Cultural Adaptation of the Cardiff Acne Disability Index to a Hindi Speaking Population: A Pilot Study

Abstract

Background:

Acne vulgaris is known to impair many aspects of the quality of life (QoL) of its patients.

Aim:

To translate the Cardiff Acne Disability Index (CADI) from English into Hindi and to assess its validity and reliability in Hindi speaking patients with acne from India.

Methods:

Hindi version of CADI, translated and linguistically validated as per published international guidelines, along with a previously translated Hindi version of dermatology life quality index (DLQI) and a demographic questionnaire were administered to acne patients. The internal consistency reliability of the Hindi version of CADI and its concurrent validity were assessed by Cronbach's alpha co-efficient and Spearman's correlation co-efficient respectively. Construct validity was examined by factor analysis. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA) for Windows.

Results:

One hundred Hindi speaking patients with various grades of acne participated in the study. Hindi version of CADI showed high internal consistency reliability (Cronbach's alpha co-efficient = 0.722). Mean item-to-total correlation co-efficient ranged from 0.502 to 0.760. Concurrent validity of the scale was supported by a significant correlation with the Hindi DLQI. Factor analysis revealed the presence of two dimensions underlying the factor structure of the scale.

Conclusion:

Hindi CADI is equivalent to the original English version and constitutes a reliable and valid tool for clinical assessment of the impact of acne on QoL.

What was known?

• Many tools exist to measure the impairment in quality of life (QoL) in patients with acne vulgaris

• However, none of the disease-specific tools have ever been validated for a Hindi speaking population

• Cardiff Acne Disability Index is a well-validated acne-specific self-administered QoL tools specifically designed for young adults and teenagers that can be completed quickly.

Introduction

Acne vulgaris is a common multifactorial inflammatory disease of the pilosebaceous unit affecting >80% of individuals at some time during their lives. Endogenous as well as exogenous factors, including increased sebum production, altered follicular keratinization, inflammation, and increased colonization by the anaerobic, Gram-positive commensal bacterium Propionibacterium acnes underlie the pathogenesis of acne vulgaris.

Rather than being an acute disease, the long continuing changes in the distribution and severity of the condition can be physically scarring and psychologically damaging.[1] In many patients, acne has a prolonged course, a pattern of recurrence or relapse, onset gradually or as acute outbreaks, and a psychological and social impact that affects the individual's quality of life (QoL) – all characteristics that the World Health Organization has used to define chronicity of diseases.[2,3]

The interaction of acne and psychosocial issues like body image, socialization and sexuality, is complex, particularly so during adolescence.[4] Acne can also be negatively associated with intention to participate in sports and exercise and leads to suicidal ideation in about 5–6%.[5,6]

Integration of the information based on QoL with the severity of acne has not only enabled a more holistic clinical management of acne sufferers but also added a patient orientated dimension to their medical records. There are a number of questionnaires that could be used to assess the impact of acne on QoL. Generic health status measures- such as the short form-36 or EuroQoL (EQ-5D), designed to be used across all diseases- are less sensitive than dermatology or disease-specific ones.[7] Dermatology life quality index (DLQI)[8] and Skindex[9] are the most widely used dermatology specific measures for adults; children DLQI being the only such measure for children.[10] Specific measures for assessment of acne-related QoL include the Cardiff Acne Disability Index (CADI),[11] the acne-specific QoL questionnaire,[12] the acne QoL scale,[13] and the 4-item index of acne QoL (acne-Q4).[14]

Cardiff Acne Disability Index is a five-question scale designed to assess the disability caused by acne. First two of its questions address the psychological and social consequences of acne in general; the third, targets those with acne of the chest or back; the fourth, enquires into the patient's psychological state; and the last, asks for the patients’ (subjective) assessment of current acne severity. The response to each question is scored from 0 to 3, the higher score indicating greater disability.[11] The original language of the CADI was English, subsequently it has been translated into Arabic, Cantonese, Czeck, Dutch, Filipino, French, Persian, Portuguese, Serbian and Ukranian.[15] There being no acne specific QoL questionnaire in Hindi, we undertook this pilot study to carry out the translation and cultural adaptation of the CADI into Hindi and to assess the validity and reliability of this translated version.

Methods

Translation

Written permission to translate CADI into Hindi was obtained from Professor Andrew Finlay, the copyright holder. Repeated forward-backward translation without utilizing any professional translators, was adopted as per the international recommendations[16] emphasizing the conceptual equivalence, rather than a word-for-word translation. During this process, two independent bilingual translators produced a joint version after reconciling any problems they might have encountered during the process. Two other independent bilingual individuals translated this joint version back into English. Discrepancies from the original English version were noted and rectified, followed by further checking, back-translation and resolution of disparities/difficult issues by discussion with the original author. Ten patients suffering from acne were cognitively debriefed with respect to comprehensibility, ambiguity of the items, and relevance to the social context. Final refined version then generated was subsequently accepted by the original authors and placed on their website [Appendix 1].[15]

Validation study

A cross-sectional questionnaire-based study was carried out on a cohort of acne patients attending our outpatient department. Ethical clearance was taken from our Institute. After obtaining informed consent, each patient was asked to fill in the Hindi CADI and Hindi DLQI (previously translated)[17] questionnaires along with a short demographic questionnaire without any time limit. The clinical severity of acne was assessed using the global acne grading system score that considers six locations; five on the face (forehead, right and left cheek, nose and chin) and a combined one for chest and upper back, with a factor for each location based on surface area, distribution, and density of pilosebaceous units. Acne severity is graded using the global score (the sum of scores for each location); score of 1–18, considered mild; 19–30, moderate; 31–38, severe; and >39, very severe.[18]

Assessments of the differences in mean values of CADI between males and females, internal consistency, and item-to-total score correlations were done by t-test, Cronbach's alpha, and Spearman's correlation analysis respectively. Spearman's rho co-efficient was used to examine the correlation between the Hindi versions of the newly translated CADI and the previously translated DLQI. The factor structure of the measure was examined using the principal component analysis (PCA) with varimax rotation. All statistical analyses were performed using the Statistical Package for the Social Sciences, SPSS version 20 (SPSS Inc., Chicago, IL, USA). A two-tailed P < 0.05 was considered significant.

Results

A total of 100 patients, 63 male and 37 female, of age ranging from 14 to 45 (mean: 22.49 ± 5.381) years participated in the study. The overall mean CADI score was 6.09 (±3.153, range: 0–15). The score was higher in males (6.33 ± 0.385) than females (5.68 ± 0.544). Mild, moderate, severe and very severe acne were recorded in 44, 42, 12 and 2 patients, respectively. The internal consistency reliability of the overall scale was found to be high (Cronbach's alpha co-efficient = 0.722). The item-to-total correlation ranged between 0.502 and 0.760 [Table 1]. The concurrent validity of the newly translated Hindi version was shown by its significant correlation with the Hindi version of DLQI (Spearman's rho = 0.880; P = 0.01). The descriptive data of the Hindi CADI and its comparison with the original English CADI[8] are shown in Table 2. PCA with varimax rotation revealed a Kaiser–Meyer–Olkin measure of sampling adequacy as 0.721 and showed two underlying factors; the first, consists of three items pertaining to emotional well-being of acne patients and the second comprised of two items concerning the social impact of acne, explaining 48.17% and 19.61% of the variance respectively.

Table 1.

CADI item-to-total correlations (n=100 acne patients)

Table 2.

Results of the validation study for the Hindi version of the CADI and the reported study of the original English version

Discussion

Chronic skin diseases have long been recognized to have a significant effect on the QoL of patients, patients typically perceiving their skin disease to be more troubling than their physicians.[19] The use of standardized subjective QoL measures in routine clinical practice is an important step in moving away from a physician-centered approach to a more patient-centered one.

Among various acne-specific QoL measures, the CADI was selected to be translated and validated into Hindi because of it being a well-validated scale designed specifically for young adults and teenagers and having only five questions that can be completed quickly in a busy dermatology clinic.[11] Following the principles of good practice for cross-cultural adaptation of patient-reported outcome measures as per the International Society for Pharmacoeconomics and Outcome Research,[16] the original English version of the CADI was translated into Hindi. In addition, consideration of a conceptual rather than literal approach in our translation process guaranteed usage of specific words and phrases reflecting the Indian culture.

In order to assess the reliability and validity of the translated and culturally adapted Hindi version of the CADI, a cross-sectional validation study was conducted. The total mean score of the CADI in our study was 6.09; lower in comparison with a Persian study,[20] but higher than Serbian[21] and Scottish studies.[22] Relatively higher scores could be explained by the relatively large proportion of subjects with higher grades of acne in our institution- based study as compared to a community-based one.

The concurrent validity of CADI was deemed satisfactory by a Spearman's correlation co-efficient of 0.88.[23] Internal consistency reliability was found to be adequate with a Cronbach's alpha value of 0.722 and item-to-total correlation (Spearman's rho = 0.502–0.760)[23] indicating that the Hindi version of CADI is a valid and reliable questionnaire.

The limitations of this study were its small sample size and the lack of guaranteed reliability of self-reported QoL.

Conclusion

In summary, the findings of the present study indicate that the Hindi version of the CADI is a reliable and valid measure of the impact of acne on QoL and can now be used in such Hindi speaking patients. Larger multicentric studies to further validate this version may be undertaken.

What is new?

• The English version of Cardiff Acne Disability Index (CADI) has, for the first time, been translated into Hindi and validated

• This version of CADI can be now easily used, to measure the impairment in QoL, in a Hindi speaking population suffering from acne.

Appendix 1.