Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

NIHR Global Health Research Unit on Global Surgery, James Glasbey*

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

Abstract

Introduction
The Bluebelle Wound Healing Questionnaire is a universal reporter outcome measure developed in the UK for remote detection of surgical site infection (SSI) after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries (LMICs) and make recommendations for its adaptation.

Methods
This was a mixed-methods study within a trial (SWAT) embedded in an international randomised trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). First, structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale and conduct a translatability assessment. Second, translation was completed in accordance with Mapi recommendations into five languages. Next, data from a prospective cohort SWAT were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.

Results
In the qualitative phase, 10 structured interviews and 6 focus groups were performed with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval and judgment were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Due to the number of extreme (floor) values the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality indicating validity of the ordinal total WHQ score. There was significant overall model misfit, misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index (PSI) was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach’s alpha was high at 0.81. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ of items 1 (Redness), 3 (Clear fluid), 7 (Deep wound opening), 10 (Pain), 11 (Fever), 15 (Antibiotics), 16 (Debridement), 18 (Drainage), 19 (Reoperation). Changes to three item response categories (1 = Not at all, 2 = A little, 3 = A lot) were adopted for symptom items 1 to 10 and two categories (0 = No, 1 = Yes) for item 11 (Fever).

Conclusion
This study made recommendations for the cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed methods data from three continents. Translations are now available for implementation into remote wound assessment pathways.
Original languageEnglish
Article numberznad058
Pages (from-to)685–700
Number of pages16
JournalBritish Journal of Surgery
Volume110
Issue number6
Early online date3 Apr 2023
DOIs
Publication statusPublished - 1 Jun 2023

Bibliographical note

Funding Information:
TALON-1 was funded through a doctoral research fellowship from the National Institute for Health Research (NIHR) Academy (NIHR300175). The FALCON trial was funded by a NIHR Global Health Research Unit Grant (NIHR 16.136.79). The funder and sponsor had no role in study design or writing of this report. The funder has approved the submission of this report for publication. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the UK Department of Health and Social Care. Acknowledgements

Publisher Copyright:
© 2023 The Author(s). Published by Oxford University Press on behalf of BJS Society Ltd.

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