Moroccan Arabic Version of Hip Outcome Tool Shows Strong Reliability

Researchers in Marrakech have produced and tested a Moroccan dialectal Arabic version of the International Hip Outcome Tool, a 33-item questionnaire designed for young and physically active people with hip problems. Their cross-sectional observational validation study, conducted in the traumatology and orthopedics departments of two hospitals in the Mohammed VI university hospital center, found that the adapted scale, called iHOT-33 MOR, achieved a 100 percent response rate, excellent internal consistency with a Cronbach’s alpha of 0.98 for the overall score, and excellent test–retest reliability with an intraclass correlation coefficient of 0.91 in a subgroup of 26 stable participants. The work was published in the Bulletin of Faculty of Physical Therapy.

The original iHOT-33 was developed and validated in 2012 by Mohtadi and colleagues with the Multicenter Arthroscopy of the Hip Outcomes Research Network. It is a patient-reported outcome measure aimed at people aged 18 to 60 with a pre-injury Tegner activity score of at least 4, meaning they took part in recreational sports training at least twice a week. The questionnaire contains 33 items divided into four categories: symptoms and functional limitations with 16 questions, sports and recreational activities with 6 questions, job-related concerns with 4 questions, and social, emotional and lifestyle concerns with 7 questions. Each item is scored from 0 to 100 on a visual analog scale, with respondents marking a slash on a 10-centimeter line, which allows individual and overall scores to be calculated without mathematical transformations.

The original version showed excellent internal agreement, with a Cronbach’s alpha of 0.99, good test–retest reliability with an intraclass correlation coefficient of 0.78, a responsiveness of 6.7, and a minimal clinically important difference of 6.1. It has since been translated into Spanish, German, Dutch and French, and those versions produced results similar to the original. In Morocco, however, the use of the questionnaire has been limited by language and cultural barriers, which the authors say can lead to inaccurate interpretations of a patient’s health condition, unsuitable treatment and dissatisfaction among participants.

The adaptation followed the method described by Guillaume and colleagues, after the team obtained permission from the original author, Nicholas Mohtadi. The process ran through five consecutive steps. First, two translators independently translated the English original into Moroccan dialectal Arabic: one was an anesthesia and intensive care nurse with a bachelor’s degree in English studies who is completing a master’s degree in linguistics, and the other was a general nurse working in a trauma-orthopedic unit with a bachelor’s degree in English language and literature. A reporter then synthesized the two translations into a single version, resolving differences while considering dialect variation across Moroccan regions.

Next, two translators who were unaware of the original questionnaire produced back translations of the synthesized Arabic version into English, allowing the team to identify inconsistencies and differences introduced by translation. An experts committee, made up of the head professor of the traumatology and orthopedics department at Arrazi hospital, a university professor of linguistics, the translators and the reporter, then reviewed all versions. The committee confirmed equivalences between the source and target languages and the accuracy of the medical terminology, judged that each item was suitable for the dimension it explores, and validated item, conceptual and semantic equivalences, meaning that clinical and psychological manifestations are significant in both cultures, the evaluated domains carry the same importance, and the meaning is preserved. Finally, a pre-test with five young and active participants with hip pathology, who were excluded from the validation sample, found the questionnaire simple and comprehensible, and the final version was retained without changes. No item was deleted, added or completely modified during the adaptation.

The validation cohort comprised 66 participants recruited between May 12 and May 26, 2023, from the traumatology and orthopedics departments of the Arrazi and Ibn Tofail hospitals. Participants were men and women aged 18 to 60 who presented with hip pain, were physically active with a pre-injury Tegner score of at least 4 out of 10, and could read and understand Moroccan dialectal Arabic. People with dorsolumbar or contralateral lower limb pain, ipsilateral knee pain, active hip joint infection, malignant pathology affecting the hip, or any condition that could limit follow-up were excluded. The study protocol was approved by the ethics committee of the Higher Institute of Nursing and Health Technical Professions in Marrakech, and all participants gave written informed consent under principles consistent with the Declaration of Helsinki.

The cohort had a mean age of 40.39 years with a standard deviation of 10.51, ranging from 20 to 59 years old, and 57.6 percent of participants, 38 people, were women. On physical activity, 60.61 percent had a Tegner score of 4, 27.27 percent a score of 5, 9.09 percent a score of 6, and 3.03 percent a score of 7. About 43 percent of participants reported problems with their right hip. The initial total score on the adapted questionnaire averaged 65.1 with a standard deviation of 24.27 on day zero, and 61 with a standard deviation of 25.67 at retest.

On the psychometric results, acceptability was judged excellent, with a 100 percent response rate, no missing information, and no incoherence or discordance reported. Face and content validity were approved by the experts committee and confirmed by participants during pretesting and validation. Internal consistency, measured with Cronbach’s alpha, reached 0.98 for the overall score and 0.97, 0.93, 0.91 and 0.93 for the four categories of symptoms and functional limitations, sports and recreational physical activities, job-related concerns, and social, emotional and lifestyle concerns, respectively. By the study’s thresholds, an alpha of at least 0.9 counts as excellent.

For test–retest reliability, 26 participants whose health status was stable, defined as a global score change of less than 6 points, retook the questionnaire after an interval of 4 days, with intervals ranging from 2 to 6 days. The intraclass correlation coefficient, a type C statistic with an identical estimator, was 0.91, which the study classifies as excellent, since values above 0.9 fall in the excellent range on the scale the authors used. The systematic error of measurement was 3.06 and the smallest detectable change was 8.48, and a Bland–Altman plot of the test–retest results supported the absence of measurement error. These figures compare with an intraclass correlation coefficient of 0.78 for the original English version and values of 0.97 for the Spanish, 0.88 for the German, 0.87 for the Chinese, 0.92 for the Dutch and 0.87 for the French adaptations reported in the discussion.

The authors acknowledge important limitations. The sample of 66 was sufficient for an initial validation but too small for advanced analyses such as factor analysis of structural validity. Because no other hip-specific outcome measure has been validated in Moroccan dialectal Arabic, construct validity could not be tested through correlation with comparable instruments such as the Non-Arthritic Hip Score or the Hip Outcome Score. The cross-sectional design and short timeframe also meant that longitudinal properties, including responsiveness and the minimal clinically important difference, await a future test–retest study involving treatment. The team recommends larger multicenter and longitudinal studies, validation of additional outcome measures in Moroccan Arabic, an adapted version for Amazigh-speaking populations, and epidemiological studies using the new scale. Within those limits, the study concludes that the iHOT-33 MOR is an acceptable, reliable and valid tool for assessing quality of life in young, active Moroccan speakers of dialectal Arabic with hip pathology.

Subject of Research: Cross-cultural adaptation and validation of the International Hip Outcome Tool into Moroccan dialectal Arabic for young, physically active patients with hip pathology

Article Title: Cross cultural adaptation and validation of the Moroccan International Hip Outcome Tool (iHOT-33 MOR) in young and physically active individuals with hip pathology

Article References: Merrou, S., Elatlassi, A., Baslam, A., Jarraki, M., El Aallaoui, K., Mazouz, M., Demnati, B., Boumediane, E., Elhaloui, A., & Abkari, I. (2026). Cross cultural adaptation and validation of the Moroccan International Hip Outcome Tool (iHOT-33 MOR) in young and physically active individuals with hip pathology. Bulletin of Faculty of Physical Therapy, 31(1), Article 41. https://doi.org/10.1186/s43161-025-00318-7

Image Credits: AI Generated

DOI: 10.1186/s43161-025-00318-7

Keywords: iHOT-33 MOR, cross-cultural adaptation, patient-reported outcome measures, hip pathology, psychometric validation, Morocco, reliability, Cronbach's alpha, intraclass correlation coefficient, traumatology, orthopedics, questionnaire translation