Korean Translation and Linguistic Validation of Urgency and Overactive Bladder Questionnaires
Article information
Abstract
Purpose
Given the importance of evaluating the severity of overactive bladder (OAB) symptoms and outcomes after treatment, several questionnaires have been developed to evaluate OAB patients. However, only limited questionnaires are available in Korea for use with Korean patients. Therefore, this study aimed to develop Korean versions of OAB questionnaires through a rigorous linguistic validation process.
Methods
The Indevus Urgency Severity Scale, Urgency Perception Scale, Urgency Severity Scale, and Patient Perception of Intensity of Urgency Scale underwent translation and linguistic validation. The linguistic validation procedure consisted of permission for translation, forward translations, reconciliation, back-translation, cognitive debriefing, and proofreading. Two independent bilingual translators translated the original version of each questionnaire, and a panel then discussed and reconciled the 2 initial translations. Next, a third independent bilingual translator performed a backward translation of the reconciled version into English. Five Korean patients diagnosed with OAB were interviewed for cognitive debriefing.
Results
Each item of the questionnaires was translated into 2 Korean versions in the forward translation process. Terms such as ‘urgency’ and ‘wetting’ were translated into ordinary language by the translators and adjusted by the panel members to more conceptually equivalent terms in a medical context. In the back-translation process, the panel made a few changes regarding details based on a comparison of the back-translated and original versions. During the cognitive debriefing process, 5 patients provided a few pieces of feedback on the naturalness of the wording of the questionnaires, but generally agreed on the translated terms.
Conclusions
In this study, the panel produced a successful linguistic validation of Korean versions of multiple OAB questionnaires, which can be utilized to evaluate the severity and treatment outcomes of OAB.
INTRODUCTION
Overactive bladder (OAB) is a component of lower urinary tract symptoms, which were defined as “urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of infection or other proven etiology” in 2003 by the International Continence Society (ICS) [1]. It is well known that OAB and urinary incontinence (UI) have a negative impact on health-related quality of life (HRQoL) in aspects of physical, social, psychological, ecological well-being [2,3].
In 2006, the Korean EPIC (European Prospective Investigation into Cancer and Nutrition) study demonstrated that the overall prevalence of OAB in the Korean population was 12.2% and the prevalence of OAB with UI was 5.1% [4]. Furthermore, the Korean Burden of Incontinence Study, which was conducted in 2013, showed a substantial economic impact of OAB in the Korean population due to the costs of diagnosis, medications, and incontinence pads, especially in patients with severe UI [5].
Given the prevalence of OAB and its economic and social impact on the Korean population, it is necessary to evaluate HRQoL and patient-reported outcomes (PRO) after OAB treatment [6]. However, insufficient questionnaires are available as tools to evaluate the severity of urgency and UI in the Korean population.
Therefore, the authors of this study investigated validated questionnaires available for evaluating the severity of OAB and UI, and selected the Indevus Urgency Severity Scale (IUSS), Urgency Perception Scale (UPS), Urgency Severity Scale (USS), and Patient Perception of Intensity of Urgency Scale (PPIUS) based on the PRO assessment review in the Fifth International Consultation on Incontinence, published in 2013 [7].
MATERIALS AND METHODS
Original Questionnaires
The IUSS questionnaire was developed by Nixon et al. [8]. The UPS questionnaire was developed by Cardozo et al. [9]. The USS was developed by Chung et al. [10] by modifying the IUSS. The PPIUS was developed by Cartwright et al. [11].
Translation and Linguistic Validation
This study was approved by the Institutional Review Board of the Seoul Metropolitan Government - Seoul National University Boramae Medical Center (approval number: 26-2016-60). A linguistic validation procedure was implemented to obtain translated Korean versions of the IUSS, UPS, USS, and PPIUS questionnaires that should be conceptually equivalent to the original questionnaires. The procedure of translation and linguistic validation was performed following a well-established process that consisted of forward translation, reconciliation, back-translation, cognitive debriefing, and proofreading, as described in previous investigations [12-14].
In each step of the process, all translators and a panel consisting of 2 Korean experts (SJO and SYC) commented on the difficulty and naturalness of the translations and alternative translation options.
Permission
The panel contacted all copyright holders of each questionnaire, and requested and acquired permission to translate and utilize a Korean version of each questionnaire.
Forward Translation
Two trained bilingual translators independently translated the original version of each questionnaires into conceptually equivalent Korean phrasing (version 1.0a and 1.0b). The translators did not have a medical license, and they were forbidden to contact each other.
Reconciliation by the Panel
The 2 independently translated versions were compared by the panel, including both independent translators, and were reconciled considering delicate cultural differences and linguistic nuances into a single new version (version 1.1).
Back-Translation
A third bilingual translator received the reconciled Korean version of each questionnaire (version 1.1), and back-translated it into English. The back-translated English version of each questionnaire was compared with the original English version. The panel, including all translators, discussed the translations and made changes (version 1.2).
Cognitive Debriefing
The questionnaires (version 1.2) were given to 5 Korean-speaking patients with OAB with different educational backgrounds. They were asked whether the questionnaires were understandable, clear, and intuitive. After the interview, the panel discussed the patients’ responses, and agreed on a new version (version 1.3).
Proofreading
Version 1.3 was proofread by the panel to check for grammatical problems and availability for evaluating OAB (version 1.4).
RESULTS
Forward Translation and Reconciliation
As shown in Table 1, all items of the IUSS, USS, PPIUS, and UPS questionnaires were translated into Korean by 2 independent translators. The transcriptions given below of the Korean text of the translated questionnaires follow the official Revised Romanization of Korean system developed by the National Academy of the Korean Language.
Indevus Urgency Severity Scale
The name of the IUSS questionnaire was translated as Indevus yojeolbakseongui simgak jisu. The word “urgency” was translated as gingeup and gingeupseong (“emergent”) by translators 1 and 2, respectively, but the panel agreed on yojeolbakseong as alternative option that appropriately conveyed the medical nuance of this term. “Degree of urgency is meant to describe your urge to urinate” in the original text was translated as yojeolbakseongui jeongdoneun gwihaui sobyeon maryeoumui jeolbakameul pyohyeonhamnida. The phrase “urge to urinate” was translated as sobyeon yokgu by translator 1 and sobyeon maryeoum by translator 2, and the panel agreed on sobyeon maryeoum as a more familiar expression. “Sometimes you may feel a very strong urge to urinate, and at other times, you may feel a milder urge prior to the onset of a toilet void” in the original text was translated as gwihaga sobyeoneul bogi jikjeone, ttaeroneun sobyeon maryeoumeul maeu ganghage neukkil ttaedo isseuna, geu oeeneun, sobyeon maryeoumi yakal ttaedo itseumnida. The panel agreed on the general tone of the sentence as rendered by translator 1, as it was a more honorific form.
“Rate this feeling by circling 0, 1, 2, or 3, defined as:” in the original text was translated as daeumgwa gateun seolmyeonge ttara 0, 1, 2, 3 euro pyogihayeo neukkimeul pyeonggahayeo juseyo. “0: NONE-no urgency” in the original text was translated as 0: eopseum- jeolbakaji aneum. “1: MILD-awareness of urgency, but is easily tolerated and you can continue with your usual activity or tasks” in the original text was translated as 1: yakam-jeolbakameul uisikal su isseuna, gwihaui hwaldonggwa eommureul jisokal su isseul jeongdoro swipge chameul su isseum. “2: MODERATE-enough urgency discomfort that interferes with or shortens your usual activity or tasks.” in the original text was translated as 2: botong- jeolbakameuro inhae ilsangjeogin hwaldonggwa eommue banghaega doel jeongdoui bulpyeonhameul neukkim. “3: SEVERE: extreme urgency discomfort that abruptly stops all activity or tasks” in the original text was translated as 3: simgakam- jeolbakameuro inhae modeun hwaldonggwa eommuga gapjakseureopge jungdandoel jeongdoro bulpyeonhameul neukkim. The panel agreed on an alternative option for the proper translation of “abruptly.”
Urgency Perception Scale
The name of the UPS questionnaire was translated as yojeolbakseong inji jisu. “The patient is asked to describe his/her typical experience when he/she feels the desire to urinate” in the original text was translated as hwanjabunege sobyeon maryeoul ttae ilsangjeogeuro neukkineun gyeongheomeul seolmyeonghadorok hamnida. The panel agreed to translate “typical” as ilsangjeogeuro neukkineun (“routinely felt”), as it is a familiar expression.
“The response options are” in the original text was translated as seontaekangmogeun daeumgwa gateum. “1. I am usually not able to hold urine” in the original text was translated as 1. naneun juro sobyeoneul chameul su eopda. “2. I am usually able to hold urine until I reach the toilet if I go immediately” in the original text was translated as 2. naneun juro hwajangsireul jeuksi gandamyeon sobyeoneul chameul su itda. “3. I am usually able to finish what I am doing before going to the toilet” in the original text was translated as 3. naneun juro hwajangsil gagi jeone naega hadeon ireul kkeunnael su itda.
Urgency Severity Scale
The name of the USS questionnaire was translated as yojeolbakseong simgak jisu (hogeun jeongdo) seolmunji. “How do you feel before each void?” in the original text was translated as gwihaneun maebeon sobyeoneul bogijeone eotteoke neukkisimnikka? The word “void” was translated as sobyeoneul bogi (“relieve oneself ”) by translator 1 and sobyeoneul biul (“empty”) by translator 2, and the panel agreed on sobyeoneul bogi as it is a more precise and familiar expression than sobyeoneul biul. “Please record the score that best describes how you feel before voiding” in the original text was translated as sobyeoneul bogi jeon gwihaui sangtaereul gajang jal pyohyeonhaneun hangmoge (jeomsureul) pyogihaseyo. The word “best describe” was translated as gajang jal banyeonghaneun (“best reflect”) by translator 1 and gajang jal myosahan (“best portray”) by translator 2, and the panel agreed on gajang jal pyohyeonhaneun (“best express”).
“Record at each voiding in the diary according to the following descriptions” in the original text was translated as araee seolmyeonge ttara baenyoilgie sobyeoneul biul ttaemada girokaejuseyo. The panel agreed on translating “the diary” as baenyoilgie, as it is a widely accepted translation of “voiding diary.” “0. No feeling of urgency: I can continue activities until I choose to use the bathroom” in the original text was translated as 0. yojeolbakseong eopseum: naneun hwajangsireul sayonghaneun geoseul gyeoljeonghagi jeonkkaji hadeon hwaldongeul jisokal su isseum. The panel determined that the translation of “choose to use the bathroom” as hwajangsireul sayonghaneun geoseul gyeoljeonghagi was appropriate, but was an awkward expression that required feedback. “1. Mild feeling of urgency: I can feel the need to urinate, but it is easily tolerated. I can finish my activity or task before going to the bathroom” in the original text was translated as 1. yakan jeongdoui yojeolbakseong: naneun sobyeon maryeoumeul neukkil su isseuna, swipge chameul su isseum. hwajangsil gagijeone hwaldonggwa eommureul mamurihal su isseum. The phrase “easily tolerated” was translated as swipge tongjehal su itda (“easily controlled”) by translator 1 and gyeondil su itda (“tolerated”) by translator 2, and the panel agreed on swipge chameul su isseum (“easily bearable”). “2. Moderate feeling of urgency: The sensation of urgency causes a compelling desire to void. I need to stop my activity or task and go to the bathroom” in the original text was translated as 2: junggan jeongdoui yojeolbakseong naneun yojeolbakseongeuro inhae sobyeoneul bogoja haneun yokgureul ganghage neukkim: eommuwa hwaldongeul jungdanhago hwajangsireul gal piryoga isseum. The panel determined that the translation of “sensation of urgency” as yojeolbakseong (“urgency”) did not reflect the meaning of “sensation.” “3. Severe feeling of urgency: The sensation of urgency causes a compelling desire to void. I have difficulty holding urine. I have to my stop activity or task to avoid a wetting accident and hurry to the bathroom” in the original text was translated as 3. simgakan jeongdoui yojeolbakseong: naneun yojeolbakseongeuro inhae sobyeoneul bogoja haneun yokgureul ganghage neukkim. sobyeoneul chamneunge eoryeoum. sobyeoneul jiriji anki wihae eommuwa hwaldongeul jungdanhago geupage hwajangsireul gal piryoga isseum. The phrase “a wetting accident” was translated as sobyeon silsu (“voiding accident”) by translator 1 and sobyeoni naoneun geot (“voiding”) by translator 2, and the panel agreed on sobyeoneul jiriji (“wetting”) as it is common translation of “wetting” or “incontinence.” “4. Unable to hold urine: The urine leaks from my bladder and I have a wetting accident before arriving at the bathroom” in the original text was translated as 4. sobyeoneul chameul su eopseum: naneun hwajangsire dochakagi jeone (banggwangeseo sobyeoni yuchuldoego) sobyeoneul jiryeo oseul jeoksinda. The panel agreed on the non-literal translation of “have a wetting accident” as sobyeoneul jiryeo oseul jeoksinda (“get one’s clothes wet”), as it is a widely used idiom.
Patient Perception of Intensity of Urgency Scale
The name of the PPIUS questionnaire was translated as yojeolbakseong jisuui gangdoe daehan hwanjaui inji. “0. No urgency, I felt no need to empty my bladder, but did so for other reasons” in the original text was translated as 0. jeolbakaji aneum, banggwangeul biwoya handaneun piryoseongeul neukkiji anchiman dareun iyuro geureoke handa. “1. Mild urgency, I could postpone voiding as long as necessary, without fear of wetting myself” in the original text was translated as 1. yakan jeongdoui yojeolbakseong, sobyeoneul jirineun geose daehan geokjeong eopsi piryohan mankeum oraetdongan sobyeoneul chameul su itda. “2. Moderate urgency, I could postpone voiding for a short while, without fear of wetting myself” in the original text was translated as 2. junggan jeongdoui yojeolbakseong, sobyeoneul jirineun geose daehan geokjeong eopsi jamkkan dongan sobyeoneul chameul su itda. “3. Severe urgency, I could not postpone voiding, but had to rush to the toilet in order not to wet myself” in the original text was translated as 3. simgakan jeongdoui yojeolbakseong, sobyeoneul chameul su eopseo sobyeoneul jiriji anki wihae hwajangsillo dallyeogaya handa. “4. Urge incontinence, I leaked before arriving to the toilet” in the original text was translated as 4. jeolbakseong yosilgeum, hwajangsire dochakagi jeone sobyeoneul jirinda. The word “incontinence” was translated as sobyeon yuchul (“urine leak”) by translator 1 and yosilgeum (“incontinence”) by translator 2, and the panel agreed on yosilgeum as it is a medical term that is widely understood.
Back-Translation and Retranslation
As shown in Table 2, all items of the OAB questionnaires that were reconciled by the panel were reverse-translated, and the panel then discussed the differences between the back-translated versions and original versions, as described below.
Indevus Urgency Severity Scale
The panel discussed the differences between the translations of “enough urgency discomfort that interferes with or shortens” in the original version and “You feel enough discomfort that it interferes with” in the reconciled version. The panel ultimately agreed to omit “shortens” because the translation could fully convey the message through only “interferes with.”
Urgency Perception Scale
The panel discussed the differences between translations of “the desire to urinate” in the original version and “urge to urinate” in the reconciled version. The panel finally agreed on the translation sobyeoneul bogosipeul ttae as the best expression of the phrase “the desire.”
Urgency Severity Scale
The panel discussed the differences between translations of “until I choose to use the bathroom” in the original version and “before I decided to go to the toilet” in the reconciled version in terms of the nuances of the translation. The panel finally agreed on the translation hwajangsireul sayonghaeyagetdago maeummeokgi jeonkkaji, as it is a more familiar and communicative expression.
Patient Perception of Intensity of Urgency Scale
The panel had no disagreements with the back-translation of the PPIUS, given the translation process of the above questionnaires.
Cognitive Debriefing and Proofreading
The revised version of the translations after forward and reverse translation were tested by 5 patients with OAB (3 men and 2 women; age range, 30–70 years) who had received medical therapy, including anticholinergics. Their levels of education ranged from high school to university. All patients completed the translated questionnaires within 8 minutes. The patients stated that the items of questionnaires were generally easy to understand.
One patient reported that there was a discrepancy among the questionnaires in terms of whether they phrased the items as referring to “patient” or “you,” and stated that this difference was not harmonious. In the IUSS and USS questionnaires, “you” was translated as gwiha (a polite expression for “you”), while in the USS, “patient” was translated as hwanjabun (a polite expression for “patient”). The panel discussed this difference, but decided to keep those terms in consideration of the original text. Another patient reported that in the USS questionnaire, the description of an item was so long that the meaning of the sentence was lost in the middle. The panel discussed the patient’s feedback and agreed that the sentence was long and distracting. Therefore, the panel decided to emphasize the main words by underlining them. Furthermore, the panel proofread the all four questionnaires and agreed to unify the translation of “urgency” as yojeolbak rather than yojeolbakseong, as yojeolbak is a briefer and clearer expression.
Finally, the panel revised the translations by consistently organizing the expressions, especially honorific forms, in the questionnaires. The final versions are shown in Fig. 1.
DISCUSSION
During the translation process of multiple OAB questionnaires, a few words showed persistent differences between the translators and the panel. The word “urgency” was translated as gingeup and gingeupseong by the translators, both meaning “emergency.” Yojeolbak is a popular translation used in urological publications, and the panel therefore agreed to use yojeolbak. In the same context, it was observed that symptom-related adjectives such as “urgent” were challenging words to translate; therefore, they were not translated literally, and were replaced by colloquial expressions [15].
The word “moderate” was translated as botong and junggan by the translators, and the word “usually” was translated juro and botong. The translated term botong, which generally means “normal” or “normally,” was used differently by the translators. In the forward translation, the panel agreed to translate “usually” as juro, but the translation of “moderate” was inconsistent (botong in the IUSS and junggan in the UPS). The panel discussed this inconsistency, and given the tendency of lists to proceed in the order of “mild,” “moderate,” and “severe,” they decided that it was natural to unify this expression as junggan.
A limitation of this study is that the authors did not conduct a reliability analysis; thus, a further evaluation of the correlation and agreement between scores on the original English versions and the translated Korean versions of the questionnaires is required. Therefore, further psychometric validation of the translated Korean versions of these questionnaires should be conducted in the future.
In conclusion, this study provides a successful and appropriate linguistic validation of Korean versions of the IUSS, UPS, USS, and PPIUS questionnaires. These Korean versions of the questionnaires could contribute to evaluating the severity of symptoms and PROs of Korean patients who suffer from OAB.
Acknowledgements
This article was supported by the members of the Questionnaire Investigation Committee of the Korean Continence Society. Soon Ho Kang performed a previous linguistic validation study and provided support for this article.
Notes
Research Ethics
This study was approved by the Institutional Review Board of the Seoul Metropolitan Government - Seoul National University Boramae Medical Center (approval number: 26-2016-60).
Conflict of Interest
MSC and SYC, members of the Editorial Board of International Neurourology Journal, are the fifth and corresponding authors of this article. However, they played no role whatsoever in the editorial evaluation of this article or the decision to publish it. Except for that, no potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTION STATEMENT
· Conceptualization: SEK, SJO, SYC
· Data curation: HSL, HNL, SYL, MSC, MGP, JYC, SEK, SYC
· Formal Analysis: HSL, HNL, SYL, MSC, MGP, JYC, SEK, SYC
· Investigation: HSL, HNL, SYL, MSC, MGP, JYC, SEK, SYC
· Methodology: SEK, SYC
· Validation: SEK, SYC
· Project Administration: SEK, SYC
· Writing – Original Draft: SEK, SYC
· Writing – Review & Editing: SEK, HSL, HNL, SYL, MSC, MGP, JYC, SYC