Newer direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, and dabigatran offer predictable pharmacokinetics and no routine coagulation monitoring, but both classes carry bleeding risk. A knowledge test that could serve both populations, in the patient's own language and dialect, was the study's central goal. The adaptation followed two internationally recognized frameworks: the ISPOR Task Force's Principles of Good Practice for translating patient-reported outcome measures and the COSMIN taxonomy for health measurement instruments.

Two native Arabic speakers translated the 28-item tool independently, a third blinded translator translated it back into English, and the team reconciled discrepancies to secure conceptual equivalence. A panel of ten cardiovascular and anticoagulation specialists then rated every item for relevance on a five-point scale. A pilot with ten patients refined the language further, producing a mean clarity score of 4.44 out of 5, with roughly ninety percent of items rated clear or very clear.

The revisions were mostly dialectal: Iraqi Arabic handles idioms about diet and bleeding symptoms differently from Modern Standard Arabic, and the team adjusted phrasing so the questions resonated with local vernacular. The validation cohort then enrolled 280 adult outpatients at the Ibn Al-Bitar Center for Cardiac Surgery in Baghdad between mid-October and mid-December 2025, split evenly between 140 warfarin users and 140 DOAC users, matching the recommended ten participants per questionnaire item. Mean age was 54.5 years, with DOAC patients significantly older on average than warfarin patients.

Education levels also differed between the groups, a detail that would prove central to the findings. That central finding is stark: educational attainment was the only sociodemographic variable that significantly predicted knowledge scores in both cohorts. Among DOAC patients, one-way ANOVA yielded p = 0.003 for education; among warfarin patients, p = 0.006.

Patients with college or higher education scored highest (11.00 and 16.65 mean points respectively), while illiterate patients and those with only primary schooling occupied the lowest strata. Sex, age group, and even duration of therapy showed no significant association with knowledge in either group. Neither warfarin nor DOAC users showed any measurable improvement in pharmacological understanding as a function of how long they had been on therapy.

The assumption that patients gradually absorb knowledge through repeated clinic visits and prescription refills does not survive contact with this data. Knowledge of oral anticoagulation, the authors argue, is not acquired passively; it requires active, structured, health-literacy-appropriate education, which points directly at pharmacist-led counseling programs as the intervention of choice. The psychometric structure of the tool turned out to be more intricate than a single reliability number can capture.

For DOAC patients, the 20-item general scale showed acceptable internal consistency with Cronbach's alpha of 0.700. For warfarin patients, the full 28-item scale aggregated to a poor alpha of 0.512 — but that headline number conceals excellent domain-level reliability. Principal component analysis with varimax rotation extracted ten components explaining 75.44 percent of total variance, and the five items covering warfarin-specific INR knowledge loaded between 0.832 and 0.981 on a single factor with an alpha of 0.972.

Bleeding-safety items and healthcare-communication items formed further coherent, independently reliable clusters. The DOAC cohort yielded eight components explaining 70.17 percent of variance, led by a strong adverse-effects-and-bleeding factor with loadings up to 0.935. This pattern makes sense once anticoagulation knowledge is treated as what psychometricians call a formative index rather than a reflective scale.

In a reflective model, all items are driven by one underlying trait and should correlate; in a formative index, distinct factual elements — INR targets, missed-dose protocols, dietary interactions — combine to build the construct, and there is no theoretical reason they must covary. The low global alpha for the warfarin scale is therefore not a failure of the tool but a description of how fragmented real-world medication knowledge actually is, and it is precisely this fragmentation that lets the instrument triage education toward specific deficits. The cross-sectional design cannot track how knowledge evolves, predictive validity against clinical outcomes such as time in therapeutic range or bleeding events was not assessed, and recruitment at a specialized tertiary center in Baghdad may overestimate knowledge relative to resource-constrained rural clinics.

The Iraqi-dialect tuning, while a strength locally, may need cognitive debriefing before use in other Arab countries.

Subject of Research: Cultural adaptation and psychometric validation of the Oral Anticoagulation Knowledge Tool for Arabic-speaking Iraqi patients

Article Title: Cultural adaptation and validation of the Oral Anticoagulation Knowledge Tool in Arabic-speaking Iraqi patients

Article References: Al-Jailawi, Y. T. S., Al-Metwali, B. Z., & Ouj, R. H. (2026). Cultural adaptation and validation of the Oral Anticoagulation Knowledge Tool in Arabic-speaking Iraqi patients. Pharmacia, 73, Article e197938. https://doi.org/10.3897/pharmacia.73.e197938

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e197938

Keywords: oral anticoagulants, warfarin, DOACs, patient knowledge, psychometric validation, cross-cultural adaptation, Iraq, health literacy, INR monitoring, Cronbach's alpha, principal component analysis, clinical pharmacy