|Ahead of print
Marathi translation, linguistic validation, and cross-cultural adaptation of speech handicap index and voice handicap index in patients of head and neck squamous cell cancer
Chaitali M Waghmare1, Vasundhara Aggarwal2, Anup L Kharde3, Vandana S Jain1, Pradeep Kumar Thakur1
1 Department of Radiation Oncology, Rural Medical College and Pravara Rural Hospital, Loni, Tal Rahata, Ahmadnagar, Maharashtra, India
2 Rural Medical College, Pravara Medical Trust's Pravara Institute of Medical Sciences, Loni, Tal Rahata, Ahmadnagar, Maharashtra, India
3 Department of Preventive and Social Medicine, Rural Medical College, Pravara Medical Trust's Pravara Institute of Medical Sciences, Loni, Tal Rahata, Ahmadnagar, Maharashtra, India, Indiax
|Date of Submission||18-Jul-2019|
|Date of Decision||11-Jan-2020|
|Date of Acceptance||12-Jan-2020|
Chaitali M Waghmare,
Department of Radiation Oncology, Rural Medical College and Pravara Rural Hospital, Loni, Tal Rahata, Ahmadnagar, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Patient reported treatment outcomes is a better way to measure the quality of life (QOL). This study was undertaken to translate the speech handicap index (SHI) and voice handicap index (VHI) in Marathi language and its linguistic validation and cross-cultural adaptation in patients of head and neck squamous cell cancer (HNSCC).
Methods: SHI and VHI were translated into Marathi with prior permission from the respective authors of original English questionnaire (RAs). The translation procedure for each tool included two forward translations (English to Marathi), the formation of first intermediate Marathi translation (FIT), two back translations (Marathi to English) of FIT, and interim Marathi translation (IT) formation. The second intermediate Marathi translation (SIT) was prepared after face validation of IT by a subject expert. Pretesting of SIT was done in 20 patients of HNSCC to validate linguistic and cross-cultural adaptation. By incorporating the patient's suggestions, the final Marathi translation was prepared and sent to primary authors for approval.
Results: The grammatically and conceptually acceptable and face validated SIT was prepared and administered to HNSCC patients. The patients of the oral cavity and larynx were in SHI and VHI group, respectively (ten patients in each group). The questionnaire was well understood reflecting its linguistic and cross-cultural adaptation. Some of the patients suggested changes in a few words which were then corrected, rechecked with back translation, and final Marathi translated questionnaire was prepared. It was approved by RAs.
Conclusion: Marathi translation of SHI and VHI are well accepted and comprehensible. It can be used for future studies.
Keywords: Marathi translation, speech handicap index, voice handicap index
Key Message: Speech and voice-related treatment outcomes in head and neck cancer patients that need to be documented separately are assessed in a better way using patient's self-reported quality of life tools available in the local language.
|How to cite this URL:|
Waghmare CM, Aggarwal V, Kharde AL, Jain VS, Thakur PK. Marathi translation, linguistic validation, and cross-cultural adaptation of speech handicap index and voice handicap index in patients of head and neck squamous cell cancer. Indian J Cancer [Epub ahead of print] [cited 2020 Oct 20]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=297027
| » Introduction|| |
Head and neck squamous cell cancer (HNSCC) is more common in developing countries. In India, it is the first and fourth most common cause of cancer among males and females, respectively.
 HNSCC is well managed with multimodality treatment with resultant good local control rates. The disease and the side effects of treatment are bound to have a measurable impact on the patient's quality of life (QOL), especially with speech and voice.
As the patients are cured and are long-term survivors, the functional outcome plays a major role in providing good QOL. Patients during diagnosis, treatment, and follow-up go through physical, psychological, and social issues. Patient-reported QOL is a more reliable tool. Unfortunately, most of the HNSCC QOL tools are available in English. European Organization for Research and Treatment in Cancer, quality of life questionnaire- Head and Neck 35 (EORTC QLQ- H and N 35) is available in Marathi language but it cannot assess the speech and voice separately.
Speech is commonly affected in the oral cavity and oropharyngeal lesions while voice is affected in laryngeal lesions. The majority of HNSCC patients need radiation therapy (RT) either as radical or adjuvant treatment. RT even for nonlaryngeal HNSCC can affect the voice. The rehabilitation strategies for speech and voice are different. Hence, there is a need to evaluate the speech and voice separately.
Speech Handicap Index (SHI) and the Voice Handicap Index (VHI) are available in the English language. This study was undertaken with the aim to translate SHI and VHI in grammatically and conceptually acceptable Marathi, a regional Indian language, and its linguistic validation and cross-cultural adaptation in patients of HNSCC.
| » Materials And Method|| |
Institutional ethics committee approval was taken before beginning this study.
Part I. Translation
The permission for Marathi translation was taken from the respective authors and the copyright company. The guidelines by Beaton et al. for the cross-cultural adaptation of self-report measures were followed. The forward translations (FT) (English to Marathi) of the original English questionnaire of each tool were done by two independent translators whose mother tongue was Marathi and were also fluent in English. The translators had not seen this questionnaire before, and one translator of each tool was primed with the aim of this study. Two different questionnaires (SHI and VHI) were given to four independent native Marathispeakers who were considered as language experts for FT. After a discussion among the study coordinator and two translators of each tool, the first intermediate Marathitranslation [FIT] of each was formed. This FIT was then translated back in English by other two independent translators for each tool (total four) who were fluent in both languages and had English as the first language in school. An interim Marathitranslation (IT) was formed by comparing the back translations (BT) (Marathi to English) with the original English tool and adding appropriate modifications. This IT was then proof-edited by a Marathi subject expert. Incorporating the suggested corrections, second intermediate Marathitranslation (SIT) was made.
Part II. Pretesting
Pretesting was done to validate linguistic and cross-cultural adaptation. The SIT was given to literate Marathi speaking, histopathology proved, nonmetastatic HNSCC patients, of all age groups, and either sex with Karnofsky performance score of more than or equal to 70. The study group had never seen these questionnaires before and gave informed written consent for participation in the study. SHI was given to the ten nonlaryngeal HNSCC patients and VHI was given to the ten laryngeal cancer patients. After completing the questionnaire, each patient was interviewed for the difficulty in comprehension, difficulty in answering, and confusion regarding any question or word. They were also asked if they found any question or word objectionable or offensive. Patients were then asked for their suggestions for framing a specific question or replacement of a specific relevant word. Incorporating the patient's suggestion, the final Marathitranslation was made and sent to primary authors of the original English questionnaire for approval.
| » Results|| |
Part I. Translation
The aim of translation was to form a linguistically and conceptually correct translation that is comprehensible, culturally acceptable, and inoffensive. Further, it should be correct in its grammar, syntax, and orthography.
FT (Original English to Marathi)
Two independent FTs of each original English questionnaire (SHI and VHI) were done by independent translators of native Marathi language who were also fluent in English. The two FTs of each tool were compared by a study coordinator. The joint discussion was held between the study coordinator and the two forward translators of each tool separately. FTs were mostly identical to each other except for few words giving the same meaning as in the original English version and different ways of forming a sentence.
E.g. 1. Question 14 of SHI was 'Mi mazya ashya bolnyamule mitranshi, natewaikanshi kiwa shejaranshi jast bolne talto/talte' (Because of my speaking issues, I avoid talking with friends, relatives, or neighbors.) in FT1 and was 'Mi mazya ashya bolnyamule mitranshi, natewaikanshi kiwa shejaranshi kami bolato' (Because of speaking issues, I speak less with friends, relatives, or neighbors) in FT2. Hence, we accepted FT1, which was closer to the original English version.
2. Question F5 of VHI was translated as 'Aawajamule mi itar lokanmadhe kami misalto' (Because of voice, I interact less with people.) in FT1 and as 'Aawajamule mi itar lokanmadhe misalne talto/talte' (Because of voice, I avoid interacting with people.) in FT2. The second FT was accepted.
3. Question F9 of VHI was 'Mazya ashya aawajamule mala kontyahi sambhashnat sahbhagi hota yet nahi' (Because of my such voice, I cannot participate in any conversation.) in FT1 and it was 'Awajaule mala sambhashnatun vagalale jat aahe ase watate' (Because of voice, I feel left out of conversation) in FT2. The second FT was accepted.
4. Question eight of SHI was written as 'Mazya aashya bolnyamule mala lokanshi gappa martanana tanav yeto.' (I am tense while conversation because of my speech.) in FT1 while it was 'Mazya aashya bolnyamule lokanshi gappa martanana mala tanav yeto' (I am tense while conversation because of my speech.) in FT2. Though the meaning was the same and there was a small difference in sentence formation, we accepted the FT2.
Since the language structure of Marathi is different from English, word to word translation was not possible. Hence, the modified sentence which gives the conceptually similar meaning as the original English version was accepted.
E.g. 1. Question 2 of SHI – I run out of the air when I speak.
2. Question P10 of VHI – My voice gives on to me in the middle of speaking.
After discussion among the study coordinator and two translators of each tool, FIT for each tool was formed.
BT (Marathi to English)
This FIT was then translated back in English by the other two independent translators for each tool (total four) who were fluent in both languages. IT was formed by comparing the back translations with the original English tool and adding appropriate modifications. As the BTs were comparable and gave the conceptually same meaning as the original English questionnaire intended to ask, we accepted FIT as interim Marathi translation (IT).
SIT-IT was then proof edited by a Marathi subject expert. Incorporating the suggested corrections (mainly corrections for punctuation and velanti) second intermediate Marathitranslations (SIT) were formed.
Part II. pretesting
The SIT was administered to the study population. The characteristics of the study group are described in [Table 1]. The SIT of SHI was given to nonlaryngeal HNSCC patients and SIT of VHI was given to laryngeal cancer patients. Each patient was interviewed personally after completing the questionnaire.
Patient interview report of SHI –
Question number two: Two patients faced difficulty in understanding the word 'dam lagto' (shortness of breath). One patient suggested the word 'Dhap lagtae' (shortness of breath) which was incorporated in the final Marathi translation as an alternative word as the back translation was giving the same meaning as in the original English questionnaire.
Question number 18: Five patients had confusion over question number 18 which was translated as 'Mazya bolnyachya paddhticha andaj lawta yevu shakat nahi' (Intelligibility of my voice is unpredictable). Therefore, it was reframed as 'Maze bolane prateykweli samorchyas kalelach ase nahi'. (It is unpredictable that every time the next person will understand my speech.) It was rechecked with back translation and accepted with retesting on the same subjects.
Question number 23: It was stated as 'Vegle aiku yave mhanum mi mazi bolnyachi padhat badlavnyacha prayatna karto' (I try to change my speech to sound different.) in SIT. One patient suggested the word 'Yogya' (right) in place of 'Vegle' (different). This was accepted and the word is replaced in final Marathi translation as 'Yogya aiku yave mhanum mi mazi bolnyachi padhat badlavnyacha prayatna karto' (I try to change my speech to sound correctly.).
Patient interview report of VHI-
Question number F10: One patient reframed the sentence as 'Awajachya trasamule maze aarthik nuksan zale aahe' (My voice problem caused me to lose income.) in place of 'Awajachya trasaule mazi aawak kami zali aahe' (My voice problem has reduced my income). As both were giving the same meaning we retained the translation as in SIT.
Question number E10: One patient was not comfortable in answering this question. 'Mazya awajachi mala laj watate'. (I am ashamed of my voice problem.) He said it's there because of disease and he must accept it. He felt bad because of his poor voice quality. But he did not mention the question was objectionable or should not be used. The other nine patients did not report it as objectionable or offensive, so we used the same translation.
Options zero to four – One patient suggested that he would have been more comfortable in answering as yes or no rather than never/almost never/sometimes/almost always/always.
None of the patients reported that the questions or any specific word used in the questionnaire were objectionable or offensive. This reflects the translation is well and correctly understood and is culturally acceptable. The suggested corrections were incorporated, rechecked with back translation and footnote mentioning the credit statement (referring the primary authors) were incorporated in the final Marathi translation [Appendix 1] and [Appendix 2]. It was then sent to the primary authors who approved and accepted it.
| » Discussion|| |
Claudius Galen is hailed as the founder of laryngology and voice science. He was the first person to bring to notice the difference between speech and voice. Voice is an audible sound produced by the act of phonation while speech is a combination of the act of phonation, resonance, and articulation.
Increasing awareness and advances in the treatment had reflected in high cure rates of HNSCC. Both the speech and voice are affected by the disease and its treatment. This speech and voice impairment can be reduced by rehabilitation and specific care during and after treatment. The corrective measures for speech and voice are different. For this, the problem needs to be quantified separately as speech or voice problems. This is made possible using the self-reported quality of life tools for the patients. But the majority of QOL tools are available in the English language. Patients can report their problems correctly if the QOL tool is available in the local language. To use these English questionnaires in a new country, culture, and language, it is necessary to have a pretested correctly understandable translation, which also must be adopted culturally to maintain the content validity.
SHI is a 30 question document assessing the speech function, psychosocial functions, and intelligibility of speech.
 VHI is divided into three domains i.e., functional, physical, and emotional with ten questions in each group.
 The translation is needed as patients can understand and answer in a better way if the questionnaire is in the local language. We tried to fulfill the aim of producing a conceptually equivalent translation of SHI and VHI, which is culturally acceptable and is reported as unobjectionable/offensive by patients of HNSCC.
We translated the SHI and VHI in the Marathi language by language experts. The SIT was made after face validation by a Marathi subject expert. The patient's interviews proved that the wordings were well and correctly understood reflecting a good linguistic and cross-cultural validation. This Marathitranslation needs to be provided to another group of patients to confirm the modifications and for psychometric analysis.
| » Conclusion|| |
Speech and voice impairment need to be documented separately in HNSCC patients. Self-reported tools can measure the problem correctly if it is available in the patient's language. Marathitranslation of SHI and VHI for head and neck cancer patients is well accepted and understood. It can be used for future studies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Our sincere thanks to Dr Padmini Nirmal, Dr Tejal Khadskar, Mr Sagar Tambe and Mr Swapnil Kute for their help in the forward translation. We thank Dr Pravin Zopate, Dr Priyanka Aher, Miss Kanchan Kakade and Mrs Dipali for their help in back translation. We are thankful to Mr P P Varpe for proof-editing (subject expert) and Mr Vijay Pawar for his help in Marathi typing. We thank Dr Arya Bhanu and Dr Meenakshi Ravichandarn (Junior Resident, Department of Radiation Oncology, Pravara Rural Hospital and Rural Medical College, Pravara Medical Trust's Pravara Institute of Medical Sciences, Loni) for their help in English language editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. C A Cancer J Clin 2018;68:394-424.
Chaukar DA, Das AK, Deshpande MS, Pai PS, Pathak KA, Chaturvedi P, et al
. Quality of life of head and neck cancer patients: Validation of European organization for research and treatment of cancer QLQ –C30 and European organization for research and treatment for cancer QLQ-H and N
35 in Indian patients. Indian J Cancer 2005;42:178-84.
] [Full text]
Fung K, Yoo J, Leeper H, Hawkins S, Heeneman H, Doyle PC, et al
. Vocal function following radiation for non-laryngeal versus laryngeal tumors of the head and neck. Laryngoscope 2001;111:1920-24.
Rinkel RN, Irema MV, Reij EJ, Aaronson NK, Leemans R. Speech handicap index in patients with oral and pharyngeal cancers: Better understanding of patients complaints. Head Neck 2008;30:868-74.
Jacobson B, Johnson AF, Grywalski C, Silbergleit A, Jacobson G, Benninger M. Voice handicap index: Development and validation. Am Jr Speech Language Pathol 1997;6:66-70.
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross cultural adaptation of self-report measures. Spine 2000;25:3186-91.
Sataloff RT. Chapter 1: Introduction. In: Professional Voice: The Science and Art of Clinical Care. 4th
ed, vol 1. USA: Pleural Publishing; 2017, p. 4.