Translation, Cultural Adaptation and Validation of the Kidney Disease

Quality of LifeeShort Form 1.3 in an African Country

H. Rhoua, F. Ezaitounia, N. Ouzeddouna, R. Bayahiaa, K. Elhajjib, R. Roudièsb, F.Z. Sekkatb, R. Razinec,
R. Abouqalc, A. Alghadid, A. Azennoude, and L. Benamara
a
Department of Nephrology-Dialysis-Transplantation, Ibn Sina University Hospital, Rabat, Morocco; bDepartment of Psychiatry, Ibn
Sina University Hospital, Rabat, Morocco; cDepartment of Epidemiology, Ibn Sina University Hospital, Rabat, Morocco; dDepartment of
English, Faculty of letters and Humanities, Rabat, Morocco; and eAl Akhawayn University, Ifrane, Morocco

ABSTRACT
Background. The impact of dialysis on patient quality of life has been recognized as an
important outcome measure. The Dialysis Outcomes and Practice Patterns Study
compared quality of life in 4 continents [1], but very scarce information is available about
dialysis patients’ quality of life in Africa. The objective of this study was to translate the
Kidney Disease Quality of LifeeShort Form (KDQOL-SF) into Moroccan and measure its
psychometric properties.
Methods. The questionnaire was first translated into Moroccan by 2 independent
translators, and then 2 backward translations into English were performed after pretesting
in 10 dialysis patients. The final questionnaire was then administered to 80 dialysis patients.
Reliability was estimated by internal consistency and testeretest reliability. Validity was
assessed using known group comparisons and correlations between overall health rating
and scales scores.
Results. Some activities were substituted since they were not common in Morocco. All
subscales had a Cronbach a above the recommended value except for 3 scales. All of the
items showed good testeretest reliability. Correlation of items within subscales was higher
than that of items outside subscales in 87% of cases. Regarding construct validity, all
KDQOL-SF scales had significant correlation with overall health rating except for sexual
function and dialysis staff encouragement. Furthermore, the questionnaire could be used
to discriminate between subgroups of the patients.
Conclusions. The psychometric properties of the KDQOL-SF resulting from this first-
time administration of the instrument support the validity and reliability of the
KDQOL-SF as a measure of quality of life of patients having hemodialysis in Morocco.

H EALTH-RELATED QUALITY OF LIFE (QOL) is

known to be impaired in patients undergoing dialysis
compared to general population [2,3]. In the last decades,
advances in dialysis therapy led to increasing life expec-
tancy, but few efforts were made to improve patients’ QOL.
Currently, QOL is increasingly recognized as one way of
measuring treatment outcome [4,5]. As a consequence, a
number of generic and specific questionnaires of QOL have
been developed.
The Kidney Disease Quality of LifeeShort Form (KDQOL-
SF) is a disease-specific instrument, developed in the United
States by Ron Hays to assess the functioning and well-being
of people with kidney disease [6]. It is one of the most
complete instruments currently available in patients with
chronic kidney disease [2]. This questionnaire has been
translated in multiple languages [7e11] and has been widely
used in studies, particularly in the Dialysis Outcomes and
*Address correspondence to Bayane Bouidida, 30, Voie Romaine,
Internat Pasteur, 06000, Nice, France. E-mail: b.bayane@hotmail.
com

ª 2014 by Elsevier Inc. All rights reserved. 0041-1345/14/$esee front matter

360 Park Avenue South, New York, NY 10010-1710 http://dx.doi.org/10.1016/j.transproceed.2014.02.011

Transplantation Proceedings, 46, 1295e1301 (2014) 1295

1296 RHOU, EZAITOUNI, OUZEDDOUN ET AL

Practice Patterns Study [1] and in the United States Renal Backward Adaptation. Two backward translations were done by
Data SystemdAnnual Data Report [12]. English native translators and a consensus version was compared to
To date, a Moroccan version of the questionnaire has not the original English version.
yet been developed. Therefore, the purpose of this study
was to translate the KDQOL-SF into Moroccan, to adapt it Test Field
culturally and test its psychometric properties in a Moroc-
To measure psychometric properties, the Moroccan version was
can dialysis population.
administered to 80 patients on dialysis at Ibn Sina Hospital. In-
clusion criteria were (1) age more than 18 years, (2) dialysis treat-
PATIENTS AND METHODS ment for 3 months without life-threatening disease at the time of
The Questionnaire the test, (3) patient consent. Exclusion criteria were language
difficulties.
The KDQOL-SF consists of 79 items divided into 19 scales (8 In this cross-sectional study, 78% of patients were in hemodial-
generic scales, 11 disease-specific scales) and an overall health ysis and 22% in peritoneal dialysis (Table 1). The majority were
rating item [6]: females and mean age was 43.9  14.2 years. The mean time on

Short-form 36 (SF-36) [13] (8 dimensions/36 items): physical dialysis among the patients was 104.8  120 months.
functioning (10 items), role limitations caused by physical
problems (4 items), role limitations caused by emotional prob- Statistical Analysis and Psychometric Properties
lems (3 items), pain (2 items), general health (5 items), social
functioning (2 items), emotional well-being (5 items), energy/ Means of each scale and standard deviation were determined.
fatigue (4 items), and 1 item about health status compared to 1 Reliability and validity were determined. Percentages of floor and
year previously. ceiling were also assessed. Ceiling effects were taken as being the

Kidney diseaseetargeted items (11 dimensions/43 items): symp- percentage of respondents with scores of 100 and floor effects were
tom/problem list (12 items), effects of kidney disease (8 items), the percentage of respondents having a score of 0. Ceiling and floor
burden of kidney disease (4 items), cognitive function (3 items), effects should be less than 30% to ensure that the scale captures the
quality of social interaction (3 items), sexual function (2 items), full range of potential responses within the population and that
sleep (4 items), social support (2 items), work status (2 items), changes over time can be detected.
patient satisfaction (1 item), dialysis staff encouragement Multitrait/Multi-Item Correlations. Correlation coefficients were
(2 items). calculated by using Pearson correlation to assess the strength of

Overall health rating (1 item scored separately). relationships between items within and outside each scale.
For each scale, a score can be calculated according to a standard The item internal consistency assesses item correlation with a
procedure available on: http://gim.med.ucla.edu/kdqol. Scores corresponding scale, corrected for overlap. A correlation corrected
range from 0 to 100, with a higher score indicating better QOL. for overlap is the correlation of an item with the remaining items of
the scale, which removes the bias of correlating an item with itself.
Translation Procedure A correlation of 0.4 or more has been used as the standard for
supporting the item’s internal consistency.
The study protocol was approved by R. Hays and the local ethical The discriminant validity was assessed by comparing item cor-
committee of Ibn Sina University Hospital Center. The translation relation within and outside each scale. We hypothesized that each
steps were carried out according to specifications established by the
KDQOL Working Group.
Table 1. Patient Characteristics
Forward Adaptation. Parameters Patients on Dialysis (n ¼ 80)
1. Items and response choices of the original version of the
Age (y) 43.9  14.2
KDQOL-SF were independently translated into Moroccan by 2
Sex ratio 0.7
translators whose first language is Moroccan. Following this, a
Peritoneal dialysis (%) 22
seminar including translators, nephrologists, psychiatrists, and a
Hemodialysis (%) 78
sociologist was organized. All the options were reviewed, prob-
Educational level (%)
lems with specific terms and differences in the cultures of the
Illiterate 28
countries were resolved, and a consensus version of the ques-
Elementary 22
tionnaire was made. After this meeting, the translators inde-
High school 23
pendently rated the level of difficulty of the translation between
College 27
0 (not at all difficult) and 100 (extremely difficult).
Civil status: married (%)
2. Two external translators evaluated the equivalence of each item
Yes 61
and response scale according to a scale from 0 (“not at all
No 39
equivalent”) to 100 (“exactly equivalent”).
Duration on dialysis (mo) 104.8  120
3. The Moroccan version of the questionnaire was tested in a
Cause of kidney disease (%)
sample of 10 patients on hemodialysis to detect comprehension
Glomerulonephritis 26
problems. Mean patient age was 39  13 years (20e57 years), 6
Diabetes 14
were males, and 8 had not completed elementary school or were
Tubulointerstitial nephritis 18
illiterate. The test took the form of face-to-face interviews
Vascular 5
immediately followed by retrospective interviews about compre-
Unknown etiology 34
hension problems and choices among a number of alternative
Other 3
renderings.
KDQOL-SF 1.3 IN AN AFRICAN COUNTRY
item’s correlation with its intended scale would be at least two
standard errors greater than its correlation with other scales.
Internal Consistency Reliability and TesteRetest Reliability. Cronbach
a coefficient was used to assess internal consistency reliability. As
recommended by Nunnally [14], a Cronbach value of 0.70 was taken
as an indicator of adequate internal consistency reliability.
Testeretest reliability was assessed by convenience sample (n ¼
20) of the original respondents. The same questionnaire was
administered to these patients after 10 to 14 days. Testeretest
reliability was measured using intraclass correlation coefficient.
Construct Validity. Construct validity was assessed by comparing
scales of KDQOL-SF with overall health rating by means of the
Pearson and Spearman correlation coefficient.
External Discriminant Validity. External discriminant validity as-
sesses the ability of the KDQOL-SF subscales to differentiate
between patient groups with different clinical characteristics.
We used the t test to examine the differences of QOL scores in
subgroups of patients based on sex, educational level, marital
status. We also looked at the correlations of scales scores with
age, and dialysis duration by using Pearson and Spearman
correlations.
The SPSS 13 statistical package for Windows (SPSS, Chicago, Ill,
United States) was used for statistical analysis.
RESULTS
Translation Procedure
Forward Translation. Difficulty mean rates ranged from
0 to 60 with an average difficulty rating of 13.1  3.5 (results
not shown). Items and response choice equivalence between
the Arabic and the US version ranged between 75 and 100,
and the mean equivalence rating was 93.3. Cultural adap-
tation concerned some activities rather uncommon in
Morocco like “pushing a vacuum cleaner,” “playing golf,”
and “bowling” (item SF3b), which needed to be replaced by
activities requiring the use of similar body parts. Changes
also involved distances that were rendered in meters rather
than blocks and miles (items SF3g, SF3h, SF3i).
Lexical problems were met with the following words:

Physical health as the word health implies physical health
in Moroccan. It was finally rendered by your health (ie, of
your body).

Activities rendered by matters, things to do. It was
preferred to a word-for-word translation, as the seem-
ingly equivalent word is too formal.

Dissatisfied changed to not at all satisfied and then
somewhat dissatisfied was rendered by not very satisfied.

Definitely true and definitely false, respectively, rendered
by 100% true and 100% false.
Syntactic changes were often necessary when there were
differences in structure between the English and the Arabic
sentence. Few words were changed during the pilot test and
some explanations were added in parenthesis (ie, “You
respond after a delay to things that were said or done
around you” was added in parentheses in item SF13b). The
patients were a bit puzzled by the item SF11b where they
were asked if their health was “excellent.” The interviewers
explained that they were asked about their subjective point
of view and not about their medical state.
1297
Backward Translation. The backward translation caused
few problems. A few words were corrected before the tests.
Field Test
Completeness of Data. Completeness at the scale level
was of 100% except for portions on dialysis staff encour-
agement (99%) and sexual function (40%).
Floor and Ceiling. The scales work status, role limitations
caused by physical problems, and role limitations caused by
emotional problems suffered from high percentage of floor
scores, whereas social support dialysis and staff encour-
agement had a high percentage of ceiling scores (Table 2).
Multitrait/Multi-item Correlations, Internal Consistency
Reliability, and TesteRetest Reliability. The item internal
consistency, corrected for overlap, was above 0.4 for 94% of
items. Correlation of items within subscales was higher than
that of items outside subscales in 87% of cases. Internal
consistency reliability was adequate, with Cronbach a values
above 0.70 for all scales except 3 dimensions: quality of
social interaction (0.67), work status (0.38), and cognitive
function (0.57; Table 2). Cronbach a did not improve after
removing 1 item from quality of social interaction and
cognitive function scales. No item could be removed from
work status scale as it only consisted of 2 items.
The intraclass coefficient correlation of the kidney
diseaseetargeted scales ranged from 0.67 (pain) to 0.9 (en-
ergy/fatigue, symptom/problems and overall health rating;
Table 2).
Construct Validity. Health rating was significantly corre-
lated with all KDQOL-SF scales except sexual function and
dialysis staff encouragement and patient satisfaction scales
(Table 3).
External Discriminating Validity. Table 4 shows the cor-
relation coefficients between the scales of the KDQOL-SF
and age and dialysis duration. There are significant
correlations between age and 5 subscales of the KDQOL-
SF: physical functioning (r ¼ 0.27; P ¼ .006), energy/
fatigue (r ¼ 0.33; P ¼ .001), work status (r ¼ 0.23;
P ¼ .023), burden of kidney disease (r ¼ 0.22; P ¼
.037), overall health rating (r ¼ 0.23; P ¼ .024).
Duration of dialysis correlated significantly with 6 scales
of the KDQOL-SF: pain (r ¼ 0.27; P ¼ .008), energy/fa-
tigue (r ¼ 0.26; P ¼ .01), work status (r ¼ 0.29; P ¼
.004), sexual function (r ¼ 0.28; P ¼ .09), sleep (r ¼ 0.26;
P ¼ .001), and overall health rating (r ¼ 0.23; P ¼ .022).
We also compared mean KDQOL-SF scores in groups
expected to differ in their QOL (Fig 1). Regarding gender,
men scored significantly higher than women on symptom/
problem, cognitive function, physical functioning, social
functioning, and pain (Fig 1A). Literate patients compared
with illiterate patients showed significant higher scores on 5
scales: burden of kidney disease, work status, role limita-
tions caused by physical problems, role limitations caused by
emotional problems, and energy/fatigue (Fig 1B). Illiterate
patients showed significant higher scores on dialysis staff
encouragement and patient satisfaction. Regarding marital
1298 RHOU, EZAITOUNI, OUZEDDOUN ET AL

Table 2. Scores Obtained for the Moroccan Version, Percentage of Floor and Ceiling, Internal Consistency, and TesteRetest Reliability
Dimensions No. of Items Mean  SD Floor (%) Ceiling (%) Cronbach a Intraclass Correlation

Physical functioning 10 68  23 2.1 6.3 0.86 0.89

Role limitations caused by physical problems 4 33  38 46.3 14.7 0.81 0.81
Pain 2 67  30 5.3 29.5 0.89 0.67
General health perceptions 5 42  23 1.1 0 0.71 0.84
Emotional well-being 5 61  20 0 3.2 0.83 0.87
Role limitations caused by emotional problems 3 43  40 35.8 25.3 0.74 0.83
Social functioning 2 66  25 1.1 17.9 0.7 0.8
Energy/fatigue 4 51  21 0 0 0.8 0.9
Symptom/problem 12 66  20 0 6.3 0.82 0.9
Effects of kidney disease 8 63  22 11 5.3 0.8 0.88
Work status 2 40  37 37.9 18.9 0.38 0.82
Cognitive function 3 73  20 0 12.6 0.57 0.85
Quality of social interaction 3 74  22 0 24.2 0.67 0.8
Sexual function 2 73  31 3.2 16.8 0.9 0.81
Sleep 4 64  21 2.1 3.2 0.74 0.84
Social support 2 83  24 0 55.8 0.7 0.78
Burden of kidney disease 4 43  29 7.4 3.2 0.77 0.88
Dialysis staff encouragement 2 85  21 2.1 47.4 0.82 0.81
Patient satisfaction 1 57  24 3.2 13.7 NA 0.87
Overall health rating 1 59  22 3.2 9.5 NA 0.9
Abbreviations: NA, not applicable for a single-item measure; SD, standard deviation.

status, no significant differences were observed for scores of The guidelines established by the authors are binding and
married and unmarried patients (results not shown). led to a long translation process but each step of the trans-
lation procedure was fundamental to improve the quality of
DISCUSSION
translation and adaptation of the original KDQOL-SF1.3 to
our setting.
To our knowledge, this has been the first study to evaluate The forward translation was done by 2 translators, whose
the reliability and validity of the KDQOL-SF among dialysis first language is Moroccan according to the KDQOL group
patients in an African country. This questionnaire would specifications; but the consensus version of the questionnaire
then give information about QOL in this continent and was made in the presence of nephrologists, psychiatrists, and
allow international comparisons of QOL in dialysis.
Table 4. Correlation Coefficients (With P Values) Between the
Table 3. Correlation Coefficients (With P Values) Between Kidney Disease-Targeted Scales and Clinical Parameters of the
the Kidney Disease-Targeted Scales and the Overall Health Patients
Rating Scale
Dialysis
Overall Scales Age Duration
Health
Dimensions Rating P Value Physical functioning 0.27* 0.13
Role limitations caused by physical problems 0.15 0.16
Physical functioning 0.53 <.001
Pain 0.15 0.27*
Role limitations caused by physical problems 0.45 <.001
General health perceptions 0.17 0.18
Pain 0.51 <.001
Emotional well-being 0.004 0.04
General health perceptions 0.52 <.001
Role limitations caused by emotional problems 0.189 0.13
Emotional well-being 0.29 .004
Social functioning 0.036 0.1
Role limitations caused by emotional problems 0.36 <.001
Energy/fatigue 0.33* 0.26*
Social functioning 0.28 .007
Symptom/problem 0.07 0.054
Energy/fatigue 0.49 <.001
Effects of kidney disease 0.13 0.052
Symptom/problem 0.55 <.001
Work status 0.23* 0.29*
Effects of kidney disease 0.32 .002
Cognitive function 0.04 0.03
Work status 0.38 <.001
Quality of social interaction 0.07 0.1
Cognitive function 0.23 .02
Sexual function 0.099 0.28*
Quality of social interaction 0.23 .02
Sleep 0.13 0.26*
Sexual function 0.16 .35
Social support 0.038 0.13
Sleep 0.32 .002
Burden of kidney disease 0.22* 0.06
Social support 0.4 <.001
Dialysis staff encouragement 0.07 0.02
Burden of kidney disease 0.36 <.001
Patient satisfaction 0.006 0.08
Dialysis staff encouragement 0.13 .2
Overall health rating 0.23* 0.23*
Patient satisfaction 0.12 .3
*P < .05 for the correlation.
KDQOL-SF 1.3 IN AN AFRICAN COUNTRY
a sociologist. This multidisciplinary participation was not
imposed by the KDQOL group but was deemed necessary to
better define concepts and medical terms, as the translators
have no contact with the medical domain.
The pilot test detected problematic items and inconsis-
tent sentences. It also revealed a comprehension problem
with the concept described in item SF11b. Our patients
judged the term excellent inappropriate when talking about
their health.
The statistical analysis provides satisfying psychometric
properties. Items generally correlated with their corre-
sponding scales more than with other scales. Testeretest
correlations were satisfactory. Internal consistency reli-
ability of all scales was good in comparison with other
countries (Table 5), except 3 dimensions: work status,
cognitive function, and quality of social interaction.
The work status scale was the most problematic scale. A
high proportion of patients reported floor level scores and a
1299
Fig 1. Mean Kidney Disease Quality of
LifeeShort Form scores for categories of pa-
tients: (A) male vs female groups; (B) illit-
erate vs educated patients. PF, physical
functioning; RP, role limitations caused by
physical problems; P, pain; G, general
health perceptions; EN, energy/fatigue; RE,
role limitations caused by emotional prob-
lems; SF, social functioning; E, emotional
well-being; SP, symptom/problem; EF, ef-
fects of kidney disease; W, work status; C,
cognitive function; Q, quality of social interac-
tion; SX, sexual function; S, sleep; SS, social
support; B, burden of kidney disease; D, dial-
ysis staff encouragement; PS, patient satis-
faction; O, overall health rating. *P < .05.
value was very low (0.38). Dutch, Hungarian, French, and
Spanish studies also reported high proportion of floor scores
and low a values in this scale [7,11,15,16]. One reason
proposed in these studies was the irrelevance of the items on
this scale for patients above retirement age. We have a
young population and therefore having a job is not a real-
istic expectation. On the other hand, one possible explana-
tion could be the high percentage of unemployment in our
developing country at the origin of discordance of the
answer to both items: patients have no paying job but their
health does not keep them from working. Another expla-
nation could be difficulty to understand and answer item
SF21 because of its negative form (keep you from) in a
dialysis population with low cognitive function. Such a
comprehension problem was not related, however, during
the pilot test. Anyway, the interpretation of the scores on
the work status scale in Moroccan version must be made
with caution.
1300 RHOU, EZAITOUNI, OUZEDDOUN ET AL

Table 5. International Comparison of Internal Consistent Reliability A

Morocco USA [6] France [11] Spain [16] Japan [8]

Physical functioning 0.86 0.92 0.89 0.87 0.9

Role limitations caused by physical problems 0.81 0.87 0.78 0.89 0.88
Pain 0.89 0.87 0.8 0.81 0.83
General health perceptions 0.71 0.78 0.81 0.73 0.8
Emotional well-being 0.83 0.8 0.84 0.88 0.84
Role limitations caused by emotional problems 0.74 0.86 0.82 0.88 0.92
Social functioning 0.7 0.87 0.64 0.7 0.73
Energy/fatigue 0.8 0.9 0.83 0.85 0.81
Symptom/problem 0.82 0.84 0.85 0.79 0.81
Effects of kidney disease 0.8 0.82 0.84 0.78 0.79
Work status 0.38 0.83 0.38 0.46 0.69
Cognitive function 0.57 0.68 0.85 0.76 0.73
Quality of social interaction 0.67 0.83 0.48 0.42 0.35
Sexual function 0.9 0.89 0.9 0.92 0.92
Sleep 0.74 0.9 0.72 0.67 0.61
Social support 0.7 0.89 0.75 0.57 0.76
Burden of kidney disease 0.77 0.83 0.86 0.71 0.81
Dialysis staff encouragement 0.82 0.9 0.92 0.78 0.8
Patient satisfaction NA NA NA NA NA
Overall health rating NA NA NA NA NA
Abbreviation: NA, not applicable for a single-item measure.

Cronbach a for the cognitive function scale did not reach
the recommended value. This scale’s a was notably lower
both in the original and some published international vali-
dation studies [6,15,17].
Sexual function was also problematic. Completeness rate
was low for this scale (40%). One possible explanation is
that sexuality is still a taboo subject in the Moroccan pop-
ulation. We therefore suggest that due to the personal/
sensitive nature of this question, patients refused to
respond. Another explanation is that sexual relations out of
wedlock are quite uncommon in a conservative society like
Morocco. Only 61% of our patients were married. Yet,
KDQOL scoring considers that answering “no” to item
SF16 as missing data.
Owing to missing data for this scale, the internal consis-
tency reliability of the sex scale was evaluated in only 32
patients. The result of internal consistency reliability testing
of the ‘sex scale’ even if good is then less precise than that
for the other scales. This result must therefore be inter-
preted with caution.
The validity of the KDQOL-SF was confirmed. All the
scales were significantly correlated with the overall health
rating except 2 dimensions: sexual function and dialysis staff
encouragement. The clinical discriminant validity of the
KDQOL SF is supported by the fact that age, gender, ed-
ucation, and dialysis duration influence KDQOL SF scores,
as shown in other studies [18e20].
We conclude that the Moroccan version of the KDQOL-
SF can be used for assessing patients’ health-related QOL
for clinical and investigative purposes. The Moroccan
version demonstrated an acceptable level of reliability and
validity for the evaluation of QOL of Moroccan patients on
chronic dialysis except for the work status scale. Further
applications of this version on a larger Moroccan population
are warranted to confirm our results and to determine why
some items and scales function differently in Morocco and
the United States. Testing of the longitudinal validity of the
instrument in future studies would also be important if it
would reflect clinical changes over time.
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