsp" style=""></span>974<span class="elsevierStyleHsp" style=""></span>881 persons registered as doing freelance work on September 30, 2016, namely 10% to 11% of the country's active population.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In addition, a small portion of workers have no contract and are paid sums that are not legally declared. Statistics about such workers are not available, but most patients in this situation who come to our clinic will report that they do not work at all because they fear revealing that they work illegally.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the results of our study, we then examined the original English version of item 1 of the questionnaire, which asks, “Are you currently employed (working for pay)?” The definition of the word <span class="elsevierStyleItalic">pay</span> includes any type of monetary compensation. The Spanish version, on the other hand, specifies compensation received as a salary, which is a fixed regular payment made to a worker or professional within a company. This subtle difference presents us with a possible problem in the Spanish adaptation of the English questionnaire.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A new, validated adaptation to Spanish of the WPAI for use in Crohn disease (the WPAI:CD, v.2.1)<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a> has rendered item 1 as follows: “<span class="elsevierStyleItalic">¿Está actualmente empleado (tiene un trabajo remunerado)?</span>” The back-translation of the parenthetical phrase would be, “Do you do paid work?” The use of <span class="elsevierStyleItalic">paid work</span> rather than <span class="elsevierStyleItalic">salary</span> widens the meaning of the concept of work considerably, so that respondents can more clearly see what information the questionnaire is attempting to elicit. In spite of the availability of this version for Crohn disease, most studies of Spanish patients with psoriasis use the WPAI:PSO v.2.0.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary, in order to obtain more reliable responses to the Spanish WPAI:PSO v.2.0, clinicians should explain item 1 to patients, saying it asks them to report any type of paid work, not just work done in a salaried position. Patients should also be reminded that the questionnaire they are filling out is not concerned with the legality of their work situation and that the information they provide will remain completely anonymous. It would be useful to make a new version 2.1 of the Spanish WPAI:PSO available in order to avoid bias in gathering information from our patients with psoriasis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as: Margarit E, López-Ferrer A, Vilarrasa E, Puig L. Sesgo en el cuestionario de productividad laboral y deterioro de las actividades: psoriasis (WPAI:PSO v2.0) en la población española. Actas Dermosifiliogr. 2018;109:365–366.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Work Situation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Employee (with an indefinite-term contract) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unemployed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Retired \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Homemaker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Student \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">On sick leave \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737267.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Situations including freelance work, jobs done off the books (compensated with cash in hand that is not reported for tax purposes), internships or work done under a grant, or ownership of a business.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Categorized Responses to Our Survey Question About Work Status.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ABBREVIATION: WPAI:PSO v.2.0, Work Productivity and Activity Impairment—Psoriasis, version 2.0 in Spanish.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No, Not Working (Our Survey) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes, Working (Our Survey) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No, not working (WPAI:PSO v.2.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (32%)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (18%)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes, working (WPAI:PSO v.2.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (50%)<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737268.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Patients who were officially unemployed, retired, homemakers, students, or on sick leave.</p>" ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">All 9 were in the category “Other” (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), which includes freelancers, those working off the books or receiving stipends from a grant, or business owners.</p>" ] 2 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Salaried workers plus others.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Contingency Table Showing Reported Work Status Distributed According to Responses to Item 1 of the Spanish WPAI:PSO v.2.0 Versus Our Survey Records.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "WPAI:PSO 2016 [cited 2016 Feb 19]. Available from: http:www.reillyassociates.net/WPAI" ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The validity and reproducibility of a work productivity and activity impairment instrument" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.C. Reilly" 1 => "A.S. Zbrozek" 2 => "E.M. Dukes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pharmaco Economics" "fecha" => "1993" "volumen" => "4" "paginaInicial" => "353" "paginaFinal" => "365" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "WPAI:PSO (v2.0 Spanish-Spain) 2016 [cited 2016 Feb 19]. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 9 | 16 |
| 2024 October | 100 | 48 | 148 |
| 2024 September | 112 | 22 | 134 |
| 2024 August | 147 | 51 | 198 |
| 2024 July | 86 | 31 | 117 |
| 2024 June | 90 | 35 | 125 |
| 2024 May | 75 | 31 | 106 |
| 2024 April | 80 | 33 | 113 |
| 2024 March | 70 | 29 | 99 |
| 2024 February | 66 | 39 | 105 |
| 2024 January | 65 | 33 | 98 |
| 2023 December | 58 | 20 | 78 |
| 2023 November | 66 | 20 | 86 |
| 2023 October | 67 | 25 | 92 |
| 2023 September | 69 | 33 | 102 |
| 2023 August | 45 | 24 | 69 |
| 2023 July | 75 | 33 | 108 |
| 2023 June | 63 | 27 | 90 |
| 2023 May | 62 | 23 | 85 |
| 2023 April | 55 | 20 | 75 |
| 2023 March | 83 | 33 | 116 |
| 2023 February | 65 | 25 | 90 |
| 2023 January | 49 | 35 | 84 |
| 2022 December | 98 | 38 | 136 |
| 2022 November | 56 | 38 | 94 |
| 2022 October | 32 | 22 | 54 |
| 2022 September | 23 | 34 | 57 |
| 2022 August | 22 | 35 | 57 |
| 2022 July | 24 | 35 | 59 |
| 2022 June | 21 | 19 | 40 |
| 2022 May | 36 | 35 | 71 |
| 2022 April | 42 | 29 | 71 |
| 2022 March | 36 | 37 | 73 |
| 2022 February | 59 | 38 | 97 |
| 2022 January | 69 | 35 | 104 |
| 2021 December | 49 | 41 | 90 |
| 2021 November | 46 | 53 | 99 |
| 2021 October | 66 | 50 | 116 |
| 2021 September | 56 | 41 | 97 |
| 2021 August | 81 | 40 | 121 |
| 2021 July | 36 | 28 | 64 |
| 2021 June | 36 | 43 | 79 |
| 2021 May | 40 | 41 | 81 |
| 2021 April | 72 | 100 | 172 |
| 2021 March | 90 | 28 | 118 |
| 2021 February | 62 | 36 | 98 |
| 2021 January | 43 | 26 | 69 |
| 2020 December | 47 | 28 | 75 |
| 2020 November | 36 | 29 | 65 |
| 2020 October | 45 | 16 | 61 |
| 2020 September | 43 | 29 | 72 |
| 2020 August | 42 | 25 | 67 |
| 2020 July | 41 | 32 | 73 |
| 2020 June | 41 | 31 | 72 |
| 2020 May | 17 | 24 | 41 |
| 2020 April | 32 | 15 | 47 |
| 2020 March | 27 | 14 | 41 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 10 | 0 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 7 | 0 | 7 |
| 2019 April | 6 | 1 | 7 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 2 | 0 | 2 |
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