Arabic language skin-related stigmatization instruments: Translation and validation process

Background. Skin diseases are frequently the reason for social rejection. Therefore, the assessment of stig-matization level in patients suffering from dermatoses plays a crucial role in providing proper health service. Objectives. The aim of this study was to create and validate Arabic language versions of stigmatization instruments – the 6-item Stigmatization Scale and the Feelings of Stigmatization Questionnaire. Material and methods. Development of the Arabic language versions was done with international standards of forward-back translations. The validation was performed on 39 psoriatic individuals. The group included 11 females and 28 males. The subjects were asked to fill out both questionnaires: the 6-item Stig-matization Scale and the Feelings of Stigmatization Questionnaire (Arabic language versions) at the time of examination and 7 days after enrollment for reassessment to evaluate test-retest reliability. During the first visit the patients additionally filled out an already existing Arabic version of Dermatology Life Quality Index (DLQI), which was used as a reference questionnaire. Results. The results concerning the integrity of instruments were very good, and the Cronbach's α coefficient for both scales was 0.89. The reproducibility level assessed with interclass correlation coefficient (ICC) stood at 0.91 for the 6-item Stigmatization Scale and 0.92 for the Feelings of Stigmatization Questionnaire. There was a strong correlation between total score of the 6-item Stigmatization Scale and DLQI. Significant negative moderate correlation was documented between the Feelings of Stigmatization Questionnaire and DLQI. Moreover, both stigmatization instruments correlated significantly with each other. Conclusions. The developed Arabic language versions of the abovementioned stigmatization instruments can be successfully used in daily clinical practice as well as in clinical research.


Introduction
Medical dictionaries define stigmatization as an assignment of negative perceptions to an individual because of a perceived difference from the population at large.This may occur on the basis of physical appearance (including race or sex), of mental or physical illness, or of various other qualities. 1The medical field recognizes a number of health problems, the sufferers of which are stigmatized, and certain skin diseases are among them.][4] Skin conditions are frequently the reason of social rejection and might result in a negative influence on the personal and social life of patients.Skin plays an important role in establishing interpersonal relationships, and thus cutaneous disorders, which have significant impact on physical appearance, influence other people's attitudes. 5Visible skin changes may arouse fear, disgust, aversion, or even intolerance, and other people may be afraid of the possible contagious character of the disease.Having in mind the great impact of the stigmatization process on one's life, measuring its level is necessary to provide proper service to the patients.This underlines the importance of proper stigmatization assessment in patients suffering from various dermatoses.Numerous instruments for assessing the stigmatization experience exist in the form of questionnaires.Our previous search in the English literature found 14 instruments used by different researchers for different skin conditions and we classified them into 2 main groups: dermatology-specific and disease-specific stigmatization instruments. 6Psoriasis appeared to be most commonly studied dermatologic condition where stigmatization has been assessed. 7To the best of our knowledge, there is no single skin-related stigmatization instrument available in the Arabic language.Therefore, the aim the current study was to create and validate the Arabic language version of 2 commonly used questionnaires to assess stigmatization in all dermatology patients (6-item Stigmatization Scale 8 ) and especially in psoriatic individuals (Feelings of Stigmatization Questionnaire 9 ).

Methods
The study was conducted in the Department of Dermatology of Sheikh Khalifa Medical City (SKMC), General Hospital in Abu Dhabi, UAE, and supervised by experts from the Wroclaw Medical University, Poland.

Translation
The translation of the questionnaires was a multi-stage process based on a reverse translation and involved several independent translators.At the first stage the original questionnaires (English language ones) were given to 2 independent translators: consultant dermatologist and consultant psychiatrist.They translated them from English into Arabic (Version 1 and Version 2).The results were compared, slight differences were found and a bilingual expert helped with the editing (Version 3).After that, Version 3 was given to a 3 rd translator (consultant dermatologist) who was not familiar with the original questionnaires.He performed a reverse translation from the already translated Arabic version into English.The back translation of a 6-item Stigmatization Scale was sent to Prof. Dr. Andrea Evers, who created the original questionnaire, for her comments.Prof. Dr. Mohammad Jafferany from Association for Psychoneurocutaneous Medicine of North America (APMNA) served as a consultant of the back translation of Feelings of Stigmatization Questionnaire.Some minor differences were found, discussed and corrected accordingly.The final versions (Version 4) of the Arabic language of both questionnaires were approved based on comments by dermatology experts and linguistic consultations.The aim of the translation was not only to render it in grammaticaly correct Arabic language, but to make the questions understandable for people outside the medical field.All translators mentioned above were of Arabic origin, fluent in both Arabic and English with long experience in the medical field (dermatologist or psychiatrist).Version 4, treated as a final one, was used for the validation process.

Validation
Validation was based on 39 Arabic psoriatic patients.The group included 11 females and 28 males.The mean age of the patients was assessed as 36.3±12.2 years.The current mean psoriasis intensity evaluated with Psoriasis Area and Severity Index (PASI) was 3.6 ±5.2 points (range 0-24.5 points).
Patients were asked to fill both questionnaires: 6-item Stigmatization Scale and Feelings of Stigmatization Questionnaire (Arabic language versions) at the time of examination and 7 days after enrollment for reassessment to evaluate test-retest reliability.During the first visit the patients additionally filled already existing Arabic version of Dermatology Life Quality Index (DLQI), which was used as a reference questionnaire.The DLQI was selected as it was the first questionnaire to assess quality of life in dermatologic patients and is currently the most commonly used instrument among dermatologic subjects.Moreover, DLQI is available in various validated language versions.Statistical analyses were performed using STATIS-TICA v. 12 software (StatSoft Inc., Tulsa, USA).Internal consistency was evaluated with Cronbach's α coefficent.Coefficient scores above 0.7 indicate high internal consistency.Correlations of individual components and the total score of the questionnaires were calculated with Spearman's rank correlation test.Spearman's correlation coefficient (ρ) was interpretered as follows: ρ = 0-0.1 -no correlation; ρ = 0.11-0.29 -weak correlation; ρ = 0.3-0.49-moderate correlation; ρ = 0.5-0.69-strong correlation, and ρ > 0.7 -very strong correlation. 10ifferences between 1 st and 2 nd assessment were verified with Wilcoxon signed-rank test.Interclass correlation coefficient (ICC) was used to assess test-retest reliability.ICC <0.4 indicated poor reliability, ICC >0.4 or/and ICC <0.75 -fair to high reliability, and ICC ≥0.75 -excellent reliability. 11he correlation between both stigmatization questionnaires and DLQI was calculated also with Spearman's rank correlation test.The p-values for all statistical analyses were considered significant if p < 0.05.

Internal consistency
The evaluation of internal consistency showed that the different items of both questionnaires are interrelated with one another.Cronbach's α coefficient for 6-item Stigmatization Scale was calculated as 0.89 and for Feelings of Stigmatization Questionnaire was also 0.89.The results described above indicated a strong internal consistency of Arabic language versions of both studied instruments.

Convergent validity
All single questions of the 6-item Stigmatization Scale significantly strongly correlated with the total score of the questionnaire (Table 1).Most questions included in Feelings of Stigmatization Questionnaire correlated with the total score as well (Table 2).Twenty out of 33 questions revealed a strong and very strong significant correlation with the total score.Of note, 7 questions (i.e., Q9, Q20, Q22, Q29, Q31, Q34, and Q40) exhibited no significant correlation with the total score.Based on the overall analysis, one may conclude that 6-item Stigmatization Scale demonstrated very good convergent validity; the convergent validity of Feelings of Stigmatization Questionnaire may also be considered as satisfactory.

Test-retest comparison
The reproducibility of both instruments was high.The ICC between scores obtained at the 1 st and 2 nd visit were 0.91 and 0.92 for 6-item Stigmatization Scale and Feelings of Stigmatization Questionnaire, respectively.There were no significant differences between separate questions and the total scores in conducted assessments for both scales (Table 3, 4).

Correlation with Dermatology Life Quality Index
There was a strong correlation between the total score of 6-item Stigmatization Scale and DLQI (ρ = 0.54, p < 0.001) (Fig. 1a).A significant negative moderate correlation was documented between the Feelings of Stigmatization Questionnaire and DLQI (ρ = -0.49,p = 0.001) (Fig. 1b).This illustrates that both newly created Arabic versions of stigmatization instruments showed highly satisfactory correlations with the quality of life assessment.Moreover, both stigmatization instruments correlated significantly with each other (ρ = -0.42,p = 0.007) (Fig. 2).

Access to instruments
All above results clearly suggest that the Arabic versions of the 6-item Stigmatization Scale and Feelings of Stigmatization Questionnaire fulfilled the criteria for high standard instruments and may be used in clinical practice.They are presented as Appendixes 1, 2 and are available in the electronic version on request directly from Dr. Dimitre Dimitrov (chibi90@yahoo.com).

Discussion
Arabs inhabit the 22 Arab states within the Arab League but can also be found in the global diaspora. 12They have their own customs, language, art, literature, music, media, cuisine, society, etc. 13 The enormous emotional burden of patient with skin diseases is well recognized.In fact, the visibility of skin lesions plays an important role in this burden and that was indicated in numerous publications including our previous research. 7The attitude to individuals with skin diseases can vary widely in different countries and cultures and in certain areas; the fear of stigmatization due to skin disorders can be devastating. 2,4As mentioned above, our previous research found that psoriasis is the most common skin disease, where the stigmatization experience was studied. 7e performed an extensive search online in the available English-language literature and could not find any reports about stigmatization experience in dermatological patients among the Arabic population.Most of the research about stigmatization in the medical field in Arabic countries was related to mental health. 14,15We previously clearly confirmed that the visibility of the skin lesions is a key factor for stigmatization experience and, as we have already emphasized, proper stigmatization assessment in dermatological patients would contribute to the entire, complete understanding of their suffering and would facilitate the holistic therapeutic approach. 6Therefore, the creation of Arabic-language instruments to assess skin-related stigmatization level was crucial for daily clinical practice and for the future research in this field.Our current results showed better internal consistency of Arabic versions of both instruments in comparison with, for instance, the results of validated Polish language versions, where the Cronbach's α coefficient for the 6-item Stigmatization Scale was calculated as 0.84 and for the Feelings of Stigmatization Questionnaire as 0.86. 16Both Arabic versions showed 0.89 Cronbach's α coefficient.The ICC between scores obtained at 1 st and 2 nd visit were also higher: The results obtained in the Polish language versions were 0.82 and 0.73 for the 6-item Stigmatization Scale and Feelings of Stigmatization Questionnaire, respectively.The Arabic version showed ICC of 0.91 for the 6-item Stigmatization Scale and of 0.92 for the Feelings of Stigmatization Questionnaire.These results were obtained after enrolling the majority of patients with mild disease.We are aware of the fact that this could be considered as a limitation of the study.Another example in regard to the above-mentioned parameters is the Polishlanguage version of the Family Dermatology Life Quality Index (FDLQI).The authors found that Cronbach's α coefficient was 0.84 and reproducibility level, established with ICC, was calculated at 0.69. 17All the data presented above clearly suggests a high international standard of the Arabic-language versions of both the 6-item Stigmatization Scale and the Feeling of Stigmatization Questionnaire.We believe that the availability of those questionnaires in the Arabic language will contribute to the service provided to dermatology patients and will stimulate further research on the stigmatization in patients of Arabic origin suffering from various dermatoses.
The approvals from The Institutional Review Board/Research Ethics Committee (IRB/REC) of SKMC(REC-29.01.2017 [RS-473]) and Ethical Committee of Wroclaw Medical University (KB-604/2016) were obtained prior to commencement of any study procedure.

Table 1 .
Correlation of each item (Q) score with total score of 6-item Stigmatization Questionnaire

Table 2 .
Correlation of each item (Q) score with total score of Feelings of Stigmatization Questionnaire

Table 3 .
Reproducibility of results obtained with 6-item Stigmatization Scale

Table 4 .
Reproducibility of results obtained with Feelings of Stigmatization Questionnaire