Translation and Linguistic Validation of Korean Version of the Expanded Prostate Cancer Index Composite for Clinical Practice for Patients With Prostate Cancer

Original Questionnaires

Chang et al. [5] proposed a handier version of the 50-item EPIC-CP and EPIC-26 for use in clinical practice. The questionnaire is categorized by symptoms: urinary incontinence, lower urinary tract symptoms, sexual function, and hormonal problems.

Translation and Linguistic Validation

Our study was approved by the Institutional Review Board of Seoul National University Hospital (approval number: H-1305-033-487). The linguistic validation was conducted to design a Korean version of EPIC-CP questionnaire, which is conceptually similar to the original work. The validation entailed forward translation, reconciliation, backward translation, and cognitive debriefing in order [6-9].

Two bilingual persons took forward translation individually and discussed the difficulties associated with describing the questionnaires in Korean with urologists (SJO and SYC). The experts provided helpful comments to resolve any challenges involving translations and suggested alternative expressions at all steps.

Permission

The panels requested the original authors who developed EPIC-CP for consent to translate and utilize the questionnaire as a Korean version [5].

Forward Translation

Both bilingual translators individually rendered the original questionnaire into Korean. They were separated until the translation was completed.

Reconciliation

The translators and the panels gathered and reviewed 2 forward translated versions and combined it into a single translated questionnaire, for meaning and nuance.

Backward Translation

The other bilingual translator rendered the reconciled Korean version of EPIC-CP into English. The 3 linguistic experts undertook forward or backward translation, and the panels reviewed the original version of the questionnaire and backward translated version, changing indigestible phrases into more digestible expressions. Finally, the revised version was generated for cognitive debriefing.

Cognitive Debriefing

The authors administered the revised version of the questionnaire to 10 patients with prostate cancer, who had different educational and regional backgrounds. They were asked to respond to the questionnaire and then notify any difficulties in completing the questionnaire. Well-trained interviewers gathered patients’ opinions regarding the challenges encountered. The panels examined the patients’ response and then amended the questionnaire accordingly.

Proofreading

The questionnaire after cognitive debriefing was finally proofread by panels to identify grammatical errors and availability to assess HRQoL after the management of prostate cancer. As a result, we developed the final Korean version of EPIC-CP.

Forward Translation and Reconciliation

As given in (Table 1), 10 questions of the EPIC-CP were translated into Korean. The questions can be divided into 4 domains: overall urinary problem, bowel, sexual, vitality, or hormonal domains [5]. English expression of the final questionnaires was based on “Revised Romanization of Korean,” proposed by National Academy of the Korean Language

Table 1.

Forward translation of questionnaire into Korean

Overall Urinary Problem

Question 1, “Overall, how much of a problem has your urinary function been for you” in the original questionnaire was translated into “jeonbanjeogeuro gwihaui sobyeongineungi gwihaege eolmana munjega doeeotseumnikka.” The expression “urinary function” was translated into “baenyo gineung” and “yorogineung” by translator 1 and 2 repsectively. “baenyo” or “yoro” was considered hard to understand for low-educational persons, so the panels agreed on “sobyeon.” “moderate problem” in the original questionnaire was translated into “botong jungdoui munjaega issda” and “munjaega iss da” by translator 1 and 2 respectively, and the panels accepted “junggan jungdoui munjaega issda” because of its nuance.

Urinary Incontinence

Question 2, “Which of the following best describes your urinary control” in the original questionnaire was translated into “daeum jung gwihaui sobyeon jojeol jeongdoreul gajang jal seolmyeonghago inneun geoseun mueosimnikka.” The expression “urinary control” was translated into “baenyo jojeol jeongdoae” and “binyogi jeeo sangtae” by translator 1 and 2 respectively, and the panels accepted “sobyeon jojeol jeongdo,” considering patients’ educational status. “0 Total control” was translated “0 wanjeonhi jojeoldoem.” “1 Occasional dribbling” was translated into “gakkeumssik sobyeon banguri tteoreojim.” “2 Frequent dribbling” was translated into “2 jaju sobyeon banguri tteoreojim.” “4 No urinary control” was translated into “4 jeonhyeo jojeolhal su eopseum.”

Question 3, “How many pads or adult diapers per day have you been using for urinary leakage” in the original questionnaire was translated into “sobyeoni saegi ttaemune gwihaneun paedeuna seonginyong gijeogwireul harue myeot jang sayonghae watseumnikka.” The expression “using for urinary leakage” was translated into “sobyeoni saeneun iyuro” and “binyogiui nuchul ttaemune” by translator 1 and 2 respectively, and the panel accepted “sobyeoni saegi ttaemune.” “0 None /1 One pad per day/2 Two pads per day/4 Three or more pads per day” in the original questionnaire was translated into “0 jeonhyeo sayonghaji aneum/1 harue han jang/2 harue du jang/4 harue se jang isang.”

Question 4, “How big a problem, if any, has urinary dripping or leakage been for you” in the original questionnaire was translated into “manyak sobyeon banguri tteoreojigeona saen jeogi itdamyeon igeosi gwihaege eolmana keun munjeyeotseumnikka.” The expression “if any, has urinary dripping or leakage” was translated into “manyak sobyeon banguri tteoreojigeona saen jeogi itdamyeon igeosi gwihaege eolmana keun munjeyeotseumnikka” and “binyogiui nuchurina bunbi deungui munjega isseotdamyeon” by translator 1 and 2 respectively, and the panels accepted “manyak sobyeon banguri tteoreojigeona saen jeogi itdamyeon.”

“CLINICIANS: ADD the answers from questions 2–4 to calculate the Urinary Incontinence Symptom Score (out of 12)” in the original questionnaire was translated into “uisa: yosilgeum jeungsang jeomsu (chongjeom 12jeom jung)reul gyesanhagi wihae 2beoneseo 4beonkkajiui jilmune daehan daedabeul modu deohae juseyo.” “Clinician” was translated into “jillyoui” and “imsangui” by translator 1 and 2 respectively and the panels accepted “uisa.”

Urinary Irritation/Obstruction

Question 5, “How big a problem, if any, has each of the following been for you” in the original questionnaire was translated into “manyak daeume haedanghaneun gakgagui jeungsangi itdamyeon gwihaege eolmana keun munjeyeotseumnikka.” “a. Pain or burning with urination” was translated into “baenyoreul halttae oneun tongjeungina ttagaum” and “baenyojagyong jung gotongina sseurarim” by translator 1 and 2 respectively, and the panels accepted “sobyeon bol ttae tongjeungina hwakkeungeorim” since “ttagaum” means pricking and “hwakkeungeorim” means closer to burning. “b. Weak urine stream/incomplete bladder emptying” in the original questionnaire was translated into “yakan sobyeon julgi/banggwangeul modu biuji motam (jannyogam)” and “yakan gannyo/baenyo” by translator 1 and 2 respectively, and the panels accepted “yakan sobyeon julgi/banggwangeul modu biuji motam” since “jannyogam” (“incomplete bladder emptying”) can be indigestible to low-educational persons. “Need to urinate frequently” in the original questionnaire was translated into “jaju baenyoreul haeya ham” and “jajeun bangnyo” by translator 1 and 2 respectively, and the panels accepted “sobyeoneul jaju bwaya ham.” “0 No problem/1 Very small problem/2 Small problem/3 Moderate problem 4 Big problem” in the original questionnaire was translated into “0 munje eopseum/1 aju jageun munjega doem/2 jageun munjega doem/3 junggan jeongdo munjega doem/4 keuge munjega doem.”

Bowel Symptoms

Question 6, “a. Rectal pain or urgency of bowel movements” in the original questionnaire was translated into “hangmunui tongjeungina gapjakseureon baebyeon hwaldong” and “jikjangtong hogeun geupan baebyeonundong” by translator 1 and 2 respectively, and the panels accepted “jikjang tongjeung hogeun geupbakan baebyeongam.” “b. Increased frequency of your bowel movements” in the original questionnaire was translated into “baebyeon hoetsuui jeungga” and “baebyeon undongui bindoreul nopida” by translator 1 and 2 respectively, and the panels accepted “baebyeon hoetsuui jeungga”. “c. Overall problems with your bowel habits” in the original questionnaire was translated into “baebyeon hoetsuui jeungga” and “baebyeon undongui bindoreul nopida” by translator 1 and 2 respectively, and the panels accepted “baebyeon hoetsuui jeungga” since “baebyeon” is more frequently used by ordinary people.

Sexual Symptoms

Question 7, “How would you rate your ability to reach orgasm (climax)” in the original questionnaire was translated into “oreugajeum (seongjeok jeoljeonggam)e ireul su inneun gwihaui neungnyeogeul eotteoke pyeonggahasigetseumnikka.” “orgasm (climax)” was translated into “oreugajeum (jeongjeom)” and “oreugajeume” by translator 1 and 2 respectively, and the panels accepted “oreugajeum (seongjeok jeoljeonggam).” The panels added “seongjeok” (“sexual”) to describe climax more detailed. “0 Very good 1 Good 2 Fair 3 Poor 4 Very poor to none” in the original questionnaire was translated into “0 maeu joeum/1 joeum/2 botong/3 jochi aneum/4 maeu jochi ankeona eopseum.” “Poor” was translated into “jochi anta” and “misuk” by translator 1 and 2 respectively, and the panels accepted “jochi aneum.”

Question 8, “How would you describe the usual quality of your erections” in the original questionnaire was translated into “pyeongso gwihaui balgiui jireun eotteoseumnikka.” “quality” was translated into “jil” and “gineung by translator 1 and 2 respectively, and the panels accepted “jil.” “0 Firm enough/1 Firm enough for masturbation/2 Not firm enough for any sexual activity/4 None at all” in the original questionnaire was translated into “0 chungbunhi dandanham/1 jawihagie chungbunhi dandanham/2 eotteon seonghaengwireul hagiedo chungbunhi dandanhaji aneum/4 balgiga jeonhyeo andoem.” “masturbation” was “seonghaengwi” (“sexual activity”) by translator 1 and 2, and the panels accepted “jawi” (“masturbation”).

Question 9, “Overall, how much of a problem has your sexual function or lack of sexual function been for you” in the original questionnaire was translated into “jeonbanjeogeuro gwihaui seonggineungina seonggineung bujogi gwihaege eolmana keun munjeyeotseumnikka.”

Vitality/Hormonal Symptoms

Question 10, “How big a problem, if any, has each of the following been for you” in the original questionnaire was translated into “manyak daeume haedanghaneun gakgagui jeungsangi itdamyeon gwihaege eolmana keun munjeyeotseumnikka.” “a. Hot flashes or breast tenderness/enlargement” in the original questionnaire was translated into “eolgul hwakkeungeorimina yubangeul nureul.” “Hot flashes” was translated into “momui hwakkeungeorim” and “ilgwaseong yeolgam,” which mean both “heating sensation of the entire body.” The panels accepted “eolgul hwakkeungeorimina” (“sensation of heat, especially in the face”). “b. Feeling depressed” in the original questionnaire was translated into “uulhan neukkim.” “c. Lack of energy” in the original questionnaire was translated into “eneoji gamso” and “mugiryeokameul neukkida” by translator 1 and 2 respectively, and the panels accepted “mugiryeokam.”

Backward Translation and Retranslation

As given in (Table 2), all questions in EPIC-CP questionnaire, amended by the panels, were translated in reverse (back-translated), then the panel commented on the distinctions between back-translated text and original text.

Table 2.

Back translation

In the domain of urinary incontinence, the panels commented on the distinctions between translations of “no urinary control” in the original text and “completely out of control” in the reconciled text. The panels finally agreed to remove “jeonhyeo” in Korean since the phrase “jeonhyeo” made the translation a stronger emphasis on the extent of control.

Cognitive Debriefing and Proofreading

Ten patients with prostate cancer (aged from 58 to 76 years) completed the revised version of translated questionnaire after the forward and backward translation. Their education levels ranged from elementary school to university (Table 3).

Table 3.

Patient data summary sheet

They took time for completing the questionnaire from 4 to 8 minutes. Most patients answered that the translated questionnaire was digestible. Two patients did not answer the question 3 because there was no exact number of pads they used. However, the original text contains only 4 choice alternatives, no change was needed. Four patients did not check on each choice alternatives of 5a, 5b, 5c so we added the phrase that “arae gak hangmoge daehayeo ucheugui 0, 1, 2, 3, 4 jung hanaman seontaekayeo jusigi baramnida” in Korean (“Select one of the right choice alternatives 0, 1, 2, 3, 4 for each following question”). The panel ultimately finished translations by comprehensively organizing the expression, and the final version of the translated EPIC-CP questionnaires is shown in Fig. 1.

Fig. 1.

Korean version of the Translation and Linguistic validation of Korean version of the Expanded Prostate Cancer Index Composite for Clinical Practice for patients with prostate cancer.

Some patients were hard to comprehend the expressions in the revised questionnaire. For example, one patient did not understand “sobyeon gineung” and another patient did not understand “seongjeok jeoljeonggam,” but it was hard to find alternative expression and only single person did not understand each phrase, so the panels decided not to change it.