Cross-cultural Adaptation and Validation of the Arabic Version of the Harrus Hip Score


 Background: The goal of this study was to translate the Harris Hip (HHS) questionnaire into the Arabic language with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of total hip arthroplasty outcome. Methods: This questionnaire was translated following A clear and user-friendly guideline protocol. The Cronbach’s alpha was used to assess the reliability and internal consistency of the items of HHS. Additionally, The constructive validity of HHS was evaluated against the 36-Item Short Form Survey (SF 36). Results: A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. Cronbach’s alpha of the total score of Arabic HHS is 0.528 and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Lastly, The correlation between HHS and SF 36 was r=0.71 (p<0.001) which represents a strong correlation between Arabic HHS and SF-36. Conclusion: Based on the results, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and total hip arthroplasty treatment efficacy.

is one of the most common hip pathologies and is characterized mainly by joint pain and stiffness that interferes with a patient's function and quality of life. (4,5) It is estimated that around 27 million people in the US have been diagnosed with osteoarthritis, while 25% of people over 55 years old are suffering from OA in the United Kingdom. (6)(7)(8) Moreover, hip and knee OA was ranked as the 11th highest contributing factor to global disability. (8) In the 1960s, due to the highly disabling nature of hip pathologies, Total Hip Arthroplasty (THA) was introduced as an effective option in the management of severely damaged hip joints. (9,10) This procedure signi cantly improves joint function by greatly decreasing or eliminating joint pain. The successful long-term results of THA are well documented, especially in elderly patients with hip OA (11) and the number of performed THA surgeries is increasing worldwide. (12,13) Currently in the United States about 7 million individuals have had a THA. Most of these individuals suffered primarily from hip OA followed by hip avascular necrosis (AVN), with a higher prevalence among females compared to males. (14)(15)(16) Many questionnaires have been employed to evaluate both the impact of a patient's hip joint disease on their function and the e cacy of its treatment. (17) Two types of scales are used to follow the patient's condition. (18) The rst type is a generic health status scale which measures the patient's quality of life, such as the SF-36 questionnaire. The other type are disease-speci c questionnaires such as Hip disability and Osteoarthritis Outcome Score (HOOS), Intermittent and Constant Osteoarthritis Pain (ICOAP), and Harris Hip Score (HHS). (19)(20)(21)(22)(23) Multiple studies have shown increased utility in reporting outcomes with disease-speci c scales over generic health questionnaires for patients who have undergone THA. (18) Many disease-speci c questionnaires were created in order to evaluate speci c symptoms and signs of the disease. (17) The ICOAP instrument was developed to differentiate between intermittent and constant pain among patients with hip OA. (22) The HOOS scale was used to measure the function of daily living, quality of life, and function in sport and recreation.(21) These disease-speci c questionnaires have been translated from English and culturally adapted to many languages including Arabic. (24,25) They have demonstrated validity in re ecting patient opinions about their condition.(25)(24) However, no questionnaire has shown superior measurement properties over the others. (23) The HHS questionnaire has been translated and validated into many languages including Italian, Portuguese, and Turkish but not Arabic. The goal of this study was to translate the HHS questionnaire into Arabic with cross-cultural adaptation to include and bene t Arabic speaking communities as it is the most widely used instrument for disease speci c hip joint evaluation and measurement of THA outcome. (23,29) It has demonstrated excellent responsiveness when compared to generic health scales such as 36-Item Short Form Survey (SF 36). (29,31) Developing an Arabic version of the HHS questionnaire available will improve cultural accessibility, patient care, clinical practice and future research.
Our study was conducted in the Orthopedic Out-Patient Clinics at King Saud University Medical City during the period from January 2020 to March 2020. Inclusion criteria were: all adults aged 18 and above, who spoke, read and wrote Arabic, and with hip pathology including arthritis, fracture, or impingement syndrome among patients seen in our orthopedic clinic.
Our study was conducted in two stages. The rst stage was translation of the questionnaire to Arabic, followed by translation back to English, while the second stage included data collection for reliability and cross-cultural adaptivity.
The questionnaire was translated to Arabic language by two independent translators who were uent in both Arabic and English and experienced in the cultural differences between communities speaking both languages. (32) The rst translator (T1) had a background in medical terminology, experience in clinical orthopedics, and knowledgeable about the construct of the instrument. The second translator (T2) did not have a medical background and no previous experience with the construct of the instrument. Translation from the rst translator was labeled as TL1, while that of the second translator was labeled as TL2. The translated versions (TL1 and TL2) and the original version of the HHS were compared by another two independent reviewers (R1 and R2), who are bilingual and bicultural, and no signi cant difference between the two translated versions (TL1 and TL2) was observed. Following consensus among both reviewers, a nal Arabic translation version was adapted and labeled PI-TL. The questionnaire was then translated back from the nal Each participant approved verbally after they were informed of the study purpose and the right to withdraw at any time without any obligation toward the study team.
Also, participants' anonymity was assured by not collecting identifying data, all participants are anonymous. There were no incentives or rewards given to participants. Lastly, The IRB allowed to the authors to have the verbal approval of the participants as long as no medical treatment will be decided to the participants based on their answers of the questionnaire Statistical analysis: Data were analyzed using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Pearson Correlation coe cient was used to assess the correlation between Harris Hip Score and SF36. The Cronbach's alpha was used to assess reliability and internal consistency of the items in the Harris Hip questionnaire. A p-value <0.05 was considered statistically signi cant. The correlation between the Arabic HHS and SF-36 was determined by using Pearson's correlation coe cient The following guidelines were used to interpret the correlation coe cients (r): mild correlation (r <0.3), moderate correlation (0.3 < r < 0.6), strong correlation (r>0.6)

Results
A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. The participants lled in all the sections of the HHS and the SF 36 questionnaires.
Based on the participant's feedback, the "duration time" was the preferred term instead of "blocks" for de ning the walking distance.
Otherwise, all the questions were clear and understandable.
As shown in Table I, reliability was assessed by using Cronbach's Alpha which was found to be0.528 for the current study. Following standardization (deleting Pain item) it increased to 0.742.
Cronbach's Alpha was determined following alternating removal of each item of the scale; the results are summarized in Table 2.
Test and retest values for 30 participants was 0.7 which is acceptable with no difference for all the HHS items with P-values < 0.001.
( Table 3) Finally, the correlation between HHS and SF-36 was examined using criterion validity and the results was r = 0.705 (P < 0.001).
Therefore, based on the criterion validity, there is strong correlation between the Arabic HHS and SF-36 score. (Table 4).

Discussion
There are approximately 20 questionnaires currently employed to assess patient perception of hip joint diseases and their treatment, The reliability of the Arabic HHS was evaluated by using Cronbach's alpha and test-retest reliability to assess the reliability of this scale.
Cronbach's alpha of the total score of Arabic HHS is 0.528 and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Also, this reliability is similar to the Cronbach's Alpha reported in the Turkish, and Italian translations, which were 0.7, 0.816 respectively. (34)(35)(36) Test-rest value was 0.7 which is considered acceptable reliability while the Italian, and Turkish results were 0975, 0.91 respectively. We think that the Turkish study has excellent reliability since the time interval for the reliability testing was short (one week only). In the current study, the time interval was three weeks which is the recommended period (34,35,37) The constructive validity of the Arabic HHS and Sf-36 was identi ed by nding the correlation between the two scales. The correlation was r = 0.71 (p < 0.001) which represents strong correlation between Arabic HHS and SF-36. When looking to the correlation of Harris questionnaire with the subdivision of SF-36, we found a strong correlation between the Arabic Harris questionnaire with SF-36 physical role functioning, SF-36 pain and SF-36 social functioning with PCC of 0.6, 0.628 and 0.63 respectively. Compared to the Turkish study, they found a strong correlation of Turkish Harris with SF-36 pain subscales with PCC of 0.7 while a moderate correlation with SF36 social functioning and SF-36 physical role functioning with PCC of 0.53 and 0.46 respectively. Additionally, a moderate correlation was seen between Arabic HHS and SF-36 Physical function, SF-36 Role limitation due to emotional problems with PCC of 0.57 and 0.55 respectively. The Turkish study found a strong correlation with SF 36 physical function with PCC of 0.72 while a mild correlation was identi ed with SF 36 SF-36 Role limitation due to emotional problems with PCC of 0.37.

Conclusion
In this study, we translated and adapted the HHS questionnaire into Arabic with cross-cultural considerations speci c to Arabic communities while maintaining its psychometric properties. Its translation reliability and validity was thoroughly tested via forward and backward translation and found statistically similar to those of other translated versions of the HHS. This disease speci c questionnaire can effectively capture how the patient feels about their condition. Therefore, we believe that the Arabic HHS can be used by clinicians, researchers and patients to evaluate and report hip pathologies and THA treatment e cacy. Having this version of the HHS questionnaire available will make a great additional tool for improving care and accessibility for Arabic speaking patients as well as improve representation of this patient demographic in future research contributions.

List Of Abbreviation
Harris Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests