Health Assessment Questionnaire (HAQ)

Abstract

The Health Assessment Questionnaire (HAQ), also known as the Stanford Health Assessment Questionnaire, is a seminal patient-reported outcome measure developed by James F. Fries and colleagues in 1980. It was originally designed to assess the Functional Status and disability experienced by patients with Rheumatoid Arthritis and other chronic musculoskeletal diseases. The HAQ provides a quantifiable measure of the patient’s capacity to perform Activities of Daily Living (ADLs) across eight critical domains, allowing clinicians and researchers to monitor disease progression, evaluate treatment efficacy, and assess overall health outcomes.

Keywords

Health Assessment Questionnaire, HAQ, Functional Status, Disability Index, Rheumatoid Arthritis, Patient-Reported Outcome, Activities of Daily Living, Outcome Measurement, Stanford HAQ.

Authors

James F. Fries, P. Spitz, R.G. Kraines, Kate Lorig.

Purpose

The primary purpose of the HAQ is to measure the degree of physical disability and functional limitation in individuals, particularly those suffering from chronic conditions such as arthritis. It serves as a robust instrument for longitudinal follow-up, providing a standardized method to quantify changes in a patient’s ability to perform routine tasks over time, which is essential for clinical trials and routine care.

The scale also captures associated dimensions of health outcomes, including pain levels and the need for assistive devices or assistance from other persons, thereby providing a comprehensive snapshot of the patient’s health-related quality of life. A widely used derivative, the Stanford HAQ 8-Item Disability Scale (Lorig et al., 2001), offers a briefer assessment focusing specifically on core functional tasks.

Construct

The HAQ fundamentally measures the construct of Physical Function and Disability, defined by the patient’s self-reported difficulty in executing standard Activities of Daily Living (ADLs) over the preceding week. The instrument operationalizes disability across eight distinct functional domains (Dressing & Grooming, Arising, Eating, Walking, Hygiene, Reach, Grip, and Activities), which collectively form the main Disability Index (DI) score.

The HAQ uses a four-point response scale ranging from “Without ANY Difficulty” (0) to “UNABLE To Do” (3). A critical component of the scoring methodology is the inclusion of aids or assistance: if a patient requires a special device or help from another person to complete a task, the minimum score recorded for that domain is 2, regardless of the perceived difficulty level, ensuring that the measure accurately reflects the true burden of disability.

Validity

The HAQ has demonstrated strong construct validity, showing significant correlations with traditional clinical measures of disease activity in Rheumatoid Arthritis (RA), such as joint counts, radiographic changes, and laboratory markers (Pincus et al., 1989). Its ability to predict long-term outcomes, including mortality and work disability, further supports its predictive validity.

The instrument exhibits high face validity, as the items directly relate to common challenges faced by patients with musculoskeletal disorders. Cross-cultural validation studies, such as those conducted for the Persian version in patients with RA and Osteoarthritis, have confirmed the scale’s applicability and structural integrity across diverse populations (Rastmanesh et al., 2010; Mobini et al., 2012).

Reliability

The HAQ is consistently reported to have excellent internal consistency and test-retest reliability. The eight functional categories contribute reliably to the overall Disability Index score. Studies often cite high Cronbach’s alpha values, indicating that the items within the scale are highly intercorrelated and measure the same underlying construct of functional disability.

The instrument’s reliability is maintained even in shorter versions, such as the Stanford HAQ 8-Item Disability Scale, which has been psychometrically evaluated for use in various populations, including the elderly (Tagharrobi et al., 2013). This stability ensures that changes in scores reflect genuine changes in the patient’s physical ability rather than measurement error.

Factor Analysis

While the HAQ is designed to yield a single Disability Index score, reflecting a unified dimension of physical disability, factor analysis often confirms the existence of the eight distinct functional domains. These domains are highly correlated, supporting the use of a single summary score, but also demonstrating that the scale covers a broad spectrum of daily activities.

The initial structure, comprising eight components (Dressing & Grooming, Arising, Eating, Walking, Hygiene, Reach, Grip, and Activities), has been consistently upheld in various validation studies. This multi-dimensional yet highly intercorrelated structure is crucial for accurate measurement in complex chronic diseases where mobility, dexterity, and self-care are simultaneously affected.

Instrument

Test Type: Self-administered Patient-Reported Outcome Measure (PROM)

Format: The full HAQ contains 20 core items rated on a 4-point ordinal scale (0=Without ANY Difficulty to 3=UNABLE To Do). It also includes supplementary visual analog scales for assessing pain (0–100) and overall health rating (0–100).

Language Available: English (original) and numerous international translations, including Persian, due to its global relevance in rheumatology research.

Population Group: Primarily patients with chronic musculoskeletal diseases, especially Rheumatoid Arthritis, Osteoarthritis, and Systemic Lupus Erythematosus.

Age Group: Adult population, often used across the lifespan of chronic disease patients, including elderly populations.

Population Details: Widely used internationally in clinical trials and epidemiological studies focusing on health outcomes and disease management. The HAQ-DI is a standard measure of disability progression.

Test Methodology: The patient reports their usual abilities over the past week. Scoring involves taking the highest difficulty score within each of the eight categories (0-3). If the patient reports using an aid/device or needing help from another person for any activity in that category, the category score is elevated to a minimum of 2. The eight category scores are then averaged to produce the final HAQ Disability Index score (ranging from 0 to 3).

Keywords

Patient outcome, Disability measurement, Psychometrics, Quality of Life, HAQ-DI, Pain scale, Assistive devices, Stanford University.

Authors

Author ORCID Identifier: Not provided in source content.

Affiliation Email addresses: [email protected] (James F. Fries, Stanford University)

Correspondence Address: Stanford University, Division of Immunology and Rheumatology (implied).

Permissions & Fee and Test Year

The original Health Assessment Questionnaire was developed and published in 1980 by Fries et al. While the instrument is widely used, specific permissions and licensing requirements, especially for commercial use or modification, should be directed to the Stanford University Patient Education Research Center. The instrument has been continually adapted and validated since its original publication.

Reference’s

The instrument and related methodology are extensively documented. Key publications include:

1. Fries, JF, Spitz, P., Kraines, RG., et al. (1980). Measurement of patient outcome in arthritis. Arthritis and Rheumatism, 23:137–145.
2. Fries, JF., Spitz, PW., Young, DY. (1982). The dimensions of health outcomes: the Health Assessment Questionnaire, disability and pain scales. J Rheumatol, 9:789–793.
3. Fries, JF. (1983). Toward an understanding of patient outcome measurement. Arthritis and Rheumatism, 26:697–704.
4. Pincus, T., Summey, JA., Soraci, SA., Jr., et al.(1983). Assessment of patient satisfaction in activities of daily living using a modified Stanford Health Assessment Questionnaire. Arthritis and Rheumatism, 26:1346–1353.
5. Goeppinger, J., Doyle, M., Murdock, B. (1985). Self-administered function measures: the impossible dream? Arthritis and Rheumatism, 28(suppl):145.
6. Pincus, T., Callahan, LF., Brooks, RH., et al. (1989). Self-report questionnaire scores in rheumatoid arthritis compared with traditional physical, radiographic, and laboratory measures. Ann Intern Med, 110:259–266.
7. Fries, JF., Spitz, PW. (1990). The hierarchy of patient outcomes. In: Spilker B, ed. Quality of life assessments in clinical trials. New York: Raven Press, 25–35.
8. Ramey, DR., Raynauld, J-P, Fries, JF. (1992). The Health Assessment Questionnaire 1992: status and review. Arthritis Care Res, 5:119–129.
9. Milligan, SE., Hom, DL., Ballou, SP., et al. (1993). An assessment of the Health Assessment Questionnaire functional ability index among women with systemic lupus erythematosus. J Rheumatol, 20:972–976.
10. Lorig, KR., Sobel, DS., Ritter, PL., Laurent, D., Hobbs, M. (2001). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4:256-262.
11. Bruce, Bonnie., Fries, JF. (2003). The Stanford Health Assessment Questionnaire: Dimensions and Practical Applications. Health and Quality of Life Outcomes, 1: 20
12. McDowell, Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires, Third Edition. OXFORD UNIVERSITY PRESS
13. Rastmanesh, R., Rabiee, S., Shaabani, Y., Mazinani, H., Ebrahimi, AA., Jamshidi, AR. (2010). Validation of the Persian version of the Stanford Health Assessment Questionnaire (HAQ) in patients with rheumatoid arthritis. Journal of Paramedical Sciences (JPS), 1(1): 16-25
14. Mobini, Maryam., Mohammadpour, Reza Ali., Khalilian, Ali Reza., Anvari, Fatemeh., Lamsehchi, Narges. (2012). Measuring the Validity and Reliability of the Persian Version of Stanford Health Assessment Questionnaire in Iranian Patients with Osteoarthritis. Zahedan Journal of Research in Medical Sciences, 16(9): 30-33
15. Tagharrobi, Z., Sharifi, KH., Sooky, Z. (2013). Psychometric evaluation of Stanford health assessment questionnaire 8-item disability index (HAQ 8-item DI) in elderly people. Holistic Nursing And Midwifery Journal, 24(71): 9-20

The instrument can be found at: http://patienteducation.stanford.edu/research/haq20.html

The original PDF for “Measuring Health” can be downloaded here: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf

The HAQ 8-item PDF can be found here: http://patienteducation.stanford.edu/research/haq8.pdf

Items of the Health Assessment Questionnaire (HAQ)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

DRESSING & GROOMING

Without ANY Difficulty, With SOME Difficulty, With MUCH Difficulty, UNABLE To Do

Are you able to:

1. Dress yourself, including shoelaces and buttons?
2. Shampoo your hair?

ARISING

Are you able to:

3. Stand up from a straight chair?
4. Get in and out of bed?

EATING

Are you able to:

5. Cut your meat?
6. Lift a full cup or glass to your mouth?
7. Open a new milk carton?

WALKING

Are you able to:

8. Walk outdoors on flat ground?
9. Climb up five steps?

• Please check any AIDS OR DEVICES that you usually use for any of the above activities:

• Cane, Walker, Crutches, Wheelchair, Devices Used for Dressing (button hook, zipper pull, etc.), Built Up or Special Utensils, Special or Built Up Chair

• Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

• Dressing & Grooming, Eating, Arising, Walking

• Please place an ‘x’ ( ) in the box which best describes your usual abilities OVER THE PAST WEEK:

• Without ANY Difficulty, With SOME Difficulty, With MUCH Difficulty, UNABLE To Do

HYGIENE

Are you able to:

10. Wash and dry your body?
11. Take a tub bath?
12. Get on and off the toilet?

REACH

Are you able to:

13. Reach and get down a 5 pound object (such as a bag of sugar) from above your head?
14. Bend down to pick up clothing from the floor?

GRIP

Are you able to:

15. Open car doors?
16. Open previously opened jars?
17. Turn faucets on and off?

ACTIVITIES

Are you able to:

18. Run errands and shop?
19. Get in and out of a car?
20. Do chores such as vacuuming or yard work?

• Please check any AIDS OR DEVICES that you usually use for any of these activities:

• Raised Toilet Seat, Bathtub Bar, Bathtub Seat, Long-Handled Appliances for Reach, Jar Opener (for previously opened), jars Long-Handled Appliances in Bathroom

• Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

• Hygiene, Gripping and Opening Things, Reach, Errands and Chores

• How much pain have you had because of your arthritis IN THE PAST WEEK?

• NO PAIN 0 _________________________________ 100 VERY SEVERE PAIN

• In general, how would you rate your current health?

• VERY WELL 0 _________________________________ 100 VERY POOR

Stanford HAQ 8-Item Disability Scale (Lorig, et al. 2001)

1. Dress yourself, including tying shoelaces and doing buttons?
2. Get in and out of bed?
3. Lift a full cup or glass to your mouth?
4. Walk outdoors on flat ground?
5. Wash and dry your entire body?
6. Bend down to pick up clothing from the floor?
7. Turn faucets/taps on and off?
8. Get in and out of a car?