The 6-item Work Productivity and Activity Impairment–Psoriasis questionnaire (the WPAI:PSO)1 has been used in numerous clinical trials and other studies to evaluate the impact of psoriasis. It is supported by the WPAI validation study,2 version 2.0 of the Spanish language adaptation (the WPAI:PSO v.2.0),3 and a validated adaptation to Spanish of the general health version of the questionnaire (the WPAI:GH).4 This questionnaire, which measures effects on both work and other activities of daily living, includes items to be answered with yes or no, 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.

We devised an observational, cross-sectional survey to assess the validity of information obtained from the Spanish questionnaire's first item, on work status: “¿Está actualmente empleado (tiene un trabajo a sueldo)?” 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, “¿Realiza actualmente algún tipo de trabajo remunerado?” (“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 Table 1.

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 (α=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 (Table 1) 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 (Table 2).

The incorrectly responding patients were all freelancers, occasional-contract workers, or persons working without any contract whether legally or not. These 9 patients answered no to the Spanish item 1, which asked specifically if they had a “job with a salary.” We should point out that Spain had 1974881 persons registered as doing freelance work on September 30, 2016, namely 10% to 11% of the country's active population.5 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.

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 pay 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.

A new, validated adaptation to Spanish of the WPAI for use in Crohn disease (the WPAI:CD, v.2.1)6,7 has rendered item 1 as follows: “¿Está actualmente empleado (tiene un trabajo remunerado)?” The back-translation of the parenthetical phrase would be, “Do you do paid work?” The use of paid work rather than salary 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.

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.