Translation and Validation of the Health-Related Quality of Life in Stroke Patients - 26 (HRQoLISP-26) Scale into Filipino for Filipino Adult Stroke Patients

Shanelle Katrina N. Tan, Portia Margarita D. Simsuangco, Fatima Mae S. Singson, Joselle T. Sinson, Celina Therese R. Solomon, Arnold Christopher P. Soriano, Stephen Lorenzo P. Sulay, Mikhael Thaddeus S. Supe, Rafael Alfonso S. Syfu, Althea Jannary C. Talens, Ian Cedric D. Tan, Jan Tyrone Cabrera, Wennielyn F. Fajilan, Elenita Mendoza, John Dale Trogo

Apr 2026 DOI 10.35460/2546-1621.2025-0112

Introduction

Globally, stroke is considered the second leading cause of death, accounting for about 11% of the total deaths in 2019.[1] In the 50–74 years and 75 years and older age groups in low-income and middle-income countries (LMICs), it is reported to be the second leading cause of disability-adjusted life-years worldwide in the same year.[2] In the Philippines, cardiovascular diseases, which include stroke, are the third leading causes of death in 2020 [3] and are reported to be part of the top five leading causes of disability in the said country.[4]

Aside from varying degrees of neurological disabilities as a result of stroke, survivors are reported to experience post-stroke emotional distress that is associated with poor medical adherence, slower recovery and higher mortality.[5] Hence, understanding the concept of quality of life (QoL) is considered crucial to better understand the patients’ respective dispositions so as to be able to improve symptom relief, care and their respective rehabilitations.[6] A more specific concept that primarily focuses on the clinical impact of disease and respective treatment to patients would be the health-related quality of life (HRQoL).[7] HRQoL is defined as the measure of value assigned to the duration of life that could be modified by impairments and functional states which can be influenced by disease, injury, treatment and policy. Its assessment is reported to be a predictor of treatment success and survival. Thus, it is of prognostic importance.[6]

The HRQoL in stroke patients (HRQoLISP) is a stroke-specific novel scale that is composed of 102 questions grouped into physical and spiritual spheres composed of seven domains. It has shown good face, content, known-groups and construct validity in addition to internal consistency and test-retest reliability.[8] However, due to the increased number of questions and consequently, long duration of administration, it is seldom used for routine clinical evaluation. Thus, a shortened version of the HRQoLISP-102 exists, the HRQoLISP-40, and an even shorter version, HRQoLISP-26, a comprehensive assessment composed of four domains, namely, physical, psycho-emotional, cognitive and eco-social. The cognitive domain comprises five items, while the physical, psycho-emotional and eco-social domains have seven items each.[9] According to Owolabi, a shortened version is important for routine assessment of HRQoL in patients with stroke, especially since it could be accomplished in a few minutes, thereby reducing respondent burden. At the same time, it should still be comprehensive and multidimensional enough to remove the need for supplementary questionnaires.[8]

The findings of the study by Owolabi show that HRQoLISP has good construct and known-groups validity as it could discriminate between the stroke groups and control groups among all domains, particularly the physical and eco-social domains.[8] HRQoLISP-26 also has good criterion validity. Its single-rater and test-retest kappa statistics were mostly excellent (>0.75) and the rest were good. The HRQoLISP-26 can be completed 20 minutes faster than the HRQoLISP-102, but it strikes a good balance between content validity and brevity as compared to Stroke Specific Quality of Life Scale 12 (SSQoL-12) and stroke impact scale 16 (SIS-16). Moreover, it has been tested and validated for use in Ibadan and is multiculturally valid.[9]

The studies by Mojica [10] and Abarico, et al. [11] utilize the approved Barthel index and SSQoL questionnaire, respectively. However, currently, limited data fail to point to a single specific assessment tool recommended for QoL of stroke patients in the Philippines. With the variety of questionnaires available, it may be necessary to translate them into Tagalog to ensure proper understanding and accuracy of patient responses, as well as proper management and improved outcomes. It would also be necessary to assess validity of the translated questionnaire for it to be established as a standard for assessing the QoL of stroke patients.

Based on a search of HERDIN Plus, ASEAN Citation Index, National Library of Medicine (NIH) and Google Scholar, as of 2022, the HRQoLISP-26 has not been translated nor validated in the Filipino language. Moreover, Owolabi reports that the HRQoLISP-26 questionnaire was tested for its psychometric properties in diverse cultural settings mainly in different parts of Africa and Europe, but no mention of that in Asia.[8] Cultural adaptation to Filipino will lead to a more accurate measure of HRQoL of the Filipino participants, which will improve research and clinical management of stroke patients. Thus, this study aims to translate the HRQoLISP-26 into Filipino and subsequently determine its content validity as a tool for adult Filipino stroke patients.

Methodology

STUDY DESIGN

This study used a quantitative psychometric study design to translate the HRQoLISP-26 questionnaire to Filipino and subsequently determine its validity. The original developers of the questionnaires gave permission to use their questionnaire for this study. The study received ethical approval from the University of Santo Tomas Hospital Research Ethics Board.

STUDY PROCEDURE

Translation of Questionnaire: The translation of the questionnaire was conducted in collaboration with the Sentro Sa Salin of the University of Santo Tomas. Sentro Sa Salin adheres to the ISO 17100:2015 Translation Quality Standard and uses the Translation, Review, Adjudication, Pretest, Document (TRAPD) method for the translation process (European Values Study, n.d.). The following translating procedures that were done by Sentro ng Salin are described as follows. Initially, the original HRQoL-26 questionnaire was translated into Filipino by a Filipino-speaking translator from the Sentro Sa Salin, who was proficient not only in Filipino but also in English. After translation, the translator evaluated the initial translated version of the questionnaire for any semantic, grammatical and spelling issues. Items with comments and recommendations from language and content experts were revised accordingly while items with no comments or recommendations had no revisions done. A second version was done for items with comments and recommendations for revision and subsequently re-evaluated by another language expert addressing why such changes were done. Subsequently, a third version was done to consolidate items with no revisions and items with revisions.

Then, the evaluated work was given to a panel of experts (an expert in the Filipino language with significant experience in translation and an expert in the medical field with adequate knowledge in the process of translation, equally fluent in English and Filipino that meets the inclusion criteria) who reviewed the first intermediary version to assess semantic accuracy, cultural relevance and representation. Reviews, modifications and revisions were done as necessary until a final translation was ready for content validity testing.

Content Validation: After the translated HRQoLISP-26 Filipino questionnaire had undergone final revisions, the expert committee members composed of a neurologist, a rehabilitation medicine doctor and a psychiatrist with at least one year of work experience and all fluent in both English and Filipino, assessed the clarity and representativeness of all aspects and characteristics of the original English construct in the translated Filipino questionnaire. The expert committee members independently rated each item in the questionnaire by relevance using a scale from 1-4: 1 for not relevant, 2 for somewhat relevant, 3 for quite relevant and 4 for highly relevant. Their ratings were then used to compute content validity index (CVI).

Item-level CVI (i-CVI) for each item was calculated. Scores of 3-4 were categorized as “relevant” and scores of 1-2 were categorized as “non-relevant”. i-CVI was calculated by dividing the number of agreements or number of “relevant” scores per item by three, which is the number of raters.

If the CVI is equal to 0.78 or greater, this indicates that the corresponding item exhibits good content validity and would no longer need revisions. However, if the CVI was less than 0.78, the item was modified accordingly.[12]

 

Figure 1: Flowchart of the study procedure

Figure 1: Flowchart of the study procedure

 

Scale level CVI (s-CVI) measures overall content validity of the questionnaire. It is computed through two parameters: sCVI/UA and sCVI/Ave. sCVI/UA represents the average i-CVI of all items as rated by content experts. sCVI/Ave is the percentage of items in the questionnaire that were categorized as “relevant” after being rated by content experts. Acceptable s-CVI/UA and s-CVI/Ave values are above the minimum score of 0.80 - 0.90.[12]

Aside from determining the CVI, a focus group discussion about the translated structured questionnaire was also conducted which included expert committee members and language experts.

Results

See Table 1 for results of the discussion between the language and content experts. Majority of the revisions were made in items 1 and 2 of the physical domain, items 8, 11 and 14 of the psycho-emotional domain and item 21 of the cognitive domain of the questionnaire. Item 1 of the physical domain and item 11 of the psycho-emotional domain were reworded for better contextual information. In item 8 of the psycho-social domain, changes were made to better translate the item for improved linguistic and cultural context. Item 2 of the physical domain was reworded for grammatical appropriateness, as well as items 14 and 21 were reworded for cultural appropriateness.

Refer to Table 2 for tabulated scoring of the rating of relevance per item done by each content expert. i-CVI for each item under the domains of “Kalagayang Pisikal”, “Kalagayang Sikolohikal at Emosyonal”, “Kalagyang Pagiisip” and “Kalagyang Pangkapaligiran at Panlipunan” was 1.0, which means that all items were relevant. In the study, s-CVI/Ave was 1.0 and s-CVI/UA was 1.0 as all items were rated as highly relevant by all three content experts.

 

Table 1: Language and Content Experts Recommendations 

Item 

Comments 

Translation of Physical Domain

Translation was reworded into a more appropriate one in terms of context. 

1 

Content expert recommends that “pananatili sa kama” as a translation of bed bound may be inaccurate and suggests to change it to “ nakaratay sa kama ” or “ Pananatili ”. Language expert suggested a different translation: “ Kadalian/hirap sa Pagkilos, nakahiga na lamang nakaupo na lamang Paglalakad na may Umaalalay, paglalakad na may pantulong na kagamitan, Nakapaglalakad mag-isa ”

Both comments were taken into consideration in the second version, however, were further revised according to the essence of the context. Furthermore, as there is a need to focus on the meaning of the item, the translation was made more direct and respective grammatical changes applied. 

Translation of Responses in the HRQoLISP-26

It was suggested by the language expert to change it to “Hindi naman Kaunti Katamtaman Sobra Sobra-sobra”

However, it was noted that it would be easier to understand “hinding-hindi” as a translation of “not-at-all”. Thus, this was further revised. 

2 

It was pointed out by the language expert that “carrying heavy objects” was lost in the translation.

This was addressed as a technical error when the translated version was copied to the first version. No relevant changes were made. 

3 

No revision done 

4 

There were no comments from the language and content experts.

In the second version, minor change was done wherein the “pisikal na sakit” was replaced with “sakit sa katawan” as the context of the item was about what the person’s overall body feels 

Translation of Responses in the HRQoLISP-26

No revisions done 

5-7 

Minor grammatical change was suggested by the language expert. However, this was further revised according to a more appropriate translation according to context.

This was the same for items 6 and 7 

Translation of Psycho-emotional Domain

Instead of the word “saklaw” for domain, “kalagayan” was suggested by the language expert. This was further revised by rearranging words to make it more appropriate.  

Translation of Responses in the HRQoLISP-26

There were no comments from the language and content experts.

It was then revised to simplify the translation further. 

8 

One content expert notes that it would be better to use “pagkabalisa” rather than “pag-aalala” for the translation of the word anxiety. Another content expert suggests to translate “how often” to “gaano ka kadalas” instead.

In the final version, anxiety remained as “pag-aalala.” 

9 

Minor grammatical change was suggested by the language expert and was subsequently revised. No further modifications done. 

10 

Content expert notes that “sinusubukan” might have been displaced in the sentence.

The statement was revised to be made more simple. 

11 

Language expert notes that “enjoyment sa trabaho” varies from satisfaction based on how the statement was framed.

This was then addressed to change the wording of “nasisiyahan”  to “kasaya” to take into consideration the context of enjoyment 

12 

No revisions done 

13 

No revisions done 

Translation of Responses in the HRQoLISP-26

No revisions done 

14 

Content expert notes that in this item, feelings are said in the context of emotion and that using “nararamdaman” as a direct translation might misconstrue it as a physical condition rather than emotional. Another content expert suggested that it would be better to translate “how satisfied” to “gaano ka nasisiyahan”

After revision, only “gaano ka nasisiyahan” was taken into consideration 

Translation of Cognitive Domain

There were no comments from the language and content experts.

It was then revised to simplify the translation. 

15 

It was suggested by the language expert to use “gaano ka nakakapokus” instead of “ kakayahang magpokus”

This recommendation was made and a minor grammatical revision was done. 

16 

One content expert suggested using a simpler translation of the question instead of the word “accessible”

The statement was revised to be more straightforward. 

17 

The language expert recommended using the term “gaano” to evaluate the respondent's communication ability, and suggested omitting the term “kaayos” as it was irrelevant to the assessment of communication skills.

This recommendation was done. 

18 

No revisions done 

19 

No revisions done 

20 

The language expert suggested a minor grammatical change, and it was subsequently revised. No further modifications were done. 

21 

One content expert suggested that "kadaming tao"  is more appropriate, while the language expert recommended using "kapwa"  for others in the initial revision.

The language expert suggested using “ibang tao” as a translation for others since “kapwa” conveys a deeper meaning. This recommendation was accepted. 

22 

The content expert commented that “how much” was not translated appropriately. It was suggested to use “gaano mapamahalaan”. This suggestion was followed. 

23 

Content experts suggested using a better translation for the word “accessible”. The language expert suggested using “madali” to measure accessibility, and it was accepted. Translation of transport facilities to “pasilidad para makabiyahe o mag-commute” was also implemented. 

24-27 

The content expert suggested using “gaano” to measure the degree of how satisfied the respondent is. This recommendation was accepted. Minor grammatical adjustments were also implemented.

This was the same for items 25 and 27 

 

Table 2: Summary of Content Validity Indices 

HRQOLISP-26: The Health-Related Quality of Life in Stroke Patients (HRQOLISP) Questionnaire  

KALAGAYANG PISIKAL  

Rater 1 

Rater 2 

Rater 3 

Number of Agreement  

I-CVI 
Item 1 

4 

4 

4 

3 

1 
Item 2 

4 

4 

4 

3 

1 
Item 3 

4 

4 

4 

3 

1 
Item 4 

4 

4 

4 

3 

1 
Item 5 

4 

4 

4 

3 

1 
Item 6 

4 

4 

4 

3 

1 
Item 7 

4 

4 

4 

3 

1 

KALAGAYANG SIKOLOHIKAL AT EMOSYONAL 

Rater 1 

Rater 2 

Rater 3 

Number of Agreement  

I-CVI 
Item 1 

4 

4 

4 

3 

1 
Item 2 

4 

4 

4 

3 

1 
Item 3 

4 

4 

4 

3 

1 
Item 4 

4 

4 

4 

3 

1 
Item 5 

4 

4 

4 

3 

1 
Item 6 

4 

4 

4 

3 

1 
Item 7 

4 

4 

4 

3 

1 

KALAGAYAN NG PAG-IISIP  

Rater 1 

Rater 2 

Rater 3 

Number of Agreement  

I-CVI 
Item 1 

4 

4 

4 

3 

1 
Item 2 

4 

4 

4 

3 

1 
Item 3 

4 

4 

4 

3 

1 
Item 4 

4 

4 

4 

3 

1 
Item 5 

4 

4 

4 

3 

1 

KALAGAYANG PANGKAPALIGIRAN AT PANLIPUNAN 

Rater 1 

Rater 2 

Rater 3 

Number of Agreement  

I-CVI 
Item 1 

4 

4 

4 

3 

1 
Item 2 

4 

4 

4 

3 

1 
Item 3 

4 

4 

4 

3 

1 
Item 4 

4 

4 

4 

3 

1 
Item 5 

4 

4 

4 

3 

1 
Item 6 

4 

4 

4 

3 

1 
Item 7 

4 

4 

4 

3 

1 
 
  S-CVI/Ave 

1 
Total Agreement 

26 
S-CVI/UA 

1 

 

 

Discussion

In this study, the HRQoLISP-26 was translated into the Filipino language by Sentro sa Salin of the University of Santo Tomas using the TRAPD method which involves forward translation of the questionnaire and review of the translated version by a panel of experts in the Filipino language and medical field to assess its semantic accuracy, cultural relevance and representation. Majority of the revisions made were done to improve the semantic and grammatical accuracy of items in the Filipino version of the HRQoLISP-26. Only a few items had no revisions implemented.

Significant changes to the HRQoLISP-26 were made during the translation process into Filipino to ensure conceptual clarity, cultural appropriateness and simplicity of comprehension for stroke patients in the Philippines. To fit terms more often used in everyday Filipino and clinical settings, phrases like "bed-bound" were altered from pananatili sa kama to nakaratay sa kama in the physical realm. Similarly, words like paglalakad na may umaalalay were used to improve descriptions of mobility limitations in order to better communicate the range of functional capacities. To better express emotional experiences, kalagayan was used in the psycho-emotional domain in contrast to abstract words like saklaw. After a critical review, emotional phrases like "enjoyment" and "anxiety" were changed from nasisiyahan to kasaya to better convey emotional satisfaction, while pagkabalisa was more appropriate for anxiety and pag-aalala was kept since it was more familiar.

Minimal changes improved contextual comprehension in the cognitive and social domains. By changing the term "kakayahang magpokus" to "gaano ka nakakapokus," the question became more precise and relatable. To make the item more understandable for the target population, terms like "accessible" were translated into simpler alternatives like madali, and "transport facilities" were changed to pasilidad para makabiyahe o mag-commute. Additionally, because of its deeper cultural meanings, ibang tao was used in place of the word kapwa to prevent misunderstandings. Response choices were modified throughout the tool, with "not at all" being translated as hinding-hindi to represent a more natural Filipino language. By making these specific changes, the HRQoLISP-26 will be both valid and understandable for adult stroke patients in the Philippines, demonstrating a dedication to language accuracy and cultural relevance. Refining the contextual and cultural accuracy of the translated questionnaire, which results in ease of test administration for Filipino stroke patients will also further support the objective of the original questionnaire, which is to have a version of the HRQoLISP that is shorter and suitable for regular assessment of all routinely crucial domains of HRQOL.[8]

Content validity of the translated questionnaire was then determined by computing for the i-CVI of each item. If the i-CVI is equal to 0.78 or greater, this would indicate that the corresponding item exhibits good content validity and would no longer need revisions. As shown in Table 2, each item had an i-CVI of 1, thus no further revisions were made in any item. The s-CVI which measures the overall content validity of the questionnaire was also computed through calculating the s-CVI/UA and s-CVI/Ave where an s-CVI/UA and s-CVI/Ave of 0.80-0.90 were considered acceptable. The translated questionnaire garnered a s-CVI/UA and s-CVI/Ave of 1, thus the overall content validity of the questionnaire was good.

However, the study had its limitations. The study focused on content validity through CVI and had not considered other important psychometric properties such as consistency, construct validity and criterion validity. Though these were not conducted in this study, the content validation method was rigorously done in this study, and future studies may opt to explore those other validity measures.

Our study was also unable to conduct pilot testing and cognitive interviews with the target respondents. This limited our study’s ability to assess how well stroke patients would have understood the questions and whether the language used was appropriate for their level of understanding. Despite this, we strongly feel that inclusion of all health care providers that deal with stroke patients was able to capture all relevant health-related aspects of the target respondents’ QoL, which may make up for this lack.

Lastly, although we collaborated with expert linguists who specialize in translation tasks, our study utilized only one language expert per phase, potentially limiting linguistic diversity. There is a possibility of translator bias or interpretative bias in how the final version was chosen, particularly when there were conflicting recommendations between experts and only some were incorporated. However, given the experience of the Sentro ng Salin experts, we expect this bias to be less than if we had employed linguists with lesser translation experience.

Conclusion

Using the TRAPD method, involving forward translation that was followed by review and revision by a panel of experts, we were able to create a culturally adapted version of the HRQoLISP-26 that shows strong overall agreement among health care experts. This translated version may already be used in clinics or research to quantify the QoL of stroke patients.

Conflicts of Interest

The research investigators declare that there are no conflicts of interest related to this study. No financial interests or affiliations with organizations that could potentially influence the interpretation or presentation of research findings exist. The authors did not receive any funding or support from organizations.

Acknowledgements

The members of the research team would like to extend their appreciation to the following people for their contribution: Dr. Maria Elizabeth Mercado, Dr. Jan Michael Lleva, Dr. Teresita Martinez and Dr. Jojo Evangelista. The team would also like to thank the author of the original questionnaire, Dr. Mayowa Ojo Owalabi. To the researchers’ friends and family, the researchers thank them for their support in the best way they could. Lastly, the researchers would like to thank God Almighty for their blessing and guidance for enduring the conduct of the study.

Author’s Contributions

1. Research Project: A. Conception, B. Organization

2. Statistical Analysis: A. Design, B. Execution, C. Review and Critique

3. Manuscript Preparation: A. Writing the First Draft, B. Review and Critique

4. Translation

Tan, Shanelle Katrina N: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Simsuangco, Portia Margarita D: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Singson, Fatima Mae S: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Sinson, Joselle T: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Solomon, Celina Therese R: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Soriano, Arnold Christopher P: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Sulay, Stephen Lorenzo P: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Supe, Mikhael Thaddeus S: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Syfu, Rafael Alfonso S: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Talens, Althea Jannary C: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Tan, Ian Cedric D: 1A, 1B, 2A, 2B, 2C, 3A, 3B

Jan Tyrone Cabrera, MD: 1A, 2C

Prof. Wennielyn F. Fajilan, PhD/UST SSAS: 2C, 4

Asst. Prof. John Dale Trogo, LPT, MA/UST SSAS: 4

Asst. Prof. Elenita Mendoza/UST SSAS: 2C

 

 

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