Measurement Properties of the European Portuguese Michigan Hand Outcomes Questionnaire (MHQ) in Paper and Electronic Formats: Instrument Validation Study.

Abstract

Background: The Michigan Hand Outcomes Questionnaire (MHQ) is a key instrument for assessing hand and wrist conditions, but a validated version for European Portuguese speakers is unavailable. Furthermore, the potential of an electronic format to improve data collection and clinical workflows has not been formally evaluated.

Objective: This study aimed to translate and culturally adapt the MHQ for European Portuguese and to evaluate the measurement properties and comparability of its paper and electronic formats.

Methods: An observational study was conducted in three phases: (1) translation and expert review, (2) content validation through cognitive interviews, and (3) psychometric evaluation in a cohort of 81 adult patients with hand or wrist conditions. Exploratory known-groups analyses were performed according to clinical, sociodemographic, and digital-access variables. Analysis also included internal consistency (Cronbach α and McDonald ω), measurement error (standard error of measurement [SEM]), relative and absolute reliability (intraclass correlation coefficient [ICC], Spearman correlation coefficient [ρ], and Bland-Altman analysis). The electronic format's usability was assessed with the System Usability Scale (SUS).

Results: The translation and cognitive interviews confirmed the content validity and conceptual equivalence of the European Portuguese MHQ. The instrument demonstrated excellent internal consistency (Cronbach α=0.85-0.98; McDonald ω=0.88-0.99). Exploratory known-groups analyses showed significant gender-related differences and suggested side-specific clinical discrimination in fracture cases. While group-level relative reliability between formats was strong (ρ=0.68-0.91; ICC=0.76-0.95), individual-level absolute reliability was poor, with wide 95% limits of agreement spanning a 32.83-point interval. Format-related score discrepancies were most pronounced among older participants, those with lower educational attainment, and those with low digital literacy. The electronic MHQ was the preferred format (43 out of 74, 58%), showed acceptable usability (median SUS score 70, IQR 66-88), and had lower SEM in pain and function domains.

Conclusions: The European Portuguese MHQ is a relevant and reliable instrument with adequate measurement properties for both clinical practice and research. The electronic version demonstrated superior precision and user preference. However, maintaining the paper format as a viable alternative is essential to ensure equitable access for patients with digital barriers. Due to the overall low absolute reliability between formats, once a patient-preferred format is adopted, it should be used consistently for longitudinal patient monitoring.