|Year : 2015 | Volume
| Issue : 1 | Page : 29-32
Adaptation and validation of stroke-aphasia quality of life (SAQOL-39) scale to Hindi
Ishita H Mitra, Gopee Krishnan
Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
|Date of Submission||17-Feb-2014|
|Date of Decision||06-Mar-2014|
|Date of Acceptance||08-May-2014|
|Date of Web Publication||10-Feb-2015|
Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Stroke is a major detriment to the quality of life (QOL) in its victims. Several functional limitations following stroke contribute to the denigrated QOL in this population. Aphasia, a disturbance in the comprehension, processing, and/or expression of language, is a common consequence of stroke. Yet, in most Indian languages, including the national language (Hindi), there are no published tools to measure the QOL of persons with stroke-aphasia. Objective: The current study was carried out to adapt and validate a well-known tool to measure the QOL (i.e., Stroke-Aphasia Quality of Life-39; SAQOL-39) to Hindi. Materials and Methods: We presented the original (English) version of the SAQOL-39 to a group of six Hindi-speaking Speech Language Pathologists hailing from the central and northern regions of India to examine the sociocultural suitability of items and indicate modifications, if any. The linguistic adaptation was performed through a forward-backward translation scheme. The socioculturally and linguistically adapted (to Hindi) version was then administered on a group of 84 Hindi-speaking persons with aphasia to examine the acceptability, test-retest reliability as well as the internal consistency of the instrument. Results: The SAQOL-39 in Hindi exhibited high test-retest reliability (ICC = 0.9) as well as acceptability with minimal missing data. This instrument exhibited high internal consistency (Chronbach's ∝ = 0.98) as well as the both item-to-total and inter-domain correlations. Conclusions: The socioculturally and linguistically adapted Hindi version of SAQOL-39 is a robust tool to measure the QOL of persons with stroke-aphasia. It may serve as an essential tool to measure the QOL in this population for both clinical and research purposes.
Keywords: Aphasia, Hindi, India, stroke, quality of life
|How to cite this article:|
Mitra IH, Krishnan G. Adaptation and validation of stroke-aphasia quality of life (SAQOL-39) scale to Hindi. Ann Indian Acad Neurol 2015;18:29-32
| Introduction|| |
In recent times, the quality of life (QOL) has been one of the major outcome measures in health-care interventions.  Health-related quality of life (HRQOL) is an index of the person's subjective perceptions on several domains of his/her functioning in the day-to-day life. Thus, the concept of HRQOL represents an individual's ability to lead a productive life.  At a broader level, it has substantial ramifications for planning, implementing, and evaluating health-care policies as well as for the resource allocation. 
Among several medical conditions, stroke is a major detriment to the quality of life due to the widespread impact of this condition on the day-to-day life of its victims. About 1/3 of the population with stroke experience aphasia (an inability to speak and/or understand language) and in a majority of them aphasia persists even after 2 years of onset.  Considering the proposal that the ultimate aim of aphasia rehabilitation is to improve the quality of life in people with this disorder,  there lies the dire need to measure the QOL of this population. This, in turn, entails the development of specific instruments for this purpose.
Questionnaires have been the primary tool to measure both health- and non-health-related quality of life. In the health-care domain, generic instruments used in the earlier years are increasingly replaced by disease-specific tools as the latter type is tailored to the specific disease under consideration. Aphasia is no exception to this. For instance, Hilari and colleagues  adapted the stroke-specific quality of life (SS-QOL) to meet the unique needs of people with aphasia following the stroke and compiled a modified version of the instrument (SAQOL). Though the initial version (SAQOL) consisted of 53 items, subsequent to the evaluation of psychometric properties of this version, the authors reduced the number of items to 39, deriving SAQOL-39. Since its introduction, the SAQOL-39 has been adapted to several European languages (Spanish, Italian) as well as to two Indian languages (Kannada  and Malayalam  ). The cross-linguistic and cross-cultural adaptation of such widely used instruments permits the comparison of QOL data across centers and nations.
The quality of life in people with aphasia: The Indian scenario
Although precise data on the prevalence of aphasia is lacking in the Indian context, some estimations are possible from the available stroke data. For instance, the prevalence of stroke in India is 203 per 100,000 population.  Considering the giant population of the country and the fact that about 1/3 of the total stroke victims experience aphasia,  it may be inferred that several thousands to a few millions experience aphasia in India. Added to such gigantic number of people with aphasia is the multilingual status of the country that necessitates the development of language-specific tools for the assessment of QOL. Apparently, there is a visible dearth of published tools in many Indian languages. Considering the potential danger in mere translation of tools from culturally and linguistically distinct populations (for instance, European and American) there have been recent attempts to adapt and validate such tools in the Indian context.  Yet, several languages in India experience the dearth of validated instruments to assess the QOL of people with aphasia including Hindi, the national language of the country, spoken by about 50 million people in the country. In this context, we decided to fill this lacuna by adapting and validating the original (English) version of widely used SAQOL-39  to Hindi.
| Materials and Methods|| |
We followed the Methods used by Kiran and Krishnan  in the current study. Permission to adapt the original version of SAQOL-39 to Indian languages was obtained from the corresponding author of the original study. To judge the sociocultural adequacy of original items to the Hindi-speaking communities, we employed six speech-language pathologists (SLPs) hailing from central and northern India. They were instructed to examine each item for its social and cultural suitability and suggest modifications, wherever needed. However, based on the judgments by these SLPs, none of the items required any modifications and we retained all items as in the original version for the purpose of use in Hindi. Subsequent to this, we selected six bilingual (Hindi-English) SLPs for the linguistic adaptation of the instrument through a forward-backward translation scheme. Three each served as forward and backward translators. The forward translators were instructed to translate English items to Hindi with utmost care to retain the meaning of items. The three forward translators collectively showed certain differences in the use of words (11 instances) as well as some grammatical structures (13 instances). We reached a consensus on these instances of differences through a simultaneous discussion with all three forward translators to obtain the final forward translated version of SAQOL-39 to Hindi. This was subsequently presented to the second group of translators (backward: to English) with similar instructions as to the first group except for the direction of translation. The backward translated English version did not show any notable difference from the original version of SAQOL-39 (i.e., English), indicating that the Hindi version was essentially similar to the original English version.
The Hindi version of SAQOL-39 was administered on a group of 84 people with aphasia from several central and north Indian regions. All had the history of stroke minimum 3 months prior to their participation in the current study. Further, those with known/reported cognitive deficits as well as other significant comorbidities such as heart disease, acquired immunodeficiency syndrome (AIDS), metastatic carcinoma, and/or uncorrected peripheral visual impairments were excluded from the current study.
Within 15-30 days from the initial administration, we read ministered the instrument on a small group of 10 participants to assess the test-retest reliability. The intraclass correlation coefficient (ICC) analysis of the data was performed using Statistical Package for the Social Sciences (SPSS; Version 16) to compute the test-retest reliability. The results of ICC analysis showed a high test-retest reliability (ICC = 0.9) of the Hindi version of SAQOL-39.
The acceptability of the Hindi version is apparent from the minimal missing data (0.72% of total data; contributed by four items: M4-0.33%; M6-0.33%; UE-0.03%; P1-0.03%) as well as only two skewed items (P1 = 1.1; SR8 = 1.02).
The internal consistency of the Hindi SAQOL-39 was established primarily through the computation of Chronbach's alpha. This statistic is an index of the correlation between each item and the remaining (total) items in the instrument. A high value of alpha, therefore, is indicative of high item-to-total correlation, which in turn, signifies the high internal consistency of the instrument. With an extremely high value of alpha (∝ = 0.98), the Hindi SAQOL-39 showed excellent internal consistency. The item-to-total correlations of all 39 items are provided in [Table 1]. Further, the items in each domain showed acceptable to high alpha values (physical-0.98; communication-0.96; psycho-social-0.92; Energy-0.72) relative to the remaining items in their respective domains.
|Table 1: Item-to-total correlation of 39 items in Hindi version of SAQOL-39|
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In addition to the computation of Chronbach's alpha, we explored the correlation between various domains in the current instrument. The results of this analysis showed significant correlation (P < 0.01) among all four domains. [Table 2] provides the inter-domain correlation coefficient of Hindi SAQOL-39.
The quality of life of people with aphasia
The ratings obtained from 84 participants with aphasia were used to measure their QOL. We calculated the mean of all four domains to compute the overall QOL data [see [Table 3]]. The mean overall QOL of the participants under the current investigation was 2.71 (SD = 0.95). [Table 3] provides the domain-specific mean values (and SD) of QOL data.
|Table 3: The group Mean (SD) scores of the overall items as well as the four sub-domains of Hindi SAQOL-39 (n = 84)|
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| Discussion|| |
The current study aimed to adapt and validate the globally-used SAQOL-39 scale to Hindi, the national language of India. As the mere translation of instruments developed in the western countries may prove socio-culturally inappropriate, we examined the suitability of the original English items to Hindi-speaking communities. However, six SLPs hailing from central and northern regions of India approved the items without any significant modifications. Following this, the forward-backward translation of items rendered the original English version to the validated Hindi version.
The Hindi version of SAQOL-39 was subsequently administered on a larger group of 84 persons with aphasia following the stroke. These scores were used for the computation of the psychometric properties of the instrument. The Hindi version of SAQOL-39 yielded an overall high test-retest reliability (ICC = 0.9) as well as internal consistency (∝ = 0.98), which in turn were comparable to the original instrument in English (∝ = 0.93; ICC = 0.98) as well as many of its translations to other languages (Kannada: ∝ = 0.9; ICC = 0.8; Italian: ∝ = 0.916; ICC = 0.898; Spanish: ∝ = 0.95; ICC = 0.949). Further, the extremely small percent of missing data from the current study, like in the original version, was indicative of its higher acceptability by the participants. Finally, within-scale, inter-domain correlational analysis revealed significant correlations among all four domains of the instrument indicating that each domain of the instrument was sensitive to the actual quality of life in people with aphasia following the stroke.
Finally, the current study showed that the overall QOL of Hindi-speaking persons with aphasia after stroke, on an average, was 2.71 (SD = 0.95) on a scale of 1 to 5. This was comparable to Kannada-speaking population (Mean = 2.69; SD = 1.05).  However, it differed markedly from the Spanish-speaking (Mean = 3.75; SD = 0.86)  as well as English-speaking counterparts (Mean = 3.26; SD = 0.7).  The comparable rating of QOL in Hindi-speaking people with aphasia with another Indian population (e.g., Kannada) and marked difference with two European populations signifies that, in general, the quality of life of the population under consideration is poorer in India. Nevertheless, it is in agreement with the data from different region within the nation. This finding further reflects the usefulness of the tool in cross-centric comparison of QOL data.
| Conclusion|| |
The Hindi version of SAQOL-39 is a valid, reliable, and robust scale like its original version in English and translations to several other languages. Thus, it may be readily used for the measurement of QOL in Hindi-speaking persons with aphasia. Further, it permits easy comparison with cross-cultural and cross-linguistic QOL data from people with aphasia following the stroke across centers.
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[Table 1], [Table 2], [Table 3]
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