TY - JOUR
AU - Thayal, Piyush K
AB - Abstract The American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire (BOQ) is burn-specific quality of life assessment questionnaire for children. In this study, we modified the questionnaire to suit the Indian population and also translated it to Hindi. Three questions were modified according to its Indian context. One new question was added to the “Transfers and mobility” domain; a new domain “Economic impact” with two questions was added to study the economic impact on families. Twenty-five patients of age 5 to 18 years were included in the study. The Indian adaptation of Burn Outcome Questionnaire—Hindi Version 5 to 18 years (I-BOQ-HV 5–18 years) was found to be feasible in the Indian population. The internal consistency of the modified scale was good with all except one domain with Cronbach’s alpha greater than 0.7. Test–retest reliability was done with intraclass correlation which was good, with values of greater than 0.7 for all domains. Pearson’s correlation coefficient showed good discriminant validity between the domains. Factor analysis using principle component analysis with orthogonal rotation resulted in 10 of the 12 components with good factor loadings. The I-BOQ-HV 5 to 18 years has been shown to reliably predict quality of life of children with burns in India. Burn injuries are a global health problem. Burn injuries that are not fatal are an important cause of morbidity. It is a preventable health problem that puts a great strain on the already scarce resources of a developing country like India. The incidence of burn injuries in India is estimated at 6 to 7 million per year.1 The exact epidemiological data of incidence, morbidity, and mortality for burn injuries is not known in India due to underreporting. Improvements made in supportive management of patients with burns including fluid resuscitation, infection control, and timely surgical intervention have led to decreased mortality from 51.8% to 40.20% over the years.2 This reduction in mortality has occurred despite the little change in the mean % TBSA burned over the years. Improvement in mortality rates has shifted the focus toward assessment of morbidity in terms of deficits in functionality. Quality of life (QoL) scales in adults have been translated and validated in many languages.3 However, in children, only few such QoL measures have been studied and validated. The most commonly used questionnaire in children is the American Burn Association/Shriners Hospitals Burn Outcomes Questionnaire (BOQ).4 With no standardized BOQ (5–18) available for Indian pediatric population, we developed Indian adaptation of Burn Outcomes Questionnaire—Hindi Version (I-BOQ-HV) for pediatric subgroup 5 to 18 years to assess functional, emotional, and economic impact on the victim and family. Thus prior to implementing the newly developed questionnaire, we proposed a pilot study to validate the I-BOQ-HV for 5 to 18 years. MATERIAL AND METHODS The study was conducted at the Department of Burns and Plastic Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi. Twenty-five pediatric burn patients aged 5 to 18 years presenting to our center between March 2019 and September 2019 were enrolled in the study after obtaining the institutional ethics committee approval. The inclusion criteria for enrollment included 1) patients aged between 5 and 18 years old, 2) burn survivors who had sustained burns of greater than 10% TBSA due to thermal, scalds, electrical, or chemical etiology, 3) burn patients 6 months postburn injury, and 4) after complete wound healing. The following patients were excluded: 1) psychiatric illness prior to burn injury, 2) burns that are suicidal in nature, 3) chronic illnesses that can be debilitating like end-stage renal disease and malignancies known to affect QoL of the individual, 4) patients who had sustained trauma prior to burn injury, 5) burn victims who had sustained associated injury along with burns, and 6) children with developmental disorders. Patients and their parents were interviewed in the out-patient department after obtaining due consent. An interview format was used by the author (P.K.A.) to administer the questionnaire. This approach was used as illiteracy is very common among patients presenting to our center. The questionnaire was administered a second time 1 week later to assess test–retest reliability. For children more than 11 years old, they were interviewed along with the parent and scoring done accordingly. This was done to reduce possible discordance due to interviewing only the parent. Modification, Adaptation, and Hindi Translation In accordance with the sociocultural relevance in the Indian subcontinent, relevant adaptations were incorporated into the BOQ 5 to 18 years. The original questionnaire described by Daltroy et al5 has 12 domains: upper extremity function, physical function and sports, transfers and mobility, pain, itch, appearance, compliance, satisfaction with current state, emotional health, family disruption, parental concern, and school reentry. Three questions were modified to fit the cultural practices of Indians. In the upper extremity function domain, “pour a half a gallon of milk” was changed to “a glass of milk” as gallon is not used as a measure in India, which follows the metric system similar to the one used in the work of Sveen et al.6 In the same domain, “use a fork or spoon” was changed to “use a spoon/hand to eat” as eating with the hands is a common practice in India. In the physical function and sports domain, “walk 3 blocks” was changed to “walk for half a kilometer” as “blocks” is not used as a standard in India. Three new questions were added. “Able to squat in an Indian toilet” was added to the transfers and mobility domain as the Indian toilet is uniquely different requiring one to squat rather than sit. A new domain “Economic impact” with two questions was added. The questions added were—“postburn, my family income has gone down” and “I have had to sell my savings for my child’s treatment” similar to the one done by Mulay et al7 in Burn-Specific Health Scale—revised brief and adapted. The Likert scale was modified for the economic impact domain. A score of 0 was given if there was greater than 75% loss of income or greater than 75% assets sold for the child’s treatment, a score of 1 if income loss or assets sold was between 50% and 75%, a score of 2 if income loss or assets sold was between 25% and 49% loss, a score of 3 if income loss or assets sold was less than 25%, and a score of 4 was given if there was no income loss or assets sold. As described in the original study by Daltroy et al,5 at least 50% of the items in each domain had to be answered for a mean to be calculated. Each subscale value was graded from 0 to 4 (Likert scale) and converted into a linear scale from 0 to 100. Except for domains of pain, itch, family disruption, and parental concern, higher scores indicated better outcome. The BOQ was then translated into Hindi as per standard guidelines (Supplementary file). The authors (P.K.A. and P.K.T.) made two independent forward translations of the questionnaire. Two language experts in Hindi and English made the reverse translations. The translations were discussed in depth in the departmental review meeting and approval obtained. Data Analysis Clinical and sociodemographic characteristics were recorded. Clinical characteristics included age, sex, etiology of burn, TBSA burned, site of burn (parts of body involved), duration of hospital stay, duration of ICU admission, postburn deformities, number of surgeries performed, place of living, socioeconomic status (by Modified Kuppusamy scale),8 type of family, number of school days lost, total expense in treatment, and time for completion of questionnaire. Descriptive data were described as mean and standard deviation for parametric data; nonparametric data were expressed as median and range. Reliability. Reliability of the scale was tested by Cronbach’s alpha which is a measure of internal consistency. It was calculated for each of the 13 domains. A value of greater than 0.7 is regarded as satisfactory. Test–retest reliability was calculated for each of the domains. Patients and their parents were again interviewed after 1 week and intraclass correlation coefficient was calculated. A value of greater than 0.75 is regarded as good reliability. Validity. Construct validity of the scale was tested using Pearson’s correlation coefficient taking into consideration discriminant validity. Furthermore, the discriminant validity was assessed by analyzing the domain scores with time since burn (≤ and >24 months, because the median time since burn injury was 24 months). Factor analysis. A factor analysis was done with all questions of the domains using principal component analysis with orthogonal rotation. Values greater than 0.5 were considered significant. All data analyses were done using SPSS v.23 software. OBSERVATIONS AND RESULTS The demographic representation of the subjects enrolled in the study has been tabulated in Table 1. Sixty percent of the enrolled subjects were females (n = 25). The mean age at the time of assessment was 12.6 ± 4.3 years. Seventy-two percent of the patients belonged to the lower socioeconomic status. The urban and rural dwellers were equal (44%), and 12% were from semi-urban areas. Seventy-two percent of the patients were from nuclear families. Table 1. Characteristics of children (5–18 years) included in the study Demographic Characteristics . n (%) . Number of patients 25 Mean age 12.60 ± 4.3 years Sex  Male 10 (40)  Female 15 (60) Place of living  Urban 11 (44)  Semi-urban 3 (12)  Rural 11 (44) Socioeconomic status  Upper 0 (0)  Upper middle 1 (4)  Lower middle 6 (24)  Upper lower 8 (32)  Lower 10 (40) Type of family  Nuclear 18 (72)  Joint 7 (28) Discontinued school 14 (55) Median number of school days lost 12 months (range 1–120 months) Median expense in treatment 50,000 INR (range 5000– 250,000 INR) Burn Characteristics n (%) Burn etiology  Flame 21 (84)  Electric contact 1 (4)  Electric flash 1 (4)  Scald 1 (4)  Chemical 1 (4)  Thermal contact 0 (0) Mean % TBSA 26.2 ± 10.23% Contracture 80% Site of burns  Hand 28%  Face 40% Median time since burn injury 24 months (range 6–120 months) Time to completion of questionnaire 23.36 ± 5.14 min Demographic Characteristics . n (%) . Number of patients 25 Mean age 12.60 ± 4.3 years Sex  Male 10 (40)  Female 15 (60) Place of living  Urban 11 (44)  Semi-urban 3 (12)  Rural 11 (44) Socioeconomic status  Upper 0 (0)  Upper middle 1 (4)  Lower middle 6 (24)  Upper lower 8 (32)  Lower 10 (40) Type of family  Nuclear 18 (72)  Joint 7 (28) Discontinued school 14 (55) Median number of school days lost 12 months (range 1–120 months) Median expense in treatment 50,000 INR (range 5000– 250,000 INR) Burn Characteristics n (%) Burn etiology  Flame 21 (84)  Electric contact 1 (4)  Electric flash 1 (4)  Scald 1 (4)  Chemical 1 (4)  Thermal contact 0 (0) Mean % TBSA 26.2 ± 10.23% Contracture 80% Site of burns  Hand 28%  Face 40% Median time since burn injury 24 months (range 6–120 months) Time to completion of questionnaire 23.36 ± 5.14 min Open in new tab Table 1. Characteristics of children (5–18 years) included in the study Demographic Characteristics . n (%) . Number of patients 25 Mean age 12.60 ± 4.3 years Sex  Male 10 (40)  Female 15 (60) Place of living  Urban 11 (44)  Semi-urban 3 (12)  Rural 11 (44) Socioeconomic status  Upper 0 (0)  Upper middle 1 (4)  Lower middle 6 (24)  Upper lower 8 (32)  Lower 10 (40) Type of family  Nuclear 18 (72)  Joint 7 (28) Discontinued school 14 (55) Median number of school days lost 12 months (range 1–120 months) Median expense in treatment 50,000 INR (range 5000– 250,000 INR) Burn Characteristics n (%) Burn etiology  Flame 21 (84)  Electric contact 1 (4)  Electric flash 1 (4)  Scald 1 (4)  Chemical 1 (4)  Thermal contact 0 (0) Mean % TBSA 26.2 ± 10.23% Contracture 80% Site of burns  Hand 28%  Face 40% Median time since burn injury 24 months (range 6–120 months) Time to completion of questionnaire 23.36 ± 5.14 min Demographic Characteristics . n (%) . Number of patients 25 Mean age 12.60 ± 4.3 years Sex  Male 10 (40)  Female 15 (60) Place of living  Urban 11 (44)  Semi-urban 3 (12)  Rural 11 (44) Socioeconomic status  Upper 0 (0)  Upper middle 1 (4)  Lower middle 6 (24)  Upper lower 8 (32)  Lower 10 (40) Type of family  Nuclear 18 (72)  Joint 7 (28) Discontinued school 14 (55) Median number of school days lost 12 months (range 1–120 months) Median expense in treatment 50,000 INR (range 5000– 250,000 INR) Burn Characteristics n (%) Burn etiology  Flame 21 (84)  Electric contact 1 (4)  Electric flash 1 (4)  Scald 1 (4)  Chemical 1 (4)  Thermal contact 0 (0) Mean % TBSA 26.2 ± 10.23% Contracture 80% Site of burns  Hand 28%  Face 40% Median time since burn injury 24 months (range 6–120 months) Time to completion of questionnaire 23.36 ± 5.14 min Open in new tab Flame burns represented 84% of the cases; electric contact, electric flash, scald, and chemical burn were 4% each. Mean age at the time of burn injury was 10 years. The mean TBSA burned was 26.20 ± 10.23%. Twenty-eight percent children had hand burns and 40% had face burns. Eighty percent of patients had contractures at the time of assessment. Eight of the 25 patients (32%) had undergone corrective procedures at the time of assessment. Eleven of them had contracture of a single body part while the rest had more than one. The most common contracture was of the neck (40%, n = 10) followed by axillary contracture (36%, n = 9). Five patients had contractures of the elbow and hand (20%). Two patients had contracture of the groin (8%). There was one patient each with contracture of the knee and ankle (4%). There were two patients with lip ectropion. Median time since burn injury at the time of interview was 24 months (range 6–120 months). The average time to completion of the questionnaire was 23.36 ± 5.14 minutes. Fifty-five percent of children had discontinuation of school, and the median number of school days lost was 12 months. Median expense incurred for treatment was 50,000 INR (range 5000–250,000 INR). BOQ Domain Scores Higher scores were obtained in domains of “Upper extremity function” (82 ± 20), “Physical function and sports” (86 ± 20), and “Transfers and mobility” (89 ± 17) with high ceiling effect scores. Lower scores were obtained for “Appearance” (47 ± 42), ”Itch” (46 ± 30), and “Parental concern” (57 ± 19). The domains “Family disruption,” “Parental concern,” and “School reentry” had the lowest ceiling effect. The new domain “Economic impact” that was added had a score of 63 ± 29 with a ceiling effect of 26%. The mean score of each domain has been summarized in Table 2 (Mean score per item is available as a supplementary file). Table 2. Score distribution of the domains of the I-BOQ-HV (5–18 years) Domain . Mean Score . Std Deviation . Ceiling Effect . Upper extremity function 82 20 65.14% Physical function and sports 86 20 71.33% Transfers and mobility 89 17 75.3% Pain 12 15 60.0% Itch 46 30 24.0% Appearance 47 42 47.0% Compliance 74 23 33.6% Satisfaction with current state 78 16 50.0% Emotional health 64 35 64.0% Family disruption 37 18 18.4% Parental concern 57 19 14.66% School reentry 64 20 9.33% Economic impact 63 29 26.0% Domain . Mean Score . Std Deviation . Ceiling Effect . Upper extremity function 82 20 65.14% Physical function and sports 86 20 71.33% Transfers and mobility 89 17 75.3% Pain 12 15 60.0% Itch 46 30 24.0% Appearance 47 42 47.0% Compliance 74 23 33.6% Satisfaction with current state 78 16 50.0% Emotional health 64 35 64.0% Family disruption 37 18 18.4% Parental concern 57 19 14.66% School reentry 64 20 9.33% Economic impact 63 29 26.0% Open in new tab Table 2. Score distribution of the domains of the I-BOQ-HV (5–18 years) Domain . Mean Score . Std Deviation . Ceiling Effect . Upper extremity function 82 20 65.14% Physical function and sports 86 20 71.33% Transfers and mobility 89 17 75.3% Pain 12 15 60.0% Itch 46 30 24.0% Appearance 47 42 47.0% Compliance 74 23 33.6% Satisfaction with current state 78 16 50.0% Emotional health 64 35 64.0% Family disruption 37 18 18.4% Parental concern 57 19 14.66% School reentry 64 20 9.33% Economic impact 63 29 26.0% Domain . Mean Score . Std Deviation . Ceiling Effect . Upper extremity function 82 20 65.14% Physical function and sports 86 20 71.33% Transfers and mobility 89 17 75.3% Pain 12 15 60.0% Itch 46 30 24.0% Appearance 47 42 47.0% Compliance 74 23 33.6% Satisfaction with current state 78 16 50.0% Emotional health 64 35 64.0% Family disruption 37 18 18.4% Parental concern 57 19 14.66% School reentry 64 20 9.33% Economic impact 63 29 26.0% Open in new tab Feasibility Not applicable responses ranged from 8% to 55%. Fifty-five percent of the children had discontinued school at the time of assessment and hence the domain “School reentry” could not be assessed for these children. There was an 8% missing response in the domain “Physical function and sports” as some of the children did not have a bicycle. In the “Compliance” domain, 14.4% not applicable response rate was obtained in view of the few children not treated with pressure garments. In the domain “Satisfaction with current state,” 9.3% not applicable responses were noted in subscale “ability to do schoolwork” as many children had not re-joined school. Reliability The internal consistency of the modified scale was measured with Cronbach’s alpha. The internal consistency of the BOQ scales was good. Scores ranged from 0.625 to 0.951. with the highest scores in “Compliance” (0.951), and the lowest score was observed in parental concern (0.625). Twelve of the 13 domains had values more than 0.7. Two of the 13 domains had excellent α value greater than 0.9 (Compliance and Itch) and 6 of 13 had α value greater than 0.8 (Upper extremity function, Physical function and sports, Pain, Appearance, Family disruption, and Economic impact). Only one domain, “Parental concern” had a low α value of 0.625. Mean interitem correlation between the variables were good except for “Satisfaction with current state” and “Emotional health” (0.356, 0.382; Table 3). Table 3. Reliability data for the I-BOQ-HV (5–18 years) Domain . Cronbach’s Alpha . Mean Interitem Correlation . Upper extremity function 0.802 0.411 Physical function and sports 0.893 0.586 Transfers and mobility 0.792 0.510 Pain 0.833 0.728 Itch 0.909 0.834 Appearance 0.892 0.672 Compliance 0.951 0.807 Satisfaction with current state 0.732 0.356 Emotional health 0.720 0.382 Family disruption 0.833 0.500 Parental concern 0.625 0.417 School reentry 0.743 0.503 Economic impact 0.832 0.744 Domain . Cronbach’s Alpha . Mean Interitem Correlation . Upper extremity function 0.802 0.411 Physical function and sports 0.893 0.586 Transfers and mobility 0.792 0.510 Pain 0.833 0.728 Itch 0.909 0.834 Appearance 0.892 0.672 Compliance 0.951 0.807 Satisfaction with current state 0.732 0.356 Emotional health 0.720 0.382 Family disruption 0.833 0.500 Parental concern 0.625 0.417 School reentry 0.743 0.503 Economic impact 0.832 0.744 Open in new tab Table 3. Reliability data for the I-BOQ-HV (5–18 years) Domain . Cronbach’s Alpha . Mean Interitem Correlation . Upper extremity function 0.802 0.411 Physical function and sports 0.893 0.586 Transfers and mobility 0.792 0.510 Pain 0.833 0.728 Itch 0.909 0.834 Appearance 0.892 0.672 Compliance 0.951 0.807 Satisfaction with current state 0.732 0.356 Emotional health 0.720 0.382 Family disruption 0.833 0.500 Parental concern 0.625 0.417 School reentry 0.743 0.503 Economic impact 0.832 0.744 Domain . Cronbach’s Alpha . Mean Interitem Correlation . Upper extremity function 0.802 0.411 Physical function and sports 0.893 0.586 Transfers and mobility 0.792 0.510 Pain 0.833 0.728 Itch 0.909 0.834 Appearance 0.892 0.672 Compliance 0.951 0.807 Satisfaction with current state 0.732 0.356 Emotional health 0.720 0.382 Family disruption 0.833 0.500 Parental concern 0.625 0.417 School reentry 0.743 0.503 Economic impact 0.832 0.744 Open in new tab Test–Retest Reliability It was measured by intraclass correlation which was high (0.708–0.960) for all 13 domains and significant with all values greater than .7 (P value <.001–.002; Table 4). Table 4. Intraclass correlation of all the domains of the I-BOQ-HV (5–18 years) Domain . Intraclass Correlation . . . ICC . P . Upper extremity function 0.960 <.001* Physical function and sports 0.924 <.001* Transfers and mobility 0.817 <.001* Pain 0.708 .002* Itch 0.896 <.001* Appearance 0.924 <.001* Compliance 0.845 <.001* Satisfaction with current state 0.859 <.001* Emotional health 0.802 <.001* Family disruption 0.855 <.001* Parental concern 0.850 <.001* School reentry 0.899 <.001* Economic impact 0.949 <.001* Domain . Intraclass Correlation . . . ICC . P . Upper extremity function 0.960 <.001* Physical function and sports 0.924 <.001* Transfers and mobility 0.817 <.001* Pain 0.708 .002* Itch 0.896 <.001* Appearance 0.924 <.001* Compliance 0.845 <.001* Satisfaction with current state 0.859 <.001* Emotional health 0.802 <.001* Family disruption 0.855 <.001* Parental concern 0.850 <.001* School reentry 0.899 <.001* Economic impact 0.949 <.001* *P value significant <.05. Open in new tab Table 4. Intraclass correlation of all the domains of the I-BOQ-HV (5–18 years) Domain . Intraclass Correlation . . . ICC . P . Upper extremity function 0.960 <.001* Physical function and sports 0.924 <.001* Transfers and mobility 0.817 <.001* Pain 0.708 .002* Itch 0.896 <.001* Appearance 0.924 <.001* Compliance 0.845 <.001* Satisfaction with current state 0.859 <.001* Emotional health 0.802 <.001* Family disruption 0.855 <.001* Parental concern 0.850 <.001* School reentry 0.899 <.001* Economic impact 0.949 <.001* Domain . Intraclass Correlation . . . ICC . P . Upper extremity function 0.960 <.001* Physical function and sports 0.924 <.001* Transfers and mobility 0.817 <.001* Pain 0.708 .002* Itch 0.896 <.001* Appearance 0.924 <.001* Compliance 0.845 <.001* Satisfaction with current state 0.859 <.001* Emotional health 0.802 <.001* Family disruption 0.855 <.001* Parental concern 0.850 <.001* School reentry 0.899 <.001* Economic impact 0.949 <.001* *P value significant <.05. Open in new tab Validity Correlation between the domains of BOQ 5 to 18 years was calculated using Pearson’s correlation coefficient (Table 5). Seventy of the 78 correlations were within values of −0.5 to +0.5. The direction of correlation was as expected. “Physical function and sports” correlated positively with “Transfers and mobility.” Better score in “Upper extremity function,” “Pain,” and “Itch” correlated with better “Satisfaction with current state.” “Transfers and mobility” correlated moderately with “Emotional health.” “Itch” and “Pain” scores correlated with “Parental concern” and inversely with “Satisfaction with current state.” “Parental concern” inversely correlated with “Satisfaction with current state.” “Family disruption” negatively correlated with “School reentry.” “Pain” and “Itch” correlated with each other. Table 5. Pearson’s correlation coefficients of all domains of the I-BOQ-HV (5–18 years) Domains . Upper extremity function . Physical function and sports . Transfers and mobility . Pain . Itch . Appearance . Compliance . Satisfaction with current state . Emotional health . Family disruption . Parental Concern . School Reentry . Economic impact . Upper extremity function 1 −0.103 −0.059 −0.104 −0.104 0.344 0.176 0.516* 0.154 −0.161 −0.064 0.583 0.120 Physical function and sports 1 0.852* −0.039 0.021 −0.182 0.313 0.272 0.362 0.029 0.040 0.250 −0.081 Transfers and mobility 1 −0.087 −0.030 −0.235 0.145 0.364 0.427† −0.238 −0.047 0.280 −0.211 Pain 1 0.406† −0.224 0.130 −0.399† −0.084 0.239 0.665* −0.013 −0.177 Itch 1 −0.257 0.138 −0.603* −0.230 0.227 0.562* −0.300 −0.254 Appearance 1 0.327 0.395 0.269 −0.198 −0.351 0.715† 0.116 Compliance 1 0.178 0.337 0.145 0.008 0.248 0.025 Satisfaction with current state 1 0.480† −0.390 −0.593* 0.501 0.076 Emotional health 1 −0.339 −0.331 0.313 0.031 Family disruption 1 0.203 −0.624† 0.003 Parental concern 1 −0.124 −0.190 School reentry 1 0.487 Economic impact 1 Domains . Upper extremity function . Physical function and sports . Transfers and mobility . Pain . Itch . Appearance . Compliance . Satisfaction with current state . Emotional health . Family disruption . Parental Concern . School Reentry . Economic impact . Upper extremity function 1 −0.103 −0.059 −0.104 −0.104 0.344 0.176 0.516* 0.154 −0.161 −0.064 0.583 0.120 Physical function and sports 1 0.852* −0.039 0.021 −0.182 0.313 0.272 0.362 0.029 0.040 0.250 −0.081 Transfers and mobility 1 −0.087 −0.030 −0.235 0.145 0.364 0.427† −0.238 −0.047 0.280 −0.211 Pain 1 0.406† −0.224 0.130 −0.399† −0.084 0.239 0.665* −0.013 −0.177 Itch 1 −0.257 0.138 −0.603* −0.230 0.227 0.562* −0.300 −0.254 Appearance 1 0.327 0.395 0.269 −0.198 −0.351 0.715† 0.116 Compliance 1 0.178 0.337 0.145 0.008 0.248 0.025 Satisfaction with current state 1 0.480† −0.390 −0.593* 0.501 0.076 Emotional health 1 −0.339 −0.331 0.313 0.031 Family disruption 1 0.203 −0.624† 0.003 Parental concern 1 −0.124 −0.190 School reentry 1 0.487 Economic impact 1 *Correlation is significant at the 0.01 level (2-tailed). †Correlation is significant at the 0.05 level (2-tailed). Open in new tab Table 5. Pearson’s correlation coefficients of all domains of the I-BOQ-HV (5–18 years) Domains . Upper extremity function . Physical function and sports . Transfers and mobility . Pain . Itch . Appearance . Compliance . Satisfaction with current state . Emotional health . Family disruption . Parental Concern . School Reentry . Economic impact . Upper extremity function 1 −0.103 −0.059 −0.104 −0.104 0.344 0.176 0.516* 0.154 −0.161 −0.064 0.583 0.120 Physical function and sports 1 0.852* −0.039 0.021 −0.182 0.313 0.272 0.362 0.029 0.040 0.250 −0.081 Transfers and mobility 1 −0.087 −0.030 −0.235 0.145 0.364 0.427† −0.238 −0.047 0.280 −0.211 Pain 1 0.406† −0.224 0.130 −0.399† −0.084 0.239 0.665* −0.013 −0.177 Itch 1 −0.257 0.138 −0.603* −0.230 0.227 0.562* −0.300 −0.254 Appearance 1 0.327 0.395 0.269 −0.198 −0.351 0.715† 0.116 Compliance 1 0.178 0.337 0.145 0.008 0.248 0.025 Satisfaction with current state 1 0.480† −0.390 −0.593* 0.501 0.076 Emotional health 1 −0.339 −0.331 0.313 0.031 Family disruption 1 0.203 −0.624† 0.003 Parental concern 1 −0.124 −0.190 School reentry 1 0.487 Economic impact 1 Domains . Upper extremity function . Physical function and sports . Transfers and mobility . Pain . Itch . Appearance . Compliance . Satisfaction with current state . Emotional health . Family disruption . Parental Concern . School Reentry . Economic impact . Upper extremity function 1 −0.103 −0.059 −0.104 −0.104 0.344 0.176 0.516* 0.154 −0.161 −0.064 0.583 0.120 Physical function and sports 1 0.852* −0.039 0.021 −0.182 0.313 0.272 0.362 0.029 0.040 0.250 −0.081 Transfers and mobility 1 −0.087 −0.030 −0.235 0.145 0.364 0.427† −0.238 −0.047 0.280 −0.211 Pain 1 0.406† −0.224 0.130 −0.399† −0.084 0.239 0.665* −0.013 −0.177 Itch 1 −0.257 0.138 −0.603* −0.230 0.227 0.562* −0.300 −0.254 Appearance 1 0.327 0.395 0.269 −0.198 −0.351 0.715† 0.116 Compliance 1 0.178 0.337 0.145 0.008 0.248 0.025 Satisfaction with current state 1 0.480† −0.390 −0.593* 0.501 0.076 Emotional health 1 −0.339 −0.331 0.313 0.031 Family disruption 1 0.203 −0.624† 0.003 Parental concern 1 −0.124 −0.190 School reentry 1 0.487 Economic impact 1 *Correlation is significant at the 0.01 level (2-tailed). †Correlation is significant at the 0.05 level (2-tailed). Open in new tab We tested the ability of I-BOQ-HV to discriminate between the subgroups of pediatric burn patients presenting before or after a period of 24 months since burn injury. Children presenting more than 24 months since burn had significantly better scores in the domains “Transfers and mobility,” “Pain,” “Satisfaction with current state,” and “Parental concern” (Table 6). Table 6. Mean scores of I-BOQ-HV for children presenting ≤24 months or >24 months after burn injury Time Since Burn . ≤24 Months (n = 14) . . >24 Months (n = 11) . . P . . Mean . Std. Deviation . Mean . Std. Deviation . . Upper extremity function 3.19 .809 3.39 .826 .558 Physical function and sports 3.16 .975 3.80 .305 .050 Transfers and mobility 3.25 .818 3.92 .156 .013 Pain .71 .611 .18 .462 .025 Itch 1.96 1.134 1.73 1.367 .640 Appearance .43 .454 .52 .410 .597 Compliance 2.78 1.059 3.20 .633 .257 Satisfaction with current state 2.86 .605 3.44 .561 .022 Emotional health .59 .362 .70 .350 .431 Family disruption 1.51 .687 1.44 .758 .790 Parental concern 2.57 .685 1.88 .734 .023 School reentry 2.44 .192 2.58 .939 .811 Economic impact 2.68 1.234 2.32 1.102 .456 Time Since Burn . ≤24 Months (n = 14) . . >24 Months (n = 11) . . P . . Mean . Std. Deviation . Mean . Std. Deviation . . Upper extremity function 3.19 .809 3.39 .826 .558 Physical function and sports 3.16 .975 3.80 .305 .050 Transfers and mobility 3.25 .818 3.92 .156 .013 Pain .71 .611 .18 .462 .025 Itch 1.96 1.134 1.73 1.367 .640 Appearance .43 .454 .52 .410 .597 Compliance 2.78 1.059 3.20 .633 .257 Satisfaction with current state 2.86 .605 3.44 .561 .022 Emotional health .59 .362 .70 .350 .431 Family disruption 1.51 .687 1.44 .758 .790 Parental concern 2.57 .685 1.88 .734 .023 School reentry 2.44 .192 2.58 .939 .811 Economic impact 2.68 1.234 2.32 1.102 .456 Bold values are statistically significant (P < 0.05). Open in new tab Table 6. Mean scores of I-BOQ-HV for children presenting ≤24 months or >24 months after burn injury Time Since Burn . ≤24 Months (n = 14) . . >24 Months (n = 11) . . P . . Mean . Std. Deviation . Mean . Std. Deviation . . Upper extremity function 3.19 .809 3.39 .826 .558 Physical function and sports 3.16 .975 3.80 .305 .050 Transfers and mobility 3.25 .818 3.92 .156 .013 Pain .71 .611 .18 .462 .025 Itch 1.96 1.134 1.73 1.367 .640 Appearance .43 .454 .52 .410 .597 Compliance 2.78 1.059 3.20 .633 .257 Satisfaction with current state 2.86 .605 3.44 .561 .022 Emotional health .59 .362 .70 .350 .431 Family disruption 1.51 .687 1.44 .758 .790 Parental concern 2.57 .685 1.88 .734 .023 School reentry 2.44 .192 2.58 .939 .811 Economic impact 2.68 1.234 2.32 1.102 .456 Time Since Burn . ≤24 Months (n = 14) . . >24 Months (n = 11) . . P . . Mean . Std. Deviation . Mean . Std. Deviation . . Upper extremity function 3.19 .809 3.39 .826 .558 Physical function and sports 3.16 .975 3.80 .305 .050 Transfers and mobility 3.25 .818 3.92 .156 .013 Pain .71 .611 .18 .462 .025 Itch 1.96 1.134 1.73 1.367 .640 Appearance .43 .454 .52 .410 .597 Compliance 2.78 1.059 3.20 .633 .257 Satisfaction with current state 2.86 .605 3.44 .561 .022 Emotional health .59 .362 .70 .350 .431 Family disruption 1.51 .687 1.44 .758 .790 Parental concern 2.57 .685 1.88 .734 .023 School reentry 2.44 .192 2.58 .939 .811 Economic impact 2.68 1.234 2.32 1.102 .456 Bold values are statistically significant (P < 0.05). Open in new tab Factor Analysis Factor analysis with principle component analysis was done (Table 7). Two questions in the domain “Physical function and sports,” one question in each of the domains “Transfers and mobility,” “Compliance,” and “Satisfaction with current state,” and questions of the domain “School reentry” were not included in the analysis due to their “not applicable responses.” Twelve components were extracted after applying orthogonal rotation with good factor loadings, values greater than 0.5 were taken as significant and the results are summarized in Table 7. Ten of the 12 components had good factor loadings. In two domains “Satisfaction with current state” and “Parental concern,” the factors did not cluster together. Table 7. Component matrix after factor analysis of the I-BOQ-HV (5–18 years; using principal component analysis with orthogonal rotation)* Domains . . Component . . . . . . . . . . . . . . 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . Physical function and sports q8 0.800 q9 0.953 q11 0.932 q13 0.833 Transfers and mobility q14 0.806 q15 0.751 q16 0.613 q17 0.921 q19 0.887 Upper extremity function q1 0.906 q2 0.567 q3 0.504 q4 0.863 q5 0.766 q6 0.744 q7 0.804 Family disruption q43 0.622 q44 0.824 q45 0.871 q46 0.510 −0.588 q47 0.820 Pain q20 0.892 q21 0.856 Appearance q24 0.739 q25 0.844 q26 0.870 q27 0.676 Compliance q28 0.633 q29 0.746 q30 0.913 q32 0.873 Itch q22 0.917 q23 0.895 Emotional health q39 q40 q41 0.684 q42 0.822 Satisfaction with current state q33 −0.835 q34 −0.926 q35 −0.580 q36 q38 0.532 Economic impact q54 0.943 q55 0.855 Parental concern q48 0.592 q49 0.726 q50 0.506 Domains . . Component . . . . . . . . . . . . . . 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . Physical function and sports q8 0.800 q9 0.953 q11 0.932 q13 0.833 Transfers and mobility q14 0.806 q15 0.751 q16 0.613 q17 0.921 q19 0.887 Upper extremity function q1 0.906 q2 0.567 q3 0.504 q4 0.863 q5 0.766 q6 0.744 q7 0.804 Family disruption q43 0.622 q44 0.824 q45 0.871 q46 0.510 −0.588 q47 0.820 Pain q20 0.892 q21 0.856 Appearance q24 0.739 q25 0.844 q26 0.870 q27 0.676 Compliance q28 0.633 q29 0.746 q30 0.913 q32 0.873 Itch q22 0.917 q23 0.895 Emotional health q39 q40 q41 0.684 q42 0.822 Satisfaction with current state q33 −0.835 q34 −0.926 q35 −0.580 q36 q38 0.532 Economic impact q54 0.943 q55 0.855 Parental concern q48 0.592 q49 0.726 q50 0.506 *The questions 10, 12, 18, 31, and 37 and questions of the domain “School reentry” were not included in the analysis due to their “not applicable responses.” Open in new tab Table 7. Component matrix after factor analysis of the I-BOQ-HV (5–18 years; using principal component analysis with orthogonal rotation)* Domains . . Component . . . . . . . . . . . . . . 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . Physical function and sports q8 0.800 q9 0.953 q11 0.932 q13 0.833 Transfers and mobility q14 0.806 q15 0.751 q16 0.613 q17 0.921 q19 0.887 Upper extremity function q1 0.906 q2 0.567 q3 0.504 q4 0.863 q5 0.766 q6 0.744 q7 0.804 Family disruption q43 0.622 q44 0.824 q45 0.871 q46 0.510 −0.588 q47 0.820 Pain q20 0.892 q21 0.856 Appearance q24 0.739 q25 0.844 q26 0.870 q27 0.676 Compliance q28 0.633 q29 0.746 q30 0.913 q32 0.873 Itch q22 0.917 q23 0.895 Emotional health q39 q40 q41 0.684 q42 0.822 Satisfaction with current state q33 −0.835 q34 −0.926 q35 −0.580 q36 q38 0.532 Economic impact q54 0.943 q55 0.855 Parental concern q48 0.592 q49 0.726 q50 0.506 Domains . . Component . . . . . . . . . . . . . . 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . 9 . 10 . 11 . 12 . Physical function and sports q8 0.800 q9 0.953 q11 0.932 q13 0.833 Transfers and mobility q14 0.806 q15 0.751 q16 0.613 q17 0.921 q19 0.887 Upper extremity function q1 0.906 q2 0.567 q3 0.504 q4 0.863 q5 0.766 q6 0.744 q7 0.804 Family disruption q43 0.622 q44 0.824 q45 0.871 q46 0.510 −0.588 q47 0.820 Pain q20 0.892 q21 0.856 Appearance q24 0.739 q25 0.844 q26 0.870 q27 0.676 Compliance q28 0.633 q29 0.746 q30 0.913 q32 0.873 Itch q22 0.917 q23 0.895 Emotional health q39 q40 q41 0.684 q42 0.822 Satisfaction with current state q33 −0.835 q34 −0.926 q35 −0.580 q36 q38 0.532 Economic impact q54 0.943 q55 0.855 Parental concern q48 0.592 q49 0.726 q50 0.506 *The questions 10, 12, 18, 31, and 37 and questions of the domain “School reentry” were not included in the analysis due to their “not applicable responses.” Open in new tab Discussion Pediatric burn survivors pose a special challenge in assessing the impact of burns, with relatively fewer reported studies which focus on QoL. In 2000, Daltroy et al5 developed a standardized questionnaire to assess the QoL among the pediatric burn patients and thus a separate questionnaire for age 0 to 5 years and 5 to 18 years was framed. Translations of this BOQ for 5 to 18 years old have been done in Swedish and Dutch languages.6,9 The original Swedish and Dutch versions have shown good reliability and validity and internal consistency. We used this questionnaire and modified it to suit the Indian socioeconomic culture. This Indian Adaptation of BOQ (5–18) was then translated into Hindi language and labeled as I-BOQ-HV 5 to 18 years. Parents generally are able to assess physical aspects of QoL of children when compared with emotional aspects.10 In a study with the PedsQL questionnaire in children, feasibility of administering the questionnaire to children as young as 5 years was demonstrated.11 Daltroy et al5 administered questionnaires to both parents and children aged 11 to 18 years. They found good correlation on most domains between the two scores. In our study, parents were interviewed. In age group 11 to 18 years, children were interviewed along with parents. There is a possibility of some degree of discordance especially in emotional domains. A burn injury to the child will require a prolonged period of treatment which is a financial challenge for the parents as the majority of them are from a low socioeconomic background (72% in this study). In this context, a new domain studying the economic impact of burn was added. The average cost for treatment incurred by the parents was 50,000 INR (~650 USD). This in turn adversely affects the family financially, which causes a delay in further treatment such as corrective surgeries for postburn deformities, and this can affect the child’s QoL. The score in the economic domain was a mean of 63 ± 29 with a low ceiling effect of 26% showing the relevance of adding this new domain. A similar finding was observed in the study by Mulay et al7 in adult burn patients showing the financial burden on Indian patients. The uniqueness of our questionnaire is the addition of economic impact on the family in addition to the physical, functional, and mental aspect of the victim per se. This economic impact on the family of pediatric burn survivor was not considered in the standard BOQ or any of its modification. Not applicable responses were most in the “School reentry” domain. Fifty-five percent of the children had not re-joined school at the time of the assessment. Similar missing responses in School reentry domain were reported in the Swedish version of BOQ by Sveen et al6 and can be attributed to the cross-sectional nature of the questionnaire. The other domains had lower numbers of not applicable responses (8–14.4%). There was an 8% missing response in the domain “Physical function and sports” as some of the children did not have a bicycle owing to their economic status and so the subscale “Ride bicycle” was not applicable. In the “Compliance” domain, there was a 14.4% not applicable response to the subscale “wearing pressure garments” as some of the children were not treated with pressure garments. This can probably be attributed to the fact that these patients did not get primary treatment from a burn center and presented to our center due to burn complications. In the domain “Satisfaction with current state,” 9.3% not applicable responses were noted in subscale “ability to do schoolwork” as many children had not re-joined school. Apart from these, the parents had no trouble comprehending the questions or grading the child’s outcomes indicating good feasibility. The average time to complete the questionnaire was 23.36 ± 5.14 minutes. This was longer than that observed in the self-reported questionnaire by van Baar et al (13 min) because our questionnaire was administered as an interview considering the ease for persons who were illiterate. Some of the advantages of an interview-based questionnaire are low cognitive burden, high survey response, high rates of completion, low question order effects, and low recall bias.12 The parents were made comfortable before administering the questionnaire so as to reduce bias. Highest BOQ scores were obtained for “Transfers and mobility,” “Physical function and sports,” and “Upper extremity function,” in that order, with higher ceiling effects ranging from 65.14% to 75.3%. In their studies, Daltroy et al, van Baar et al, and Sveen et al also reported highest values among these domains.5,6,9 Upper extremity function BOQ score was lesser than in previous studies probably because our patients presented with contractures of upper limb. The domain “Pain” also had a good BOQ score with ceiling effect of 60%. The reliability of the scale as measured by Cronbach’s alpha was very good for most subscales being greater than 0.7 except for one domain “Parental concern” (0.62). This is comparable to the Swedish and Dutch versions of the BOQ. The Swedish version had poor Cronbach’s alpha for transfers and mobility domain (0.52). The Dutch version had poor reliability in the Emotional health domain. Daltroy et al’s5 original study had higher reliability (>0.90) in domains involving Upper extremity function, Physical function and sports, Transfers and mobility, Pain, and Itch. The highest Cronbach alpha scores in our study were seen in Itch, Compliance, Physical function and sports, Pain, Appearance, Upper extremity function, and Family disruption. We observed a good mean interitem correlation except for two domains “Satisfaction with current state” and “Emotional health.” Test–retest reliability was very good in all the domains. Sveen et al6 reported a poor test and retest reliability in the Family disruption domain. Similarly, van Baar et al9 reported a poor test–retest reliability in Satisfaction with current state domain. These two domains could have a poor test–retest reliability as they tend to change over time. However, this was not observed in our study. Using Pearson’s correlation, the total number of correlations were 78, out of which 70 of them were with the values of −0.5 to +0.5. There were only two correlations greater than 0.7 and two greater than 0.6. Based on these findings, the construct validity of the questionnaire is confirmed as it shows good discriminant validity between various domains of the scale. The high correlation (0.852) between “Physical function and sports” and “Transfers and mobility” is probably due to the physical nature of the two domains and being able to move independently helps children in playing as well. A similarly high value was obtained by Sveen et al.6 Children who had a longer duration since burn injury had better scores in the domains “Transfers and mobility,” “Pain,” “Satisfaction with current state,” and “Parental concern.” This can be explained by the fact that many of these parameters improve with time in burn injuries. Similar findings were observed by van Baar et al.9 A factor analysis was done to examine the structure of the questionnaire. Principal component analysis with orthogonal rotation resulted in extracting 12 components explaining 89.36% of all variance. The domains “Physical function and sports” and “Transfers and mobility” clustered together as component 1. This can be due to fact that both determine components of physical attributes. A similar finding was obtained by Blalock et al13 in the domains “Affect” and “Body image” in their study in the revision of the burn-specific health scale. The factors corresponded well to the domains “Upper extremity function,” “Family disruption,” “Pain,” “Appearance,” “Compliance,” “Itch,” “Emotional health,” and “Economic impact.” In two domains “Satisfaction with current state” and “Parental concern,” the factors did not cluster together. Ten of the 12 components had good factor loadings showing good factorial validity of the instrument. Limitations The limitation of current study is the small sample size. This sample size was not ideal for factor analysis, however it helped in understanding the structure of the questionnaire. This study was cross-sectional in design. Hence the evolution of QoL over time could not be captured. We did not compare I-BOQ-HV with generic QoL questionnaires. CONCLUSION The I-BOQ-HV for 5 to 18 years pediatric subgroup developed by us is a valid and reliable questionnaire for assessment of QoL among children postburn along with the socioeconomic impact on the family. A multicenter assessment may be done from various zones of the country with recruitment of large sample size to support our questionnaire being most relevant and appropriate. Place of the study: Department of Burns, Plastic & Maxillofacial Surgery, VM Medical College & Safdarjung Hospital, Delhi. Funding: There was no direct or indirect funding received by authors. Author contributions: P.K.T. contributed in the form of concept, design, and drafting the manuscript. P.K.A. contributed by administering the questionnaire in the form of interview, collecting and analyzing data, and drafting the manuscript. Both the authors read and approved the final manuscript. There was no writing assistance obtained. Conflict of interest statement. The authors declare that they have no conflict of interests. References 1. Gupta JL , Makhija LK, Bajaj SP. National programme for prevention of burn injuries . Indian J Plast Surg 2010 ; 43 : S6 – 10 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Ahuja RB , Bhattacharya S, Rai A. Changing trends of an endemic trauma . Burns 2009 ; 35 : 650 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Spronk I , Legemate CM, Dokter J, van Loey NEE, van Baar ME, Polinder S. Predictors of health-related quality of life after burn injuries: a systematic review . Crit Care 2018 ; 22 : 160 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Spronk I , Legemate CM, Polinder S, van Baar ME. Health-related quality of life in children after burn injuries: a systematic review . J Trauma Acute Care Surg 2018 ; 85 : 1110 – 18 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Daltroy LH , Liang MH, Phillips CB et al. 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Blalock SJ , Bunker BJ, DeVellis RF. Measuring health status among survivors of burn injury: revisions of the Burn Specific Health Scale . J Trauma 1994 ; 36 : 508 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Validation of Indian Adaptation of Burn Outcomes Questionnaire—Hindi Version (I-BOQ-HV) for Pediatric Subgroup 5 to 18 Years
JF - Journal of Burn Care & Research
DO - 10.1093/jbcr/iraa182
DA - 2020-10-23
UR - https://www.deepdyve.com/lp/oxford-university-press/validation-of-indian-adaptation-of-burn-outcomes-questionnaire-hindi-c9um0ZDr7I
SP - 1
EP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -