Journal of General - Procedural Dermatology & Venereology Journal of General - Procedural Dermatology & Venereology Indonesia
Indonesia
Volume 4
Number 2 Vol. 4, No. 2 (June 2020) Article 2
6-30-2020
Validity and reliability of melasma quality of life scale Validity and reliability of melasma quality of life scale questionnaire in Bahasa Indonesia for female patients questionnaire in Bahasa Indonesia for female patients
Rubby Aditya
Department of Dermatology and Venereology Faculty of Medicine, Universitas Indonesia; Dr. Cipto Mangunkusumo General Hospital
Aida S. D. Hoemardani
Department of Dermatology and Venereology Faculty of Medicine, Universitas Indonesia; Dharmais National Cancer Hospital
Irma Bernadette
Department of Dermatology and Venereology Faculty of Medicine, Universitas Indonesia; Dr. Cipto Mangunkusumo General Hospital
Levina Chandra
Department Community Medicine, Faculty of Medicine Universitas Indonesia Rajesh Balkrisnan
Population Health and Prevention Research, University of Virginia School of Medicine Follow this and additional works at: https://scholarhub.ui.ac.id/jdvi
Part of the Dermatology Commons, Integumentary System Commons, and the Skin and Connective Tissue Diseases Commons
Recommended Citation Recommended Citation
Aditya, Rubby; Hoemardani, Aida S. D.; Bernadette, Irma; Chandra, Levina; and Balkrisnan, Rajesh (2020)
"Validity and reliability of melasma quality of life scale questionnaire in Bahasa Indonesia for female patients," Journal of General - Procedural Dermatology & Venereology Indonesia: Vol. 4: No. 2, Article 2.
DOI: 10.19100/jdvi.v4i2.170
Available at: https://scholarhub.ui.ac.id/jdvi/vol4/iss2/2
This Article is brought to you for free and open access by UI Scholars Hub. It has been accepted for inclusion in Journal of General - Procedural Dermatology & Venereology Indonesia by an authorized editor of UI Scholars Hub.
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 58 Original Article
Validity and reliability of Melasma Quality of Life Questionnaire in Indonesia Language for female patients
Rubby Aditya
1,2, Aida S. D. Hoemardani
1,3, Irma Bernadette
1,2, Levina Chandra
4, Rajesh Balkrisnan
51Department of Dermatology and Venereology Faculty of Medicine, Universitas Indonesia
2Dr. Cipto Mangunkusumo General Hospital
3Dharmais National Cancer Hospital
4Department Community Medicine, Faculty of Medicine Universitas Indonesia
5Population Health and Prevention Research, University of Virginia School of Medicine
E-mail: [email protected]
Abstract
Background: At present, there is no questionnaire in Bahasa Indonesia to assess the quality of life of female patients with melasma. The aim of this study is to adapt the existing English questionnaire, MELASQOL, into Bahasa Indonesia, and to assess its validity and reliability
.
Methods: This is a cross-sectional study consisting of two stages. The initial stage is cross-cultural and language adaptation. The final stage is the validity and reliability test. The original MELASQOL questionnaire is in English and is adapted into Bahasa Indonesia according to the cross-cultural and language adaptation guidelines. The subjects were recruited from two sites, The Cipto Mangunkusumo Hospital and a factory in Tangerang. A construct validity method was used for the validity analysis. Cronbach’s α was used for internal reliability analysis.
Results: The initial stage involved 30 subjects, and 32 subjects were involved with the final stage. The validity of The MELASQOL Bahasa Indonesia was calculated by the item-total score. The correlation coefficient is 0.712–0.935. Its reliability was calculated by the Cronbach α score is 0.962.
Conclusions: MELASQOL Bahasa Indonesia is a valid and reliable instrument for assessing the quality of life of female patients with melasma in Indonesia.
Keywords: MELASQOL, Bahasa Indonesia, quality of life, validity, reliability.
Background
The term, melasma, originates from the Greek word, melas, which means “black”1 Melasma is the localized, chronic, and acquired2 melanogenesis disorder of the skin, with predilection locations at the superior of the lips, at the nasal, chin, frontal, and cervical areas.3 Melasma could occur in all ethnicities and races, with a higher prevalence found on the skin of individuals belonging to races with highly pigmented skin. 4 The prevalence of melasma is
higher in females compared with males at a ratio of 21:1. Based on the studies in Singapore5 and Brazil 39:1.6 Epidemiologic data from the Outpatient clinic of Dermatology and Cosmetic at the Department of Dermatology and Venererology in Dr. Cipto Mangunkusumo (RSCM) Hospital, in Jakarta-Indonesia in the year 2011, stated that the number of melasma patients is 18.1% from a total of 3,763 patient visits, with the distribution of 98.4% female and 1.6% male patients.7
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 59 Cosmetic and psychological disorders are
commonly found in melasma patients. Thus, they negatively affect patients’ quality of life, emotional health, and social interactions. Patients tend to feel ashamed, have low self-confidence, feel unsatisfied and lack eagerness for outdoor activities. Suicidal ideation has even been reported.2
The measurement of a patient’s quality of life could be performed by a questionnaire, which could be generic or specific. A generic questionnaire is commonly used to evaluate the various kinds of diseases, including dermatology.
A specific questionnaire has been developed for a more specific disease, such as melasma. The use of the generic questionnaire in a specific population, such as patients with skin disorders, could reduce the capability of evaluation. In contrast, the use of a more specific questionnaire would be more sensitive for evaluation.8 Balkrishnan et al.9 in 2003 developed the MELASQOL (melasma quality of life scale), which was found to be reliable in measuring the quality of life of only female melasma patients. Based on the previous studies, to date, the MELASQOL is the only specific questionnaire to measure the quality of life of female melasma patients. The tool consists of 10 questions to measure the emotional, social life, and leisure and recreational time aspects. MELASQOL showed higher internal consistency and validity when compared with the generic questionnaire, Dermatology Life Quality Index (DLQI) and SKINDEX-16.9 MELASQOL has been translated from the English language and adapted into several languages, such as Spanish, Brazilian, Turkish, French, Indian Hindi, Iranian, Korean, and Arabian.
At present, there is not a valid and reliable questionnaire in Bahasa Indonesia to measure the quality of life, specifically of female melasma patients. The adaptation of one questionnaire into a different language is not a simple process due to the various standardized steps.10
The study will perform cross-cultural and language adaptation of MELASQOL from the English language into the Bahasa Indonesia and will investigate the validity and reliability of the questionnaire for the female melasma patients, thus achieving an objective tool to measure the subjective complaints of female melasma patients.
Methods
This study is a cross-sectional study. The study was conducted in the RSCM Jakarta and at a factory in Tangerang, from November to December 2017. The sampling technique was performed using the consecutive sampling technique. The initial stage of the study was the cross-cultural and language adaptation, and based on Guilleman et al.’s study, suggested 30–
40 samples for this phase.10 A total of 32 samples were recruited as the research subjects. The final phase was the investigation of the validity and reliability of the Bahasa Indonesia version of MELASQOL among 32 samples. It was not mandatory for the initial and final stage to have the same persons as subjects. Subjects at the initial stage could also be the subjects in the final stages. The study’s inclusion criteria were female, 18–55 years old, clinically diagnosed with melasma, literate in Bahasa Indonesia, and agreed to participate as a research subject by signing the informed consent letter of the study.
The exclusion criteria were postmenopausal females, pregnancy, and a history of labor within the preceding 12 months.
The initial stage of the study was the cross- cultural and language adaptation. The questionnaire translation process complied with the guidelines developed by Guillemin et al. in 1993.11 The study had been ethically approved according to the document published by The Standing Committee of Research Ethics of Faculty of Medicine, Universitas Indonesia under document number of 999/UN2.F1/ETIK/2017. The study was also ethically approved by the document published by The Standing Committee of Research Ethical Review of Cipto Mangunkusumo Hospital under the document number of LB.02.01/X.2/960/2017.
Forward translation
The translation process involved two professional translators of Indonesian nationality from two different backgrounds. The first was from medical, whereas the second was non-medical. Both translators spoke Bahasa Indonesia as their native language. The translator with the medical background received a detailed explanation of the aims of the translation process, whereas the other did not receive any explanation. This was to detect the presence of divergent interpretations
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 60 from the original questionnaire and to prevent
bias.10 After each translator finished translating, both translators then met to synthesize the translation results.
Comitee review
The synthesized results from both translators were then discussed in a committee, consisting of experts in methodology, dermatovenereology, and psychology. It also had translators and experts in Bahasa Indonesia. The committee reviewed the original questionnaire against the translated- synthesized results. The review results served as the basis for retranslating.
Backward translation
The committee’s review results were retranslated by two translators. Both were foreign translators who speak English as their native language, which is the language of the original MELASQOL.
Both did not have any medical backgrounds and were not informed on the purpose or the concept of the translation process. This was to evaluate whether the first translation into Bahasa Indonesia altered the meaning and purpose of the original questionnaire and to prevent bias.10
Review by the questionnaire’s author
Both translation results were reported to the questionnaire’s author to be reviewed to determine whether there were any alterations in the meaning and purpose of each original question within the questionnaire. Both retranslated documents were approved by Professor Rajesh Balkrishnan, Ph.D. as the questionnaire’s author.
Cognitive debriefing
In this phase, the subjects were interviewed to determine if each question and each answering instruction was understood and whether any questions needed to be modified regarding their structure or choice of words. Subjects were not assigned to answer the Bahasa Indonesian MELASQOL questionnaire (MELASQOL-INA).
The purpose of this stage was to determine the subject’s understanding and if any translational alternatives would enable a better understanding of the Indonesian culture.11 In this stage, 30 subjects participated. All subjects claimed to understand each question clearly, and the instructions for answering them. The results of cross-cultural and language results are displayed in Table 1.
Table 1. Results of MELASQOL English to Indonesian Language translation in the validity and reliability questionnaire test of MELASQOL-INA
No MELASQOL MELASQOL-INA
1 The appearance of your skin condition Penampilan kondisi kulit Anda 2 Frustration about your skin condition Frustrasi akan kondisi kulit Anda 3 Embarrassment about your skin condition Rasa malu akan kondisi kulit Anda 4 Feeling depressed about your skin condition Merasa depresi akan kondisi kulit Anda 5 The effects of your skin condition on your
interactions with other people (e.g., interactions with family, friends, close relationship, etc.)
Pengaruh kondisi kulit Anda terhadap hubungan Anda dengan orang lain (seperti hubungan dengan keluarga, teman-teman, kerabat dekat, dll.)
6 The effects of your skin condition on your desire to be with people
Pengaruh kondisi kulit Anda terhadap keinginan Anda untuk bergaul dengan orang lain
7 Your skin condition making it hard to show affection
Kondisi kulit Anda membuat Anda sulit untuk menunjukkan perhatian
8 Skin discoloration making you feel unattractive to others
Perubahan warna kulit membuat Anda merasa tidak menarik bagi orang lain
9
Skin discoloration making you feel less vital or productive
Perubahan warna kulit membuat Anda merasa kurang penting atau kurang produktif
10 Skin discoloration affecting your sense of freedom
Perubahan warna kulit memengaruhi rasa kebebasan Anda
MELASQOL-INA: melasma quality of life scale Indonesian Language
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 61
Validity and Reliability Tests
In this stage, 32 subjects participated with the demographic as shown in table 2. The first validity test performed was the content validity test.
Content validity is how relevant the elements within a measurement tool are in presenting the purpose of measurement. Content validity is the starting point of content evaluation of a method.
Content validity is a qualitative evaluation from a panel of experts.12
The content validity test began with the initial review of the committee. The committee consisted of multidisciplinary experts who produced a questionnaire that aimed to measure the quality of life of female patients with melasma in Indonesia.
The following validity test was performed was to construct the validity test. The test was performed through the calculation of Pearson’s moment, which was considered valid if the total score is
>0.3. In this study, the internal reliability test was performed through the calculation of the Cronbach score. The expected score is ≥0.5, and the Cronbach α > 0.9 is considered exceedingly good.12
Results
In the cognitive debriefing stage, 30 subjects participated, which consisted of 18 subjects from the factory in Tangerang, and 12 subjects who were visiting from the Dermatovenereology Policlinics at RSCM. The median age of subjects was 41 years old. As many as 23 subjects had a history of pregnancy, and seven subjects had none. Also, 60% of subjects had a family history of melasma.
In the final stage of the study, 32 subjects participated, which consisted of 15 subjects from the Dermatovenereology outpatient clinic at RSCM, and 17 subjects from the factory in Tangerang. The subjects’ characteristics in this stage were comparable to those in the initial stage and are displayed in Table 2. The construction validity test was performed by calculation of Pearson’s moment, which was considered valid if the correlation coefficient total score of >0.3.12 The correlation coefficient score for all questions on the MELASQOL-INA was >0.3 with the range of 0.712–0.935.
The reliability test of this questionnaire was represented by the value of the total Cronbach α of 0.962, which is displayed in Table 3. The value of Cronbach α for the emotional, social life, leisure time, and recreation were all >0.9. The results of the validity and reliability tests are displayed in Table 3.
Discussion
Melasma is a persistent hyperpigmentation disorder affecting many populations globally.13 Melasma often leads to psychological disorders that affect the quality of life.6 At present, there is no questionnaire to measure disruptions in the quality of life of patients with melasma in Indonesia.
Balkrishnan et al.9, in the year 2003, developed the MELASQOL, a questionnaire to measure the quality of life of female patients with melasma.
The questionnaire is distinct from other existing questionnaires of quality of life of patients with a skin disorder, such as the DLQI. In the DLQI, the measurement emphasizes the physical and psychological disruptions due to the presence of skin disease. This focus is not suitable for melasma as it does not produce any physical disruptions. Thus, the questionnaire is not sufficiently sensitive for measuring the quality of life of patients with melasma.14
The MELASQOL was developed in English and had been translated into various languages.14 For female patients with melasma in Indonesia to be able to utilize the questionnaire, it must be adapted into Bahasa Indonesia. The adaptation process was performed under the guidelines developed by Guillemin.11 In the cognitive debriefing stage, 30 subjects were recruited. They comprised 18 subjects from the factory in Tangerang, and 12 subjects treated at RSCM. In this stage, all subjects claimed to understand all the questions and answering instructions on the questionnaire. The median age of all subjects was 41 years old. All 23 subjects had a history of pregnancy, whereas seven subjects had none.
Also, 60% of subjects had a family history of melasma. This is in accordance with the report, suggesting that melasma was associated with a genetic factor.15
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 62 Table 2. Subjects’ demographic characteristics of validity and reliability tests of the MELASQOL-INA questionnaire
Characteristics Initial stage
n (%)
Final stage n (%)
Age [median (min–max)] 41 (27–49) 41 (27–49)
Location Factory RSCM
18 (35) 12 (65)
17 (53.13) 15 (46.87) Status
Unmarried Married
Had been married
2 (6.67) 27 (90) 1 (3.33)
2 (6.24) 29 (90.63)
1 (3.13) Education
Junior high school Senior high school Diploma
Bachelors
5 (16.67) 16 (53.33)
8 (26.67) 1 (3.33)
5 (15.63) 16 (50)
8 (25) 3 (9.37) Occupation
Private employee Factory laborer Others
5 (16.67) 18 (60) 7 (23.33)
9 (28.13) 17 (53.13)
6 (18.74) History of pregnancy
Yes No
23 (76.67) 7 (23.33)
25 (78.13) 7 (21.87) Family history of melasma
Yes No
18 (60) 12 (40)
21 (65.63) 11 (34.37) History of hormonal contraception
Yes No
20 (66.67) 10 (33.33)
23 (71.87) 9 (28.13) Sunlight exposure [mean (SD)] 1.367 (1.290) hours/day 1.14 (0.795) hours/day Duration of melasma [mean (SD)] 47 months (24.51) 46.69 months (27.42) RSCM: Dr. Cipto Mangunkusumo Hospital, SD: Standard Deviation, MELASQOL-INA: melasma quality of life in Indonesian Language, n(%) : numbers (percentage), min: minimum, max: maximum.
This idea of a genetic predisposition is in contrast to the study suggesting that exposure to sunlight as the main factor of melasma.15 This is due to the work regulation of working hours from morning to evening at the subject recruitment site. Another factor that may affect the low value of sunlight exposure could be memory bias. Society tends to perceive that sunlight exposure is considered when one is directly exposed to sunlight. The low value of the duration of sunlight exposure had also been reported in a study by Melyawati in 2014.7
The content validity test is a qualitative review by a panel of experts.12 The content validity test started when the review was performed by the committee during the initial stage. The committee consisted of multidisciplinary experts who
produced a questionnaire that aimed to measure the quality of life of female patients with melasma in Indonesia. The following stage was the cognitive debriefing process, which was to ensure that all subjects clearly understood the intention and purpose of every question and the instructions for answering them. All subjects claimed to clearly understand all the questions and instructions for answering them, thus showing that the MELASQOL-INA questionnaire had good validity.
The correlation coefficient obtained for all the questions on the MELASQOL-INA questionnaire is >0.3 with the range of 0.712–0.935. The adaptation process using the construct validity was also performed by Taleb et al.,16 who translated it into the Arabian language and.
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 63 Table 3. The correlation coefficient value of validity and reliability tests of the MELASQOL-INA questionnaire
Question Correlation total score
Q1 0.775
Q2 0.847
Q3 0.847
Q4 0.755
Cronbach α of emotional aspect (Q1-Q4) 0.928
Q5 0.869
Q6 0.935
Q7 0.863
Cronbach α of social life (Q5-Q7) 0.943
Q8 0.886
Q9 0.818
Q10 0.712
Cronbach α of leisure time and recreation (Q8-Q10) 0.93
Cronbach α total of 0.962. All questions are significant, with the p-value of <.001.
MELASQOL-INA: melasma quality of life scale questionnaire in Indonesian Language.
obtained the correlation of the coefficient of 0.314.
The MELASQOL-INA questionnaire is considered valid for measuring the quality of life of female patients with melasma in Indonesia
The reliability test resulted in a total Cronbach α value of 0.962. The Cronbach α value for emotional, social life, and leisure time and recreation are >0.9. Thus, every aspect measured by the questionnaire also has good reliability.
The Cronbach α value obtained is similar to those in the study by Cestari et al.17 in 2006 of 0.919 (adaptation to the Brazilian Portuguese language) and Misery et al.18 in 2010 of 0.95 (adaptation to French). The questionnaire utilized for the measurement of a population is expected to have a minimum reliability coefficient value of 0.7, whereas the individual measurement requires a minimum of 0.9.19 Our results showed that the MELASQOL-INA questionnaire (appendix 1) could be implemented in the routine outpatient clinic examination.
Conclusion
The MELASQOL-INA questionnaire is proven to be valid and reliable. It could be utilized as the objective tool for the measurement of the quality of life of female patients with melasma in Indonesia. The questionnaire is applicable for evaluating the effect of melasma on the quality of life, and to assess treatment in female patients with melasma in Indonesia.
Conflicts of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Acknowledgment
The authors thank The Dermatovenereology Department of FKUI-RSCM for approving the study and also to dr. Susana Santoso for allowing data collection at her company clinic site.
J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 64
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J Gen Proced Dermatol Venereol Indonesia. 2020;4(2):58-65 65
MELASQOL-INA
Berikan penilaian mengenai kondisi bercak kehitaman/ kecoklatan pada wajah Anda dengan melingkari angka 1-7. Nilai 1 (sama sekali tidak terganggu) hingga nilai 7 (terganggu sepanjang waktu).
1 2 3 4 5 6 7
No Pertanyaan Nilai 1-7
1 Penampilan kondisi kulit Anda 1 2 3 4 5 6 7
2 Frustasi akan kondisi kulit Anda 1 2 3 4 5 6 7 3 Rasa Malu akan kondisi kulit Anda 1 2 3 4 5 6 7 4 Merasa depresi akan kondisi kulit Anda 1 2 3 4 5 6 7
5
Pengaruh kondisi kulit Anda terhadap hubungan
Anda dengan orang lain (seperti hubungan dengan keluarga, teman-teman, kerabat dekat, dll)
1 2 3 4 5 6 7
6 Pengaruh kondisi kulit Anda terhadap keinginan Anda untuk bergaul dengan orang lain untuk bergaul dengan orang lain
1 2 3 4 5 6 7
7 Kondisi kulit Anda membuat Anda sulit untuk menunjukkan perhatian 1 2 3 4 5 6 7 8 Perubahan warna kulit membuat Anda merasa tidak menarik bagi orang lain 1 2 3 4 5 6 7 9 Perubahan warna kulit membuat Anda merasa kurang penting atau kurang
produktif
1 2 3 4 5 6 7
10 Perubahan warna kulit memengaruhi rasa kebebasan Anda 1 2 3 4 5 6 7
Total Appendix 1
Nama : Tanggal :
Sama sekali tidak terganggu
Terganggu sepanjang waktu
