The turkish version of the well-being in pain questionnaire: Cross-cultural adaptation,validation,and evaluation of measurement properties in individuals with chronic low back pain

Abstract

Background

The Well-Being in Pain Questionnaire (WPQ) assesses psychosocial aspects in individuals with chronic pain.

Objective

To translate and culturally adapt the WPQ into Turkish (WPQ-Tr) and evaluate its psychometric properties in individuals with chronic low back pain (CLBP).

Methods

The study included 155 participants (105 with CLBP and 50 pain-free controls). Cross-cultural adaptation followed guidelines. Psychometric evaluation assessed internal consistency, test–retest reliability, structural validity, known-groups validity, and convergent validity. Structural validity was examined using principal component analysis (PCA) and confirmatory factor analysis (CFA). Known-groups validity was assessed by comparing WPQ-Tr scores between CLBP and pain-free controls. Convergent validity was evaluated by correlations between WPQ-Tr scores and the EuroQol 5-Dimension 5-Level Questionnaire (EQ-5D-5L), Pain Catastrophizing Scale (PCS), Pittsburgh Sleep Quality Index (PSQI), Roland-Morris Disability Questionnaire (RMDQ), Central Sensitization Inventory (CSI), and Generalized Anxiety Disorder-7 (GAD-7).

Results

The WPQ-Tr demonstrated acceptable internal consistency (Cronbach's α = 0.713). Test–retest reliability was excellent, with an intraclass correlation coefficient of 0.987 (95% CI: 0.972–0.994). Known-groups validity was supported by significant differences in WPQ-Tr scores between individuals with CLBP and pain-free controls (p < 0.01). PCA indicated a unidimensional structure explaining 54.66% of the variance, supported by CFA. Convergent validity was supported by strong correlations with EQ-5D-5L (ρ = 0.902), PCS (ρ = −0.923), CSI (ρ = −0.923), PSQI (ρ = −0.794), RMDQ (ρ = −0.893), and GAD-7 (ρ = −0.828) (all p < 0.01).

Conclusion

The WPQ-Tr is a valid and reliable instrument for assessing well-being in Turkish-speaking individuals with CLBP.

Keywords

chronic low back pain chronic pain psychometrics reliability validity

Introduction

Chronic musculoskeletal pain (CMP) is a significant public health issue and one of the leading causes of disability globally.¹ Beyond diminishing individual quality of life, it imposes substantial burdens on healthcare systems and national economies. According to the Global Burden of Disease (GBD) 2019 report, CMP—including neck and low back pain—affects more than 1.7 billion people worldwide.^2,3

Chronic low back pain (CLBP) is the most prevalent and extensively studied subtype of CMP, significantly associated with physical limitations and reduced quality of life in the general population.^4,5 Recent findings indicate that chronic pain is not solely a biological phenomenon but rather a complex interplay of cognitive, emotional, and behavioral factors.⁶ Accordingly, traditional symptom-focused approaches are considered inadequate, and positive psychological resources—such as optimism, subjective well-being, and resilience—are increasingly recognized as important contributors to successful adaptation.^6–9

In this context, patient-reported outcome measures (PROMs) are widely used in both clinical practice and scientific research. Commonly utilized instruments include the Bournemouth Questionnaire (BQ), the Oswestry Disability Index (ODI), the Roland-Morris Disability Questionnaire (RMDQ), and the Core Outcome Measures Index (COMI). However, these tools generally focus on negative aspects such as symptom severity and functional limitations, and there is a limited number of instruments that adequately assess positive psychosocial dimensions such as emotional resilience, positive life experiences, and individual strengths.^10,11

Recent research has highlighted the necessity for concise and positively focused instruments to comprehensively evaluate well-being and psychological resilience in patients experiencing chronic pain.^12–14 To address this need, Mikkonen et al. developed the Well-Being in Pain Questionnaire (WPQ) in 2024.¹⁵

The WPQ is an innovative, self-reported tool intended to evaluate protective elements of well-being, including optimism, vitality, social connectedness, and sense of purpose, by concentrating on psychological, social, and lifestyle dimensions. Health-related quality of life measures typically focus on assessing overall physical, mental, and social functioning, whereas the WPQ differs from traditional instruments by providing a concise and holistic evaluation of the personal resources that support well-being and individuals’ adaptation processes in the context of chronic pain.

While the original WPQ demonstrated acceptable psychometric properties in Finnish-speaking populations, no validated Turkish version of the scale currently exists. Considering the cultural differences that may influence the perception of well-being, and the growing need for culturally appropriate well-being assessments in Turkish-speaking individuals with chronic pain, cross-cultural adaptation and psychometric validation of the WPQ into Turkish are essential.

Therefore, the aim of the present study was to translate the WPQ into Turkish, culturally adapt it for Turkish-speaking individuals, and evaluate its psychometric properties, including internal consistency, test-retest reliability, construct validity, and convergent validity.

Material and methods

Study population and data collection

This study was carried out in the Department of Physical Medicine and Rehabilitation. Participants were recruited using a convenience sampling method between May and July 2025. Eligible individuals were males and females aged 18 to 65 years. Inclusion criteria comprised individuals with CLBP—defined as experiencing low back pain at least three days per week over the previous three months—or pain-free controls with no ongoing or recent (within the past month) pain complaints.

Participants were excluded if they had a history of malignancy, including active cancer; a diagnosis of a neurological disorder involving the central nervous system, such as dementia or multiple sclerosis; a rheumatic condition such as fibromyalgia, ankylosing spondylitis, or rheumatoid arthritis; or had undergone any type of spine surgery in the 12 months prior to enrollment. All participants were required to have adequate proficiency in both written and spoken Turkish. All patients received written information and signed an informed consent form.

Demographic data—including age, gender, education level (1. primary school, 2. secondary school, 3. undergraduate degree, 4. postgraduate degree), and the presence of chronic illness—were collected through a structured interview form. Data collection was conducted face-to-face by trained healthcare professionals in an outpatient clinic setting.

Ethical considerations

Permission to translate and adapt the WPQ into Turkish was obtained via e-mail correspondence from Jani Mikkonen et al., the original developers of the WPQ. Ethical approval for this study was granted by the Institutional Ethics Committee (Approval No: E-10840098-202.3.02-3148). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Translation and cultural adaptation

The translation and cultural adaptation of the WPQ into Turkish were conducted in accordance with the standardized methodology proposed by Beaton et al..¹⁶ Initially, two independent bilingual translators—both fluent in English and Turkish—translated the original English version into Turkish. One translator had a clinical background and was familiar with the concept measured by the instrument, while the other had no medical training and was therefore naive to the content. These two forward translations were reviewed and synthesized into a single preliminary version (Version 1) following a consensus meeting involving the translators and the study team.

Next, back-translation was performed by two different bilingual translators, whose native language was English. These translators were blinded to the original English version and had no prior exposure to the WPQ. Each of them independently translated Version 1 back into English, resulting in two separate back-translations. These were compared to the original WPQ to evaluate conceptual and semantic equivalence.

Expert review

All translation steps—including the synthesized forward translation and the two back-translations—were reviewed by a multidisciplinary expert committee, which included specialists in geriatrics, physiotherapy, public health, internal medicine, and psychometric validation. The expert panel assessed the clarity, cultural appropriateness, and conceptual accuracy of each item. Based on consensus within the committee, necessary modifications were made, and the pre-final Turkish version (Version 2) of the WPQ was developed.

To further evaluate content validity, each item of the pre-final version was rated using a four-point Likert scale: 1 = “not appropriate,” 2 = “needs major modification,” 3 = “useful but requires minor changes,” and 4 = “very appropriate.” The Content Validity Index (CVI) was calculated using the Davis technique, and items with lower CVI scores were revised accordingly to enhance clarity and cultural relevance.^17,18

Pre-Testing

The pre-final Turkish version was then administered to a pilot sample of 30 individuals, aged 18 to 65 years, to evaluate comprehension, clarity, and cultural relevance. Participants completed the questionnaire independently and were subsequently interviewed to identify any difficulties in understanding or interpretation. Based on participant feedback, minor linguistic adjustments were made. This process resulted in the final Turkish version of the WPQ (WPQ-Tr), which was subsequently used in the main validation study. The entire translation and adaptation procedure is illustrated in Figure 1, and the finalized WPQ-Tr is provided as Supplementary Material 1.

Figure 1.

Flowchart of the translation and cultural adaptation process of the WPQ into Turkish.

Measurement instruments

Several comparator instruments assessing dimensions known to be associated with well-being in individuals with CLBP were selected. Health-related quality of life was assessed using the EuroQoL 5-Dimension questionnaire (EQ-5D-5L), as well-being is theoretically expected to be associated with better perceived overall health status; moreover, due to its short administration time and low respondent burden, it is considered a practical assessment tool in studies that include multiple patient-reported outcome measures. The Pain Catastrophizing Scale (PCS) was included to evaluate pain-related catastrophizing thoughts, which are generally negatively associated with psychological well-being. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality, which is frequently impaired in individuals with chronic pain and may negatively affect well-being. Functional disability was measured using the Roland–Morris Disability Questionnaire (RMDQ), given that greater physical limitations are expected to be associated with lower levels of well-being. The Central Sensitization Inventory (CSI) was included to evaluate symptoms related to central sensitization and the neurophysiological dimensions of the chronic pain experience. Finally, the Generalized Anxiety Disorder-7 (GAD-7) scale was used to assess anxiety symptoms that may influence perceived well-being. Collectively, these instruments enabled the evaluation of convergent validity by examining the associations between WPQ-Tr scores and theoretically related constructs. The selected instruments are as follows:

Well-Being in pain questionnaire

The WPQ was originally developed and validated by Mikkonen et al. in a Finnish cohort of individuals with CLBP to assess emotional, social, and daily activity dimensions of personal well-being over the past month in individuals experiencing chronic musculoskeletal pain. Unlike many traditional pain-related questionnaires that primarily focus on symptom severity or disability, the WPQ was designed to evaluate positive psychosocial resources such as optimism, vitality, social connectedness, and sense of purpose. To date, the WPQ has not yet been widely translated or validated in other languages. The instrument consists of 11 items scored on a 5-point Likert scale ranging from 0 (“never”) to 4 (“almost always”). The total WPQ score is calculated by summing the responses to all items, yielding a score between 0 (minimal well-being in pain) and 44 (maximum well-being in pain). The WPQ demonstrated excellent internal consistency (Cronbach's alpha = 0.89) in individuals with CLBP, supporting its reliability in this patient population.

Euroqol 5-dimension questionnaire

The EQ-5D-5L is a standardized measure designed to evaluate health-related quality of life through five dimensions: mobility, self-care, engagement in usual activities, pain or discomfort, and anxiety or depression. Each domain is rated on a five-level Likert scale, where 0 indicates no problems and 4 reflects an inability to perform or extreme problems. In addition, it includes a visual analogue scale (VAS) that allows individuals to score their overall health from 0 (“the worst health you can imagine”) to 100 (“the best health you can imagine”).¹⁹

Pain catastrophizing scale

The PCS assesses the degree to which a person engages in exaggerated and negative thought patterns or emotional responses when facing actual or potential pain. It consists of 13 statements, each scored on a 5-point Likert scale from 0 (“not at all”) to 4 (“always”). Higher total scores indicate more severe pain-related catastrophizing. The Turkish adaptation of the PCS was validated and demonstrated strong reliability in the study by Uğurlu et al.^20,21

Pittsburgh sleep quality Index

The PSQI is a 19-item tool used to assess overall sleep quality over the past month. It covers seven domains, including sleep duration, latency, disturbances, efficiency, and daytime dysfunction. Each domain is scored from 0 to 3, yielding a total score between 0 and 21. Scores ≥5 indicate poor sleep quality, whereas scores <5 reflect good sleep quality.^22,23

Roland-Morris disability questionnaire

The RMDQ is a widely used tool for assessing functional limitations in individuals with low back pain. It comprises 24 statements reflecting daily life restrictions, to which patients respond “yes” if the statement applies to them, or “no” if it does not. Each “yes” response is scored as 1 point, while “no” is scored as 0, resulting in a total score ranging from 0 to 24; higher scores indicate greater functional impairment.²⁴ The Turkish version of the RMDQ has previously been validated and shown to be reliable in local clinical settings.²⁵

Central sensitization inventory

The CSI is divided into two sections. Part A consists of 25 items assessing somatic and emotional symptoms commonly associated with central sensitization, each rated from 0 to 4, yielding a total score between 0 and 100. Higher scores indicate greater symptom severity. Part B lists physician-diagnosed conditions linked to central sensitization, such as fibromyalgia, migraine, irritable bowel syndrome, and anxiety disorders. The Turkish version of the CSI was validated by Düzce et al.²⁶

Generalized anxiety disorder-7

The GAD-7 is a brief self-report instrument comprising seven items, developed based on the core diagnostic criteria from the DSM-IV for generalized anxiety disorder. It serves both as a screening tool and a measure of symptom severity. The Turkish adaptation of the GAD-7 was validated by Konkan et al., confirming its reliability and psychometric adequacy.²⁷

Psychometric evaluation

In this section, the current recommendations of the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) group were followed.²⁸ The following psychometric properties were assessed:

Phase 1: reliability and internal consistency

The internal consistency of the WPQ-Tr was evaluated using Cronbach's alpha coefficient. An alpha value of ≥0.70 was considered sufficient.²⁹ To assess test–retest reliability, 30 participants were asked to complete the questionnaire for a second time following a two-week interval. A two-week interval is commonly used in reliability studies of patient-reported outcome measures because it minimizes recall bias while maintaining the assumption that the measured construct remains stable. In individuals with CLBP, both clinical status and psychosocial well-being are generally expected to remain relatively stable over such a short period in the absence of major clinical interventions. During this process, administration procedures, setting, and instructions were standardized, and the healthcare professionals conducting the assessment were blinded to the participants’ initial responses.³⁰ The intraclass correlation coefficient (ICC) was calculated to determine the temporal stability of the scores. ICC values ≤0.5, 0.50–0.75, 0.75–0.90, and >0.90 indicated weak, moderate, good, and excellent reliability, respectively.³¹ The measurement error was evaluated using the standard error of measurement (SEM) and the smallest detectable change (SDC) at the 95% confidence level. SEM was calculated using the formula: standard deviation × √(1 – ICC), while SDC was derived as SEM × 1.96 × √2.^28,29,32

Phase 2: validity assessment

The structural validity of the WPQ-Tr was assessed through an exploratory dimensionality analysis using principal component analysis (PCA). The Kaiser–Meyer–Olkin (KMO) measure and Bartlett's test of sphericity were first performed to evaluate the suitability of the data for analysis.³³ A KMO value greater than 0.70 and a statistically significant Bartlett's test result were considered indicators of sampling adequacy. PCA with varimax rotation was used to examine the underlying component structure of the WPQ-Tr. Items with a factor loading equal to or greater than 0.50 were retained for further analysis.

A confirmatory factor analysis (CFA) was conducted using Python's semopy package to evaluate the measurement model. Given that the WPQ items are measured on a Likert-type scale, parameters were estimated using the Diagonally Weighted Least Squares (DWLS) estimator, which is considered more appropriate for ordinal data. Model fit was assessed using standard fit indices, including the Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR).³⁴

These fit indices evaluate the extent to which the proposed model corresponds with the observed data from different perspectives. The CFI compares the fit of the target model to an independent (null) model. The TLI, also known as the Non-Normed Fit Index (NNFI), penalizes overfitting by taking model complexity into account. The RMSEA is a non-centrality-based index that estimates the lack of fit per degree of freedom, considering sample size and model complexity. The SRMR represents the standardized difference between the observed and predicted correlations.

Construct validity of the WPQ-Tr was evaluated by examining its convergent validity through correlations with other established patient-reported outcome measures. Spearman's rank correlation coefficients (ρ) were calculated between WPQ-Tr scores and those of validated instruments, including the EQ-5D-5L, EQ-5D-5L VAS, PCS, PSQI, RMDQ, CSI, and GAD-7.

Hypothesis testing

Based on previous research and the original development study by Mikkonen et al. (15), a priori hypotheses were formulated regarding the expected group differences and correlation patterns. It was hypothesized that WPQ-Tr scores would be significantly lower in individuals with CLBP compared to pain-free controls (p < 0.05).

Additionally, the WPQ-Tr was expected to show statistically significant positive correlations with EQ-5D-5L and VAS, and significant negative correlations with PCS, PSQI, RMDQ, CSI, and GAD-7. Correlation strengths were interpreted as strong (ρ ≥ 0.50), moderate (0.30 ≤ ρ < 0.50), or weak (ρ < 0.30), in line with Cohen's criteria.³⁵ Construct validity was considered to be established if at least 75% of the predefined hypotheses were confirmed, in accordance with the COSMIN guidelines.²⁸

Statistical analyses

All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA) and Python's semopy package. Continuous variables were presented as mean ± standard deviation (SD) and median (first quartile [Q1]–third quartile [Q3]) and analyzed using the Mann–Whitney U test, as the data were not normally distributed. Categorical variables were summarized as frequencies and percentages, and group comparisons were conducted using the Chi-square test. Comparisons of individual WPQ-Tr item scores between groups were also performed using the Mann–Whitney U test. A p-value of < 0.05 was considered statistically significant.

Sample size adequacy was evaluated according to established methodological recommendations for studies assessing measurement properties. For exploratory dimensionality analyses, previous guidelines recommend including at least 4–10 participants per item with a minimum total sample size of 100 to ensure stability of the variance–covariance matrix.^29,36 Since the WPQ contains 11 items, the inclusion of 105 individuals was considered sufficient for both PCA and CFA. Furthermore, construct validity analyses are recommended to be conducted in subgroups of at least 50 participants, which was satisfied in the present study for both known-groups comparisons and correlation analyses.²⁹ For test–retest reliability analysis, a subsample of 30 participants was included. Previous methodological recommendations indicate that approximately 30 respondents are sufficient to assess the reliability of a questionnaire.³⁷

Ceiling and floor effects

Extreme score distributions were evaluated to determine the presence of ceiling or floor effects. These effects were considered present if over 15% of participants achieved either the maximum or minimum possible score, indicating potential limitations in the scale's sensitivity at the extremes of measurement.²⁸

Results

Linguistic validation and content validity

The average completion time of the WPQ-Tr ranged between 3 and 8 min. The CVI values of the items ranged from 0.85 to 1.00, indicating excellent content and linguistic validity for the Turkish population

Study population

A total of 173 individuals initially met the inclusion and exclusion criteria and agreed to participate in the study. However, due to incomplete questionnaire data, 12 participants from the CLBP group and 6 participants from the pain-free control group were excluded. As a result, the final analysis comprised 155 participants. The demographic characteristics and the results of patient-reported outcome measures are summarized in Table 1.

Table 1.

Participant characteristics and differences in patient-reported outcome measures.

	Subjects with CLBP (n = 105)		Pain-free controls (n = 50)		p-value
	Mean ± SD	Median (Q1-Q3)	Mean ± SD	Median (Q1-Q3)
Age (years)	45.92 ± 7.15	45 (42–49)	45.44 ± 7.4	46 (39–49)	0.756
Gender n (%)
Female	68 (64.8)		31 (62)		0.858
Male	37 (35.2)		19 (38)		0.858
BMI (kg/m²)	26.15 ± 4.2	24.8 (22.7–29.8)	26.1 ± 4.38	24.8 (22.8–29.8)	0.991
Educational level n (%)
Primary school	32 (30.5)		12 (24)		0.787
Secondary school	27 (25.7)		14 (28)
Undergraduate degree	30 (28.6)		14 (28)
Postgraduate degree	16 (15.2)		10 (20)
WPQ-Tr	31.29 ± 5.9	31 (26–36)	34.04 ± 4.3	35 (31–37)	<0.01
EQ-5D-5L	0.7 ± 0.08	0.7 (0.7–0.8)	0.87 ± 0.08	0.8 (0.8–1.0)	<0.01
EQ-5D-5L VAS	64.5 ± 11.37	65 (55–70)	93.5 ± 5.74	95 (90–100)	<0.01
PCS	23.21 ± 6.23	24 (19–28)	7.34 ± 2.19	7 (6–8)	<0.01
CSI	43.03 ± 14.81	49 (30–55)	26.24 ± 6.14	25 (23–30)	<0.01
PSQI	8.17 ± 2.85	7 (6–10)	2.72 ± 1.68	3 (1–4)	<0.01
RMDQ	13.43 ± 4.83	14 (10–17)
GAD-7	6.47 ± 2.03	7 (5–8)	3.06 ± 1.74	3 (2–4)	<0.01

Note: Values of p < 0.05 were accepted as significant and marked in bold.

Data are presented as mean ± standard deviation (SD), median (Q1–Q3), or n (%).

Abbreviation: CLBP: Chronic low back pain; BMI: Body Mass Index; WPQ: Well-being in Pain Questionnaire; Tr: Turkish version; EQ-5D-5L: EuroQol European Quality of Life 5 Dimensions 5 Level; EQ-5D-5L VAS: EuroQol European Quality of Life 5 Dimensions 5 Level Visual Analog Scale; PCS: Pain Catastrophizing Scale; CSI: Central Sensitization Inventory; PSQI: Pittsburgh Sleep Quality Index; RMDQ: Roland-Morris Disability Questionnaire; GAD-7: Generalized Anxiety Disorder 7-item scale.

RMDQ was not administered to the control group.

Group comparisons of individual WPQ-Tr item scores between the CLBP and control groups revealed statistically significant differences in several items, particularly Items 2, 4, 5, 6, and 7 (p < 0.05), indicating higher well-being scores among pain-free individuals. Detailed results of item-level comparisons are provided in Table 2.

Table 2.

Comparison of WPQ item scores between groups (n = 155).

	Subjects with CLBP (n = 105)		Pain-free controls (n = 50)
	Median (Q1-Q3)	Mean ± SD	Median (Q1-Q3)	Mean ± SD	p-value
Item 1	3 (2-3)	2.61 ± 0.73	3 (2-3)	2.64 ± 0.63	0.833
Item 2	3 (2–3)	2.83 ± 0.73	3 (2–4)	3.2 ± 0.7	0.003
Item 3	3 (2–3)	2.85 ± 0.73	3 (3–3)	2.98 ± 0.51	0.216
Item 4	3 (2–3)	2.69 ± 0.7	3 (2–4)	3 ± 0.73	0.013
Item 5	3 (2–3)	2.74 ± 0.71	3 (3–4)	3.22 ± 0.76	<0.001
Item 6	3 (2–3)	2.73 ± 0.78	3 (3–4)	3.18 ± 0.69	<0.001
Item 7	3 (3–3)	2.95 ± 0.7	3 (3–4)	3.22 ± 0.62	0.026
Item 8	3 (2–3)	2.92 ± 0.7	3 (3–3)	3.12 ± 0.56	0.092
Item 9	3 (3–3)	3.08 ± 0.58	3 (3–4)	3.24 ± 0.52	0.104
Item 10	3 (3–3)	2.96 ± 0.6	3 (3–3)	2.96 ± 0.45	0.985
Item 11	3 (3–3)	2.91 ± 0.62	3 (3–3)	3.08 ± 0.63	0.124

On the 5-point scale, scores are assigned as follows: 4 for “almost always,” 3 for “often,” 2 for “sometimes,” 1 for “rarely,” and 0 for “never.”

Note: Values of p < 0.05 were accepted as significant and marked in bold. (Mann-Whitney U test)

Abbreviation: CLBP: Chronic low back pain; SD: Standard Deviation; Q1: First quartile; Q3: Third quartile.

Psychometric validation analyses

Internal consistency and reliability

The Cronbach's alpha coefficient of the WPQ-Tr was 0.713, indicating acceptable internal consistency. Test–retest reliability showed ICCs ranging from 0.828 to 0.953, demonstrating good to excellent temporal stability (Table 3). No ceiling or floor effects were recorded.

Table 3.

Internal consistency and test–retest reliability of the WPQ-Tr (n = 30).

	Cronbach's Alpha	ICC	95% CI	SEM	SDC95%
WPQ-Tr Total	0.713	0.987	0.972–0.994
Item 1		0.830	0.622–0.902	0.284	0.787
Item 2		0.898	0.794–0.950	0.224	0.622
Item 3		0.893	0.732–0.934	0.227	0.63
Item 4		0.873	0.747–0.938	0.256	0.71
Item 5		0.881	0.763–0.942	0.256	0.71
Item 6		0.953	0.902–0.977	0.177	0.491
Item 7		0.828	0.664–0.915	0.282	0.782
Item 8		0.878	0.757–0.941	0.256	0.709
Item 9		0.924	0.839–0.962	0.175	0.486
Item 10		0.874	0.751–0.939	0.215	0.595
Item 11		0.917	0.830–0.960	0.178	0.493

Abbreviation: WPQ: Well-being in Pain Questionnaire; Tr: Turkish version; ICC: Intraclass Correlation Coefficient; SEM: Standard Error of Measurement; SDC: Smallest detectable change.

Principal component analysis

The KMO measure of sampling adequacy was 0.891, and Bartlett's test of sphericity was statistically significant (p < 0.05), confirming that the data were suitable for dimensionality analysis. PCA with varimax rotation was conducted to examine the underlying component structure of the WPQ-Tr. The analysis indicated a unidimensional structure, with only one component exhibiting an eigenvalue ≥ 1. The scree plot also demonstrated a clear inflection point after the first component, further supporting the presence of a single underlying dimension (Figure 2).

Figure 2.

Scree plot of the WPQ-Tr principal component analysis.

The first component had an eigenvalue of 6.013 and accounted for 54.66% of the total variance. All 11 items showed substantial component loadings, ranging from 0.552 to 0.849, indicating moderate to strong associations with the underlying construct. As none of the items demonstrated low loadings, all were retained in the final structure, supporting the structural coherence of the WPQ-Tr. Detailed component loadings are presented in Table 4.

Table 4.

Factor loadings from principal component analysis.

Factor	Total eigenvalue	Explained variance	Item no	Factor loads
1	6.013	54.663	1	0.552
			2	0.719
			3	0.747
			4	0.764
			5	0.823
			6	0.812
			7	0.849
			8	0.819
			9	0.772
			10	0.597
			11	0.608

Confirmatory factor analysis

An initial CFA model was estimated to test the unidimensional structure suggested by the PCA. The initial model showed less satisfactory fit indices (CFI = 0.84, TLI = 0.80, RMSEA = 0.157, GFI = 0.80, AGFI = 0.76). Given that the WPQ items are measured on an ordinal Likert-type scale, the model was subsequently re-estimated using the DWLS estimator, which is considered more appropriate for ordinal data. Modification indices and residual correlations were then examined. Based on theoretical considerations and item content similarity, a residual covariance between Item 4 and Item 8 was allowed, which resulted in a substantial improvement in model fit.

The final CFA model demonstrated excellent fit, with fit indices as follows: χ²(43) = 43.04, CFI = 0.99, TLI = 0.99, RMSEA = 0.0025, GFI = 0.98, and AGFI = 0.97. All factor loadings were statistically significant (p < .001), supporting the unidimensional latent structure of the WPQ-Tr.

Convergent validity

The convergent validity of the WPQ-Tr was supported by strong and statistically significant associations (p < 0.01) with other validated patient-reported outcome measures. The WPQ-Tr demonstrated a strong positive correlation with the EQ-5D-5L (ρ = 0.902, p < 0.01) and EQ-5D-5L VAS (ρ = 0.892, p < 0.01). In contrast, strong negative correlations were observed with the PCS (ρ = −0.923, p < 0.01), CSI (ρ = −0.923, p < 0.01), PSQI (ρ = −0.794, p < 0.01), RMDQ (ρ = −0.893, p < 0.01), and GAD-7 (ρ = −0.828, p < 0.01).

These findings provide robust evidence supporting the convergent and overall construct validity of the WPQ-Tr. Detailed correlation coefficients are presented in Table 5. To further evaluate potential outliers and restricted range effects, scatterplot matrices illustrating the relationships between WPQ-Tr scores and related outcome measures are presented in Supplementary Material 2.

Table 5.

Relationship of the Well-being in Pain Questionnaire, EuroQol 5-level EQ-5D, and other patient-reported assessments in individuals diagnosed with chronic low back pain (n = 105).

	Correlation with WPQ			Correlation with EQ-5D-5 L
	ρ	95% CI		ρ	95% CI
		Lower	Upper		Lower	Upper
WPQ-Tr	1*			0.902*	0.857	0.933
EQ-5D-5L	0.902*	0.857	0.933	1*
EQ-5D-5L VAS	0.892*	0.843	0.926	0.893*	0.845	0.927
PCS	−0.923*	−0.948	−0.888	−0.935*	−0.956	−0.905
CSI	−0.923*	−0.948	−0.887	−0.909*	−0.938	−0.867
PSQI	−0.794*	−0.857	−0.708	−0.763*	−0.835	−0.666
RMDQ	−0.893*	−0.927	−0.845	−0.906*	−0.936	−0.863
GAD-7	−0.828*	−0.881	−0.754	−-0.814*	−0.872	−0.735

Spearman's rank correlation (ρ). Correlation two tailed-statistical significance p < 0.01*.

Abbreviation: WPQ: Well-being in Pain Questionnaire; Tr: Turkish version; EQ-5D-5L: EuroQol European Quality of Life 5 Dimensions 5 Level; EQ-5D-5L VAS: EuroQol European Quality of Life 5 Dimensions 5 Level Visual Analog Scale; PCS: Pain Catastrophizing Scale; CSI: Central Sensitization Inventory; PSQI: Pittsburgh Sleep Quality Index; RMDQ: Roland-Morris Disability Questionnaire; GAD-7: Generalized Anxiety Disorder 7-item scale.

Discussion

This study aimed to translate and culturally adapt the WPQ into Turkish and to evaluate its psychometric properties among individuals with CLBP. The findings provide robust support for the reliability and validity of the WPQ-Tr, making it a valuable self-assessment tool for use in both clinical practice and research settings in Turkey.

Numerous studies conducted worldwide have consistently demonstrated that CLBP significantly affects not only physical functioning and daily activities but also psychosocial health.³⁸ Individuals with CLBP frequently experience subclinical distress, depressive symptoms, and social withdrawal.^39,40 In order to evaluate individuals with CLBP in terms of their psychological status and quality of life, various assessment tools have been developed. Commonly used instruments targeting psychological components include the PCS, the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Fremantle Back Awareness Questionnaire. These tools generally focus on a single psychological domain—such as catastrophizing, fear, avoidance, or self-efficacy—and are predominantly centered on negative experiences. On the other hand, widely used quality of life instruments such as the Short Form-36 Health Survey (SF-36), EQ-5D, and COMI are generally not designed specifically for pain populations and provide a general evaluation based on domains such as overall health status, functional capacity, and social participation.

In this context, the WPQ-Tr stands out as it was specifically developed in the context of chronic pain and addresses both psychological well-being and quality of life in an integrated manner. Considering that most conventional instruments consist of multiple subscales, they may present limitations in terms of administration time and interpretability. In contrast, the WPQ-Tr, with its unidimensional structure, offers a practical and time-efficient alternative for healthcare providers.

When examining the individual items of the scale, maintaining regular physical activity (Item I) and enjoying activities of daily living (Item II) have been consistently associated with better functional outcomes and higher quality of life among individuals with CLBP.⁴¹ Similarly, constructs such as optimism (Item VII), sense of life purpose (Item XI), and social connectedness (Items IX–X) are well-documented protective factors that buffer the negative impacts of depression, anxiety, and pain catastrophizing.^42,43 Low scores on vitality and feeling well-rested items (Items III–V) may indicate the need for targeted lifestyle or sleep-related interventions, whereas reduced job satisfaction (Item VI) may point to the occupational dimension of well-being, which is often overlooked in conventional pain management programs.

The Turkish adaptation of the WPQ-Tr extends beyond a mere linguistic translation; it also reflects the deep cultural values and psychosocial dynamics that shape perceptions of well-being. Whereas well-being in individualistic Western cultures is typically defined through personal achievement and autonomy, Turkish culture emphasizes collectivism, interdependence, and relational harmony. Indeed, meta-analytic studies conducted in Turkey have demonstrated that well-being is moderately and significantly associated with social support, family ties, and community relationships.⁴⁴ In this context, the dimensions of closeness (Item IX), contribution (Item X), and life purpose (Item XI) demonstrate a noteworthy alignment with the collectivist values that lie at the core of well-being in Turkish culture.

To evaluate the reliability of the WPQ-Tr within the Turkish context, the internal consistency of the scale was initially assessed using Cronbach's alpha coefficient. Cronbach's alpha is a statistical index that reflects the extent to which questionnaire items function cohesively as a group, that is, the degree to which they consistently capture the same underlying construct. This coefficient ranges from 0 to 1, with higher values indicating stronger internal consistency. In the current study, the Cronbach's alpha for the WPQ-Tr was calculated as 0.713, which suggests an acceptable level of internal consistency for the Turkish version of the instrument.⁴⁵ By contrast, in the original version developed in Finland—including the CLBP subgroup—the reported Cronbach's alpha was 0.89, indicating excellent internal consistency. Several factors may account for this discrepancy. Although the forward–backward translation process was conducted meticulously, the cultural connotations of certain psychological constructs may vary. For instance, the concept of freedom and autonomy (Item 8), which is typically framed around individual choice and independence in Western cultures, tends to be experienced within the framework of familial and societal relationships—referred to as “relational autonomy”—in Turkish culture. Similarly, job satisfaction (Item 6) may reflect not only personal career fulfillment but also economic conditions and familial responsibilities, thus contributing to a broader range of responses. The concept of life purpose (Item 11) may also be interpreted in culturally diverse ways, such as spiritual values, serving one's family, or contributing to society. This cultural variability may reduce item homogeneity and, consequently, lower the overall Cronbach's alpha compared to the original version.

Another plausible explanation is related to the sampling strategy. The original WPQ study employed a heterogeneous sample drawn from multiple clinical and patient organization settings across Finland, which likely resulted in greater response variability and stronger internal consistency. In contrast, the current study was conducted in a single rehabilitation center in Istanbul with a more homogeneous sample, potentially restricting item variance and weakening inter-item correlations, thus leading to a lower alpha coefficient. In conclusion, these findings suggest that differences in internal consistency may be attributed to cultural, methodological, or sample-specific factors.

Test–retest reliability refers to the degree of consistency of a measurement tool over time and is typically evaluated by administering the same instrument twice within a defined time interval.⁴⁶ If the interval is excessively long, potential changes in participants’ health status or perceptions may result in lower reliability scores. Conversely, if the interval is too short, participants may recall their previous responses, leading to biased results or perceiving the assessment as a memory test.⁴⁷ Considering these factors, a two-week interval was chosen for the test–retest evaluation of the WPQ-Tr in the present study. The test–retest reliability of the WPQ-Tr was found to be excellent across all items, with ICCs ranging from 0.828 to 0.953. These values indicate that participants provided highly consistent responses when the questionnaire was re-administered after two weeks, confirming the temporal stability of the scale. Furthermore, the ICC values obtained in this study are consistent with the findings of the original WPQ validation study and provide robust evidence supporting the reproducibility of the Turkish version.¹⁵

In this study, PCA and CFA were conducted to evaluate the construct validity of the WPQ-Tr. PCA is used to identify the underlying factor structure of a questionnaire, while CFA is applied to test whether this structure is consistent with the observed data. Consistent with the original version, PCA results indicated that the WPQ-Tr has a unidimensional structure, with only one factor demonstrating an eigenvalue greater than 1. Moreover, the scree plot (Figure 2) revealed a sharp decline in eigenvalues after the first component, forming a distinct “elbow” point. This graphical inflection suggests that only one component provides meaningful information, while subsequent components contribute minimally to the explained variance. This visual finding is consistent with the one-component solution obtained from PCA. The single retained component accounted for 54.66% of the total variance, and all items demonstrated moderate to high component loadings, ranging from 0.552 to 0.849. CFA results indicated a good model fit, confirming that the WPQ-Tr items adequately represent the construct of “well-being in pain” and supporting the structural validity of the instrument.¹⁵

In this study, the convergent validity of the WPQ-Tr was supported by statistically significant and clinically meaningful correlations with various patient-reported outcome measures that have previously demonstrated validity. As expected, strong positive correlations were found with indicators of health-related quality of life (EQ-5D-5L and EQ-VAS), suggesting that higher well-being scores despite pain are associated with better perceived health status. Similarly, strong negative correlations were observed with PCS, CSI, PSQI, RMDQ, and GAD-7. These correlation coefficients are comparable in strength and direction to those reported in the original WPQ validation study, which also found moderate correlations with similar constructs such as health-related quality of life, psychological distress, and central sensitization symptoms.

In addition to the original validity analyses of the WPQ, this study also examined the relationship between the WPQ-Tr and the RMDQ, a widely used and validated instrument for assessing functional disability related to back pain.⁴⁸ The strong negative correlation observed between the WPQ-Tr and RMDQ indicates that increased pain-related disability is associated with a significant reduction in psychosocial well-being.

This study provides important findings regarding the psychometric properties of the WPQ-Tr; however, several limitations should be considered. First, the research was conducted at a single tertiary care center in Istanbul, Türkiye, which may limit the generalizability of the findings to other clinical settings or geographical regions. Although the hospital serves a socioeconomically diverse patient population, all participants were recruited from an urban setting. Therefore, the results may not fully reflect individuals living in rural areas, where access to healthcare services, educational levels, and cultural perceptions of pain and well-being may differ considerably.

Second, the educational distribution of the sample was relatively narrow, which may affect the applicability and validity of the scale across populations with different levels of literacy and comprehension.

Third, objective clinical assessments—such as lumbar mobility or physical performance measures—that could have enhanced the evaluation of structural validity were not included. In future studies, the inclusion of objective physical performance measures such as lumbar mobility, gait speed, or balance tests, along with the evaluation of correlations between these measures and changes in WPQ-Tr scores over time during treatment follow-up, would be valuable in strengthening the validity of the instrument. Fourth, due to the absence of validated, positively framed psychological well-being instruments in Turkish, construct validity had to be evaluated using negatively oriented scales, which may not fully align with the conceptual focus of the WPQ. Moreover, multiple variables were compared between the two groups in this study, and individual p-values were calculated for each comparison. Therefore, the potential risk of Type I error due to multiple hypothesis testing should be taken into account when interpreting these results.

Finally, although relatively high correlations were observed between the WPQ-Tr and related measures, the strength of these correlations likely reflects the close conceptual relationship between well-being in chronic pain and related constructs such as health-related quality of life, pain-related cognitive processes, and psychosocial functioning. Nevertheless, the correlations were not perfect, suggesting that the WPQ-Tr captures a related but distinct dimension of well-being rather than representing redundancy with these established measures. In addition, the responsiveness of the WPQ-Tr, defined as its ability to detect clinically meaningful changes over time, was not evaluated in this study. Assessing this property in future longitudinal or intervention-based research would provide valuable insights into the scale's utility for monitoring patient progress and treatment outcomes.

Conclusions

In conclusion, the WPQ-Tr provides a novel, strength-based perspective for evaluating the psychosocial status of individuals with CLBP. Rather than focusing solely on symptom severity, it emphasizes positive psychosocial resources such as resilience and emotional vitality, thereby supporting a more patient-centered approach. Beyond its role as a research instrument, the WPQ-Tr can be integrated into clinical practice to help identify patients with reduced well-being at an early stage. This, in turn, may enable the individualization of multidisciplinary intervention strategies that address both the physical and psychological dimensions of chronic pain.

Supplemental Material

sj-docx-1-bmr-10.1177_10538127261448974 - Supplemental material for The turkish version of the well-being in pain questionnaire: Cross-cultural adaptation, validation, and evaluation of measurement properties in individuals with chronic low back pain

Supplemental material, sj-docx-1-bmr-10.1177_10538127261448974 for The turkish version of the well-being in pain questionnaire: Cross-cultural adaptation, validation, and evaluation of measurement properties in individuals with chronic low back pain by Hatice Betigül Meral, Aylin Rezvani, Sena Tolu and Mithat ğ Yavuz in Journal of Back and Musculoskeletal Rehabilitation

Supplemental Material

sj-docx-2-bmr-10.1177_10538127261448974 - Supplemental material for The turkish version of the well-being in pain questionnaire: Cross-cultural adaptation, validation, and evaluation of measurement properties in individuals with chronic low back pain

Supplemental material, sj-docx-2-bmr-10.1177_10538127261448974 for The turkish version of the well-being in pain questionnaire: Cross-cultural adaptation, validation, and evaluation of measurement properties in individuals with chronic low back pain by Hatice Betigül Meral, Aylin Rezvani, Sena Tolu and Mithat ğ Yavuz in Journal of Back and Musculoskeletal Rehabilitation

Footnotes

Acknowledgements

Not applicable.

ORCID iDs

Hatice Betigül Meral

Aylin Rezvani

Sena Tolu

Mithat Oğuz Yavuz

Ethical considerations

This study was approved by the Istanbul Medipol University Ethics Committee (Approval No: E-10840098-202.3.02-3148) and conducted in accordance with the Declaration of Helsinki.

Consent to participate

Written informed consent was obtained from all participants prior to data collection.

Consent for publication

Not applicable. This study does not include any identifiable personal data, images, or videos requiring consent for publication.

Author contributions

HBM: Conceptualization, Methodology, Data collection, Data analysis, Writing–original draft preparation. AR: Methodology, Supervision, Writing–review & editing. ST: Methodology, Writing–review & editing. MOY: Data collection, Data curation, Visualization.

All authors read and approved the final manuscript and agree with the order of authorship.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to ethical considerations and participant confidentiality, the dataset is not publicly available.

Supplemental material

Supplemental material for this article is available online.

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