4. DISCUSSION
This study demonstrated that Tr-PedsQL™ 3.0 EoE Module had good
reliability and validity among teens and their parents with EoE. These
findings are in line with previous research on the psychometric
properties of the original version of the PedsQL™ EoE
Module.7 In our country, there is currently no valid
and reliable QoL scale related to EoE developed or adapted for children
in Turkish. Although the linguistic validation and cultural adaptation
of the PedsQL™ 3.0 EoE module have been published in Spanish, there have
been no validity and reliability studies in any other languages found
outside of our study.4
Franciosi et al. have developed a specific EoE scale to determine the
disease-related quality of life in children with EoE, consisting of a
patient version for different age groups in the pediatric population and
a parent proxy version.7, 9, 21 They reported the
reliability and validity of the PedsQL™ EoE Module in a USA pediatric
EoE population. Their results showed that the module demonstrated good
internal consistency, test-retest reliability, and construct validity,
similar to the findings of the Tr-PedsQL™ 3.0 EoE Module.
Scales, originally designed in their original language, can only be
applied to the populations they were designed for. Therefore, their use
in a different context requires linguistic validation and cross-cultural
adaptation to the country in which they will be applied, while
maintaining the original meaning and intent of the items.
In the symptom I domain, our patients and their parents don’t understand
”heartburn” (item 2) because it does not have a single-word equivalent
in Turkish. In Turkish, patients describe the sensation as ” Burning
sensation behind the breastbone or bitter and sour secretion flowing
back into their mouths,” which reminds the doctor of reflux, another
symptom. The researchers resolved this issue by consulting experts and
using a description that accurately conveyed the intended meaning in
Turkish. This is a crucial step in ensuring that the translated version
is comprehensible and relevant to the target population. Secondly,
during the linguistic validation process, it became apparent that some
items in the parent report version lacked verbs. This omission affected
the clarity and comprehensibility of these items for parents. To address
this issue, we added verbs to all the items that lacked them and then
parents were able to answer without any issues. After making these
adjustments, we did not encounter any issues with parents and teens
during the cognitive interviews stage, demonstrating the effectiveness
of the revisions in enhancing the scale’s usability.
Moderate agreements were found for Treatment, Worry, Communication, and
Food feelings dimensions of Tr-PedsQL™ 3.0 EoE Module between teens and
their parents. The study by Franciosi et al. (2013) also found moderate
agreement only for symptom I and poor agreement for treatment and
communication dimensions.7 The Treatment, Worry,
Communication, and Food feelings dimensions of PedsQL™ 3.0 EoE Module
are generally related to subjective experiences and individual
perceptions.22
The construct validity of the Tr-PedsQL™ 3.0 EoE Module, as shown by
significant correlations between its Symptoms Total, Symptoms I, and
Symptoms II scores with the Tr-PEESS v2.0 scores, provides evidence of
convergent validity. Convergent validity pertains to the degree to which
two measures that are supposed to assess the same construct are indeed
related to each other.23 Additionally, the absence or
weak correlation between the Communication and Food Feeling dimensions,
which are not present in the Tr-PEESS v2.0 but are included in the
Tr-PedsQL™ 3.0 EoE Module, supports the divergent validity.
The lowest scores were obtained from the Food and Eating dimension,
indicating that this dimension is the most problematic for both teens
and their parents. These findings are consistent with previous
studies7, 24, which have highlighted the impact of EoE
on food-related activities and quality of life. In Warners et al. study24, the authors discussed the challenges faced by
patients with EoE, particularly in terms of food avoidance and dietary
restrictions, and how these factors contribute to decreased quality of
life. Our results further emphasize the importance of addressing
food-related issues in the management and treatment of EoE to improve
patient outcomes and overall well-being.
There are some limitations in this study. It is performed in Turkish
children at a single center which may limit the generalizability of the
results. The number of participants in the study may seem limited, it
should be noted that our center is a reference hospital for EoE in
Turkey and has the highest number of cases. This study evaluates the
validity and reliability of the Turkish version of the PedsQL™ 3.0 EoE
Module. Therefore, we could not compare the our results with similar
studies conducted in other languages. Due to the absence of a Turkish
scale that assesses quality of life in EoE or a Turkish quality of life
scale that is similar to dimensions in the PedsQL™ 3.0 EoE module, only
the Tr-PEESS v2.0, which assesses symptoms, was used to test convergent
validity.