Translation of the Fear Avoidance Beliefs Questionnaire Into Hausa Language

Background: Self-report measures of fear-avoidance beliefs are widely used in clinical practice and research. To date there is no Hausa version of the Fear Avoidance Beliefs Questionnaire (FABQ). This is important as the Hausa language is a widely spoken language in West Africa. Objectives: The purpose of this study was to translate and validate the Hausa version of the FABQ in patients with non-specific neck pain. Methods: Two independent bilingual Hausa translators translated the English version of the FABQ into Hausa which was thereafter back translated by one independent bilingual translator. A professional expert panel revised the translations to produce a consensus version. The psychometric testing of the final translated instrument was investigated by surveying 54 Hausa speaking patients with chronic non-specific neck pain. Cross-sectional construct validity was evaluated by comparing Hausa Fear Avoidance Beliefs Questionnaire (FABQ-H) with the English version of the FABQ. Internal consistency of the FABQ-H was examined by Cronbach alpha by comparing the scores between the FABQ-H and its subscales. Test-retest reliability was evaluated by administering the Hausa version twice. Results: The translated Hausa version of FABQ proved to be acceptable. The FABQ-H showed strong correlations (r=0.94, p=0.000) with the original English version. There was also high internal consistency between the FABQ-H and its subscales (physical activity component-α=0.88, p=0.000 and work component- α=0.94, p= 0.000). The FABQ-H also showed a high test-retest reliability (intra-class correlation coefficient =0.98). Conclusion: The FABQ-H demonstrated excellent psychometric properties similar to other existing versions. The FABQ-H is recommended for clinical practice.


Introduction
Neck pain can be defined as a subjective unpleasant sensory experience which manifests as fatigue, tension or pain with or without radiation to the shoulder, upper extremities or head (Siivola et al., 2002). It is a major public health concern associated with significant disability (Hogg-Johnson et al., 2008). Most people will experience neck pain at some points in their life although; it would not constitute disability (Hoy, Protani, De, & Buchbinder, 2010). Many researchers have attempted to classify neck pain and different methods have been proposed (Borghouts, Koes, & Bouter, 1998;Cote, Cassidy, & Carrol, 2003). The most widely accepted is the "diagnostic triage" which classifies neck pain patients as either (a) serious spinal pathology; (b) neurological involvement, or (c) non-specific neck pain (Kirchhoff et al., 2006;Klaber-Moffet & McLean, 2006). Of these three, non-specific neck pain accounts for the majority of complaints (Bertozzi et al., 2013).
Non-specific neck pain (NSNP) is pain (with or without radiation) with no specific objective underlying pathology (Binder, 2007). Many structures in the neck and surrounding regions such as muscles, joints, ligaments, intervertebral disc and neural structures may be sources of NSNP (Borghouts et al., 1998). Non-specific neck pain is perpetuated by physical, psychological, and individual related risk factors (Guzman et al., 2009). Studies have identified risk factors linked to the development of neck pain (McLean, May, Klaber-Moffet, Sharp, & Gardiner, 2010;Hogg-Johnson et al., 2008;Lee, Chiu, & Lam;2007;Hill, Lewis, Sim, Hay, & Dziedzic, 2007). These include female gender, high job demands, smoking, psychosocial factors and co-morbid low back pain. Psychosocial factors are becoming more relevant in the onset, persistence and recurrence of neck pain (Ariens, Mechelen, Bongers, Bouter, & van der Wal, 2001). Fear avoidance beliefs' are one such factor. According to Chou and Shekelle (2010), Fear avoidance beliefs describe patients' worries that their pain/injury will be exacerbated by certain activities and these should be avoided. These beliefs often cause such individuals to avoid engaging in physical activities for fear of more pain or further injury (Chou & Shekelle, 2010;Leeuw et al., 2007). Fear avoidance beliefs if unchecked, can result in increased disability, work absenteeism, heavy reliance on medications and excessive use of medical services (Myhre et al., 2013;Mannion, Wieser, & Elfering, 2013;Linton & Andersson, 2000).
The Fear Avoidance Beliefs Questionnaire (FABQ) is a valid and reliable measurement tool for assessing fear avoidance beliefs in different populations (Rostami et al., 2014;Pei, Xia, & Yan, 2010;de Souza, Marinho, Siqueira, Maher, & Costa, 2008;Waddell et al., 1993). The FABQ is a 16-item instrument that assesses patients' beliefs about the effects of physical activity and work on their musculoskeletal pain. Patients' responses for each item are on a 7-point Likert scale (0 = completely disagree, 6 = completely agree). The original factor analysis revealed two subscales: the physical activity subscale (FABQpa) with 5 questions (maximum score = 24) and the work subscale (FABQw) with 11 questions (maximum score = 42). The score range is 0 to 96, with a higher value reflecting a higher degree of fear avoidance beliefs. A higher score indicates more strongly held fear avoidance beliefs. It takes about 10 minutes to complete (Waddell, Newton, Henderson, Somerville, & Main, 1993).
The translation and cultural adaptation of instruments is an internationally recognized method (Grassi-Oliveira, Stein, & Pezzi, 2006;Akinpelu, Maruf, & Adegoke, 2006;Maneesriwongul & Dixon, 2004;Li, Wang, & Shen, 2003). Instrument translation is a process by which an instrument is translated from one language to another. However, cross-cultural adaptation not only involves the initial translation process, but also synthesis, back translation, expert committee review, pre-testing of the consensus draft, cognitive debriefing interview (a way of getting feedback from respondents on the item-content, presentation, and clarity after pretesting) and psychometric evaluation. Cross-cultural adaptation usually encompasses a team of experts including the translators, researchers versed in clinimetrics (a way of evaluating signs, symptoms and laboratory findings with measures, indices, and other quantitative instruments) and health professionals who would normally use the instrument, as opposed to translation which requires only one or two translators. Cross-cultural adaptation is essential when the instrument is intended for use on a target population with cultural differences from that of the original version (Maher, Latimer, & Costa, 2007). The entire process of cultural adaptation is tailored towards achieving semantic and colloquial uniformity between the original and translated versions.
Nigeria is an ethnically diverse country of over 500 indigenous languages. However, Hausa, Igbo and Yoruba are the major ones (Babajide, 2001). The original FABQ was developed in the English language, the official language of communication in Nigeria. However, the majority of patients in Nigeria do not speak or write English (Akinpelu et al., 2006). It is therefore imperative to translate the FABQ into Hausa, a language which is not only spoken in Nigeria but also in some other African countries. Translating the FABQ into Hausa language may enhance the ease of use and accessibility by the Hausa speaking patient. Therefore, the objectives of this study were to translate the FABQ into Hausa language, culturally adapt it and to validate its use among Hausa-speaking non-specific neck pain patients.

Instrument
The FABQ developed by Waddell et al. (1993) investigates the fear-avoidance beliefs among patients in the clinical setting. The FABQ helps to predict individuals that have high pain avoidance behaviour. The FABQ consists of 2 subscales; the Physical Activity subscale (FABQpa) with items 1-5 and the Work subscale (FABQw) with items 6-16. Though not all items contribute to the score for each subscale participants are still expected to respond to all items. This is because none of the items were omitted during the initial validation of the scale. Each subscale is graded separately by totalling the responses of the scale items (0-6 for each item). For scoring purposes, only items 2,3,4 and 5 of the physical activity subscale (24 possible points) and only items 6, 7, 9, 10, 11, 12, and 15 of the work subscale (42 possible points) are scored. The total FABQ score is obtained by adding both subscale scores.

Translation Procedure
The recommended procedures for translating self-report measures were followed to translate the FABQ into Hausa language (Terwee et al., 2007;Beaton, Bombardier, Guilleman, & Ferraz, 2000). Two expert linguists proficient in both English and Hausa languages (and whose first language is Hausa) independently translated the FABQ into the Hausa language. One of the translators had a prior knowledge of the concepts being examined in the questionnaire. The other translator who neither worked in a medical institution nor had a medical background was uninformed about the concepts being examined. Each translator produced a written report of the translation they completed highlighting challenging phrases and uncertainties. They also summarized their rationale for their choice of words. Thereafter, both translators met to develop a reconciled version from both translations. A third linguist who was not involved in the original process of translation back-translated the questionnaire to English language.
A panel of professional experts comprising two experienced physiotherapists (involved in instrument development, translation and validation studies), the translators (forward and backward) and one of the researchers involved with this study (a native Hausa speaker) revised the back translation. The consensus Hausa translated version of the FABQ was then administered to seven patients with non-specific neck pain. Thereafter, the patients participated in a cognitive debriefing interview. All the patients reported that they understood all the items and that there was no imprecision in the questionnaire. Concurrent presentations of the English and the Hausa versions of the FABQ are shown in Table 1 while the complete version of the translated FABQ is presented in the appendix.

Validity and Reliability
According to the "Quality criteria for measurement properties of health status questionnaires", it is essential to recruit no less than 50 participants for construct validity, reliability, and ceiling/floor effects analyses (Terwee et al., 2007). Therefore, 54 patients with chronic non-specific neck pain, who were bilingual in English and Hausa languages and aged 18 years and above were purposively recruited for the validation of the translated instrument. Individuals aged below 18 years and with co-morbidities that may have influenced overall wellbeing (such as sickle cell anemia, HIV/AIDS) and pregnant women with non-specific neck pain were excluded from the study. Participants were recruited from two tertiary health facilities (Aminu Kano Teaching Hospital and National Orthopedic Hospital, Dala) in Kano, Northern Nigeria. Ethical approval (AKTH/MAC/SUB/12A/P-3/VI/1175 and NOHD/RET/ETHIC/60) was sought and obtained from ethical committees of both the Aminu Kano Teaching Hospital and the National Orthopaedic Hospital. The procedure of the study was explained to each participant and thereafter his/her informed written consent was obtained before participating. Information on socio demographic characteristics (age, sex, marital status and occupation) of participants and clinical history of non-specific neck pain were obtained through interview and hospital files.
Copies of the English (FABQ-E) and Hausa (FABQ-H) versions of FABQ were concurrently self-administered to participants to determine the cross-sectional construct validity of the FABQ-H. The FABQ-H and the Hausa translated version of the Visual Analogue Scale (VAS) were also given to the participants to determine the divergent validity of the FABQ-H. After a week, the FABQ-H was given to participants to complete again to determine the test-retest reliability of the instrument.

Data Analysis
Descriptive statistics were used to summarize the age and pain intensity of participants. Percentages were used to summarize age group, gender, tribe, marital status, educational status and occupation of the participants. Participants' scores obtained on the FABQ-H and FABQ-E were analyzed using Spearman rank order correlation to demonstrate the cross-sectional construct validity of the Hausa version. Spearman rank correlation was also used to determine the divergent correlation between the FABQ-H and VAS. The intra-class correlation (ICC) was used to investigate the correlation between the scores obtained by participants on the FABQ-H at two different occasions (testretest reliability). The internal consistency between the FABQ-H and each of its two subscales: the physical activity subscale (FABQpa-H) and the work subscale (FABQw-H) were calculated using the Cronbach's alpha. The level of significance (α) was set at 0.05. Data was analyzed using SPSS version 16.

Results
The validation part of this study involved 54 patients with chronic NSNP. The participants' ages ranged between www.ccsenet.org/gjhs 4. Bai kamata in yi wasannin motsa jikin da (ka iya) qarfafa ciwo na ba 5. I cannot do physical activities which (might) make my pain worse. 5. Ba zan iya aiwatar da wasannin motsa jiki da (ka iya) qarfafa ciwo na ba 6. My pain was caused by my work or by an accident at work. 6. A dalilin haxari a wajen aiki ne sanadiyyar gamuwa ta da ciwon wuya 7. My work aggravated my pain.
7. Aikina kan kan haifar mun da tsananin ciwon wuya 8. I have a claim for compensation for my pain.
11. Aikina zai iya lahanta mun wuya 12. I should not do my regular work with my present pain.

Discussion
To the best of our knowledge, this is the first study to translate, culturally adapt and validate the FABQ for Hausa speaking patients with NSNP. Hausa is one of the three major Nigerian languages in a multi-ethnic country of over 500 indigenous languages (Babajide, 2001 Hausa as their first language. The results of this study indicate that the FABQ-H is a reliable and valid instrument for measuring fear avoidance beliefs in Hausa-speaking patients with NSNP. It is also easily understandable and quick to complete, making it appropriate for use in routine health care. Clarity, reliability, cross-sectional construct validity and internal consistency of the FABQ-H are comparable to those of the original British version (Waddell et al., 1993 (Pei et al., 2010;de Souza et al., 2008;Grotle, Brox & Vollestad, 2006;Kovacs et al., 2006). To our knowledge, there is no "gold standard" measure of fear-avoidance and therefore it is not possible to assess criterion validity. However, the high correlations between the FABQ-H (and its subscales) and the weak correlation between FABQ-H and pain intensity, as measured by the VAS, provide satisfactory evidence for the construct validity of the instrument. It is not unanticipated that the latter correlation coefficient is low, since the FABQ and the VAS measure divergent constructs. It is however recommended that such validity should be explored with other scales such as the Neck Disability Index and Tampa scale of Kinesiophobia.
More studies are needed to investigate the relationship between self-reported fear avoidance beliefs, as measured by a questionnaire, and functional performance in patients with musculoskeletal pain, especially patients with NSNP. Also, this validation was done among patients with chronic NSNP, thus there is a need to further test the psychometric properties of the Hausa version among patients with acute and sub-acute symptoms and with other musculoskeletal conditions.