Reliability of the Arabic Egyptian Version of Short Form 36 Health Survey Questionnaire to Measure Quality of Life in Burned Patient

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1 Med. J. Cairo Univ., Vol. 84, No. 2, June: , Reliability of the Arabic Egyptian Version of Short Form 36 Health Survey Questionnaire to Measure Quality of Life in Burned Patient REHAM A. EL-KALLA, M.Sc.*; MOHAMED M. ABD EL-KHALEK KHALAF, Ph.D.**; MAMMDOOH A.A. SAAD, Ph.D.*** and EMAN M. OTHMAN, Ph.D.** The Department of Burn & Surgery, Faculty of Physical Therapy, Cairo & Badr Universities*, The Department of Burn & Surgery, Faculty of Physical Therapy, Cairo University** and The Department of Statistics, Faculty of Commerce, Ain Shams University*** Abstract Background: Burns are one of the most significant health problems throughout the world. Burn patients often have physical, psychological and social problems affecting their quality of life. In Egypt there is no Arabic assessment tool of quality of life of burned patients. SF-36 is one of the most widely-used QOL evaluation tool in the world. Objectives: The aim of the study was to examine the reliability of the Arabic version of short form 36 health survey questionnaire to measure the recovery of quality of life of burn survivors. After translating and culturally adapting SF- 36 from English to Arabic language. Methods: Arabic translation and adaptation of the SF-36 scale were obtained by the "forward/backward translation" method. Then forty patients of both sex (22 males and 18 females) had been selected randomly from Outpatient Physical Therapy Clinic (Burn and Surgery Unit) Cairo University, Om El-Masreen Hospital and Ahmed Maher Hospital from May 2015 to March All of them were suffered from burn injury ranged from TBSA% affecting upper and lower limbs. Their age were ranged from 20 to 40 years. They were asked to fill the Arabic version of SF-36 questionnaire twice with one week interval between them with the same investigator. Results: The 40 patients completed the reliability test for Arabic version of the SF-36. The internal consistency of Arabic version of the SF-36 was assessed by Cronbach alpha coefficient. The Cronbach alpha was good ( a=0.8). Test-retest reliability was assessed using Pearson Correlation Coefficient (PCC). There was a strong direct relationship between prescore and post-score (PCC=0.873). Conclusion: This study demonstrated that the Arabic SF- 36 is a reliable measure of quality of life for Egyptian burned patients to document the efficacy of physical as well surgical intervention after burn. Key Words: Burns-quality of life SF-36 Reliability Adaptation. Correspondence to: Dr. Reham A. El-Kalla, The Department of Burn and Surgery, Faculty of Physical Therapy, Cairo and Badr Universities, Introduction BURNS is one of the main injuries endangering human public health worldwide, especially in extensive burn patients with critical conditions which put them at an extremely high risk of suffering from various complications. Burn patients constitute a heterogeneous population with wide variation in age, mechanism of injury, depth and site of burn and with a high level of comorbidity. The outcome therefore varies considerably, with various types of impact on all aspects of a person's life and sometimes with permanent impairments [1]. Burns have not only physical but also psychological consequences both during and after hospitalization. The goal of burn treatment today incorporates the importance of returning the burned person to their roles with equal potential and an acceptable level of social reintegration [2]. By identifying the mainly impaired areas of a patient's Quality of Life (QoL) the assessment of subjectively perceived QoL impairment can also provide an indicator of the outcome of the medical and psychological treatment [3]. It was in 1948 when World Health Organization defined health as 'not only the absence of disease and infirmity but also the presence of physical, mental, and social well-being'. Recently Health Related Quality of Life (HRQoL) has become more important in health research in general and particularly in burn care, probably due to improved survival as result of intensive care [4]. Prior to the 1980's, survival was the mark of success for burn trauma patients with little attention given to long-term health outcomes or quality of life following limited reconstruction of burn injuries. Quality of life (QoL) is a variable and very 311

2 312 Reliability of the Arabic Egyptian Version of Short Form 36 Health Survey Questionnaire complex concept, which includes many indicators such as satisfaction, liberty of choice, life style and mental behaviour. Its assessment requires adapted and validated scale. Several scales have been used to measure different QoL domains in several pathologies many of which were developed and validated in English requiring translation and adaptation to varying cultural contexts and languages [5]. The 36-item Short Form Health Survey (SF- 36) is one of the generic QoL tools which can be used in clinical practice and research, to evaluate, follow and supervise population health status [6]. It was listed as an evaluation tool by an international quality evaluation project in 1991 [7]. SF-36 is a multidimensional questionnaire that assesses eight different aspects of health. It is generic by nature which means that it as opposed to disease-specific measures can be used to measure and compare outcomes across different diseases and treatments. This feature has made generic measures of health related quality of life increasingly popular among researchers and clinicians and the SF-36 has become the most frequently used measure across a wide range of range of conditions [8]. Culturally adapting a health questionnaire, rather than developing a new one, is preferred, as it is more economical, faster, and it may facilitate future comparisons. It also allow the researcher to compare data from different samples and from different backgrounds, which enables greater fairness in the evaluation because the same instrument assesses the construct based on the same theoretical and methodological perspectives [9,10]. There is increased need to determine the reliability of cross culture adaptation of SF-36 questionnaire to be used with confidence in the Arabic community. Material and Methods Forty patients of both sex (18 females and 22 males) had been treated in Outpatient Physical Therapy Clinic (Burn and Surgery Unit) Cairo University, Om El-Masreen Hospital and Ahmed Maher Hospital as a result of previous burn injury affecting upper and lower limbs with burn ranged from 20-30% TBSA. Their age were ranged from 20 to 40 years. Inclusion criteria: Patients with surface area (20-30 TBSA %) affecting upper and lower limbs. Patients with second degree partial thickness burn. Patients have burn from 2-6 months ago. All participants were able to read and write in Arabic. All of them understand the benefits of the health survey questionnaire (SF-36). Exclusion criteria: Patients with burn less than 20% TBSA or more than 30% TBSA. Patient with mental problems. Patient with any other chronic illnesses (renal failure, heart failure, coronary artery diseases, liver cirrhosis or hepatic failure). Patient with communication, vision or hearing disorders. Patient who didn't fill the questionnaire till the end. Patient who weren't cooperative in filling the questionnaire. The SF-36 is a generic scale to measure QoL. It is a multipurpose, short form health survey with only 36 questions it yields an 8-scale profile of functional health and well-being scores: Physical Functioning (PF), role limitations due to Physical Problems (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), role limitations due to emotional problems (RE), Mental Health (MH), and one single item scale on health transition [6]. The first 4 subscales form the Physical Composite Scale (PCS) and the last 4 form the Mental Composite Scale (MCS). SF-36 is suitable for self-administration, computerized administration, or administration by trained interviewer face to face or through phone call [11]. Score ranges from 0 to 100, with higher score indicating higher level of function and/or better health and lower score indicating lower level of function and/or bad health. Translation-adaptation: We applied standard version of SF-36 questionnaire to forward/backward translation procedure. - Forward translation: Translation was carried out by two professional bilingual translators with excellent proficiency in English (Native Arabspeaking people). The translation made in the Egyptian dialect closest to the Arabic literary. Translators were encouraged to strive for idiomatic rather than word-for-word translation. None of them was familiar with this type of instrument. The investigators reviewed the translations to make cultural adaptations. Synthesis of the translations led to a unique version.

3 Reham A. El-Kalla, et al Backward translation: Two other Arabic translators then carried out a translation of this revised Arabic version into English, to verify if the meaning of the items were preserved. If there is translation difficulties, cultural diversity and vocabulary differences it were highlighted by this translation technique [12]. - Expert committee review: The committee reviewed all the translations versions of the questionnaire and the original questionnaire to ensure equivalence between the source and target version, then expert committee developed the pre-final version of the questionnaire for field testing. - Testing of pre -final version of the adapted questionnaire: The pre-final Arabic version of the questionnaire was administrated to five patients and they were asked for any difficulties in understanding or dealing with any item of the questionnaire. If there was problem in one or more than item it was reviewed with expert in linguistics for its modification. Reliability the reliability of SF-36 was assessed by test-retest procedure (intra-rater reliability). The questionnaire was administered twice during a 6- to 8 day interval by the same investigators to forty patients. This interval was chosen to avoid variations in clinical status and patient's remembering previous answers. Before the second assessment, patients were asked if they feel change in their clinical status. Only patients who fell clinically stable were tested twice. Test-retest reliability was measured by using Pearson Correlation Coefficient (PCC) and internal consistency was measured by using Cronbach's alpha coefficient. Results After translation and adaptation a final Arabic SF-36 was obtained, then the questionnaire administrated to 40 patient with burn injury from 20-30% TBSA affecting upper and lower limbs their ages ranged from and the duration from injury from 2-6 months were asked to complete the adapted Arabic SF-36 twice with one week interval with the same researcher, then the day were statistically analyzed using SPSS Subjects description: Table (1) shows the characteristics of 40 subjects with both upper and lower limbs. Categorical variables were expressed as a number with the percentage in parenthesis. 2- Reliability: The 40 patients completed the reliability test for Arabic version of the SF-36. Reliability was investigated through assessment of internal consistency and test-retest reliability. The internal consistency of Arabic version of the SF-36 was assessed by Cronbach alpha coefficient. Table (2) shows the Cronbach alpha for the gobal score of SF-36 and for each 8 subscales every scale. The Cronbach alpha was acceptable. Scale test-retest reliability was assessed using Pearson Correlation Coefficient (PCC). There was a strong direct relationship between pre-score and post-score. The PCC was strong (PCC=0.873) with p-value=0.00 (Table 3) & Fig. (1). Table (1): Demographic and clinical characteristics of the sample. Characteristics Results N % Age: Age < Age > TBSA: 20% % % % Gender: Female Male Education: Low Medium High Duration: 2 M M M M M Table (2): Cronbach alpha coefficient for 8 scale of SF-36. Scale Items Reliability (Alpha) Pre Physical Functioning (PF) Role Functioning/Physical (RP) Role Functioning/Emotional (RE) Energy/fatigue (VT) Emotional well-being (MH) Social Functioning (SF) Pain (BP) General Health (GH) SF-36 global score

4 314 Reliability of the Arabic Egyptian Version of Short Form 36 Health Survey Questionnaire Table (3): Correlation analysis between the pre-score and post-score. Scale Pre Score Pearson correlation coefficient Coefficient p- value Physical Functioning (PF) Pre Role Functioning/physical (RP) Pre Role Functioning/Emotional (RE) Pre Energy/fatigue (VT) Pre Emotional well-being (MH) Pre Social Functioning (SF) Pre Pain (BP) Pre General Health (GH) Pre SF-36 global score Pre Fig. (1): Scatter plot demonstrates a strong direct relationship between the pre-score and post-score. Discussion This study attempted to translate and culturally adapting SF-36 questionnaire into Arabic language following a systematic standardized approach. The study was performed in two main steps. First was the translation process from the original English version of the questionnaire into Arabic one according to the published guidelines and the second was the determination of its psychometric characteristics. The process of translation and cross culture adaptation of SF-36 followed the international guidelines. The translation and adaptation had been made closest to Egyptian dialect in order to be more understandable and clear for Egyptian people so this adaptation might be unsuitable to use in other Arab countries and limited to use in Egypt. In review of other Arabic SF-36 versions there were other three Arabic versions of SF-36. One of them was held in Saudi Arabia [13], one was held in Tunisia [14] and the other one was in Jordon [15]. All of them were tested for use with general population. The reliability study performed by forty patients which were asked to fill the Arabic version of SF- 36 questionnaire twice with one week interval between them with the same investigator (interrater reliability). The reliability of SF-36 was assessed by testing internal consistency of Arabic version of the SF-36 which was assessed by Cronbach alpha coefficient. The Cronbach alpha for the global score of Arabic Egyptian SF-36 was 0.8 which is considered high. When compared with the original English version Cronbach alpha was greater than 0.85 which mean that internal consistency of the Arabic version was lower than English one. When compared with other Arabic versions the cronbach alpha coefficient of Jordon SF-36 was 0.70 for all 8 scales, also Cronbach alpha for Arabic Tunisian was In Saudi Arabia version Cronbach alpha was 0.7 which mean that internal consistency of the Egyptian one was lower than Tunisian version and higher than Saudi Arabian and Jordon version. When comparing internal consistency between SF-36 subscales in different versions, cronbach alpha for VT subscale was considerd low in the Egyptian (0.60), Tunisian (0.72) and Jordon (0.71) versions relative to the English one (0.96). RE subscale scale cronbach alpha was high in the English (0.96) and Arabic Egyptian one (0.95) relative to others. PF subscale cronbach was high in the English (0.93) and Arabic Jordon versions (0.9) relative to others. RP subscale cronbach was high in English (0.96) relative to other vesions. GH subscale cronbach was low in Arabic Jordon and Saudi versions (0.6). SF subscale cronbach was low in the Arabic Egyptian version (0.6). SF subscale cronbach was low in the Arabic Egyptian version (0.6). Test-retest reliability was assessed using Pearson Correlation Coefficient (PCC). It concluded that there was a strong direct relationship between pre-

5 Reham A. El-Kalla, et al. 315 score and post-score (PCC=0.873) it ranged from 0.54 for VT subscale to 0.91 for RE subscale when compared with the Tunisian version test retest was assessed by intraclass correlation coefficient which was excellent (ICC=0.98). The correlation coefficient for the original English version was greater than for all subscales except social functioning it was From this study, it concluded that Arabic Egyptian SF-36 is reliable enough to be used for measuring quality of life of Egyptian burn patients. Conclusion: The Arabic version is reliable enough to measure quality of life of burned patients so we can trust it in assessment of efficiency of medical as well as physical therapy treatment of Egyptian burned patients. References 1- ESSELMAN P.C.: Burn rehabilitation: an overview. Arch. Phys. Med. Rehabil., 88: S3-6, FALDER S., BROWNE A., EDGAR D., STAPLES E., FONG J., REA S., et al.: Core outcomes for adult burn survivors: A clinical overview. Burns, 35: , DYSTER-AAS J., WILLEBRAND M., WIKEHULT B., GERDIN B. and EKSELIUS L.: Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. Journal of Trauma, 64: , KLEIN M.B., LEZOTTE D.L., FAUERBACH J.A., HERNDON D.N., KOWALSKE K.J. and CARROUGH- ER G.J.: The National Institute on disability and rehabilitation research burn model system database: A tool for the multicenter study of the outcome of burn injury. J. Burn Care Res., 28: 84-96, ALONSO J., FERRER M., GANDEK B., WARE J.R.J.E., AARONSON N.K. and MOSCONI P.: Health-related quality of life associated with chronic-conditions in eight countries: Results from the International Quality of Life Assessment (IQOLA) Project. Qual Life Res., 13: , BRAZIER J.E., HARPER R., JONES N.M., CATHAIN A., USHERWOOD T. and WESTLAKE L.: Validating the SF-36 health survey questionnaire: New outcome measure for primary care. B.M.J., 305 (6846): 160-4, BRAZIER J.: The SF-36 health survey questionnaire-a tool for economists. Health Econ., 2: 213-5, BUSIJA L., PAUSENBERGER E., HAINES T.P., HAYMES S., BUCHBINDER R. and OSBORNE R.H.: Adult measures of general health and health-related quality of life: Medical outcomes study Short Form 36-item (SF- 36) and short form 12-item (SF-12) health surveys, Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), medical outcomes study Short Form 6D (SF-6D), health utilities index mark 3 (HUI3), Quality of Well- Being scale (QWB), and Assessment of Quality of Life (AQOL). Arthritis Care Res., 63: , ESCOBAR BRAVO M.A.: Transcultural adaptation of measurement instruments related to health in Spanish. Enfermeria Clinica, 14: 102-6, TERWEE C.B., BOT S.D., De BOER M.R., VAN DER WINDT D., KNOL D., DEKKER J., et al.: Quality criteria were proposed for measurement properties of health status questionnaires. J. Clin. Epidemiol., 60: 34-42, MONTAZERI A., GOSHTASEBI A., VAHDANINIA M. and GRANDEK B.: The short form health survey (SF- 36): Translation and validation study of Iranian version. Quali. Life. Res., 14: , GUERMAZI M., YAHIA M., KESSOMTINI W., ELLEUCH M., GHROUBI S. and OULD S.A.: Functional disability indexes: Translation difficulties and crosscultural adaptation Problems. Tunis. Med., 83 (5): , ABDULMOHSIN S.A.AL, COONS S.J., DRAUGALIS J.R. and HAYS R.D.: Translation of the RAND 36-Item Health Survey into Arabic. Published, 1997 by RAND, GUERMAZI M., ALLOUCH C., YAHIA M., HUISSA T.B.A., GHORBEL S., DAMAK J., MRAD M.F. and ELLEUCH M.H.: Translation in Arabic, adaptation and validation of the SF-36 Health Survey for use in Tunisia. Annals of Physical and Rehabilitation Medicine, 55: , ABURUZ S., WSVA N., TWALBEH M. and GAZAWI M.: The validity and reliability of the Arabic version of the SF-36: A study from Jordan. Ann. Saudi Med., 29 (4): 304-8, 2009.

6 316 Reliability of the Arabic Egyptian Version of Short Form 36 Health Survey Questionnaire

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