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Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 1-4

The impact of age and education level in the linguistic validation of the Acute Cystitis Symptom Score (ACSS) questionnaire

1 Department of Urology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
2 Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University, Giessen, Germany
3 Department of Urology, Technical University of Munich, Munich, Germany

Date of Submission29-Apr-2021
Date of Decision21-May-2021
Date of Acceptance07-Jun-2021
Date of Web Publication15-Feb-2022

Correspondence Address:
Konstantinos Stamatiou
Department of Urology, Tzaneio General Hospital of Piraeus, Piraeus
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HUAJ.HUAJ_19_21

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Introduction/Purpose: The Acute Cystitis Symptom Score (ACSS) was developed as a simple and self-reporting questionnaire for diagnosing and monitoring acute uncomplicated cystitis in female patients. It consists of 18 questions placed in four subcategories: (1) typical symptoms, (2) differential diagnosis, (3) quality of life and (4) coexisting gynecological conditions. It has been translated into many languages. The purpose of this work is the linguistic evaluation of ACSS in the Greek language. Materials and Methods: The translation of ACSS into Greek was carried out in accordance with international standards and guidelines. The process consisted of 4 stages: in the 1st and 2nd stage a translation was made into the target language (Greek) from the original (Russian, English) by native speakers, while reverse translation and re-evaluation was made by experts whose mother tongue language is the target language. In stage 3, a cognitive assessment was performed by female subjects with and without a history of uncomplicated urinary tract infection. At this stage, based on the degree of understanding, the final draft was chosen between the two drafts of different origins (Russian or English). In stage 4: the final clinical evaluation was performed by female subjects with acute episode of uncomplicated cystitis (Arm 1 - Patients) and female subjects undergoing treatment for any other diseases (Arm 2 - Control). The Memorandum of Understanding between the Greek Study Group of ACSS and the copyright holders of ACSS was made on 17 November 2019 while it has been approved by the Ethics Committee of the Hospital. The diagnosis of acute uncomplicated cystitis was made based on the history and results of laboratory findings. Results: The two pre-final versions in Greek were randomly applied to 15 healthy women aged between 89 and 22 years. The mean age of the final sample was 23.84 years. The level of education differed between a doctorate and a primary school diploma with most participants graduating from universities (8/30) and high school (8/30). According to the answers, 20 women would prefer the English standard translation, compared to 10 women, who preferred the Russian translation. The 2: 1 ratio was similar whether the participants had higher education or not. No significant difference was observed in the mean age of the participants who chose one or the other version. Conclusion: The process of translating and adapting a study instrument such as a questionnaire for a different ethnic group is a difficult task since it requires to adapt it in a culturally relevant and comprehensible form despite peculiarities of the target language. Considering these difficulties, we were able to develop a linguistically validated Greek version of the ACSS, which now can be used for clinical and research purposes in a multidisciplinary fashion.

Keywords: Age, education level, linguistic validation, medical questionnaire

How to cite this article:
Stamatiou K, Samara E, Alidjanov JF, Naber KG, Pilatz A, Wagenlehner FM. The impact of age and education level in the linguistic validation of the Acute Cystitis Symptom Score (ACSS) questionnaire. Hellenic Urology 2021;33:1-4

How to cite this URL:
Stamatiou K, Samara E, Alidjanov JF, Naber KG, Pilatz A, Wagenlehner FM. The impact of age and education level in the linguistic validation of the Acute Cystitis Symptom Score (ACSS) questionnaire. Hellenic Urology [serial online] 2021 [cited 2022 Nov 29];33:1-4. Available from:

  Introduction Top

Acute cystitis, an infection of the urinary bladder, is the most frequent bacterial infection in women.[1] It most commonly affects young, sexually active women (between the ages of 16 and 35 years), with 10% of women getting an infection yearly and more than 40%–60% having an infection at some point in their lives.[2] The classic clinical symptoms of cystitis consist of dysuria, urinary frequency, urinary urgency, and suprapubic pain. Frequency, length, and intensity of symptoms vary from patient to patient.[3] In several patients (most often the very old and the very young), symptoms may be vague or nonspecific; however, the majority of symptoms are bothersome.[3] Clinical evaluation of the bothersome is somehow controversial, given that improvements assessed in patient interview may be subjective and may be affected by recall biases. The acute cystitis symptom score (ACSS) was developed and validated as a simple and self-reporting questionnaire for diagnosing and monitoring acute uncomplicated cystitis (AUC) in female patients, by assessing typical and differential symptoms and additional health conditions, which may play an important role in such a clinical setting.[4] Additionally to the detection and evaluation of the severity of acute cystitis symptoms, the ACSS questionnaire can assess the impairment of everyday activities and quality of life caused by the symptoms and differentiates AUC from other disorders that present with similar symptoms.[5] In most guidelines' antibiotics are recommended as first-line treatment[6],[7] although; symptomatic therapy also has shown similar good results.[8],[9] The necessity to shift from symptomatic therapy to antibiotics, the actual duration of antibiotic treatment, and the addition of other drugs to the treatment regimen (such as urinary tract pain reliever) depend often on the level of discomfort and symptoms persistence[10] and therefore, the ACSS questionnaire is the ideal tool to manage the above issues. The ACSS questionnaire can also serve to predict transition to pyelonephritis. In fact, infection of the kidney usually occurs in a retrograde, ascending fashion from the bladder and in most of cases, symptoms of cystitis such as dysuria and hematuria precede those of renal infection (fever, flank pain, and nausea or vomiting). Young sexually active women are the patients that are most often affected by both acute cystitis and acute pyelonephritis.[11] Since AUCs recurrences are common, with up to 40% of patients getting a second infection within a year, the ACSS questionnaire can also be used to monitor recurrences. To our knowledge, the ACSS has been ultimately used in a larger prospective phase III trial comparing the outcome of an antibacterial agent with that of herbal treatment in women with AUC.[12] This study is aiming to translate the ACSS questionnaire from the original Russian language and American English as a new master version into the Greek language and to validate the Greek version linguistically in female patients with Greek as their first language.

  Materials and Methods Top

To create a Greek version of the ACSS questionnaire using a cross-cultural adaptation process, we appointed two independent translators, of native Greek language origin, both experts in English and Russian language, respectively, and two English and Russian native-speaking translators. The first group of translators had to translate the original Russian version and American English as the new master version into the target Greek language. The second group of translators had to back-translate the translated versions (Russian to Greek [RG] and English to Greek [EG]) into the original languages. Translators had then to compare the original and back-translated versions to correct any discrepancies compared to the original text and provide the first draft of each questionnaire in the Greek language (RG and EG) after applying any necessary modifications.[13] These drafts had to be printed and distributed to randomly selected females of different educational levels who had to be asked whether they prefer either the RG or the EG version and had to score the different items of each version. After careful discussion within the scientific committee the final Greek version composed from both translations considering the item scoring had further to undergo evaluations including face to face validation and internal consistency.[13] A statistical analysis using the (p) Pearson correlation coefficient had then to be performed. A P ≤ 0.05 was considered statistically significant.

  Results Top

We have initially interviewed 15 randomly selected females, of different ages (30–89 years old) and of different levels of education (from elementary school to postgraduate studies). All were asked to choose their favorite translation. Eight of them have chosen the EG translation, whereas 7 have chosen the RG version. No significant differences existed in the median age (50 vs. 54 years) and educational level between the two groups although the number of the technical school and university graduates was slightly higher among those having chosen the RG translation as compared to those, who preferred the translated EG questionnaire (5/7 vs. 4/8). Of note, EG translation considered more the spoken language, while that of RG questionnaire resembled the written formal language. Reasons explaining this result were attributed to the translators and the languages' characteristics: While no difference in the level of education (postgraduate studies) between translators existed, age of the RG questionnaire translator was significantly higher than that of the EG questionnaire (76 vs. 38 years). On the other hand, differences between spoken and written language are prominent in both Greek and Russian, compared to American English.[14] To achieve a reliable comparison, we repeated the process for the Russian version of the ACSS questionnaire with another translation from the Russian version to Greek, this time from a younger translator (not related to the previous ones). This version of the RG questionnaire still resembled written language but was somehow closer to the EG translation. The two prefinal versions in the Greek language were randomly applied to 30 healthy women aged between 22 and 89 years [Table 1]. Education level varied between Ph.D. and Elementary School degree. Participants were invited to compare the two versions and indicate the most comprehensive version of each item. According to the responses, 20 females would have preferred the translated EG questionnaire, as compared to 10 females, who preferred the translated RG questionnaire. The proportion of 2:1 was similar regardless of the participant's age. The difference in the educational level between participants was significant since most of the respondents in higher education (university graduates) preferred the translated RG questionnaire rather than the EG questionnaire (6/10 vs. 4/20).
Table 1: Level of education, age, and preferred translated version

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As many of the responders suggested that they would prefer specific translated questions from each questionnaire, we afterward created a questionnaire providing both translations for each individual question, asking the participants to choose their preferred translated question. Responders were also asked to comment on the given choices. Thirty participants responded, including female patients as well as healthcare professionals (urologists, gynecologists, nurses, pharmacists). The consensus version was based mainly on the last survey's results and was composed by the items of both translations assigned to the grade of understanding and clarity as reported by the respondents. For this procedure, a scoring system from 1 (low) to 10 (highest) was used. This consensus version underwent a process of cognitive assessment. A link was sent by mail to Greek physicians and other healthcare professionals (pharmacists, nurses) and acute cystitis patients.[15] The first 30 respondents of each group consisted of the study group. The sample size was considered adequate for safe results to be extracted since; previously published articles on the topic refer to similar numbers.[4],[5],[16],[17] Subjects have been asked to comment if they understood each question and write whatever comment they would like to make on each question of the questionnaire. Several acute cystitis patients commented that they would prefer descriptive sentences instead of medical terms. As it was proved to be understood and accepted by both healthcare professionals and patients, this version was constituted as final version [Appendix 1].

  Discussion Top

By translating the ACSS into the Greek language and then to validate it in Greek-speaking patients we encountered challenges not priorly described among common translation issues regarding questionnaires. The difficulties are probably connected to the peculiarities of the modern Greek language. In fact, in the modern era, the Greek language entered a state of diglossia: The coexistence of vernacular and archaizing written forms of the language. What came to be known as the Greek language question was a polarization between two competing varieties of Modern Greek: Dimotiki, the vernacular form of Modern Greek proper, and Katharevousa, meaning “purified,” a compromise between Dimotiki and Ancient Greek, which was developed in the early 19th century, and was used for literary and official purposes in the newly formed Greek state. In 1976, Dimotiki was declared the official language of Greece, having incorporated features of Katharevousa and giving birth to Standard Modern Greek, which is used today for all official purposes and in education.[18] Several of these incorporated features of Katharevousa are used in formal language which is more common in written communication, especially in public documents including medical forms. These features are usually filtered down into the vernacular, though often in a changed from, which is generally used by sophisticated persons or certain professionals, for example, lawyers.[19] Of note, formal language and informal language are associated with particular choices of grammar and vocabulary. Differences between formal language and informal language-which are more common in oral communication-are prominent in the modern Greek language. As shown in this study, a questionnaire with an old-fashioned style such as the RG version of ACSS is better acceptable by persons with tertiary education who are familiar with formal written communication. Currently, most uses of American English are rather informal than formal.[20] As a result, the consensus version which was mainly resulted from the EG prefinal version was more informal, more descriptive, and longer than the RG prefinal version, and uses more words and explanatory sentences to explain medical terms. After the publication of its clinical validation, the Greek ACSS can be widely used as a suitable instrument for patient-reported outcome assessment, for clinical and research purposes in a multidisciplinary fashion. The impact of AUC on everyday activities and quality of life, the role of co-morbidities in the development and outcome of AUC, the ideal duration of antibiotic treatment, and the necessity and the timing of treatment regimen modification are some issues that could be further investigated with the use of the Greek ACSS in both everyday practice and research. To our knowledge, the current study was performed at a single center, which may be considered a limitation. Nevertheless, the results of clinical validation (will be presented in a future paper) suggest, that the questionnaire can describe the dynamics of this particular clinical condition very well.

  Conclusions Top

The process of translating and adapting a study instrument such as a questionnaire for a different ethnic group is a difficult task since it requires to adapt it in a culturally relevant and comprehensible form despite peculiarities of the target language. Considering these difficulties, we were able to develop a linguistically validated Greek version of the ACSS, which now can be used for clinical and research purposes in a multidisciplinary fashion.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician 2011;84:771-6.  Back to cited text no. 1
Nicolle LE. Epidemiology of urinary tract infection. Infect Med 2001;18:153-62.  Back to cited text no. 2
Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287:2701-10.  Back to cited text no. 3
Di Vico T, Morganti R, Cai T, Naber KG, Wagenlehner FM, Pilatz A, et al. Acute cystitis symptom score (ACSS): Clinical validation of the Italian version. Antibiotics (Basel) 2020;9:104.  Back to cited text no. 4
Alidjanov JF, Naber KG, Abdufattaev UA, Pilatz A, Wagenlehner FM. Reevaluation of the acute cystitis symptom score, a self-reporting questionnaire. Part II. Patient-reported outcome assessment. Antibiotics (Basel) 2018;7:43.  Back to cited text no. 5
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Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, Wegscheider K, Hummers-Pradier E. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: Randomised controlled trial. BMJ 2015;351:h6544.  Back to cited text no. 8
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