Objectives: To establish the psychometric properties of the Urdu version of Menopause Rating Scale.
Methods: The study was conducted at Lahore from 1, 2017 to 10, 2017. In first phase, the Menopause Rating Scale was forward and backward-translated and linguistic equivalence was checked by using it on a sample of bilingual respondents. In the second phase, reliability estimation of the scale was established over separate sample. Psychometric properties of the Urdu version were checked by using alpha index, split-half reliability, test-re-test reliability, exploratory and confirmatory factor analyses.
Results: There were 130 women with a mean age of 50.94±4.71 years (range: 40-55 years). Linguistic equivalence was significantly high (p<0.01). High Cronbach's alpha value (p<0.001) indicated high internal consistency reliability. Exploratory factors analysis structured 3 original factors of the Urdu version of the scale and confirmatory factor analysis value 0.965 indicated that the structured model
was acceptable with good fit. Test re-test reliability was 0.991 (p<0.01).
Conclusion: Urdu version of Menopause Rating Scale was found to be highly reliable with a valid measure for Pakistani culture.
Keywords: Linguistic equivalence, Reliability, Explorator y an d confirmator y analysis.
(JPMA 69: 224; 2019)
Menopause refers to the cessation of menstruation that women face in their midlife.1 It is a universal phenomenon and natural biological event. As a woman undergoes transition from the reproductive years through menopause and beyond, she experiences many physical as well as psychological changes. Interestingly, each woman experiences menopause in a unique way; for some women menopause means a transitional phase leading to a new dimension of life which contains confidence and empowerment than younger years, while for some other women menopause is a reminder that they are aging which may cause distress anddecrease their psychological well-being. Sometimes a slight change in lifestyle, eatin habits and general health practice may improve healthrelated quality of women's life going through menopause, but at times it is difficult to manage without seeking any treatment. During menopause, women experience vasomotor, urogenital, psychological symptoms and also sexual dysfunctions that result in menopausal symptoms.2,3 Some complications may occur because of hormonal changes at midlife and some health-related risks factors may expose at this stage as well i.e. oestrogen secretion, metabolic changes, general health etc.4-6 In several women, these menopausal symptoms are so severe that they affect their
social and individual lives.7 During menopause phase, various symptoms have been obser ved such as neurological symptoms (i.e. memory impaired), depressive symptoms (i.e. insomnia, fatigue, low energy etc.), anxietyrelated symptoms (i.e. poor concentration, anxiousness, nervousness, sweating or hot flushes) and physical symptoms (i.e. joint pain, headache, muscle contraction etc.).8,9 The purpose of the Menopause Rating Scale (MRS) was to establish an instrument that will help measure the symptoms purely related to menopause among women. A study involving follow-up of 306 women from th original study showed correlation from scores on two occasions and yielded a significant test-retest reliability.
It added to the temporal stability of the scale. The scale total correlation of the three factors is also significant showing strong internal consistency,10 with the scores on two standardised measures of health-related quality of life (HRQoL) that is, Kupperman index (KI)11 and the Short
Form (SF-36).12 The scores on MRS well correlated with KI and thus showed a high degree of association between the results of both the scales. Interestingly, the resultswere more significant for the comparison of MRS and SF-36. Those sub-scales of Sf-36 highly correlated with MRS which was more relevant to women's health and symptoms during menopause. As a result, the scale was declared as a measure of Global Quality of Life (GQoL) as the total score on the scale was evaluated as a single factor.11,12 The MRS covers objectives like establishing symptoms' comparison in women having various conditions. Further, to evaluate the intensity of symptoms with the passage of time and, additionally, to assess the variation in preand post-testing when comparison is required.13 This scalewas developed primarily in 1996. It is based on the data collected from a sample of 683 women aged 40-60 years.14
The technique of factor analysis was utilised and it structured 3 original factors such as somato, vegetative and urogenital factors. The responses on the scale are scored on a five-point Likert scale. The MRS is a very simple and easy measurement that
comprehensively measures the symptoms of menopause among women. Cross-cultural assessment has become a sensitive issue due to specific concerns regarding the use of standardised tests across cultures.15 Many of the tests and scales used in psychological research in Pakistan have been developed in Western settings. There are questions as to how applicable or relevant these psychological instruments would be in a primarily non-English speaking eastern nation like Pakistan. Cultural difference has restricted the use of these questionnaires and scales, as our environment shapes the person that we are and our viewpoints concerning many different essential aspects of life, such as norms, values and ideas.16 Viewing the menopausal phase in different cultures it can be seen that the nature, frequency, severity and phases of menopausal symptoms differ between the individuals of differentcultures within different countries. Therefore these symptoms need to be studied in individuals of different cultures to get a better understanding of these differences.17 The MRS comprised 11 items.18 It has three dimensions; somatic, psychological and urogenital. Somatic includeshot flushes, heart discomfort, sleeping, muscles and joint problems (items 1, 2, 3 and 11). Psychological dimension includes depressive mood, irritability, anxiety and physical and mental exhaustion (item 4, 5, 6 and 7), and urogenital dimension includes sexual problems, bladder problems and dryness of vagina (item 8, 9 and 10). Each score is rated on a 0-4 scale where 0 represents no or little complaints, 1 represents mild, 2 is moderate, 3 is severe, and 4 is very severe. In order to facilitate analysis and interpretation of the result, total MRS score is calculated by adding the three subscales. The scale has Cronbach's alpha=0.83 to 0.87, showing adequate internal consistency. There is a clear need for valid and reliable instrument if it
needs to be studied in Pakistani culture that can assess the construct of menopausal symptoms of Pakistani middle-aged women. For this purpose it needs to be translated into Urdu for studying their issues by taking into account their cultural context and for reducing the effects of language barrier as well. By translating into Urdu
language, women can get enhanced vision of the problem researcher is seeking for without speculating into complications of language as well as can express their
perceptions in a perceptive way. Therefore, the current study was planned to translate and adapt the valuableMRS in Urdu language.
Subjects and Methods
The study was conducted in Lahore, from 1, 2017 to 10, 2017. For forward translation, a group of translators is usually preferred.19 Therefore, MRS translation was done by bilingual experts; two were related to academia and two
were language experts with vast experience. Forward translations were reviewed by committee members and revisions in the items were made according to their
suggestions and comments. After completion of the forward translation, a panel of six
experts evaluated the different versions of forward translations. After this process, the draft was arranged for back-translation of MRS. The members on the committee
had familiarity with both cultures, the construct measured in the test, the basic principles along with the linguistic expertise, as suggested.20 In backward translation from Urdu to English, a bilingual expert who had not seen the original version of the test before, translated the Urdu version of MRS back into English, the source language. The committee of experts then examined and reviewed the back-translation. Judgments were made about their equivalence and the translated items were revised where necessary. Some of the items after back-translation did not relate to the original concepts, therefore they were modified and rephrased by the experts. Then the scale was finally reviewed by the panel of experts for translation inaccuracies and a final draft was prepared for a linguistic
study with consensus. Linguistic equivalence included translation of the script to ensure that the translation was serving the same purpose as the source text was serving. The translator followed the way as if they were writing the script in the native language.21 For evaluating the linguistic equivalence of two different language versions of a test is to administer the separate language versions to a group of test-takers who are fluent in both languages (bilinguals). The logic underlying this approach is that by using a single group of test-takers, "language group" effects are eliminated, and full scale equivalence can be achieved. Thus, observed differences in test or item performance across languages can be attributed to the linguistic differences between the tests or item. For the process of linguistic equivalence, a sample of 50 middle-aged, educated, menopausal women were enrolled from the community after due consent. For the purpose of reliability estimation of the Urdu version of MRS, another sample of respondents (10 participants or more per item of scale) was raised from different hospitals and community health centres of Lahore, Pakistan, through purposive sampling technique. Internal consistency was computed to assess the consistency of results across items within a test. There are several indices that can be used to measure the internal
consistency but the most popular index is Cronbach's alpha. Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy (KMO) and Bartlett's test of sphericity were used to i nvesti gate th e ad equac y of the sample size. Confirmatory factor analysis (CFA) was used to confirm if the structure model was adequate or not. CFA statistics was used by using AMOS-V22 to test the structured components of Urdu version of MRS. In CFA, the most suitable model fit indices include Root Mean Square Error
of Approximation (RMSEA) index of residual model fit and its value falls between 0 and 1, and the lowest value indicates better model fit. Comparative Fit Index (CFI) values close to 1 indicate better model fit. The reliability study comprised test-retest reliability. Estimate of internal consistency was obtained through Cronbach's alpha. For the interpretation of results, SPSS 21 was used. Pearson Product Moment Correlation and Cronbach's alpha were calculated for the presentation of
There were 130 women with a mean age of 50.94±4.71 years (range: 40-55 years). Linguistic equivalence was significantly high (p<0.01). High Cronbach's alpha value (p<0.001) indicated high internal consistency reliability (Table-1).
Exploratory factors analysis structured 3 original factors of the Urdu version of the scale and CFA value 0.965 indicated that the structured model was acceptable with good fit. Test re-test reliability was 0.991 (p<0.01) (Table-2).
KMO value of overall items of Urdu version of MRS was 0.868 (p<0.01), which indicated high sampling adequacy of the scale. Bartlett's test of sphericity showed the sample was suitable for factor analysis (p<0.001). The test-retest reliability estimate for the Urdu version of MRS (Annexure)
was 0.991 (p<0.01). Comparative Fit Index (CFI) was 0.965, the Normed Fit Index (NFI) was 0.894, Tucker Lewis Index (TLI) was 0.953, and the RMSEA was 0.057 (Table-3).
The present study examined the psychometric properties of the Urdu version of MRS in a representative sample of menopausal females. The translation from English to Urdu of MRS has proved to be a challenging and timeconsuming process.22 Our study supports the reliability and validity of MRS Urdu. The current study reported preliminary evidence for the reliability estimation of MRS Urdu in Pakistan. In the first phase of the study, forward and backward translation procedures were completed and there was a high positive strong correlation between
Urdu and English versions of MRS, indicating adequate cross-language validation. Similarly, there was a high positive correlation between Urdu and English items. In the second phase, scale reliability estimation was established. Cronbach's alpha was close to 1 which indicates high internal consistency. Moreover, exploratory factor analysis (EFA) structured the three original factors of somatic, psychological and urogenital. CFA findings reported structured model was adequate and showed good fit. MRS has been used world widely across different cultures. It has been used in different non-English-speaking countries and translated in German, English, Swedish, French, Mexican, Brazelian, Indonesian, Spanish and Turkish languages. Due to its vast utilisation, MRS was translated and adapted in Urdu language. The Urdu version of MRS is compatible with the original. MRS as a measure of health-related quality of life is considered helpful in measuring severity of menopausal symptoms. And it is
also convenient for the participants or the clients to comprehend and respond in a familiar language that is essential for the practitioners to understand the problems of the client. MRS is a brief scale and is convenient in terms of quick administration and scoring. Therefore, it can be used in a variety of settings, especially for the quick screening of the problems. Before handling such a target, it is important to consider
the time factor, and to assign continuous periods of time for the translation procedure. Another basic point is the onvenience of the expert board; the work asks for adequate, trustworthy relationship and coordinated effort. The psychometric properties of MRS Urdu were adequate. Scale linguistic equivalence indicated strong positive association between both versions. Further, scale reliability estimation was also found consistent and exploratory and confirmatory factor analysis showed the structured model as adequate and a good fit. CFI, NFI, TLI, and RMSEA values
also indicated that the translated version of MRS was a valid measure for Pakistani culture, with the structured model being a good fit.23
MRS Urdu scale can be used indigenously and Pakistani women would also have an opportunity to talk about their issues that arise during the transitional phase of
Conflict of Interest: None.
Source of Funding: None.
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