Linguistic Validation of the Kannada Language Version of Pelvic Girdle Questionnaire

 Introduction

Pelvic girdle pain (PGP) is characterized by pain affecting the area between the gluteal fold and posterior iliac crest.¹ Pain is experienced around the sacroiliac joints (SIJ). The pain may radiate to the posterior thigh and can occur with or without involvement of the symphysis region.¹ Pregnant women often report pain in the pelvic girdle region, and in some cases, this pain may persist even after the childbirth. It may occur in trauma and arthritis as well.¹ The prevalence has been estimated to be around 7% to 84% percent worldwide, with few countries showing higher knowledge and awareness compared to the others.² The condition is considered to resolve in approximately 93 percent of women after childbirth.¹ There is a distinction in terms of aetiology and pathology of PGP, which differs from that of low back pain (LBP). European guidelines indicate that PGP and LBP should be classified separately in their symptoms.¹ PGP has shown to affect the quality of life, making activities of daily living difficult. PGP affects women’s physical function, their mental state and social economy.¹ It can be diagnosed using computed tomography, magnetic resonance imaging, but in pregnancy, it would be best to diagnose with specific pain provocation tests, or multiple-test scores.^3-5 As per European guidelines, it is necessary to differentiate between LBP and PGP; hence diagnostic tools are required.⁶ Quality of life is one of the outcomes that must be assessed. It can be done using a valid and reliable tool to draft the right clinical management plan.⁶

The Pelvic Girdle Questionnaire (PGQ) was devised in Norway in the year 2011.⁶ The collection tool of PGQ was designed by Stuge et al.6 It comprises subscales each for activity and symptoms. The activity subscale contains 20 items with a maximum score is 60, while the symptom subscale includes five items with a maximum score of 15, resulting in a total possible score of 75. The responses to each item are based on a four-point Likert scale. PGQ was originally validated in 2012 and demonstrated good construct validity, internal consistency, and test-retest reliability.⁷ Pelvic girdle pain is a global concern, and this necessitates linguistic validation of the questionnaires available in various languages in order to facilitate accurate recording of responses.

Materials and Methods

When a questionnaire is used in a specific population from a different community, its translation becomes essential. Distortion of the original meaning can occur on direct translation of the questionnaire. This can lead to misinterpretation. Hence, the original version of the questionnaire must be first translated into the language of the community where the study is intended. Further on, to ensure cultural rightness and validity of the translated instrument, it must be tested using scientific measures before being adopted for future studies.⁸

Our study began with translating the English questionnaire following international guidelines. Beaton’s six step procedure was used for linguistically validating the Pelvic Girdle Questionnaire.⁸

It consisted of the forward translation, synthesis, back translation, expert review opinion, pretesting and final administration of the questionnaire among the participants. Obtaining authorization from the English version's author was also necessary for the validation process of PGQ in Kannada.

Syntheses: Discrepancies were resolved after the forward translation. Both the translators reached a consensus and the questionnaire was renewed by an independent observer (T12).

Back Translation: Two translators performed a back translation i.e., translating back to English. Here the first translator (BT1) was a native English speaker, while the other translator (BT2) was a linguistic language expert.⁸

Expert Committee Review: The committee was formed comprising of an expert with sound knowledge about the linguistic validation and the subject, the forward translators and the back translators. During the pre-final version of the PGQ, the expert committee reviewed on the words, meaning, grammar, experiential, idiomatic and semantic equivalence.⁸

Testing of the Pre-Final Version: After achieving a consensus-based prefinal version of the PGQ, it was tested among 30 pregnant women attending antenatal control at Department of Obstetrics and Gynaecology, Ramaiah Medical College. The eligibility criteria included ability to speak and read Kannada language. Pregnant women aged 18 years and upwards were given a demographic data questionnaire to assess the prevalence of pelvic girdle pain. Additionally, prior to the commencement of interview, an illustration of PGP localization was added to clarify pain area.

Participants were recruited from Department of Obstetrics and Gynaecology, Ramaiah Medical College and Hospital. Women with lesions on the skin in the lumbosacral area, chronic pelvic disease, visual, auditory or cognitive problems, any diagnosed pregnancy complications other than PGP, high risk pregnancy inclusive of women undergoing fertility treatment to conceive, history of spinal injury, ankylosing spondylitis, rheumatoid arthritis, intervertebral disc pathology were excluded. It is important to note that twin pregnancies were not considered in this research. Written consent was obtained from women who fulfilled the criteria

Thirty participants were involved in the study of which 12 were confirmed to have pain in the pelvic girdle area using special tests. Pain provocation tests (Patrick's Faber, P4/thigh thrust, modified Trendelenburg's test, and Gaenslen's test) and pain palpation tests (palpation of the symphysis and long dorsal ligament test) were used to confirm pregnancy related pelvic girdle pain.⁹ As a functional test for pelvic girdle pain, Active Straight Leg Raise (ASLR) test was recommended.⁹

Institutional research ethics committee assented to the study and written informed consent was obtained from all the participants. Participants were asked to complete the prefinal Kannada PGQ along with a brief question-naire on their sociodemographic details, including age, height, weight, educational level, and gestational age. They were asked to rate their understanding of the questionnaire with 25 items on a Likert scale ranging from 1 to 5 (where 1 is “not at all” and 5 is “absolutely”). If 10% of participants failed to understand a question, it was reviewed by the expert committee and changes were incorporated into the final version of the translated PGQ.

Post the pilot study, the Kannada Questionnaire of PGQ was tested on 122 pregnant women during the period May 2023 to February 2024.

Results

Participants responded well to the pre-test of the English and Kannada versions of the self-administered questionnaire aimed at estimating the prevalence of pain in the pelvic girdle region.

Descriptive statistics of information provided were presented as mean and standard deviation (SD). Statistical analyses to assess the validity were performed by testing the internal consistency and ceiling & floor effects. Descriptive data of the 25 items are summarized in Table 1.

During the translation process, linguistic differences were found in some items, which were resolved during synthesis. Similar differences were noted with backward translation during the cross check. Linguistic discrepancy was found in Item 23. The overall understanding of the PGP concept was also assessed using a similar Likert scale, and the most common answer provided was 4 - good (66.66%), followed by 3 - fair (25%). General comments post the pre-testing of the Kannada version of pelvic girdle questionnaire were that the questionnaire included strong relevant items to PGP, which were easy to understand and also quite brief.

Based on the results outlined in Table 2, linguistic discrepancy was found in Item 23. The 23rd question, “Has your leg/have your legs given way?” which was translated to “ನಿಮ್ಮ ಕಾಲುಗಳಲ್ಲಿ ಯಾವುದೇ ಶಕ್ತಿ ಇಲ್ಲ ಎಂದು ನೀವು ಭಾವಿಸುತ್ತೀರಾ?” was not clearly understood by all the women. Expert committee had discussions before reframing the question and subjected to final check. Thus the final version of PGQ-Kannada was achieved.

To assess internal consistency, usage of Cronbach α was explored for both activity and symptom subscales. Internal consistency measured by Cronbach α coefficient for items in activity subscale (1-20) and symptoms subscale (21-25) were .860 and .804, respectively.

In Cronbach α ranging from 0 to 1, 0 indicates no internal consistency and 1 indicates a high level of correlation or consistency. In Kannada version of PGQ, Crohnbach’s α was noted as 0.814 indicating high consistency. Internal consistency of every item is outlined in Table 3.

None of the patients in the overall PGQ-Kannada achieved a minimum or maximum score, indicating the absence of ceiling and floor effects.

Floor Effect: Floor effect is often considered to be present when more than 15-20% of respondents score at the lowest possible level on a particular item. The revised questionnaire had a flooring effect ranging between 15-20%.

Ceiling Effect: Ceiling effect is typically considered to be present when more than 15-20% of respondents score at the highest possible level on an item. In the present questionnaire, ceiling effect for all the questions was 0%.

Both the ceiling and floor effects are shown in Table 4.

Discussion

The PGQ is a valuable tool for pregnant and postpartum women to report symptoms of PGP. As per studies, the PGQ is effective in detecting “real” changes in symptoms and activity in women. The PGQ demonstrated excellent responsiveness through a correlational approach by comparing changes in PGQ scores.¹⁰

The translation of English version of PGQ into the Kannada language was followed by linguistic validation of the same. The procedure followed for translation and cultural adaptation of this questionnaire for Kannada speaking pregnant women echo the process followed in the translation and adaptation of this tool for pregnant women with PGP in Nepal, Spain, Brazil, and Iran.^7,11,12,13 Translations and cross-cultural adaptations have taken place in Urdu and also in Polish language.^14,15

The operational definition, especially when it comes to Pelvic Girdle Pain can be studied better when the same questionnaire is used in different nations among similar populations. This aids in providing a global perspective and helps compare the results multiculturally. Thus, translation becomes a critical step. Fundamental purpose of the questions must be maintained in any study; any deviation can result in disruption in the study. If the PGP must be assessed among Kannada speaking pregnant women, it is imperative to translate the same into PGQ-Kannada (PGQ-K).

Thus, the aim and objective of the present study was to translate the PGQ questionnaire for Kannada-speaking population, using Beaton's six-step procedure. This process identified linguistic differences among the three versions of the PGQ- Kannada (PGQ- K) during forward translations 1 & 2 and synthesis. Ambiguous items were clarified as needed, and consensus was reached at each stage. The version of the Kannada PGQ tested in the pre-final stage was well understood, with an exception of the 23rd question that required further explanation during the interview.

The test-retest reliability of the study displayed strong intraclass correlation coefficient values. Specifically, in case of PGQ activity subscale in the original study, the estimate was .93 (95% confidence interval ranging from .86 to .96), and for the PGQ symptom subscale, it was .91 (95% confidence interval ranging from .84 to .95).¹⁵

All the items in a test that measure the same concept or construct are best described by their internal consistency. This internal consistency indicates the degree of relatedness of various items within the test. To ensure validity, internal consistency should be measured before using a test for any project or evalua-tion or research. Subsequently, while testing the internal consistency of the PGQ-K scale, a satisfactory result with a Cronbach α of 0.814 was obtained. The Kannada version achieved a value of 0.814, indicating suitable consistency. Therefore, it may be proposed that the scale is accurate and reliable. Subscales too demonstrated good internal consistency.

The 23rd question “ನಿಮ್ಮ ಕಾಲುಗಳಲ್ಲಿ ಯಾವುದೇ ಶಕ್ತಿ ಇಲ್ಲ ಎಂದು ನೀವು ಭಾವಿಸುತ್ತೀರಾ?”, was the solitary question requiring further explanation. In pre-testing, most participants understood the items well and responded to all of them quickly. Since the PGQ is a subjective evaluation, the same was maintained during the linguistic validation process.

In terms of floor and ceiling effects, no subject showed ceiling effect, while 15 to 20% percent showed floor effect. This suggests that the questions were effective in distinguishing between the respondents.

The life of a pregnant woman is significantly affected when she suffers with PGP.¹⁶ Studies reported that pregnant women struggle to carry out daily activities when in pain.16 During pregnancy, women struggle to carry general everyday tasks within the home including housework, cleaning and daily chores. Dependency on their spouse and other family members for assistance significantly escalates when dealing with PGP.¹⁶ It has been reported that long-term PGP, similar to other chronic pain conditions, is associated with decreased function, and psychosocial factors such as depression, anxiety, disturbed sleep, self-efficacy and pain catastrophizing.^16,17 Anxiety and depression may act as facilitators of pain nociception, making the pain worse, while the pain, in turn may act as facilitator of anxiety and depression, thus establishing a vicious cycle.¹⁶

The PGQ is the only instrument that allows pregnant and postpartum ladies with pelvic girdle pain to self-report their symptoms. Research indicates that PGQ can detect “real” changes in symptoms and activity among women with PGP. The PGQ also exhibits excellent responsiveness when using a correlational approach to compare changes in PGQ scores.¹⁶

A multimodal treatment approach involving activity modification, pelvic support garments, physiotherapy exercise interventions, and management of acute exacerbations should be executed to prevent progression of symptoms.¹⁷

Take home message

The PGQ is a valid tool for assessment of pelvic girdle pain. Since no tool is currently available in Kannada which measures the quality of life of pregnant women suffering with PGP, translation and validation of the original PGQ questionnaire into Kannada will benefit healthcare professionals in the state of Karnataka.

Strengths and Limitations

The PGQ has been translated and adapted into various languages. Linguistic validation of the PGQ- K has been conducted for the Karnataka population, targeting women of child bearing age, to provide a reliable self-report tool for assessing PGP in clinical practice. This will be applicable not only in India but also internationally. At the outset, the study mentioned above was conducted in an antenatal setting, and postpartum women were not included. While the PGQ, as evaluated by Grotle et al., showed no difference in its construct validity and reliability between pregnant and postpartum women, with the exception of its discriminant validity, the absence of postpartum women in the study is a significant limitation.^15,18

Conclusion

The Kannada PGQ was translated from the English version, and can be used to study a larger population of pregnant and postpartum women to better understand pelvic girdle pain during and after pregnancy. This version can be used by healthcare professionals and researchers among the Kannada-speaking population of Karnataka. PGQ-K can aid in assessing PGP and limitations of daily living in pregnant women. With the validity of PGQ-K demonstrated, a standardized, reliable self-assessment tool for PGP will become available in Karnataka, India, for future studies. This will further contribute to the global perspective on this problem.

Ethical approval

The study was approved by the Institutional Ethics Committee (IEC) of Ramaiah Medical College, Bangalore with Reg no ECR/215/Inst/ KA/2013/RR-19

Conflicting Interest

Nil

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.