Translation and cultural adaptation of the Harris Hip Score into portuguese

Abstracts

OBJETIVO: O Harris Hip Score é instrumento de avaliação específica, desenvolvido originalmente para avaliar os resultados da artroplastia total de quadril. O objetivo deste estudo foi traduzir e adaptar culturalmente este instrumento para a língua portuguesa. MÉTODO: O método de tradução e adaptação cultural do Harris Hip Score envolveu quatro etapas: 1 - tradução inicial; 2 - retrotradução; 3 - apreciação das versões com elaboração da versão de consenso; 4 - pré-teste comentado com elaboração da versão final. RESULTADOS: A versão de consenso foi aplicada em 30 pacientes com afecção do quadril, sendo verificadas dificuldades no entendimento de algumas expressões, as quais foram substituídas por termos de mais fácil entendimento. Na reaplicação do questionário com a nova versão houve entendimento por 100% dos pacientes no que diz respeito ao sentido semântico, idiomático e contextual. CONCLUSÃO: A versão brasileira do Harris Hip Score permitiu a disponibilização de mais este instrumento para avaliação da qualidade de vida de pacientes com afecções do quadril. Há necessidade de um estudo de avaliação da confiabilidade e validade da versão adaptada culturalmente, a qual já está em desenvolvimento.

Artroplastia do quadril; Qualidade de vida; Tradução

ORIGINAL ARTICLE

Department of Orthopedics and Traumatology of Irmandade da Santa Casa de Misericórdia de São Paulo

Mailing address

ABSTRACT

OBJECTIVE: The Harris Hip Score is a specific evaluation tool, originally developed to assess the results of hip arthroplasty. The objective of this study was to translate and cross-culturally adapt the Harris Hip Score for the Portuguese language.

METHOD: The method of translating and culturally adapting the Harris Hip Score involved four steps: 1 - initial translation, 2 - back-translation, 3 - evaluation of the pre-final versions with the development of a consensus version, 4 - commented pre-test with development of the final version.

RESULTS: The consensus version was applied to thirty patients with hip disorders. Some difficulties were identified in understanding some expressions, which were replaced by more commonly-used expressions. When the questionnaire was re-applied, it was understood by 100% of the patients, in relation to the semantic, idiomatic and conceptual meanings.

CONCLUSION: The Brazilian version of the Harris Hip Score provides another important tool for assessing quality of life of patients with hip disorders. A further study is currently underway to evaluate the reliability and validity of the culturally adapted version.

Keywords: Hip arthroplasty. Quality of life. Translation (product).

INTRODUCTION

Starting in the 1960's, total hip arthroplasty (THA) has been a revolutionary treatment for elderly patients with osteoarthritis, exhibiting good long-term results, and is today among the orthopedic surgeries of greatest success. Younger patients submitted to THA manage to regain quality of life including activities of considerable physical demand.¹ Around 800,000 THA's are performed worldwide on an annual basis, and it is estimated that this number will increase in the future.² It is a surgical procedure widely used for the treatment of ailments of the coxofemoral joint (hip joint), whether degenerative, inflammatory or traumatic.³

In the last few years changes have occurred in the outcomes used in the analysis of the effectiveness of clinical or surgical treatments in orthopedics. Outcomes such as quality of life related to health, functional capacity, pain and satisfaction scales have been emphasized as they enable the analysis of the state of health and manifestations of disease in individuals' lives. Consequently instruments, questionnaires and scales that address this type of variable were developed and published. These can be classified as: generic and specific. The generic ones quantify the patient's of his or her general state of health, while the specific ones target specific areas of the body and can measure function with greater responsiveness than a scale that assesses the state of health as a whole.⁴

Among the clinical scores developed to evaluate hip ailments, one that merits special emphasis is the Harris Hip Score, a scale recognized and used worldwide.^2-7

The Harris Hip Score is a specific evaluation tool, originally developed in 1969 to assess THA results, and widely used as a result comparison method. It was compared with the Larson and Shepard system, and reproducibility and objectivity were found.^5,7 It presents a scale with the maximum of 100 points, including evaluation of pain, function, deformity and motion. Pain and function have the highest weight (44 and 47 points). Range of motion and deformity are of primary importance, receiving 5 and 4 points respectively. Function was divided up into daily life activities (14 points) and gait (33 points). A total score below 70 points is considered a poor result, 70 to 80 reasonable, 80 to 90 good and 90 to 100 excellent.^5,7

Studies are available on the responsiveness of the Harris Hip Score in the evaluation of results after hip arthroplasty. The results show high responsiveness in the rates for the Harris Hip Score when compared with generic scales such as the Short Form-36 (SF36).^8-12

Most questionnaires used in orthopedics were developed in the English language. When there is an assessment protocol described and validated in another language, it is necessary to standardize the cross-cultural equivalence methodology in the language to be used for this protocol to be employed.⁴

Historically, the adaptation of tools prepared in other language was limited to the simple translation of the original or, exceptionally, to the literal comparison of the latter with retrotranslated versions. Nowadays, however, it is acknowledged that, if measures must be used by means of cultures, the items should not just be well translated linguistically, but should also be adapted culturally, to maintain the validity of the tool's content at a conceptual level.^13,14

With the development of translation and cultural adaptation methods it is absolutely possible for a tool developed for use in a given language and culture, to also be used, after translation and adaptation, in another language and in another cultural context.¹⁵

The aim of this study is to translate and to culturally adapt the Harris Hip Score assessment tool to the Portuguese language.

MATERIAL AND METHOD

The method of translation and cultural adaptation of the Harris Hip Score used the criteria described by Guillemin et al.¹³, which involved four stages: initial translation; back-translation; examination of the versions with preparation of a consensus version; and commented pre-test with development of the final version.

Initially the Harris Hip Score questionnaire in its original English version was translated into Portuguese by two bilingual independent sworn translators (T1 and T2), who had Portuguese as their native language and fluency in the English language. One of the translators was supposed to have knowledge in the area of health. After this the two versions were compared and analyzed, arriving at the synthesis of the two translations.¹³

In the next stage the synthesized version was translated back into the English language by another two bilingual translators (R1 and R2), whose native language was English, with fluency in the Portuguese language and residing in Brazil. The translators responsible for the back-translation were not supposed to be familiar with the original version of the questionnaire in English.¹³

Next the two translations obtained were assessed by a committee, formed by translators, health care professionals (one physician and three physiotherapists) and a Portuguese teacher in order to correct discrepancies by means of comparison with the original text and to prepare a consensus version. The questionnaire items had the idiomatic and conceptual semantics preserved.^14-16

With the consensus version the pre-test was conducted with the participation of patients from the hip group of the Department of Orthopedics and Traumatology of Irmandade da Santa Casa de Misericórdia de São Paulo in treatment for a hip ailment, for evaluation of comprehension, acceptability of the tool and for the performance of any necessary alterations. This pre-test was carried out with 30 patients.¹⁶

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

The final Portuguese version of the Harris Hip Score was prepared with a basis on suggestions, including some explanations between parentheses for those expressions considered hard to understand. Afterwards the questionnaire was reapplied to the same patients.

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

RESULTS

Table 1 presents the items of the original translation version, of the back-translations and of the consensus version of the HHS (pre-test).

The versions prepared by the translators (T1 and T2) for the items and sub-items of the assessment questionnaire were identical, with exception:

In item I (Pain) and sub-item D, the translators opted to simplify the expression "stronger than aspirin" using "analgésico simples" (simple analgesic), which is better suited to our milieu.

In item II (Function) and sub-item A, the translators opted for translation T2 for the term "marcha" (gait), apparently more appropriate than "modo de andar" (style of walking) (T2)

In item II (Function) and sub-item B4, we prioritized translation T1 over T2, simpler, "tomar transporte público" (take public transportation) than "entrar em transporte público" (enter public transportation).

During the performance of the pre-test mentioned with the 30 participants, difficulties were verified in the understanding of some expressions (gait, limp and severe). Further alterations were made, in our attempt to improve the cultural adaptation of the questionnaire. As our goal was semantic and non-literal equivalence, the expression "marcha" (gait) from the pre-test was substituted by "modo de andar" (style of walking). The term "claudicação" (limp) was substituted by "mancar" (limping) and "severo" (severe) by "grave" (serious). These alterations were suggested in consensus by the authors after the application of the questionnaires. There was no apparent difficulty with any other term during the pre-test.

In the reapplication of the new version of the questionnaire there was understanding by 100% of the patients as far as the semantics were concerned.

The final version of the HHS prepared after the pre-test, and with the layout used in the study, can be seen in ^{Appendix 1}.

DISCUSSION

There is no doubt that the use of assessment protocols is necessary in scientific studies, comparison of results, analysis of the effectiveness of clinical and surgical treatments and obtainment of increasingly trustworthy results.

Several tools for evaluation of the state of health and quality of life have been developed and used by researchers all over the world.

The Harris Hip Score is a widely used and specific assessment tool for the hip joint. It presents a scale with a maximum of 100 points, including evaluation of pain, function, deformity and motion.^5,7 Although used worldwide, including Brazil, it had not yet been adapted culturally to the Brazilian situation.

The aim of this study was to translate and culturally adapt the Harris Hip Score assessment tool.

Even though clinical protocols are efficient, validated and tested, when merely translated from the source language, in a literal manner, they might not be adapted to the cultural situation of the country in which it is to be used. For this reason the process of translation and cross-cultural adaptation is necessary, also aiming, whenever possible, to maintain the semantic, idiomatic and conceptual form, preserving the original idea.^13,14

In this study the participants opted to make as few changes as possible in the structure of the original tool, not including or excluding items from the scale, to avoid promoting further alterations of the psychometric properties, allowing the comparison of versions.^16-18

A method that can facilitate the translation for terms tangible to the general population, avoiding jargon and technical terms, is the use of a translator without a background in the area of health, as utilized in the study.¹⁶

During the application of the questionnaire in the pre-test we encountered difficulties in the comprehension of some terms not known by the general population, such as "marcha", "claudicação" and "severo", which were substituted by "modo de andar", "mancar" and "grave", in order to adapt it to the patients' understanding. The final version was prepared among the authors with these changes, and the questionnaire was reapplied, verifying optimal applicability with 100% of understanding on the part of the population. This phase is of extreme importance to the cross-cultural adaptation process, as it allows us to identify whether the translation was applicable, and whether the terms used were adequate for the population.

The cross-cultural adaptation strives to ensure consistency in the validity of content between the versions of the questionnaire (original and in the target language). Subtle differences in living habits in the different cultures might make an item from the questionnaire more or less difficult to understand, and may alter the psychometric and statistical properties of the tool.^16-18

CONCLUSION

Tools prepared in a foreign language require a careful cross-cultural adaptation process for their use in a socio-cultural reality. The stages covered for preparation of the Brazilian version of the Harris Hip Score allowed the delivery of this additional standardized tool in the assessment of the quality of life of patients with hip ailments, with good comprehension and acceptance among the patients tested.

ACKNOWLEDGMENTS

To all the patients that contributed to the performance of this study.

REFERENCES

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• 3. Macedo CA; Gália CR; Rosito R; Perea CEF; Muller LM, Verzoni GG et al. Abordagem cirúrgica na artroplastia total primária de quadril: ântero-lateral ou posterior? Rev Bras Ortop. 2002;37:387-91.
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Appendix 1

Translation and cultural adaptation of the Harris Hip Score into portuguese

Rodrigo Pereira Guimarães; Débora Pinheiro Lédio Alves; Gustavo Bersani Silva; Simoni Teixeira Bittar; Nelson Keiske Ono; Emerson Honda; Giancarlo Cavalli Polesello; Walter Ricioli Junior; Nilza Aparecida Almeida de Carvalho

Publication Dates

• Publication in this collection
  24 June 2010
• Date of issue
  2010