Turkish Version of Childhood Bladder and Bowel Dysfunction Questionnaire
Condition: Children
MeSH terms: Intestinal Diseases
Study type: Observational

Summary: 
      Objectives:The aim of this study was to translate the Childhood Bladder and Bowel Dysfunction
      Questionnaire into Turkish, adapt it for use with parents of 5-12 year old children and
      determine the reliability and construct validity of the Turkish version. The main hypothesis
      of our study was that it would be possible to translate and culturally adapt the CBBDQ into a
      Turkish version, so that Turkish parents could understand it. Additionally, we hypothesized
      that the Turkish version would provide adequate internal consistency and test-rest
      reliability and acceptable construct validity.

      Methods:The Childhood Bladder and Bowel Dysfunction Questionnaire was guideline driven
      translated into Turkish and administered twice, at 7-day intervals, to parents of children to
      assess test-retest reliability. Cronbach's α was used for internal consistency and the
      inter-rater correlation coefficient was used to calculate test-retest reliability. The
      Dysfunctional Voiding and Incontinence Scoring System (DVISS) and Pediatric Quality of Life
      Inventory (PedsQL) in 5-7, 8-12 years old children were used as an external criterion to
      estimate construct validity.
    

Detailed description: 
      The study was conducted as a questionnaire-based cross-sectional survey of parents of
      children (5-12y) with urinary incontinence, enuresis, constipation/fecal incontinence in two
      phases.

      Phase 1: Translation Process & Cultural Adaptation. The CBBDQ was translated into Turkish and
      culturally adapted in accordance with the stages recommended by Beaton.

      Phase 2: Field Testing Prior to inclusion, the parents completed an informed consent form,
      which had been approved by the ethical committee at Istanbul University (IRB study protocol:
      2017/487).

      Inclusion criteria were: 1) parents of children, aged between 5 to 12 years; 2) whose
      children suffered from urinary incontinence, enuresis nocturia, constipation/fecal
      incontinence; and 3) parents and children read and approved the informed consent form.
      Exclusion criteria were: 1) the presence of urinary tract infection; 2) patients having
      spinal cord injury or neurological disease; 3) not being able to communicate.

      The parents of children were asked to complete the Turkish version of the CBBDQ and the
      previously validated Turkish version of the DVISS and the Parent-Proxy-Report of the PedsQL
      (5-7, 8-12) (12, 13). The physiotherapist distributed the Turkish CBBDQ, the DVISS and the
      PedsQL (5-7, 8-12) to the parents in the waiting room after an interview with the
      psychiatrist. The parents were then asked to complete the Turkish-CBBDQ5-12y by telephone, 7
      days after their first assessment, to determine the test-retest reliability by the same
      physiotherapist. After parents completed the questionnaire, the physical therapists checked
      for missing responses. The parents who skipped a question on the questionnaire were asked to
      give the reason for this. Any difficulty in understanding the question or incompatibility
      with their problem was noted.

      Reported Outcome Measures The CBBDQ consists of two subscales: (1) the bladder symptoms scale
      (10 items) and (2) the bowel symptoms scale, including abdominal pain and bloated belly (8
      items). The parents were asked to indicate the presence of the symptoms applying the past
      months, using a 5-point Likert scale by checking a box labelled 0-4. '0' means no, '4' means
      almost every day or every day.

      The DVISS is a 14-item questionnaire originally designed in Turkish with the aim to diagnose
      patients with dysfunctional voiding. The DVISS includes 12 questions on bladder dysfunction,
      one on bowel dysfunctions and one on quality of life and has variable (Likert scales,
      dichotomous) answering options. The total score ranged from 0 to 35 points; sum scores higher
      from 9 points indicate increased disease severity.

      The PedsQL measurement model is a modular approach to assess health-related quality of life
      in healthy children and adolescents and those with acute and chronic health conditions. This
      scale was developed for children between 5-7 years of age and 8-12 years of age and their
      parents. In the 5-7-year age group, the questionnaire is filled in by the researcher with the
      help of a diagram that symbolizes facial expressions of the child like happy, neutral or sad.
      Unlike other age groups, the response scale of the child's form has three options. There is a
      parent and child form for the 8-12 age group. Scores of 23 items are scored in 3 areas.
      First, the total score of the scale is calculated as the sum of all the items over the items
      answered on all the scales. Second is the physical health total score, and third is the total
      score of psychosocial health which is calculated by evaluating sum of the item scores
      emotional, social and school functioning (14). The items are scored between 0-100 points. If
      the answer to the question is never it is marked as 0 = 100 points, rarely is marked as 1 =
      75, sometimes is marked as 2 = 50, frequently is marked as 3 = 25, and almost always is
      marked as 4 = 0. The points are divided into the total answer number of questions. If more
      than 50% of the questions are missing, the score cannot be evaluated. The higher the PedsQL
      total score, the better perceived health-related quality of life.

      Statistical Analysis All statistical analyses were performed with the Statistical Package for
      the Social Sciences (SPSS) 17.5 (SPSS Inc., Chicago, IL, USA). A P-value < 0.05 was
      considered to indicate statistical significance. We performed a power analysis to determine
      sample size at the beginning of the study. To achieve an Intraclass Correlation Coefficient
      (ICC) of at least 0.8 a sample size of 50 participants was needed. For the descriptive
      analyses, data are expressed as means and standard deviations for continuous variables or as
      frequencies and percentages for categorical variables and the dispersion/distribution
      (standard deviations, ranges) for continuous variables. The Kolmogorov - Smirnov test was
      used to assess the normality of the distribution of scores. Internal consistency, test-retest
      reliability, construct validity, and ceiling and floor effects were analyzed in this study.

      Reliability Reliability refers to the consistency of measurement and includes internal
      consistency as well as the test-retest reliability. A measure of the homogeneity of the
      questions within a questionnaire (internal consistency) was calculated by using coefficient
      of Cronbach's alpha. An α of 0.7 is considered fair, 0.8 is good, and 0.9 represents
      excellent internal consistency. In this study, baseline data were used to assess the internal
      consistency of the Turkish version of the-CBBDQ.

      The test-retest reliability represents a scale's effectiveness in producing consistent
      results when administered on different days when an individual's status has remained stable.
      The outcome measure was applied and then re-applied after 7 days. The results were then
      compared for agreement by means of an intra-class correlation coefficient (ICC), which was
      used to measure the test-retest reliability of the Turkish-CBBDQ5-12y. The ICC was also used
      to calculate standard error measurement (SEM), which is an index of measurement precision.
      The SEM is calculated as the standard deviation (SD) of the scores the square root of
      (1-ICC). The minimal detectable change (MDC) refers to the minimal amount of change within
      the measurement error. The SEM was used to determine the minimum detectable change at the 95%
      limit of confidence (MDC 95%) and was calculated as the SEM times 1.96 times the square root
      of 2.

      Construct Validity Validity refers to the degree to which a study accurately reflects or
      assesses the specific concept that the researcher is attempting to measure. In this study, we
      examined three aspects of validity: construct (convergent and divergent) validity. Evidence
      for construct validity of the Turkish version of the CBBDQ will be tested by determining its
      relationship with the Turkish version of DVISS and the PedsQL (5-7, 8-12). The DVISS was used
      to assess the convergent validity. Evidence for divergent validity was provided by
      determining the relationships with the PedsQL (5-7, 8-12). Spearman correlation coefficients
      and their 95% confidence intervals were calculated to assess construct validity. Correlation
      values are rated as: r ≥ 0.81-1.0 is excellent; 0.61-0.80, very good; 0.41-0.60, good;
      0.21-0.40, fair; and 0.00-0.20, poor).

      Distribution and Ceiling/Floor Effects Ceiling and floor effects of the Turkish-CBBDQ at the
      first and second tests were assessed by calculating the proportion of the patients scoring
      the maximum (72) or minimum (0) scores relative to the total number of patients. Descriptive
      statistics (number of percentage) were calculated to determine distribution and ceiling/floor
      effects, which were considered to be relevant if more than 30% of the subjects experienced
      them.
    

Intervention name(s): CBBDQ
Intervention type(s): Behavioral
Intervention description(s): a questionnaire for childood bladder and bowel dysfunctions
Observational model: Case-Only
Time perspective: Cross-Sectional
Sampling method: Probability Sample
Study population: 
        The study was conducted as a questionnaire-based cross-sectional survey of parents of
        children (5-12y) with urinary incontinence, enuresis, constipation/fecal incontinence.
      
Keywords: Childhood Bladder and Bowel Dysfunction Questionnaire; Reliability; Turkish