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 Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 156-158

Translation and adaptation of english language questionnaire into arabic for implementation of a large survey on assessing the symptoms of bleeding disorders in Saudi Arabia

1 King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
2 Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Date of Web Publication12-Jan-2018

Correspondence Address:
Dr. Ayman Al-Suliman
Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joah.joah_70_17

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Bleeding disorders are infrequent health problem in most of the societies and gain less focus by medical professionals. There are some data suggesting a higher prevalence of mild bleeding symptoms and coagulation factors deficiency in societies with high consanguinity. Furthermore, few validated tools for detecting bleeding disorders through large sample sized surveys are available in Arabic language. Hereby, we are presenting our experience of translating and validating one of these tools for implementation into an Arabic speaking population. An expert committee was formulated with a primary objective of smoothly translating the questionnaire into Arabic while maintaining the reliability and validity of the instrument. Pearson's correlation coefficient was calculated to test for the significance of correlation found in test-retest reliability. In test-retest reliability assessment, we did not find the individuals' responses changing over time. Content validity was confirmed through a panel of practicing hematologists. Establishment of an expert committee to oversee the process of translation and adaptation of a foreign language questionnaire into Arabic has proven its usefulness.

Keywords: Arabic, bleeding symptoms, questionnaire, translation and adaptation, von Willebrand disease

How to cite this article:
Siddiqui KS, Abu-Riash M, Al-Suliman A. Translation and adaptation of english language questionnaire into arabic for implementation of a large survey on assessing the symptoms of bleeding disorders in Saudi Arabia. J Appl Hematol 2017;8:156-8

How to cite this URL:
Siddiqui KS, Abu-Riash M, Al-Suliman A. Translation and adaptation of english language questionnaire into arabic for implementation of a large survey on assessing the symptoms of bleeding disorders in Saudi Arabia. J Appl Hematol [serial online] 2017 [cited 2022 Nov 27];8:156-8. Available from: https://www.jahjournal.org/text.asp?2017/8/4/156/223181

  Introduction Top

In general, bleeding disorders are considered to be a spectrum of inherited disorders with prevalence varying from one ethnicity to another. Hemophilia A and B, which are the most commonly known inherited bleeding disorders, can prove to be life-threatening for an individual and costly for a family to tackle.[1] von Willebrand disease (VWD), also an inherited disorder, is a relatively common cause of bleeding with varying prevalence among reported research studies. The prevalence of VWD has been estimated in several countries on the basis of the number of symptomatic patients seen at hemostasis centers and ranges from about 23–110 per million population (0.0023%–0.01%).[2] Although several case reports and case series can be cited from the medical literature, yet no population-based screening studies have ever been conducted in the Kingdom of Saudi Arabia to examine the prevalence of inherited bleeding disorders.[3],[4],[5],[6],[7] A higher rate of consanguineous marriages observed by the authors in their routine practice at their institutions justify the development of a hypothesis of an increased prevalence of inherited bleeding disorders among the Arab communities. In this backdrop, a survey to examine the symptoms of possible bleeding disorders among the high school students in the city of Riyadh, Kingdom of Saudi Arabia was initiated. A standardized questionnaire from an international, multicenter study was adapted (MCMDM-1 VWD).[8],[9],[10] The questionnaire was translated into Arabic language and implemented for the survey. This article is intended to provide the readers with an overview of the challenging experience of translation and adaptation of an English language questionnaire for Arabic speaking community.

  Subjects and Methods Top

In face to the challenge of coming up with a questionnaire translated into Arabic, which is psychometrically sound, efficient, and effective to be used in the Arabic speaking community, an expert committee comprising of eleven professionals (including hematologists, epidemiologists, lead interviewers, statistician, systems analyst, and database programmer) was formulated.[11] Following the establishment of the expert committee, a total of twenty (20) interviewers (10 males and females each) were commissioned, as the questionnaire was to be implemented through a team of trained Arabic speaking interviewers. This gesture also facilitated us tremendously in the process of test and retest reliability assessment and validation of the questionnaire through a practical attempt of limiting the sources of variation.

The survey questionnaire consisted of thirteen items with closed-ended responses, multiple options and multi-items increasing Likert scale responses, majority of which consisted of quantitative selections.

For the initial forward translation of the questionnaire, three bilingual individuals (physicians practicing as hematologists) were asked to translate the instrument, in addition to a naïve translator from a private “Translation Service” center. For all of these individuals, Arabic was their mother tongue or first language. This arrangement was done to ascertain that nuances of Arabic language are reflected in the translation.[11],[12] The individuals with medical background provided a translation which was identical and closely resembled the original questionnaire. The translation from the naïve translator, who was not aware of the objectives of the questionnaire, provided us with a second version of the instrument to detect subtle differences between the two versions. Only difference found between the two versions was the way “VWD” was spelled. This success was credited to the adaptability and richness of Arabic language. The whole process of collection and then review of these four translations was carried out by an unbiased, bilingual independent individual who was not involved in this forward translation process. Once the first version of the Arabic translation of the instrument was available, it was forwarded to three independent bilingual translators with English as their mother tongue, who were not aware of the intended concept of what the questionnaire was designed or expected to measure.[11] Two of the English translations were received within deadline and were presented to the expert committee of the project, which made the decision to adapt the Arabic translation of the instrument. However, minor spellings mistakes in the medical conditions specified were observed due to nonmedical background of the translators.

Due to the nature of the survey and the population of the participants involved, approval from the Ministry of Education was mandatory. This approval required the final version of the translation. It was therefore decided to run the instrument on an independent group of similar individuals to assess the test-retest reliability. In parallel, a subcommittee comprising of three practicing bilingual (English – Arabic) hematologists was formulated by the chairman of the expert committee to review and report the content validity of the questionnaire independently. Following items were investigated by the subcommittee in the translated questionnaire:[11]

  1. Are the questions clear?
  2. Are the questions easy to answer with the help of a trained interviewer?
  3. Are questions sufficient to cover all the bleeding symptoms which can possibly be observed?
  4. Would the member like to use the same questionnaire in future assessment for such research studies?
  5. Does the questionnaire lack any important question regarding the bleeding symptoms survey?

No independent attempt to measure the construct validity of the questionnaire was carried out. Once the translation from English version of the instrument into Arabic was finalized after reports on test-retest reliability and contents validity were received, reviewed and approved by the expert committee, it was then submitted to the relevant authorities for initiation of the survey to the population of interest.

  Results Top

For pilot testing of the questionnaire, which had thirteen primary items and various multiple secondary items to be filled if one primary item was selected, a total of 40 individuals were invited for the interviews, half of them were females. The interviews were conducted by trained interviewers whose mother tongue was Arabic. Time between the repeated interviews was from 4 to 5 weeks depending on the availability of the individuals who were interviewed. No changes in the answers to the interview questions were observed except for two items by three participants (r = 0.562 and 0.928, P = 0.001 each). These changes were found to be related to the change in real life circumstances. Two of the participants had nosebleed due to hot and dry weather while they were outside in the sun, and one of the females had accidentally hit herself and had cutaneous symptoms. For content validation, the subcommittee formulated by the expert committee reviewed the translated questionnaire and presented their independent responses on the five items as mentioned before. All responses were found to be in positive. For all the pilot interviews conducted, verbal consents before the appointment and then initiation of the interviews were obtained from the participants.

  Discussion Top

The instrument to be used for the survey could not be pretested on the population of interest as it involved school students who were not of consenting age. It also required a mandatory approval from the Education Department, which was not possible without satisfying the requirement of a reliable Arabic language translation of the instrument. To achieve a reliable translation of the instrument, we followed a well-established procedure of establishing an expert committee to overview the process of forward translation, verifying it through backward-translation and then pretesting the instrument for their reliability followed by content validity.[11],[13],[14] Since the original English Language instrument we used was standardized and was measuring the constructs which were all directly measurable; we did not feel a need to test the construct validity as proposed by Tsang et al.[11] The primary reason behind this decision was that we had added another layer of authentication in terms of involving trained interviewers whose mother tongue was Arabic and they had received a comprehensive and exhaustive in-service before embarking on the survey. Furthermore, we also felt the need to have trained interviewers for face-to-face interviews because of the population of interest which mainly comprised of intermediate and high school students, for whom understanding of the contents of the questionnaire was of prime significance for the success of the survey. This also reflected in getting a very high degree of reliability of the translated instrument in test-retest process. The only discrepancies we found in our test-retest phase were due to the change in real-life circumstances though our time between the repeated interviews was 4–5 weeks. Our experience of translation of an instrument for a community-based survey from English to Arabic language and then testing for its reliability and validity is of great value due to the nature of the survey and primary characteristics of the population of interest. Formulation of an expert committee facilitated in the process of translation and adaptation of a foreign language questionnaire smoothly and reliably. Our plan to introduce trained interviewers to assist in answering the survey questions to get a higher degree of reliability added to the overall cost of the underlying research project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Federation of Hemophilia. World Federation of Hemophilia Report on the Annual Global Survey 2006. World Federation of Hemophilia; 2007.  Back to cited text no. 1
Nichols WL, Rick ME, Ortel TL, Montgomery RR, Sadler JE, Yawn BP, et al. Clinical and laboratory diagnosis of von willebrand disease: A synopsis of the 2008 NHLBI/NIH guidelines. Am J Hematol 2009;84:366-70.  Back to cited text no. 2
Ahmed MA, Al-Sohaibani MO, Al-Mohaya SA, Sumer T, Al-Sheikh EH, Knox-Macaulay H, et al. Inherited bleeding disorders in the Eastern Province of Saudi Arabia. Acta Haematol 1988;79:202-6.  Back to cited text no. 3
Al-Fawaz IM, Gader AM, Bahakim HM, Al-Mohareb F, Al-Momen AK, Harakati MS, et al. Hereditary bleeding disorders in Riyadh, Saudi Arabia. Ann Saudi Med 1996;16:257-61.  Back to cited text no. 4
Al-Sharif FZ, Aljurf MD, Al-Momen AM, Ajlan AM, Musa MO, Al-Nounou RM, et al. Clinical and laboratory features of congenital factor XIII deficiency. Saudi Med J 2002;23:552-4.  Back to cited text no. 5
El-Bostany EA, Omer N, Salama EE, El-Ghoroury EA, Al-Jaouni SK. The spectrum of inherited bleeding disorders in pediatrics. Blood Coagul Fibrinolysis 2008;19:771-5.  Back to cited text no. 6
Islam SI, Quadri MI. Spectrum of hereditary coagulation factor deficiencies in Eastern Province, Saudi Arabia. East Mediterr Health J 1999;5:1188-95.  Back to cited text no. 7
Rodeghiero F, Castaman G, Tosetto A, Batlle J, Baudo F, Cappelletti A, et al. The discriminant power of bleeding history for the diagnosis of type 1 von willebrand disease: An international, multicenter study. J Thromb Haemost 2005;3:2619-26.  Back to cited text no. 8
International Society on Thrombosis and Haemostasis. ISTH SSC Reference Tools 2017; 15 November, 2017. Available from: https://www.isth.org/?page=reference_tools. [Last accessed on 2017 Nov 18].  Back to cited text no. 9
Rodeghiero F, Tosetto A, Abshire T, Arnold DM, Coller B, James P, et al. ISTH/SSC bleeding assessment tool: A standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost 2010;8:2063-5.  Back to cited text no. 10
Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth 2017;11:S80-9.  Back to cited text no. 11
Hendricson WD, Russell IJ, Prihoda TJ, Jacobson JM, Rogan A, Bishop GD, et al. Development and initial validation of a dual-language English-spanish format for the arthritis impact measurement scales. Arthritis Rheum 1989;32:1153-9.  Back to cited text no. 12
World Health Organization. Process of Translation and Adaptation of Instruments. Res Tools 2017;2017:1. Available from: http://www.who.int/substance_abuse/research_tools/translation/en/. [Last accessed on 2017 Nov 10].  Back to cited text no. 13
Robichaud-Ekstrand S, Haccoun RR, Millette D. A method for validating a translated questionnaire. Can J Nurs Res 1994;26:77-87.  Back to cited text no. 14

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