Translation and cross-cultural adaptation of the International Hip Outcome Tool (iHOT) into Portuguese.

OBJECTIVE: iHOT12/33 is an outcome tool designed for young patients with hip problems. The objective of this study is to translate and establish a cross-cultural adaptation of this questionnaire to Portuguese.
METHOD: The Guillemin guidelines were followed for the translation and cross-cultural adaptation consisting on: translation, back-translation, prefinal version, administration of the Questionnaire, and editing of the final version.
RESULTS: The prefinal version was applied to 30 young patients with hip problems. Some difficulties in understanding some of the words and expressions were noted, and these were replaced with simpler ones, achieving the patient's full acceptability in the final version of the Questionnaire.
CONCLUSION: The creation of the Brazilian version of the International Hip Outocome Tool (iHOT) 12/33 enables this questionnaire to be used in the evaluation of patients with hip problems in Brazil, and was clearly understood, with good acceptance by the patients tested. Level of evidence II - Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

INTRODUCTION

Evidence-based medicine has been in the limelight in recent decades, due to the possibility of objective evaluation of a large number of conditions. Several hip outcome scores were created.[1,2] Although the initial description of the femoroacetabular impact was made by Burmann[3] in 1931, hip injuries have only recently attracted considerable interest in the literature.

The first tools for evaluating patients with hip disorders, such as that of D'Aubigné and Postel,[4] and the Harris Hip Score,[5] were designed for not very active patients with arthritic hips. On the other hand, questionnaires for quality of life evaluation are broader and less specific, such as the SF36, which evaluates function, emotional problems, pain, physical and mental health.[6,7]

With the development of different techniques for treating non-arthritic hips later on, tools were developed to evaluate this young population. These included the Harris Hip Score modified by Byrd (MHHS),[8] the Hip Outcome Score (HOS),[9] and the Non-arthritic Hip Score (NHS).[10] However, a recent study[11] demonstrated that we are still lacking a PRO, or patient-reported outcome, questionnaire with answers that are collected directly from the patient through an interview or self-completion questionnaire, for the evaluation of young and active patients with limitations or pain in the hip and groin.

The International Hip Outocome Tool (iHOT) is a self-completion questionnaire. The questions are divided into four domains: I -symptoms and functional limitations, II - Sports and recreational activities, III - Job related concerns and IV - Social, emotional and lifestyle concerns, totaling 33 questions. These questions are evaluated through a visual analogue scale with a line that should be 100mm long. The question is answered by marking the line with a slash. Thus, each question can be answered from 0 to 100 points or 0 to 100%. The final score is the sum of the answered questions, divided by the total number of answered questions.

Most questionnaires used in orthopedics are developed and validated in English.[12] The cross-cultural adaptation of a self-administered questionnaire (as is the case of iHOT33) to a new country, culture or language needs a unique methodology to achieve equivalence to the original questionnaire and its target. Nowadays it is recognized that the translation must not only be linguistically perfect but also well adapted in cultural terms, maintaining the context between the different cultures.[13,14]

The aim of this study is to translate and to culturally adapt the versions of the iHOT questionnaire of 12 and 33 questions to the Portuguese language.

MATERIAL AND METHOD

The translation and cross-cultural adaptation method used in this study was advocated by Guillemin et al., [13] composed of four stages: translation, back-translation, preparation of a consensus version, commented pretest and creation of the final version.

The iHOT33 questionnaire in its original version was translated into Portuguese by two bilingual sworn translators, with Portuguese as their native language and proficiency in English, generating the translations T1 and T2. The two versions were compared and analyzed, with summarization performed by a multidisciplinary team, called T12.

Then the T12 version was translated back into English by two native translators (English as their first language), fluent in Portuguese and with Brazil as their country of residence. These translators were not familiar with the original version in English.

Afterwards the four translations obtained were assessed by a multidisciplinary committee in order to correct discrepancies by means of comparison with the original text and to draft a consensus version. The questionnaire items had the conceptual and idiomatic semantics preserved. The 12-question version was created on a basis of the translations of the questions of iHOT33.

With the consensus versions, the pretest was conducted with the participation of patients from the outpatient section of the Hip Group of the Department of Orthopedics and Traumatology of Irmandade da Santa Casa de Misericórdia de São Paulo. Thirty young patients (under 40 years of age) with hip pain were selected for the study group, with half being submitted to iHOT12 and half to iHOT33. Understanding and acceptability of the questionnaire were assessed during this stage, with the creation of a report.

After this stage, a meeting was held among the questionnaire appliers to point out the difficulties encountered by the patients and to suggest terms of easier understanding.

The final Portuguese versions of the International Hip Outocome Tool (iHOT) were prepared with a basis on such suggestions, with explanations between parentheses for those expressions and phrases considered hard to interpret. Afterwards these versions were reapplied to the same patients.

The authors of the original questionnaire approved the stages of the process and the final Portuguese version.

RESULTS

Most of the questions obtained semantic concordance after the back-translation process, when compared with the original version. Some difficulties were encountered in questions number 2, 14, 21 and 28.

In question number 2, both Brazilian translators used the term " rígido" to translate the English word "stiff". In executing the back-translation, the term was replaced by "difficult to move", as one of the translators was in doubt about the use of the term "rigidez" in Portuguese. In applying this question 2, patients had difficulty understanding this term, but the issue was resolved by associating the word " duro" (hard) between parentheses with the original question.

There was a debate about the terms grinding, catching and clicking in question number 14. One of the translators opted for rangidos, travadas e estalos, while the other did not do a literal translation and added the notion of movement to the question. During a meeting we decided to send the first alternative for back-translation. The back-translators partially agreed on the terms, maintaining the meaning by making use of words and onomatopoeias similar to the original version.

In question number 21 the translation chosen to be sent to the native translators "Quanto você se preocupa em interromper/mudar o rumo nos seus esportes ou atividades recreativas" ("How concerned are you about cutting/changing directions during your sport or recreational activities") gave rise to ambiguity, increasing the distance between the back-translation and the original text. Thus we opted to use the term "mudanças rápidas de direção" ("fast changes of direction").

In question 28, the back-translation of the Translation (T12) generated disagreement between the back-translators with regards to the quantification of the noun "problema" ("trouble") in sexual activity. They opted for: "Quanto sua atividade sexual é prejudicada por causa do seu quadril?" ("How much trouble do you have with sexual activity because of your hip?"), obtaining good comprehension by the patients from the outpatient clinic. Three patients complained that they did not understand the last question "Quanto do seu tempo você tem consciência da deficiência em seu quadril?" (How much of the time are you aware of the disability in your hip?", requesting further clarifications from the evaluator. In the final version reapplied to the patients, the sentence "Você se preocupa constantemente com seu problema de quadril?" ("Do you worry constantly about your hip problem?") obtained better acceptance by the patients.

One patient had difficulty with the questionnaire completion instructions, not understanding the method for marking the visual analogue scale, rendering the questionnaire useless. After verbal explanation the questionnaire was properly completed.

After the above alterations with the questionnaires now in the final version, they were reapplied to the patients obtaining 100% of understanding. The final versions of both questionnaires can be seen in Attachments 1 and 2.

DISCUSSION

The comparison of results of different scientific studies such as effectiveness of treatments, whether clinical or surgical need evaluation protocols. However, most outcome tools are only available in the English language, precluding the comparison of trials carried out in our country.

iHOT is a self-applicable questionnaire of 12 or 33 questions that encompass four domains: functional limitations, sports/recreation, work and lifestyle. As it is a new questionnaire, published in 2010, the national version is not yet available.

The work of Guillhemin et al. [13] establishes that translations of these questionnaires should not only be of good literal quality, but also be a cross-cultural adaptation. It promotes the necessity of a single method for these adaptations. The application of any questionnaire in a place other than where it was created can encounter five situations according to the author, ranging from total cultural and linguistic incompatibility to total concordance. (Table 1)

Table 1

Possible situations in which some form of cross-cultural adaptation is necessary.

	Need to use the questionnaire in the following populations:	Result in modification		Necessary adaptation
		Cultural	Language	Country of use	Translation	Cultural adaptation
A	Same population. Without changes in the culture, language or country of origin	---	---	---	---	---
B	Use on immigrants already established in the source country	✓	---	---	---	✓
C	Use in another country with the same language	✓	---	✓	---	✓
D	Use on new immigrants who are not fluent in English, but in the same source country	✓		---	✓	✓
E	Use in another country, and with another language	✓	✓	✓	✓	✓

The testing of the proposed questionnaire is of extreme importance since some terms might not be fully understood by the patients undergoing the study. Adaptations were necessary in relation to the method of quantifying problems, words referring to symptoms, adaptations of onomatopoeias, or even simplifications of some terms common in the English language, yet of less habitual use in Portuguese.

Cross-cultural adaptation targets consistency of content between the versions of the original questionnaire and target language. However, it is important to remember that subtle differences in living habits in different cultures cause a questionnaire item to be more or less hard to understand, and may alter the psychometric and statistical properties of the tool, hindering comparisons between scientific studies of populations with a different language and culture.[15,16]

The iHOT 12/33[1] questionnaires are designed for the evaluation of young patients with hip problems. The need to create a questionnaire focused on this active population arises from the "Ceiling Effect" which occurs with the use of other scores such as the HHS, which are originally designed to evaluate an elderly, not very active population with arthritic hips. Using these scores, a professional athlete reaches a score that is always high, in spite of the complaint and limitation of performance resulting from his or her hip problem. The low sensitivity to limitations in high-demand activities is due to the importance that traditional questionnaires give to factors such as: "walking two to three blocks", "climbing stairs" or "traveling by public transport". Thus the evaluation of the surgical outcome in youths is hindered as the patients invariably reach high scores that would be interpreted as satisfactory results.[1]

Faced with this problem, the MAHORN Group started out on its mission of creating a valid questionnaire for this young and active population, making use of a well-established methodology. More than 500 patients were assessed, and the group generated an extensive questionnaire of 160 questions created by the patients. The patients who answered this questionnaire chose the questions of greatest importance, and based on the analysis of these data the group created two questionnaires with 12 or 33 questions.

The versions with 12 and 33 questions proved equivalent in the analysis of the surgical results of different pathologies, yet some domains can demonstrate subtle differences only in iHOT33. The MAHORN group suggests the routine use of iHOT 12 and the use for research of iHOT33. [1]

The translation of both questionnaires enables the use of these tools for analysis of surgical outcomes in our country, both for routine use, in the doctor's office, and for use in scientific research.[1,13]

CONCLUSION

The stages used for the preparation of Brazilian version of iHOT12 and 33 allowed these tools to be made available for the evaluation of patients undergoing hip surgery in our country, with good comprehension and acceptance among the patients tested.