This Article Abstract Full Text (PDF) All Versions of this Article: 29/4/369    most recent Author Manuscript (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Serefoglu, E. C. Articles by Balbay, M. D. Search for Related Content PubMed PubMed Citation Articles by Serefoglu, E. C. Articles by Balbay, M. D.

Problems in Understanding the Turkish Translation of the International Index of Erectile Function

From the Department of Urology, Ankara Ataturk Teaching and Research Hospital, Ankara, Turkey.

Correspondence to: Dr Ege Can Serefoglu, Cinnah Caddesi No 47, Cankaya, Ankara Turkey (e-mail: ege123{at}yahoo.com).

Received for publication October 10, 2007; accepted for publication February 21, 2008.

	Abstract

Top Abstract Materials and Methods Results Discussion Conclusion References

 
The objective of our study is to analyze the impact of patient age, education level, and household income on the understanding of the International Index of Erectile Function (IIEF) and to determine the patient characteristics that make this questionnaire less reliable. All men older than 18 years presenting to our clinic were asked to complete the Turkish translation of IIEF upon arrival. Self-reported information related to age, education level, and household income of the patients was also recorded from the questionnaire. The patients were requested to complete the questionnaires once again during their second visit, which was not earlier than 5 hours and no later than 5 days. The patients were requested to complete the questionnaire by themselves; however, those who were unable to do so themselves were allowed to receive the assistance of their companions. The answers of the questions that were replied to properly were defined as "appropriate," and the unanswered questions or those replied to with more than one answer were defined as "inappropriate." A total of 430 patients were included in this study. Only 289 patients (67.2%) were able to respond to all of the questions properly at first visit. The percentage of improper completion increased as age increased, whereas it decreased parallel to the increase in educational level and household income (respectively, P = .027, P < .001, P = .008). Of 430 patients, 68.4% did not need any help from their companions, and the remaining 31.6% needed some assistance during the completion of the questionnaire. A total of 131 patients who completed the questionnaire at their initial admittance to our clinic came for their second visit. Only 61.8% of the patients were capable of completion both at first and second visits. There was a low degree of consistency among the first and second administrations of IIEF (k = 0.369, P < .001). Turkish translation of the IIEF needs further validations for the self-administered mode in order to improve its comprehension as well as its reliability, validity, and specificity, especially in older patients with lower educational levels and household income status, among whom the prevalence and the severity of erectile dysfunction is higher.

     Key words: Erectile dysfunction, reliability, questionnaire, validation

The objective of our study is to analyze the impact of patient age, education level, and household income on the comprehension of the IIEF and determine the patient characteristics that make this questionnaire less reliable.

	Materials and Methods

Top Abstract Materials and Methods Results Discussion Conclusion References

 
All procedures and methods of data collection were approved by the local ethics committee before commencement of the study. All men older than 18 years presenting to our clinic with various complaints from February 10, 2007, to February 27, 2007, were asked to complete a 3-page questionnaire, including Turkish versions of the IIEF and International Prostate Symptom Score (IPSS), on a consecutive basis upon arrival. Self-reported information related to age, education level, and household income of the patients was also recorded from the questionnaire. Criteria for inclusion of all patients were 1) a stable heterosexual partnership, and 2) at least 1 attempt of sexual intercourse over the last 4 weeks. The patients were requested to complete the questionnaires once again during their second visit, which was not earlier than 5 hours and not later than 5 days. The evaluation of IPSS will be presented in another article.

The patients were asked to complete the questionnaire by themselves; however, those who were unable to do so were allowed to receive assistance from their companions. During the orientation received by the patients about the questionnaire and the manner of completion before the initiation, it was emphasized that they were supposed to leave the questions unanswered in instances in which they did not understand them. No assisted guidance was provided by any medical staff, although it was asked for by some of the patients.

The answers to the questions that were replied to properly were defined as "appropriate," and the questions left unanswered or replied to with more than 1 answer were defined as "inappropriate."

Data analyses were carried out using the SPSS 15.0 statistical package software (SPSS Inc, Chicago, Illinois). The ² test was used to evaluate the relation between demographic characteristics (age group, education, income) of the patients and the frequency of giving appropriate answers. The ² test was also used to analyze the relation between the characteristics and the need for assistance. The agreement between the given answers at the first and second administrations was evaluated using value. The level of statistical significance was set at .05.

	Results

Top Abstract Materials and Methods Results Discussion Conclusion References

 
A total of 430 patients were included in this study. The median age of the group was 54 years (range, 18–7 years; mean, 51.24 years). Appropriate and inappropriate responding percentages are shown in Table 1. Only 289 patients (67.2%) were able to respond to all of the questions properly at the first visit. The 14th question of IIEF was the most improperly answered question, among others (21.4%). The relation between characteristics of patients and the frequency of giving inappropriate answers can be seen in Table 2. There were significant differences in proper completion of the test between patient groups. The percentage of improper completion increased as age increased, whereas it decreased parallel to the increase in educational level and household income (P = .027, P < .001, P = .008, respectively; Table 2).

Of 430 patients, 68.4% did not need any help from their companions, and the remaining 31.6% needed some assistance during the completion of the questionnaire. Presumably, the patients required their companions' assistance as their age increased and their educational level and/or household income status decreased (P < .001, P < .001, P = .001, respectively; Table 3).

A total of 131 patients who completed the questionnaire at their initial admittance to our clinic came for their second visit. The first and second results of those patients were evaluated (Table 4). Among this group, 11 patients (8.4%) who completed IIEF properly in their initial visit could not complete it at the second time, and only 61.8% of the patients were capable of completion both at first and second visits. There was a low degree of consistency among the first and second administrations of IIEF (k = 0.369; P < .001). The answers of the patients who came for their second visit showed statistically significant and high test-retest correlation (Table 5).

	Discussion

Top Abstract Materials and Methods Results Discussion Conclusion References

 
Although laboratory-based diagnostic procedures, such as cavernosometry, penile blood flow studies, and nocturnal penile tumescence and rigidity (NPTR) tests, are available, sexual questionnaires have gradually replaced them for evaluating ED today, with an underlying suspicion that subjective answers to questions about erectile function might not reflect actual physiologic capacity. Recently, the IIEF has become the most used and accepted questionnaire for the assessment of male sexual function, as it has been shown to be a cross-culturally and psychometrically valid measure of male ED (Rosen et al, 1997). Rosen et al (1997) have demonstrated a good overall reliability of the IIEF for the English version. As the study population in each country differs culturally and sociodemographically from each other, the original and translated versions would not be valid to use in different populations in different countries unless the scales or instruments are validated carefully.

To our knowledge, the Turkish translation of the IIEF was initially used by Akkus et al (2002) in a prevalence study for ED and has taken place in other studies since then (Tokatli et al, 2006). Although the questionnaire was administered by a physician trained in recruiting and interviewing techniques in their study, Akkus et al (2002) received 1982 usable data from the 2422 eligible men (81.83%), 2158 of whom completed the interview. As was indicated by the authors, the use of physician interviewers may have conferred an advantage over other methods of data collection, such as self-administration, because men might be more willing to discuss sensitive psychologic and sexual issues with a doctor. On the other hand, this method allowed patients to get additional assistance from the trained physician interviewers in case they could not understand or respond to any question. This may explain the different rates of proper completion of the IIEF between this study and ours, where only 67.2% of men were able to complete the test, and 31.6% of them needed the assistance of their companions, who were not physicians. Additionally, they demonstrated that the age-adjusted overall prevalence of ED in Turkey was 69.2% and increased from 49.9% in men aged 40 to 49 years to 94.7% in men aged 70 years and older, as well as the severity of ED. They recorded that sociodemographic variables, such as having no formal schooling and current unemployment, were positively associated with increased prevalence of ED (Akkus et al, 2002).

In another study, Tokatli et al (2006) compared the IIEF with an objective test, NPTR testing. Interestingly, they did not observe a clinical correlation between IIEF erectile function domain scores and NPTR parameters. There are 2 possible explanations for this situation: 1) the Turkish patients are not understanding the questions properly, or 2) IIEF erectile function domain scores are weakly associated in both English and Turkish versions. In a similar study, Melman et al (2006) got similar results and state that rigorous statistical methods using subjective data do not equate with the results obtained from objective testing. In order to clarify this conflict, more studies are required.

Although at least 80% of patients gave appropriate answers to each question (except Q14) in our study, only 67.2% of 430 patients were able to complete the questionnaire properly, and 31.6% of them required assistance from their companions (Tables 1 and 3). The ability of proper completion at both visits was 61.8% among 131 patients who were presented to our clinic for the second visit (Table 4). The older patients, the patients with lower educational levels and/or household income status were less likely to be able to complete the questionnaire properly (Table 2). These results should be considered because the prevalence and the severity of ED are higher among these people in Turkey (Akkus et al, 2002).

Despite the fact that the rate of giving appropriate answers to each question (almost 80%) and completion rate of whole test (67.2%) are mismatched, this in fact reflects the definition of "completion" of the whole test. When we looked into the questions one by one, we saw that many of the questions were checked properly, whereas some of the answers to questions were left blank. This is an example of an inappropriately filled out questionnaire, but also properly filled in questions on the same sheet.

Some people, especially elderly ones, come to see their physicians with the help of some other people, either another family member or a close friend. These patients needed assistance for different reasons, such as being illiterate, being physically incapable of filling out forms, or having visual problems. Since these companions are not just anybody but are somewhat close to our patients, it is not embarrassing for them to reveal and share their health or sexual problems with these people. These companions simply read questions to illiterate patients or to patients with physical incapabilities (ie, visual problems) and check the appropriate box according to patient's answers, instead of deciding what to be checked on behalf of the patients.

The low number of patients who came back for the second visit and completed the questionnaire again is a limitation of this study. However, when we looked into this second group, we noted that the characteristics of this group regarding age, education level, and household income level were similar to those of the initial group.

Interestingly, the 14th question was left unanswered by 22% of the patients in 18- to 27-year age group, whereas the other questions were answered with a high rate (Table 2). This may be due to the translation to Turkish of the word "partner," which means wife or husband. This might have resulted in confusion of these patients, the majority of whom are not married in this age group. In the group of patients who were older than 68 years, a similar situation was seen (41.4% rate of inappropriate answers to 14th question), and this may be explained with the absence of their wives. These findings suggest that a formal validation procedure with an extensive backward-forward translation enables Turkish IIEF to be more understandable.

One of the patients who successfully completed the questionnaire declared that he was illiterate and also stated that he did not require any assistance. We believe that this contradiction was due to mischecking of one of the answer boxes, either being illiterate or not needing assistance (Table 3).

The purpose of this study was not to look into the impact of factors such as translation problems or the bias coming from companions on the proper completion of the questionnaires. There is no way to infer whether the reasons for incompletion are due to these factors or not. This requires a separate study with 2 different translations and repeat evaluation with and without companions.

	Conclusion

Top Abstract Materials and Methods Results Discussion Conclusion References

 
IIEF is already widely used in the prevalence studies of ED. In addition, the questionnaire has not only been used to evaluate the degree of ED in individual patients, it has also been used as a tool for evaluating treatment outcome for ED, the latter function not originally intended for the instrument. Thus, questions remain about the reliability of such a subjective tool. Additionally, Turkish translation of the IIEF needs further validations for self-administered mode in order to improve its comprehension as well as its reliability, validity, and specificity, especially in older patients with lower educational level and household income status, among whom the prevalence and the severity of ED are higher. Laboratory-based objective diagnostic procedures, such as cavernosometry, penile blood flow studies, and NPTR testing, seem to be more reliable than questionnaires in this group of patients. Further studies are needed to determine whether physician administration instead of self-administration yields more reliable results in this group of patients.

	References

Top Abstract Materials and Methods Results Discussion Conclusion References

 
Akkus E, Kadioglu A, Esen A, Doran S, Ergen A, Anafarta K, Hattat H, Turkish Erectile Dysfunction Prevalence Study Group, Prevalence and correlates of erectile dysfunction in Turkey: A population-based study. Eur Urol. 2002;41: 298 –304.[CrossRef][Medline]

Brock GB, McMahon CG, Chen KK, Costigan T, Shen W, Watkins V, Anglin G, Whitaker S. Efficacy and safety of tadalafil for the treatment of erectile dysfunction: results of integrated analyses. J Urol. 2002;168: 1332 –1336.[CrossRef][Medline]

Hellstrom WJ, Gittelman M, Karlin G, Segerson T, Thibonnier M, Taylor T, Padma-Nathan H. Vardenafil for treatment of men with erectile dysfunction: efficacy and safety in a randomized, double-blind, placebo-controlled trial. J Androl. 2002; 23: 763 –771.[Free Full Text]

Melman A, Fogarty J, Hafron J. Can self-administered questionnaires supplant objective testing of erectile function? A comparison between the international index of erectile function and objective studies. Int J Impot Res. 2006;18: 126 –129.[CrossRef][Medline]

Padma-Nathan H, Steers WD, Wicker PA. Efficacy and safety of oral sildenafil in the treatment of erectile dysfunction: a double-blind, placebo-controlled study of 329 patients. Sildenafil study group. Int J Clin Pract. 1998; 52: 375 –379.[Medline]

Rosen RC, Riley A, Wagner G, Osterloh I, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997; 49: 822 –830.[CrossRef][Medline]

Tokatli Z, Akand M, Yaman O, Gulpinar O, Anafarta K. Comparison of international index of erectile function with nocturnal penile tumescence and rigidity testing in evaluation of erectile dysfunction. Int J Impot Res. 2006;18: 186 –189.[CrossRef][Medline]

This Article Abstract Full Text (PDF) All Versions of this Article: 29/4/369    most recent Author Manuscript (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Serefoglu, E. C. Articles by Balbay, M. D. Search for Related Content PubMed PubMed Citation Articles by Serefoglu, E. C. Articles by Balbay, M. D.