|Year : 2021 | Volume
| Issue : 1 | Page : 26-30
Validity and reliability of the arabic version of the wisconsin upper respiratory symptom survey (AWURSS-11)
Mohamed Farahat1, Tamer A Mesallam2, Abdullah A Alrasheed3, Khalid H Malki2
1 Department of Otolaryngology; Department of Otolaryngology, College of Medicine, King Saud University, Riyadh, Saudi Arabiaa, Saudi Arabia
2 Department of Otolaryngology; Department of Otolaryngology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||13-Aug-2020|
|Date of Decision||13-Sep-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||08-Mar-2021|
Prof. Khalid H Malki
Department of ENT, Communication and Swallowing Disorders Unit, King Abdulaziz University Hospital, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
Background: The Wisconsin Upper Respiratory Symptom Survey (WURSS) is a patient-oriented tool that has been developed to evaluate patient QOL in a disease-specific manner. Objectives: This study aimed to generate an Arabic purview of Wisconsin Upper Respiratory Symptom Survey WURSS-11 (AWURSS-11) and to assess its validity and reliability in normal subjects and common cold patients. Materials and Methods: This cross-sectional study has been carried out in King Abdulaziz University Hospital and Prince Sultan Medical Military City Riyadh, Saudi Arabia, between October 2017 and May 2018. The generated AWURSS-11 was administered to 197 patients with common cold and 67 asymptomatic participants. Cronbach's alpha tested the internal consistency of the AWURSS-11, while intraclass correlation coefficient was used to study test-retest reliability. The patients and control results were compared to test the clinical validity of the AWURSS-11. Results: AWURSS-11 showed good internal consistency (Cronbach's α = 0.896). Furthermore, good test-retest was found for the three domains and the total scores with significantly high intra-class correlation coefficient (ICC = 0.93). Significant difference was resulted between the AWURSS-11 score of the patients and the asymptomatic group (P = 0.0001). Conclusion: The results showed that the AWURSS-11 is a tool that is valid and reliable and can be even be used to assess common cold symptoms in patients who are Arabic speakers.
Keywords: Arabic version, AWURSS-11, common cold
|How to cite this article:|
Farahat M, Mesallam TA, Alrasheed AA, Malki KH. Validity and reliability of the arabic version of the wisconsin upper respiratory symptom survey (AWURSS-11). Saudi J Otorhinolaryngol Head Neck Surg 2021;23:26-30
|How to cite this URL:|
Farahat M, Mesallam TA, Alrasheed AA, Malki KH. Validity and reliability of the arabic version of the wisconsin upper respiratory symptom survey (AWURSS-11). Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Jun 25];23:26-30. Available from: https://www.sjohns.org/text.asp?2021/23/1/26/310987
| Introduction|| |
The common cold affects the upper respiratory tract (URT) through viral infections that may be caused by the multiple types of viruses.,, Although the patients are spontaneously recovered, their symptoms have a negative impact on their quality of life (QOL), which can lead to significant social and economic burdens due to its wide prevalence. Moreover, they can result in drawbacks, such as secondary bacterial infections, worsening of chest allergy, and chronic pulmonary disorders., Laboratory measures of URT infection (URTI) include viruses identification, quantitative viral titers, counts of white blood cells, measurements of mucus weight, and quantitative detection of cytokines.,,,
One of the important indicators of the effect of common cold management are the changes in symptoms. Quantitative measures of such changes are crucial to be developed and validated if they will be used as a clinical indicator for the common cold in clinical studies.
The Wisconsin Upper Respiratory Symptom Survey (WURSS) is a patient-oriented tool that was developed by Barrett et al. and evaluates patients' QOL in a disease-specific manner. This questionnaire aids studies of the common cold in terms of overall severity, self-perception of symptoms, functional QOL, and any changes that may happen and has been verified for its validity and reliability.
A short version of the WURSS, the WURSS-21, was developed and validated, has been extensively applied in the research related to common cold and respiratory,,,, and is accepted as a useful tool. The WURSS-21 was translated into the Korean language.
To minimize redundancy, the WURSS-21 was further reduced to a shorter version, which has three domains that each include three items: Nasal, throat, and QOL. The nine retained items showed the highest correlation with most of the original questionnaire items; therefore, they were selected to be included in the short version, as they may reasonably reflect their individual meanings. The introductory and concluding items were then added to the nine items that were retained to form the WURSS-11.
The developed WURSS-11 demonstrates satisfactory results with estimates of good reliability. Most importantly, it maintains and shows the same construct regarding the different dimensions as the parent WURSS-21. It has also been suggested that it retains content validity, with satisfactory construct validity.,, WURSS-11, being a short version with simple vocabulary, is more user-friendly than other tools evaluating common cold symptoms. Validity and reliability of this short version support its clinical use.
To the best of our knowledge, this is the first research study to validate an Arabic version for WURSS-11 tool in Saudi Arabia and other Arab countries. Thus, developing an Arabic version of the WURSS-11 that reflects Arab standards is important for the assessment of the severity of common cold symptoms in Arabic-speaking patients. Accordingly, the purpose of this study was to generate an Arabic version of the WURSS (AWURSS)-11 to assess its validity and reliability in patients with the common cold and healthy controls and if needed to perform some modification as regard to Arabic culture.
| Materials and Methods|| |
Development of the AWURSS-11
The study has been conducted according to the principles of Helsinki Declaration. The study has been initiated after having required approval of the institutional review board. The validation of the Arabic Wurss-11 has been done following the standard recommendations for cross-cultural adaptation.
- Two bilingual experienced physicians translated the original WURSS-11 into the Arabic language
- The items were translated back into English by a professional translator
- A professional translator compared the translated items with the original items
- The back-translation was then forwarded to be analyzed and for comments to be provided to the authors
- The developed AWURSS-11 was piloted with 10 Saudi subjects with the common cold diagnosed by an ear–nose–throat (ENT) specialist at an ENT ambulatory care clinic
- Based on the responses of the patients, the final Arabic AWURSS-11 was then developed.
One-hundred and ninety-seven adult patients who visited the ambulatory care clinic at King Abdulaziz University Hospital and Prince Sultan Medical Military Hospital, Riyadh, Saudi Arabia between October 2017 and May 2018 were diagnosed with a recent-onset (less than 48 h) common cold participated in the study after obtaining their consent. They included 94 (48%) men and 103 (52%) women with a mean age of 30.96 years (age range 19–58 years).
The inclusion criteria were a diagnosis of the “common cold” by ENT and family medicine specialists and onset of symptoms less than 48 h prior. The exclusion criteria were age below 18 years or above 60 years, allergic rhinitis, bronchial asthma, chronic obstructive pulmonary disease, sinusitis, nasal deformity, or otitis media.,,,
The control group comprised 67 adults who were recruited from clinical staff, individuals accompanying patients, or those attending the ambulatory care clinic for reasons other than the common cold. The control group's average age was 34.14 years (age range 18–60 years). Thirty-four of the participants in the control group (50%) were female and 33 (50%) were male. The participants in the control group did not have any history of suggestive or common cold symptoms in the last month.
Patients were instructed to complete the AWURSS-11 on the first evaluation. They were then called by telephone 4–6 h from their initial assessment to re-complete the AWURSS-11 for re-testing purposes. The patients were permitted to take their cold medicines during the study. It was estimated that a minimum of 107 patients should be enrolled in the study to ensure normality and to account for potential dropouts during the study period.
Validation, testing, and statistical assessment
Sample size calculation was made based on the required effect size of 0.5 that was based on similar studies. Using t-test with the level of significance of 0.05 and a power of study of 0.8. based on this calculation the required sample size was 128 (64 in each group). Content validity was used to judge the validity of AWRUSS-11. The items of the final Arabic version of the questionnaire were judged as being relevant to the study purpose by two independent ENT consultants. The questionnaire was then distributed to the common cold and control groups.
As reported in the original study of the WURSS-11 that the AWURSS introductory (”How sick do you feel today?”) and concluding (”Compared to yesterday.”) items measure different time frames and are usually analyzed separately, they were excluded from the analysis in this study. Thus, analysis of the responses was restricted to the nine retained items (WURSS-11).
Cronbach's alpha coefficient was used to assess the internal consistency of the AWURSS-11. Values >0.9 were considered excellent, whereas values >0.8 and 0.7 were considered as good and satisfactory, respectively. Mann-Whitney test was used to study the difference between the patients and controls regarding AWURSS-11 rating. Correlation between each domain score and its individual items, as well as between the each domain score and the total AWURSS-11 score, was studied using Spearman's rank correlation coefficient. The cumulative score of AWURSS-11 was calculated by simply summing the severity scores of the nine retained items. Intraclass correlation coefficient (ICC) for both the overall AWURSS-11 and different domain ratings evaluated how accurate is the test–retest. The SPSS software version 17 (SPSS Inc, Chicago, IL, USA) was used for statistical analysis of this study and significance level was set to <0.05.
| Results|| |
Ninety-four (48%) men and 103 (52%) women were included in the common cold group with a mean age of 30.96 years (age range of 19–58 years). The mean total score of the AWURSS-11 was 26.22 (8.95), with a possible score range of 0 to 63. The total AWURSS-11 score and 3 domains (nasal, throat, and QOL) are shown in [Table 1]. The mean total score of the AWURSS-11 in the asymptomatic group was 2.16 (4.03). Comparison between AWURSS-11 items and domains among the patients and the asymptomatic group is shown in [Table 2]; the results were significant.
|Table 1: Features of Arabic purview of Wisconsin Upper Respiratory Symptom Survey-11 domains distributions of the patient group (n=197)|
Click here to view
|Table 2: Comparison of Arabic purview of Wisconsin Upper Respiratory Symptom Survey-11 items, domains, and total between patient group (n=197) and the control group (n=67)|
Click here to view
Correlations between AWURSS-11 items and the total AWURSS-11 score and between the domains and the total score of the AWURSS-11 in the common cold group are presented in [Table 3] and [Table 4]. All AWURSS-11 items were significantly correlated with the total AWURSS-11 score, except for items 2 and 5 when correlated with the QOL domain and item 2 when correlated with the throat domain.
|Table 3: Correlation between Arabic purview of Wisconsin Upper Respiratory Symptom Survey 9-items and domains/total scores of the patient group (n=197)|
Click here to view
|Table 4: Correlation between Arabic purview of Wisconsin Upper Respiratory Symptom Survey 9-domains and total scores of the patient group (n=197)|
Click here to view
The overall internal consistency of the AWURSS-11 was good for the total score of the AWURSS-11 in the study group (α = 0.896). The test–retest reliability of the total scores and three domains of the AWURSS-11 showed high reliability based on ICC [Table 5].
|Table 5: Test re-test reliability for the three domains and the total scores of Arabic purview of Wisconsin Upper Respiratory Symptom Survey-11|
Click here to view
| Discussion|| |
Apart from evaluating the etiological agents of the common cold and laboratory measures for URTI, developing a QOL self-assessment tool is very important for patients to document their perception of common cold problems. The WURSS-11 was developed as a valid and reliable self-assessment tool for the common cold reported by patients. No translated version of WURSS-11 was found neither in the Arabic language nor in any other language. The aim of the current study was to develop an Arabic version of the WURSS-11 and to test its validity and reliability. The results of this study showed significant differences in the individual items, domain scores, and total scores of the AWURSS when comparing patients with the common cold and healthy controls. The AWURSS has good internal consistency and maintains its reliability and validity. This goes with the results of the original WURSS-11 edition.
The excellent correlation between the test and retest results shows that the AWURSS is strongly reproducible. Validity of the tool was emphasized by the strong internal consistency of the AWURSS items together with the highly significant correlation found among the items, three domains (nasal, throat, and QOL), and total score. This puts emphasis on that both the overall score and each element of the AWURSS are considered while evaluating patients with the common cold. There were two items that showed non-significant correlation with QOL domain: “plugged nose” and “throat itching.” This could be explained as this did not affect the patients' QOL, as their general status of feeling ill was not related to their plugged nose and itchy throat. They could think clearly during their day, and therefore, this did not affect their daily activities.
Although some studies have involved monitoring the effect of therapy on the common cold using the WURSS-21 and revealed significant improvements in participants' self-perception of common cold symptoms,,,,, we could not find studies using the WURSS-11 in the same context. We recommend using either the original WURSS-11 or AWURSS-11 in future research to monitor the effect of certain therapy methods on the symptoms of common cold.
| Conclusion|| |
As a self-assessment tool for patients with the common cold, the AWURSS-11 maintains its validity and reliability. It showed the results comparable to those of the original WURSS-11 version when patients with the common cold were significantly differentiated from healthy controls. The AWURSS-11 was demonstrated to be an easy tool available for physicians to evaluate the way patients with the common cold perceive their problems.
Limitations of the study
The present study did not include measuring the effect of certain therapy approaches for common cold on the self-perception of common cold symptoms among the patient group. Furthermore, and up to our knowledge, there is no other Arabic tool to measure the self-perception of common cold symptoms to compare with the developed AWURSS-11.
Further studies are needed to use the AWURSS-11 in clinical settings to study the self-perception of improvements in patients with the common cold as an indicator for the efficacy of different management approaches. No other common cold self-assessment questionnaire has been translated into the Arabic language to the best of our knowledge. In future, a study comparing the AWURSS to other QOL tools may be considered.
The authors are grateful to the Deanship of Scientific Research, King Saudi University for funding through Vice Deanship of Scientific Research Chairs. We would like to thank Editage (https://www.editage.com) for English language editing of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Monto AS. Epidemiology of viral respiratory infections. Am J Med 2002;112 Suppl 6A: 4S-12.
Williams JV, Harris PA, Tollefson SJ, Halburnt-Rush LL, Pingsterhaus JM, Edwards KM, et al
. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med 2004;350:443-50.
Gwaltney JM Jr. Virology and immunology of the common cold. Rhinology 1985;23:265-71.
Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Vital Health Stat 10 1998;199:1-428.
Heikkinen T, Järvinen A. The common cold. Lancet 2003;361:51-9.
Hurst JR, Donaldson GC, Wilkinson TM, Perera WR, Wedzicha JA. Epidemiological relationships between the common cold and exacerbation frequency in COPD. Eur Respir J 2005;26:846-52.
Gern JE, Vrtis R, Grindle KA, Swenson C, Busse WW. Relationship of upper and lower airway cytokines to outcome of experimental rhinovirus infection. Am J Respir Crit Care Med 2000;162:2226-31.
Cohen S, Doyle WJ, Skoner DP. Psychological stress, cytokine production, and severity of upper respiratory illness. Psychosom Med 1999;61:175-80.
Copenhaver CC, Gern JE, Li Z, Shult PA, Rosenthal LA, Mikus LD, et al
. Cytokine response patterns, exposure to viruses, and respiratory infections in the first year of life. Am J Respir Crit Care Med 2004;170:175-80.
Turner RB. The treatment of rhinovirus infections: Progress and potential. Antiviral Res 2001;49:1-4.
Yang SY, Byun JS, Hwang JH, An JJ, Hong KE, Kang W. Study of instruments for assessment and clinical research trends in common cold. J Korean Oriental Med 2008;29:165-81.
Barrett B, Locken K, Maberry R, Schwamman J, Brown R, Bobula J, et al
. The Wisconsin Upper Respiratory Symptom Survey (WURSS): A new research instrument for assessing the common cold. J Fam Pract 2002;51:265.
Barrett B, Brown R, Mundt M, Safdar N, Dye L, Maberry R, et al
. The Wisconsin Upper Respiratory Symptom Survey is responsive, reliable, and valid. J Clin Epidemiol 2005;58:609-17.
Barrett B, Brown RL, Mundt MP, Thomas GR, Barlow SK, Highstrom AD, et al
. Validation of a short form Wisconsin Upper Respiratory Symptom Survey (WURSS-21). Health Qual Life Outcomes 2009;7:76.
Walter MJ, Castro M, Kunselman SJ, Chinchilli VM, Reno M, Ramkumar TP, et al
. Predicting worsening asthma control following the common cold. Eur Respir J 2008;32:1548-54.
Barrett B, Brown R, Mundt M. Comparison of anchor-based and distributional approaches in estimating important difference in common cold. Qual Life Res 2008;17:75-85.
Barrett B, Rakel D, Chewning B, Marchand L, Rabago D, Brown R, et al
. Rationale and methods for a trial assessing placebo, echinacea, and doctor-patient interaction in the common cold. Explore (NY) 2007;3:561-72.
Brown RL, Obasi CN, Barrett B. Rasch analysis of the WURSS-21 dimensional validation and assessment of invariance. J Lung Pulm Respir Res 2016;3:46-53.
Yang SY, Kang W, Yeo Y, Park YC. Reliability and validity of Wisconsin Upper Respiratory Symptom Survey, Korean version. J Epidemiol 2011;21:313-8.
Obasi CN, Brown RL, Barrett BP. Item reduction of the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) leads to the WURSS-11. Qual Life Res 2014;23:1293-8.
Barrett B, Brown R, Voland R, Maberry R, Turner R. Relations among questionnaire and laboratory measures of rhinovirus infection. Eur Respir J 2006;28:358-63.
Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. J Eval Clin Pract 2011;17:268-74.
Hirose Y, Yamamoto Y, Yoshikai Y, Murosaki S. Oral intake of heat-killed Lactobacillus plantarum L-137 decreases the incidence of upper respiratory tract infection in healthy subjects with high levels of psychological stress. J Nutr Sci 2013;2:e39.
Duijker G, Bertsias A, Symvoulakis EK, Moschandreas J, Malliaraki N, Derdas SP, et al
. Reporting effectiveness of an extract of three traditional Cretan herbs on upper respiratory tract infection: Results from a double-blind randomized controlled trial. J Ethnopharmacol 2015;163:157-66.
Tiralongo E, Wee SS, Lea RA. Elderberry supplementation reduces cold duration and symptoms in air-travellers: A randomized, double-blind placebo-controlled clinical trial. Nutrients 2016;8:182.
Shimizu Y, Ito Y, Yui K, Egawa K, Orimo H. Intake of 25-hydroxyvitamin D3 reduces duration and severity of upper respiratory tract infection: A randomized, double-blind, placebo-controlled, parallel group comparison study. J Nutr Health Aging 2018;22:491-500.
Dharsono T, Rudnicka K, Wilhelm M, Schoen C. Effects of yeast (1,3)-(1,6)-beta-glucan on severity of upper respiratory tract infections: A double-blind, randomized, placebo-controlled study in healthy subjects. J Am Coll Nutr 2019;38:40-50.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]