Cultural adaptation of the questionnaire on skin rejuvenation outcome evaluation (Skin Rejuvenation Outcome Evaluation - SROE)
Adaptação cultural do questionário de avaliação de resultados em rejuvenescimento de pele (Skin Rejuvenation Outcome Evaluation - SROE)

INTRODUCTION

The search for greater objectivity in evaluating treatment outcomes is necessary to improve evidence levels, especially in plastic surgery, whose major purpose is a subjective parameter, to enhance life quality (QOL)¹.

In the literature, it is clear that cosmetic procedures’ objective measurement mechanisms are still in their infancy. Anyway, they point to the trend of using patient reported outcome measures (PROM or PRO) through questionnaires, according to Morley 2012². Fortunately, there are already significant advances in this area, with the publication of several articles proposing questionnaire models⁴.

The Breast-Q, Face-Q, and Satisfaction with Facial Appearance Scale and Skindex tools, for example, have already undergone a rigorous validation process, are entirely in line with the acceptance requirements of the US Food and Drug Administration (FDA) and stand out, together with Skindex, in relation to the other PROMs, according to Morley 2012². Kosowski et al., in 2009⁴, found 442 articles evaluating outcomes in aesthetic, surgical or non-surgical procedures. Among these, 47 were specific to facial appearance, but only 9 met the study’s inclusion and exclusion criteria. None of them met all the guidelines. All tools proved to be limited, either due to their development, validation, or content. In that same study, Skin Rejuvenation Outcome Evaluation (SROE) and two other articles were specific for skin rejuvenation⁴.

The SROE (Figure 1) was described by Alsarraf, in 2000⁵, together with other questionnaires in English specific to blepharoplasty (Blepharoplasty Outcome Evaluation - BOE), rhinoplasty (Rhinoplasty Outcome Evaluation - ROE), and rhytidoplasty (Facelift Outcome Evaluation - FOE).

Figure 1 - Original SROE questionnaire in English. Source: Aesthetic Plast Surg. 2000;24(3):192-7.

Figure 1 - Original SROE questionnaire in English. Source: Aesthetic Plast Surg. 2000;24(3):192-7.

Such questionnaires address the physical, mental and social aspects, necessary for a fair assessment. The SROE questionnaire was tested concerning its validity, reliability, and responsiveness, being presented as a reliable quantitative tool for measuring outcomes^3,6,7.

The internationalization of these questionnaires, in turn, allows the comparison of treatment outcomes between different populations. However, some care must be taken so that there are no distortions due to flaws in the translation or cultural differences that alter the questions’ result. This would decrease the inter-population comparative value^8,9. Of the four questionnaires by Alsarraf (2000)⁵, only the ROE (Rhinoplasty Outcome Evaluation) and FOE (Facelift Outcome Evaluation) have been translated into Portuguese so far. The others, Blepharoplasty Outcome Evaluation (BOE) and Skin Rejuvenation Outcome Evaluation (SROE), do not have Portuguese versions yet^10,11.

The SROE consists of six questions, as shown in Figure 1. Each answer can be rated from 0 (least satisfied as possible) to 4 (most satisfied as possible). The marked values ​​must be added, divided by 24, and multiplied by 100, to obtain a score from 0 to 100, with 0 being the least satisfied possible and 100 the most satisfied⁵.

Such an instrument can be of great use for developing scientific studies and monitoring outcomes by surgeons and dermatologists. Thus, the present study’s objective is to translate and culturally adapt the SROE questionnaire to Brazilian Portuguese.

OBJECTIVE

Translate and culturally adapt the Skin Rejuvenation Outcome Evaluation (SROE) questionnaire to Brazilian Portuguese.

METHODS

The study was authorized by the Research Ethics Committee of the Universidade Federal do Ceará, under protocol number 33290513.8.0000.5589 and performed at the clinic Eduardo Furlani Cirurgia Plástica in 2019.

The SROE questionnaire was translated and culturally adapted to the Portuguese language of Brazil, according to the methodology proposed by Beaton et al. (2000)⁸, according to the flowchart in Figure 2. This methodology consists of five stages and is accepted in the literature for translation of several other instruments.

Figure 2 - Flowchart of the translation and cultural adaptation methodology proposed by Beaton el al. (2000)⁸

Figure 2 - Flowchart of the translation and cultural adaptation methodology proposed by Beaton el al. (2000)⁸

Translation

Stage 1: the questionnaire was submitted to two translations (T1 and T2) from English to Portuguese. One was performed by a lay translator and the other by a plastic surgeon translator, experienced in the procedure, as recommended by the literature.

Stage 2 (synthesis): the Portuguese versions T1 and T2 of the questionnaires were evaluated by both stage 1 translators. The translators discussed the differences between their versions and developed a consensual version, called T-12.

Stage 3 (reverse translation): the T-12 questionnaire was submitted to two lay translators (B1 and B2), unaware of each other or of the current study, whose native language was English.

Stage 4 (submission to a specialist committee): a medical board with knowledge in the area was requested to follow the process, evaluating the versions, pointing out inconsistencies and deviations. This board was composed of a dermatologist, a general surgeon, and an orthopedist.

There was pacification, through discussions, on four points:

Semantic equivalence: the translations were evaluated to preserve their meaning, for the possibility of multiple meanings, and the existence of grammatical difficulties.

Idiomatic equivalence: expressions or colloquialisms are difficult to translate. The committee sought the presence of these expressions and equivalents in the Portuguese language.

Experimental equivalence: the questioned experiences were evaluated for their existence in the Portuguese language.

Conceptual equivalence: expressions must contain the same concept. For example, when it comes to the family, in some cultures, it has the meaning of the nearest small family unit, and others include all relatives.

Cultural adaptation

Stage 5 (or pre-final version test): a pre-test with the final version T-12 was carried out with a sample of 20 people. This group was composed of graduate students of dermatofunctional physiotherapy. Each participant completed the questionnaire and was interviewed by the researcher to point out possible inconsistencies and difficulties in understanding.

Stage 6: submission of documentation to the expert committee to verify the translation process.

RESULTS

The SROE questionnaire was translated into versions T1 and T2; there were some divergence points between the two versions, but a consensus was reached on the T-12 version. This version was subjected to two reverse translations B1 and B2, which presented some divergences but without changing the original meaning.

Versions B1 and B2 were analyzed by the author of the original questionnaires, contacted by e-mail, who did not identify any change in meaning or inconsistency between the questionnaire translated from Portuguese into English and its original version.

There were no difficulties in completing and understanding the questionnaires.

The committee evaluated all steps of the translation process and contributed suggestions for changes, which were accepted. Consequently, the final result of the translation was as follows (Figure 3).

Figure 3 - SROE questionnaire translated by the authors.

Figure 3 - SROE questionnaire translated by the authors.

DISCUSSION

There were no significant difficulties in translating the questionnaires due to the small number of expressions with no known translation into Portuguese.

We believe that quality of life questionnaires are essential to make some subjective parameters more objective and comparable. This allows outcomes to be compared, providing better levels of evidence in an area of ​​knowledge that lacks it. However, there is still no perfect questionnaire.

The comparison of tools is outside the scope of this study. However, although the SROE questionnaire has shown its validity, reliability, and responsiveness statistically, its design does not seem to be as well-founded as that of Face-Q, which provides a significant interval level. This allows the construction of defined units with a uniform distance between them. For example, this means that if a person evolved from a score of 100 to 120, there was an increase similar to that of another who grew from 120 to 140, which is not true for most other instruments¹².

Unlike Face-Q, the SROE is a specific questionnaire for non-surgical, public, and freely available skin rejuvenation, facilitating its translation. Its application takes less than 1 minute. Other shortcomings of SROE are that there are still no cut-off points and normality levels, even in their original language, which we suggest for future studies.

CONCLUSION

Considering the applied methodology, we conclude that the SROE questionnaire’s translation is suitable for use in Brazilian Portuguese.