key: cord-0016353-nojl8xe0 authors: Holtzhausen, Louis J.; Souissi, Sofiane; Sayrafi, Omar Al; May, Awartani; Farooq, Abdulaziz; Grant, Catharina C.; Korakakis, Vasileios; Rabia, Safia; Segers, Souhaila; Chamari, Karim title: Arabic translation and cross-cultural adaptation of the Sport Concussion Assessment Tool 5 (SCAT5) date: 2020-08-21 journal: Biol Sport DOI: 10.5114/biolsport.2020.97673 sha: 529d91b1c149b6d1b0c70cb38b118961503a0285 doc_id: 16353 cord_uid: nojl8xe0 The aim was to create a Modern Standard Arabic SCAT5 version for different Arabic dialects. This translation and cross-cultural adaptation was performed in eight stages: initial translations, reconciliation of translations and cultural adaptation, back translation, appraisal of back translations, validation of the translation, review and adjustment by reconciliation committee, pretesting in 12 football players and document finalisation. As an alternative to the problematic Months In Reverse Order Test (MIROT) in Arabic, the Serial 3s test (32 Arabic and 30 English participants), the Days of the Week Backwards test (DWBT), and the ‘Adding Serial 3s’ test were tested (30 English and 30 Arabic participants) for accuracy, difficulty and time of completion. The Arabic SCAT5 was similar and comparable to the original English version (7-point Likert scales =< 2). Testing of the pre-final version of the Arabic SCAT5 took 20.4 (SD 3.4) and 17.7 (SD 3.0) minutes respectively to complete and was found acceptable in terms of clarity, understandability, grammatical correctness and coherence. The Arabic Serial 3s test (subtraction version) was unsuitable due to high completion time, low pass rate and high difficulty perception [time = 47.2 (SD 28.0) s; accuracy = 55.2%; difficulty = 3.2 (SD 1.1)]. The Arabic DWBT was too fast and undemanding for concentration testing [time = 4.6 (SD 1.5) s; accuracy = 90%; difficulty = 1.1 (SD 0.3)]. The Adding Serial 3s tests produced similar completion times [18.4 (SD 6.8) vs. 21.1 (SD 5.3), p = 0.088], accuracy (100%) and self-rated difficulty [English = 2.0 (SD 0.7) vs. Arabic-speaking participants = 2.1 (SD 0.8), p = 0.512] and was therefore adopted to replace the MIROT. This culturally adapted Arabic-SCAT5 questionnaire is the first concussion assessment tool available for Arabic-speaking healthcare providers and athletes. Sport Concussion Assessment Tool 5 (SCAT5). Biol Sport. 2021;38(1):129–144. The reconciliation committee, assisted by the four translators and the authors, produced a pre-final version of the SCAT5, representing six Arab nationalities (Bahrain, Egypt, Iraq, Palestine, Qatar and Tunisia). The original English SCAT5, reconciled initial translation and the back translations were merged, also considering suggestions in written reports on each stage. Attention was given to achieve semantic, idiomatic, experiential and conceptual equivalence between the source and target questionnaires [14] . The committee also considered 'comparability of language', which refers to the formal similarity of words and sentences between the original and back-translated versions, as well as 'similarity of interpretability' where the responses to the different versions were compared [15] . A formal evaluation of (i) comparability of language and (ii) similarity of interpretability was conducted. Each of the 410 items was rated by five independent reviewers (one sports physician and four physiotherapists, representing common regional dialects used in the Persian/Arabic Gulf region) on two 7-point Likert scales scoring the similarity and comparability of the two versions; where 1 = extremely similar/comparable and 7 = extremely dissimilar/incomparable. Likert scores for comparability mean score > 3, and similarity mean score > 2.5 required corrections [14] . The same reviewers conducted a group discussion on the general understandability of the SCAT5 and the results were recorded. The reconciliation committee reviewed Stage 5 results and made the necessary adjustments. The pre-final version of the Arabic SCAT5 was administered to 12 healthy football players by two Arabic speaking team physicians and four physiotherapists. The physicians and physiotherapists gave feedback in a semi-structured discussion group on clarity, understandability, absence of misinterpretations, and coherence of the Arabic SCAT5 [12] . The time of completion of the Arabic SCAT5 was recorded. The 12 players were asked to comment on the same topics after completion of the test. The comments from the pretesting process and interviews were used to make final adjustments to the document. At various stages of the translation, participants raised concerns regarding the MIROT, in the Chinese SCAT3 translation referred to as the Months Backward Test (MBT). This test is part of the SAC concentration test. It is a word sequence production test requiring the respondent to recite the months of the year in reverse order starting with 'December', 'November' and so on, until the individual reaches 'January' or is unable to continue. One point is awarded for saying all 12 correctly, and nil if one mistake is made, as was done with all the alternatives. However, in some Arabic dialects, the months are referred to by number (rather than a name), so reciting the months in reverse order merely requires ordinal backward counting (i.e., from 12, 11 and so on; month 12 being December), which is less cognitively demanding. Arabic speaking individuals who refer to the months by numbers are unable perform the test by naming the months. On the other hand, using numbering to identify the months is considerably easier than the original test and has been judged by us as insufficient to assess concentration. A similar situation has been reported in the Chinese translation of the SCAT3 [12] . The Serial 3s test was adopted as a substitute for MIROT/MBT in the Chinese SCAT3. In this test, an individual is asked to successively subtract 3 from 100 continuously until instructed to stop after 12 stages by the assessor. The Serial 3s test was therefore tested as a possible alternative option to the MIROT in the Arabic SCAT5. The experiment showed that the Serial 3s subtraction test was unsuitable for use in our Arabic population. We then tested the Days of the Week Backwards Test (DWBT) and the 'Adding Serial 3s' as alternative substitutes for the MIROT [16, 17] . The Adding serial 3s is a subtest of the Wechsler Memory Scale -Mental Control. It is a brief test of cognitive function that is commonly used and easy to administer in clinical practice, providing a convenient test of central processing speed of both focused and sustained attention [16] . Face validity was assessed in three ways throughout the translation and adaptation process: firstly, ongoing validity assessment took place during the review processes of the translation; secondly by interviews with the six healthcare providers and 12 athletes who participated in the pretesting; and thirdly, during the formal evaluation of comparability of language and similarity of interpretability that was conducted by five independent reviewers. ilar English words [12] . Moreover, the immediate memory is sensitive to word length and phonological similarity [18] . Thus, substitutions for English words in the memory tests were made based on three aspects, words: (1) belonging to the same semantic domain; (2) having the same number of syllables and (3) A comparison of the MIROT completed by 32 English speaking athletes and 30 Arabic athletes showed that the MIROT test in Arabic is significantly more difficult in Arabic than in English ( Table 2 ). The Serial 3s subtraction test was subsequently tested as the first alternative option. Contrary to the successful substitution with this test in the Chinese SCAT3, in Arabic, the test was found to be unsuitable, as explained below ( Table 2 ). The DWBT and the Adding Serial 3s test were then tested as further alternative options. Table 2 shows that the average time to complete the English MIROT was 15.5 ± 6.3 s, equivalent to the Adding Serial 3s test. The accuracy of the Adding Serial 3s test was 100% in this sample and similar to the accuracy of the English MIROT [12] . The DWBT was significantly faster to complete, and its self-rated difficulty was lower. The DWBT was thus rated as very easy in Arabic compared to the MIROT in English speaking participants. The Serial 3s subtraction test turned out to be the most difficult concentration test in a sub-sample of recreational athletes. 63.3% of the English-speakers failed to complete it and only 55.2% of the Arabic speakers managed to obtain accurate responses. Compared to English speakers, the Arabic speakers seem to emphasize accuracy over speed, being more accurate but taking longer to complete All data were coded and analysed using SPSS v21.0 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were presented as means and standard deviation (SD) for continuous variables and as frequencies for categorical variables. Student's t-test was used to compare the difficulty in rating, time taken for tasks MIROT, DWBT, Serial 3s addition and subtraction tests between athlete groups (English vs. Arabic speakers). The paired sample t-test was used to compare the same participant's performance on different tests. The chi-square test was used to compare accuracy of tests between athlete groups. The level of significance was set at p < 0.05. In the initial Arabic translations, several discrepancies regarding the use of different synonyms, omissions and additions of words, inaccurate translation of medical terms and inadequacies in direct translation without cultural adaptations were identified and addressed. Specific changes were made on the Immediate Memory Test. The reconciliation committee discussed each sentence in the initial Arabic SCAT5 translation for semantic, idiomatic, experiential and conceptual equivalence. Sixty-one words, concepts and translation options were deliberated until a consensus was reached. Specific attention was given to the ease of concept comprehension in all or most Arabic dialects. In cognitive and neuropsychological screening, word lists usually contain words from the same semantic categories, and all lists are grouped, e.g. body parts, fruits, vehicles, animals and drinks. Application of this knowledge in the Arabic translation added a new dimension to the Arabic SCAT5 as the original SCAT5 word lists selection was merely sourced from sets of commonly used and phonologically sim- In Arabic participants, the Adding Serial 3s test had a higher level of difficulty but close to that of the MIROT in a sub-sample of English participants ( Table 2) . The overall average 'similarity' score out of seven was 1. Twelve healthy athletes were tested and re-tested with the Arabic SCAT5. It took longer to complete than the estimated time to complete the English version [5] . The average time (minutes) and standard deviation (SD) were respectively 20.4 (SD 3.0) for the first and 4 17.7 (SD 3.0) for the second assessments. The six healthcare providers conducting the pre-testing were unanimous that the Arabic SCAT5 was acceptable in terms of clarity, understandability, grammatical correctness and coherence and declared it equivalent to the English version and free of misinterpretations but commented on the difficulty of the Arabic MIROT. All 12 athlete participants found the Arabic MIROT difficult. Three athletes also pointed out that the term 'dominant hand' in the Athlete Background section is an unknown concept and suggested the use of 'righthanded' and 'left-handed'. The results of acceptable comparability and understandability were shown in the validation of the translation section [15] . Ongoing validity assessment took place during the translation review processes while recording all discussion points. Furthermore, a group discussion was conducted with the six healthcare providers who conducted the pretesting of the pre-final Arabic SCAT5 version, supporting its face validity. The final version of the Arabic SCAT5 is shown in Appendix 1. The aim of the study was to translate and culturally adapt the English [10, 19, 20] . In addition, Arabic reading acquisition by beginner readers seems to be more challenging than in other languages [19, 21] . Three major reasons have been proposed for this [19] : (i) the diglossic situation in most Arab countries (where the written language is different from the spoken language) [20] ; (ii) the visual or graphic complexity of the written Arabic system; and (iii) the disability of the right hemisphere to distinguish between very similar graphemes that denote very different phonemes [20] . Eviatar et al. [20] further revealed that the right brain is involved in the reading process for English and Hebrew, but not for Arabic. The authors explained that in Arabic, identifying the number and location of dots that is critical to differentiate between letters is a hard task for the right brain since that hemisphere primarily utilizes global information to identify letters. Hence, the complexity of the written Arabic system results in high perceptual load, contributing to the difficulty and slowness of processing in reading Arabic [20] . This may well affect the practical utility of the Arabic SCAT5 for field assessment. However, it does not change utility in the office assessment setting. Particular attention was given to the comprehensibility of the Arabic translation of the SCAT5, given the huge language and cultural differences between the two languages. Furthermore, cultural adaptation of the cognitive testing was done with rigorous attention to the rules of translation and cultural adaptation to ensure semantic, idiomatic, experiential and conceptual equivalence, but also considering the influence of the semantic domain, the number of syllables, and phonological qualities on the difficulty and usability of the Immediate and Delayed Memory Tests [11, 13, 22] . The Arabic SCAT5 was written in Modern Standard Arabic, but the cultural adaptation allowed it to be of value in various spoken Arabic dialects. Firstly, the on-field assessment was not field tested and its usability in Arabic speaking athletes not verified. Secondly, the validation of the translation and pretesting were conducted with relatively low numbers of participants. Inter-rater and test-retest reliability were not performed because of the Covid-19 pandemic restrictions, ongoing since February 2020. The Arabic SCAT5 needs to be validated and tested for reliability. The psychometric properties need to be compared with the original SCAT5. The content and construct validity may be challenged by the cultural adaptations of the memory and concentration tests. This translation will form the basis for fast translation of the Child SCAT5 [23] and imminent SCAT6. Shorter alternative field-side lation has been validated [12] . In the translation and validation of patient-rated or scored instruments, adaptation of the instrument is important to accommodate cultural and linguistic differences between the original and the target language. During this translation of the SCAT5, careful attention was paid to rigorous methods of both translation and cultural adaptation. During the Chinese translation, these stages were proven necessary to avoid anecdotal and invalid outcomes [12] . The problematic use of the MIROT during our translation is a case in point. In addition, we attempted to include native speakers of Arabic dialects commonly used in most Arabic regions, to make the final product accessible and valid for several Arabic speaking populations. 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