This study used a cross-sectional, multicenter design to evaluate the reliability of the Arabic-COPM. A convenience sample of 113 parents or primary caregivers of children with physical disabilities was recruited from various rehabilitation centers and societies in Jordan. The final analysis included 100 participants who completed the study protocol, while 13 were excluded due to scheduling conflicts or failure to attend follow-up appointments.

Inclusion criteria were (1) parents or primary caregivers of children diagnosed with physical disabilities stemming from nonprogressive neurological disorders, as confirmed by neurologists; (2) children demonstrating functional limitations in multiple activities of daily living; and (3) parents possessing sufficient proficiency in Modern Standard Arabic to comprehend and respond to interview questions. Exclusion criteria included parents of children with progressive neurological conditions, parents of children with cognitive or communication impairments that would hinder interview participation, and families unable to commit to the study timeline.

The research protocol received full approval from the institutional review board of King Abdallah University Hospital of Jordan University of Science and Technology (KAUH342020). The study adhered to the principles outlined in the Declaration of Helsinki. Prior to enrollment, all participants engaged in comprehensive briefing sessions detailing the study objectives, procedures, potential risks, and benefits, following which written informed consent was obtained using institution-approved documentation.

The COPM was used as the primary client-centered assessment to identify significant challenges in the children’s daily functioning. Problem areas identified by families were categorized using a standardized coding system developed by Pollock and Stewart [22], which organizes priorities into 3 main domains: daily activities (with subcategories of self-care, mobility, and communication), productivity (including household management, school participation, and community engagement), and leisure (encompassing socialization, community entertainment, quiet recreation, and physical recreation). The self-care domain was further broken down into 5 specific components: eating, dressing, bathing, toileting, and hygiene.

All assessments were conducted by two independent licensed clinical rehabilitation therapists, each assessing participants independently with experience in pediatric rehabilitation and prior training in the administration of the COPM. Both raters underwent standardized calibration sessions before data collection to ensure consistency in interview administration, scoring procedures, and problem categorization. The administration followed a structured five-step [22] process using the validated Arabic translation of the COPM. The first step was problem identification: parents enumerated activities and tasks presenting significant challenges in their child’s daily routine. The second step was importance scaling: using a 10-point metric (1=“minimal importance” to 10=“critical importance”), parents rated all identified concerns. The third step was priority selection: through facilitated discussion, parents distilled their concerns to 5 paramount issues. The fourth step was performance evaluation: each prioritized activity received a performance rating (1=“complete inability” to 10=“optimal performance”). The fifth step was satisfaction evaluation: parents rated their satisfaction with their child’s performance or each problem (1=“not satisfied” to 10=“extremely satisfied”). Mean scores for performance and satisfaction were calculated by averaging the ratings across the 5 prioritized problems.

Although the COPM is classified as a patient-reported outcome measure (PROM), it differs from conventional self-administered PROMs because it is conducted through a semistructured clinician-led interview rather than a fixed questionnaire completed independently by respondents. During COPM administration, the clinician actively facilitates problem identification, clarification, prioritization, and scoring of performance and satisfaction. Therefore, the interrater reliability assessment is considered crucial and relevant, as it has also been evaluated in previous COPM validation studies to determine the consistency of identified priorities and scores across independent assessors.

A multiphase protocol was implemented to assess reliability. To evaluate interrater reliability, 100 parents completed the Arabic-COPM twice on the same day, administered by 2 independent raters who were blinded to each other’s findings. For test-retest reliability, a random subsample of 30 (30%) parents repeated the assessment with the same rater after a 14-day interval, following an identical administration procedure (Figure 1).

The psychometric evaluation of the Arabic-COPM incorporated comprehensive reliability and agreement analyses. Reliability was assessed using ICCs with a 2-way mixed-effects model, applying absolute agreement for interrater comparisons and consistency for test-retest analyses [23]. Interpretation of reliability coefficients was performed cautiously and in the context of previous COPM and rehabilitation reliability studies, in which the interpretation followed established benchmarks of 0.40 to 0.59 (fair), 0.60 to 0.74 (good), and >0.75 (excellent). However, categorical thresholds for ICC interpretation may vary across methodological frameworks and should not be considered absolute indicators of measurement quality.

Agreement assessment used multiple complementary approaches. For quantitative agreement, Bland-Altman methodology was implemented to evaluate measurement concordance [24]. This involved plotting differences between paired measurements against their means, with calculation of mean bias (d̄) and 95% limits of agreement (LOA; LOA=d̄±1.96×SD) [25]. To address visualization challenges in datasets with restricted ranges, traditional scatterplots were enhanced through hexagonal binning techniques that aggregate observations into density-based visualizations, providing better pattern recognition than conventional displays.

For qualitative agreement, problem prioritization consistency was assessed by calculating the proportion of first rater–identified problems that were similarly prioritized by the second rater. Additionally, Cohen κ coefficient was computed to evaluate interrater agreement across COPM domains (daily activity, productivity, and leisure) [26], with interpretation standards: <0.00 (none), 0.00 to 0.20 (slight), 0.21 to 0.40 (fair), 0.41 to 0.60 (moderate), 0.61 to 0.80 (substantial), and 0.81 to 1.00 (almost perfect agreement) [27].

All analyses were conducted using Python (version 3.12; Python Software Foundation; Matplotlib) with statistical significance set at P<.05, maintaining methodological consistency across comparisons in accordance with contemporary quantitative method evaluation standards.

The final sample consisted of 100 parents of children with physical disabilities. The children had a mean age of 5.4 (SD 2.7) years, with a near-even sex distribution (54 male children and 46 female children). The majority of respondents (n=83, 83%) were the children’s mothers. Detailed demographic characteristics are presented in Table 1.

The Arabic-COPM demonstrated excellent interrater reliability. The ICCs for the mean scores were 0.84 (95% CI 0.77-0.89; P<.001) for performance and 0.80 (95% CI 0.70-0.86; P<.001) for satisfaction.

Regarding qualitative agreement on problem identification, the first and second raters identified 460 and 450 problems, respectively. A high level of concordance was observed, with 338 (73.5%) of the 460 problems prioritized by the first rater being similarly prioritized by the second rater (Table 2). On the other hand, Cohen κ analysis across the COPM main categories (daily activity, productivity, and leisure) demonstrated slight-to-fair interrater agreement.

Regarding quantitative interrater agreement, Bland-Altman analysis with hexagonal binning visualization demonstrated strong quantitative agreement between raters for both performance and satisfaction scores. The LOA were narrow, ranging from −1.69 to 1.60 (mean bias −0.048, SD 0.84) for performance scores and from −1.03 to 0.98 (mean bias −0.024, SD 0.51) for satisfaction scores. The corresponding Bland-Altman plots (Figures 2 and 3), enhanced through hexagonal binning to visualize data density, show that most observations were clustered around the mean bias line and fell within the 95% LOA.

Supporting these findings, linear regression analysis revealed no evidence of proportional bias. The relationship between score differences and mean scores was nonsignificant for both performance (F_1,98=2.80; P=.10; R²=0.028; Figure 2) and satisfaction scores (F_1,98=0.83; P=.36; R²=0.008; Figure 3), indicating consistent agreement across the measurement scale.

The Arabic-COPM demonstrated excellent temporal stability, with test-retest reliability ICCs of 0.83 (95% CI 0.64-0.92; P<.001) for performance scores and 0.91 (95% CI 0.81-0.95; P<.001) for satisfaction scores.

In terms of test-retest quantitative agreement, Bland-Altman analysis, visualized through hexagonal binning plots (Figures 4 and 5), demonstrated strong quantitative agreement across the 2-week interval. The LOA were narrow, spanning from −1.43 to 1.51 (mean bias 0.04, SD 0.75) for performance scores and from −0.56 to 0.78 (mean bias 0.11, SD 0.34) for satisfaction scores. The density-based plots show a tight clustering of data points within the LOA, indicating minimal systematic drift and high measurement repeatability over time.

On the other hand, Cohen κ analysis across the COPM main categories (daily activity, productivity, and leisure) demonstrated slight-to-fair interrater agreement.

Across both raters, a total of 460 problems were identified by rater R and 450 by rater S (Table 2). The vast majority of parent-prioritized problems fell within the daily activity main category, accounting for 82% to 85% of all reported concerns. Within daily activity, parents expressed the greatest concern for the mobility subcategory, which represented approximately 50% of all identified problems for both raters.

The second most frequently reported main category was leisure (10%-11%), with parents primarily emphasizing difficulties in the physical recreation subcategory (≈5% of all problems). In contrast, productivity concerns were least commonly reported (5%-7%) and were almost exclusively related to the school subcategory, with no meaningful concerns in household or community tasks.

Within the daily activity category, the self-care subcategory represented a substantial proportion of the identified priorities. When examining self-care in more detail, parents reported the highest concern for dressing, followed by eating, with additional—but comparatively fewer—concerns related to toileting, bathing, and hygiene.

The Arabic-COPM exhibited excellent reliability metrics that meet or exceed established standards for outcome measures in rehabilitation. The high ICCs ranging from 0.80 to 0.91 across both interrater and test-retest evaluations indicate remarkable consistency between different clinicians and stability over time. Particularly noteworthy is the exceptional temporal reliability of satisfaction scores (ICC=0.91), suggesting that parental satisfaction with their child’s performance represents a particularly stable construct that can be reliably tracked throughout the rehabilitation process.

These reliability findings are generally consistent with several previous COPM studies conducted across different clinical populations and cultural contexts. Similar ICC ranges have been reported in patients with chronic obstructive pulmonary disease (approximately 0.90) [14], psychiatric disorders (approximately 0.85) [15], and ankylosing spondylitis (approximately 0.92) [13], supporting the stability of the COPM across diverse rehabilitation settings.

However, reliability findings in the broader COPM literature have not been entirely uniform. Some studies and reviews [28,29] have reported lower or more variable agreement levels depending on the assessed population, administration procedures, and methodological approaches. Such variability may reflect the individualized and semistructured nature of the COPM, in which participant priorities, interviewer interaction, contextual influences, and clinical interpretation can affect scoring consistency. Therefore, the findings of the present study should be interpreted within the context of the heterogeneous reliability literature surrounding the COPM.

These reliability findings demonstrate remarkable consistency with previous COPM validation studies across diverse populations and cultural contexts. The similarity of our ICC values to those reported in patients with chronic obstructive pulmonary disease (approximately 0.90) [14], psychotic disorders (approximately 0.85) [15], and ankylosing spondylitis (approximately 0.92) [13] suggests that the core client-centered methodology of the COPM maintains its measurement properties across linguistic and cultural adaptations. This cross-cultural consistency reinforces the fundamental robustness of the COPM framework while simultaneously validating the quality of the Arabic adaptation.

Beyond conventional reliability coefficients, our implementation of multiple agreement methodologies provides a more nuanced understanding of the measure’s performance. The Bland-Altman analyses with hexagonal binning visualization revealed narrow LOA with minimal systematic bias, demonstrating precise measurement characteristics at the individual score level. The 73.5% concordance in problem prioritization between independent raters indicates a moderate level of agreement between assessors. Although this finding supports a reasonable degree of consistency in the Arabic-COPM administration process, the remaining variability highlights the influence of interviewer interaction and individualized problem prioritization inherent in semistructured client-centered assessments.

When contextualized within the broader COPM literature, our interrater agreement rate of 73.5% falls between the agreement rates reported in other populations, reflecting the inherent balance between standardization and individualization in client-centered measures. This rate closely approximates the 80% agreement reported in similar pediatric populations [17] while substantially exceeding the 56% and 66% rates reported in stroke and mixed neurological populations [16,18]. This gradient likely reflects differences in cognitive clarity, goal stability, and the nature of therapeutic relationships across these diverse clinical populations.

The variability observed in qualitative agreement measures should not be interpreted as evidence against standardization or measurement consistency. The COPM combines standardized scoring procedures with a semistructured individualized interview format. Although individualized problem identification and interviewer interaction may introduce some variation in prioritized responses across assessors, the strong quantitative reliability findings observed in the present study suggest that the Arabic-COPM maintains acceptable measurement consistency within a structured client-centered assessment framework.

The pattern of problem prioritization revealed important insights into the concerns of Arabic-speaking families of children with physical disabilities. The overwhelming focus on daily activities (82%-85%), particularly mobility and self-care functions such as dressing and eating, provides empirical support for Maslow hierarchy of needs within this specific cultural and clinical context [30]. As Duncan and Blugis [31] articulated in their pediatric adaptation of this framework, families naturally prioritize fundamental needs related to nourishment, personal care, and basic functioning before addressing higher-order productivity or complex leisure pursuits.

This prioritization pattern reflects both practical caregiving realities and developmental aspirations. Parents intuitively recognize that mastery of basic mobility and self-care skills not only reduces caregiver burden but also serves as the essential foundation for peer socialization, educational participation, and eventual transition toward independent living. The predominance of mobility and self-care concerns identified in the present study suggests that families primarily prioritize essential daily functioning needs when identifying rehabilitation goals for children with physical disabilities. In contrast, productivity-related concerns were less frequently reported. These findings may reflect the central importance of functional independence in early pediatric rehabilitation and emphasize the practical relevance of addressing basic daily activities within family-centered rehabilitation planning.

The consistency of these findings with previous research involving children with cerebral palsy [32] suggests that these fundamental concerns may transcend specific diagnostic categories within the broader population of children with physical disabilities.

Although this study establishes the fundamental reliability of the Arabic-COPM, several limitations warrant consideration. The scope of this validation study did not permit exploration of how problem prioritization might vary according to disability severity, socioeconomic factors, or cultural subgroups within the Arabic-speaking population. Another limitation is that absolute reliability indices such as the SE of measurement were not evaluated in the present study. Additionally, CIs for descriptive percentage estimates were not calculated and should be considered in future psychometric studies. Future research should investigate these potential moderating variables to provide more nuanced guidance for clinical implementation. Additionally, the focus on reliability represents only the first step in comprehensive instrument validation. Subsequent studies should establish the responsiveness, minimal clinically important differences, and convergent validity of the Arabic-COPM to fully characterize its measurement properties.

Notwithstanding these limitations, our findings provide strong evidence supporting the integration of the Arabic-COPM into clinical practice throughout the Arabic-speaking world. The measure offers rehabilitation professionals a reliable, culturally adapted tool to authentically engage families in the goal-setting process. The consistent prioritization of basic daily activities underscores the importance of addressing these fundamental concerns as the foundation of any comprehensive rehabilitation program.

In conclusion, the Arabic-COPM demonstrates excellent reliability and clinical utility for implementing family-centered care in pediatric rehabilitation. Its successful validation opens new possibilities for standardized outcome measurement and culturally responsive service delivery across Arabic-speaking communities, ultimately supporting improved rehabilitation outcomes for children with physical disabilities and their families.