SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 121 Southeastern European Medical Journal, 2020; 4(2) Original article Croatian Translation and Linguistic Adaptation of the Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) 1 Terezija Berlančić 1,2,3, Marin Kuharić 4, Dragan Janković 5, Jakov Milić 1, Katarina Badak 1, Lada Zibar *1,6 1 Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, Croatia 2 Department of Gynecology and Obstetrics, County General Hospital Našice, Croatia 3 Faculty of Economics in Osijek, Josip Juraj Strossmayer University of Osijek, Croatia 4 Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Croatia 5 Department of Neurosurgery, University Hospital of Marburg, Germany 6 Department of Nephrology, Clinical Hospital Merkur, Zagreb, Croatia *Corresponding author: Lada Zibar, ladazibar@gmail.com Received: Mar 1, 2020; revised version accepted: Jul 16, 2020; published: Nov 12, 2020 KEYWORDS: Croatian language, health literacy, SAHLSA-50, translation Abstract Introduction: Population needs health literacy (HL) in order to understand health-related topics. Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) could be a high-quality tool for assessing HL in adults. Unlike questionnaires in the English language, which are not easily modifiable for Croatian, translation of SAHLSA-50 from Spanish into Croatian could be an appropriate choice. There are no similar questionnaires to assess HL in Croatian to date. Aim: To translate SAHLSA-50 into Croatian using a validated procedure and to adapt it linguistically, so that it could be used in the Croatian-speaking area to measure HL in the Croatian population. Material and Methods: SAHLSA was developed for the Spanish-speaking population by Lee et al. It consists of 50 items and is based on multiple choice questions. A score between 0 and 37 suggests that the respondent has inadequate HL. After the protocolized translation process (translation/back- translation), the final version of the Croatian translation of SAHLSA-50 was produced, after we introduced several changes that do not represent a direct translation of the Spanish items. Most of the changes were made because of a cultural difference in common use or in the meaning of the term. Conclusion: SAHLSA-50 was translated and adapted into Croatian using the standard translation/back-translation procedure. The Croatian version will now be available as an important part of epidemiological and clinical studies, as a useful tool for evaluating the levels of HL in the Croatian-speaking population. Validation of the translated Croatian version in practice would be the next step. (Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L. Croatian Translation and Linguistic Adaptation of the Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50). SEEMEDJ 2020; 4(2); 121-128) SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 122 Southeastern European Medical Journal, 2020; 4(2) Introduction Health literacy (HL) is a combination of skills, including the ability to perform basic reading and numerical tasks required to function in a healthcare environment (1). The definition used by the Institute of Medicine states that it is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions (2). HL has become an important and fruitful area of research, mostly because of the relationship of limited HL with patients’ knowledge, health behaviors, health outcomes and medical costs (3). Today, there are multiple different assessment tools for assessing HL (4, 5). Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) is an HL assessment tool containing 50 items designed to assess Spanish-speaking adults’ ability to read and understand common medical terms (6). SAHLSA-50 was originally developed and validated in Spanish. It is an easy tool for researching HL in the general population (6). It has been validated for a Spanish-speaking country – Chile, and it was recognized as a useful tool for assessing HL in the adult Chilean population. Its use and incorporation into local research can be especially recommended in areas of education and health promotion (7). While the interest in HL was until recently mainly concentrated in the United States and Canada, it has become more internationalized over the past decade (8). Although the European Union produced less than a third of the global research on HL between 1991 and 2005 (9, 10), the importance of the issue has been increasingly recognized in European health policies. As a case in point, HL is explicitly mentioned as an area of priority action in the European Commission’s Health Strategy 2008-2013 (11). We chose SAHLSA-50 as appropriate for the Croatian language because of its structure, which is intended for a language that is written phonetically (Spanish), unlike the English language. To the authors’ knowledge, there are no similar HL questionnaires in the Croatian language to date. Material and Methods SAHLSA-50 SAHLSA-50 was developed for the Spanish- speaking population by Lee et al. (6), based on the Rapid Estimates of Adult Literacy in Medicine (REALM), known as the most easily administered tool for assessing HL in English. SAHLSA-50 consists of 50 items and is based on multiple choice questions (specifically three choices). Each item consists of a stem medical term and for each term, a respondent chooses between the two offered, potentially related terms, of which only one is right. The right term is called a key term and is in some way related to the stem medical term (synonym or descriptor). The other term is a distractor, which has nothing in common with the stem medical term (or at least in comparison with the key term). The third choice is “I do not know”, which is an option for avoiding guessing the answer. For each correct related term chosen, the respondent is given a point. A score between 0 and 37 suggests that the respondent has inadequate HL (5). The authors of the original questionnaire approved the translation into Croatian language. Procedure Our translation was modeled after Francisco et al. (12) and steps taken followed those described by Wild et al. (13); they are shown in a flowchart (Figure 1). The first step included the first forward translation from Spanish into Croatian by two of the authors of this paper (two students of medicine with passive knowledge of the Spanish language) and one Spanish speaking physician, all Croats, with the help of a professor of the Spanish language (a native speaker of Croatian). In the second step, corrections were made by another professor of the Spanish language (a native speaker of Croatian). Back-translation was done by a fluent bilingual native speaker of Spanish living in Croatia, who is also a Spanish language teacher by profession. Finally, the translation team made the harmonization, including the modification for Croatian language. SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 123 Southeastern European Medical Journal, 2020; 4(2) The final version of the Croatian-language version of SAHLSA-50 was the result Results Table 1 shows SAHLSA-50 versions during the translation process, from the original version to the final translated version in Croatian. The final version of the Croatian SAHLSA-50 is available in Supplement 1. The majority of the items was translated directly and without modification. Several items underwent modification during the translation process. Most of the changes were done due to cultural or linguistic differences or divergence in meaning. For example, in item 10, “vigilance” (“budnost”) in Croatian is better associated with “coffee” (“kava”) than with the original “energy” (“energija”). In item 17, “small egg” (“jajašce”) has been replaced by ovulation (“ovulacija”), because it was less confusing, since in Croatian an “egg” colloquially also means a “testicle”. Another change was done because the authors wanted to achieve concordance with more common Croatian expressions in terms of the word category that is typically used. Thus, the adjective in item 22, “happy” (“sretan”), was replaced with “happiness” (“sreća”), which is a noun, and in item 23, the words “to lose”, which are a verb in Croatian (“izgubiti”), replaced the word “loss”, which is a noun in Croatian. Regarding miscarriage, it is more common to say that someone lost the baby (“izgubili bebu” in Croatian) and not that they experienced a “loss” (“izgubiti” vs “gubitak” in the record). Another difference was introduced in item 6, where we changed “meals”, a plural noun (“obroci”), into a singular noun – “meal” (“jelo”), which is more common and less confusing ( “obroci” has an additional different meaning besides “meals”). Through empirical medical knowledge it was concluded that in item 20, the word “irritation” (“iritacija”) in Croatian usually relates to “inflammation” (“upala”) and not “pain” (“bol”), as was the case in the original Spanish version. The final change was made with the word “convulsions” in item 49, which does not have a singular meaning in Croatian, while the word “epilepsija”, meaning “epilepsy” (related to “convulsions”), is more common and does have a recognizable related Croatian description in the word “padavica” (the term for a grand mal seizure characterized by falling down – as “pad” in “padavica”). The procedure of translation and back-translation went smoothly, without major differences between the attitudes, proposals or final solutions of the members of the translation team. The translation team agreed on the final version without lingering objections. Discussion We made the Croatian version of SAHLSA-50 in order to enable HL research in Croatia. The translation was made using standard validated translation procedures (12-14). Since the Spanish questionnaire was found to be more suitable than the English one, it was quite easy to translate the items. Croatian and Spanish have a simple way of pronouncing written text, where only one sound corresponds to each letter, and vice versa. Thus, being literate in these two languages (Spanish and Croatian) is supposed to be comparably difficult (or easy), unlike English, where each word is pronounced in a certain way, depending on many complicated rules and exceptions. However, we had to make several changes of certain Spanish words, since we wanted the questionnaire to be more appropriate for Croats in terms of recognizable content and category of words used. Similar changes in wording or scoring are commonly done to ensure cultural adaptation (15). We hope that the next step – the validation of the Croatian version of SAHLSA-50 in practice – will confirm the adequacy of our choice. The next step after this report is validation of the translated questionnaire in the Croatian-speaking population. . SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 124 Southeastern European Medical Journal, 2020; 4(2) Spanish original Forward translation Corrections Back translation 1. PRÓSTATA glándula circulación PROSTATA Žlijezda Cirkulacija PROSTATA Žlijezda Cirkulacija LA PRÓSTATA La glándula La circulación 2. EMPLEO trabajo educación ZAPOSLENJE Posao Obrazovanj e ZAPOSLENJE Posao Obrazova nje EL EMPLEO El negocio La educación 3. MENSTRUAL mensual diario MENSTRUAL AN Mjesečno Dnevno MENSTRUACIJS KO Mjesečno Dnevno MENSTRUAL Mensual Diario 4. GRIPE sano enfermo GRIPA Zdrav Bolestan GRIPA Zdrav Bolestan LA INFLUENZA Saludable Enfermo 5. AVISAR medir decir UPOZORITI Mjeriti Reći UPOZORITI Mjeriti Reći ADVERTIR Medir Decir 6. COMIDAS cena paseo OBROCI Večera Šetnja JELO Večera Šetnja LA COMIDA La cena El paseo 7. ALCOHOLISMO adicción recreo ALKOHOLIZA M Ovisnost Rekreacija, odmor ALKOHOLIZAM Ovisnost Rekreacija EL ALCOHOLISMO La adicción La recreación 8. GRASA naranja manteca MAST, MASNOĆA Naranča Maslac, mast MASNOĆA Naranča Maslac LA GRASA La naranja La mantequill a 9. ASMA respirar piel ASTMA Disati Koža ASTMA Disati Koža LA ASMA Respirar La piel 10. CAFEÍNA energía agua KOFEIN Energija Voda KOFEIN Budnost Voda LA CAFEÍNA La vigilancia Agua 11. OSTEOPOROSIS hueso músculo OSTEOPORO ZA Kost Mišić OSTEOPOROZA Kost Mišić OSTEOPOROSIS El hueso El músculo 12. DEPRESIÓN apetito sentimient os DEPRESIJA Tek Osjećaji DEPRESIJA Tek Osjećaji LA DEPRESIÓN El apetito Los sentimient os 13. ESTREÑIMIENT O bloqueado suelto OPSTIPACIJA Zatvor, blokiran Rastresit, nekomplet an KONSTIPACIJA Zatvor Proljev EL ESTREÑIMIENTO El estreñimient o La diarrea 14. EMBARAZO parto niñez TRUDNOĆA Porođaj Djetinjstvo TRUDNOĆA Porođaj Djetinjstvo EL EMBARAZO El parto La infancia 15. INCESTO familia vecinos INCEST Obitelj Susjedi INCEST Obitelj Susjed EL INCESTO La familia El vecino 16. PASTILLA tableta galleta PILULA Tableta Dvopek, kolačić PILULA Tableta Kolačić LA PÍLDORA La tableta El pastelito 17. TESTÍCULO óvulo esperma TESTIS Jajašce Sperma TESTIS Ovulacija Sperma EL TESTÍCULO La ovulación El semen 18. RECTAL regadera inodoro REKTALAN Kanta za polijevanje WC, dezodoran s REKTALNO Tuš WC RECTAL La ducha El inodoro 19. OJO oír ver OKO Čuti Vidjeti OKO Sluh Vid EL OJO El oído La vista SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 125 Southeastern European Medical Journal, 2020; 4(2) 20. IRRITACIÓN rígido adolorido IRITACIJA Ukočen Bolan IRITACIJA Ukočeno Bolno LA IRRITACIÓN Tenso Doliente 21. ABNORMAL diferente similar ABNORMALN O Drukčije Slično ABNORMALNO Drukčije Slično ABNORMAL Diferente Similar 22. ESTRÉS preocupació n feliz STRES Zabrinutos t Sretan STRES Zabrinutos t Sreća EL ESTRÉS La preocupació n La felicidad 23. ABORTO ESPONTÁNEO pérdida matrimoni o SPONTANI POBAČAJ Gubitak Brak SPONTANI POBAČAJ Izgubiti Brak EL ABORTO ESPONTÁNEO Perder El matrimonio 24. ICTERICIA amarillo blanco IKTERUS, ŽUTICA Žut Bijel IKTERUS Žuto Bijelo LA ICTERICIA Amarillo Blanco 25. PAPANICOLAO U prueba vacuna PAPANICOLA U Test Kozice PAPANICOLAU Test Cjepivo PAPANICOLAOU La prueba La vacuna 26. IMPÉTIGO pelo piel OSIP Dlaka Koža OSIP Dlaka Koža LA ERUPCIÓN El cabello La piel 27. INDICADO instrucción decisión INDICIRAN, OZNAČEN Uputa Odluka NAZNAKA Uputa Odluka LA INDICACIÓN Instrucciones La decisión 28. ATAQUE herida sano NAPAD Ozljeda Zdrav NAPAD Ozlijeđen Zdrav EL ATAQUE Lesionado Sano 29. MENOPAUSIA señoras niñas MENOPAUZA Gospođe Djeca MENOPAUZA Gospođe Djevojke LA MENOPAUSIA Señoras Chicas 30. APÉNDICE rascar dolor SLIJEPO CRIJEVO Grepsti Bol SLIJEPO CRIJEVO Ogrebotina Bol EL APÉNDICE El rasguño El dolor 31. COMPORTAMIE NTO pensamient o conducta PONAŠANJE Misao Vladanje PONAŠANJE Misao Vladanje EL COMPORTAMIE NTO El pensamiento La conducta 32. NUTRICIÓN saludable gaseosa PREHRANA Zdrav Gazirano piće PREHRANA Zdravlje Gazirano piće LA NUTRICIÓN La salud Las bebidas carbonatad as 33. DIABETES azúcar sal DIJABETES Šećer Sol DIJABETES Šećer Sol LA DIABETES El azúcar El sal 34. SÍFILIS anticoncepti vo condón SIFILIS Kontracept ivi Kondom SIFILIS Kontracept ivi Kondom LA SÍFILIS Anticoncepti vos El condón 35. INFLAMATORIO hinchazón sudor UPALJEN Oteklina Znoj UPALA Oteklina Znoj LA INFLAMACIÓN El hinchazón El sudor 36. HEMORROIDES venas corazón HEMOROIDI Vene Srce HEMOROIDI Vene Srce LAS HEMORROIDES Las venas El corazón 37. HERPES aire sexo HERPES Zrak Seks, spol HERPES Zrak Seks HERPES El aire El sexo SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 126 Southeastern European Medical Journal, 2020; 4(2) 38. ALÉRGICO resistencia reacción ALERGIČAN Otpornost Reakcija ALERGIJA Otpornost Reakcija LA ALERGIA La resistencia La reacción 39. RIÑON orina fiebre BUBREG Urin Groznica BUBREG Mokraća Vrućica EL RIÑON La orina La fiebre 40. CALORÍAS alimentos vitaminas KALORIJE Hrana Vitamini KALORIJE Hrana Vitamini LAS CALORÍAS La comida Las vitaminas 41. MEDICAMENTO instrumento tratamient o LIJEK Instrument Terapija LIJEK Instrument Terapija LA MEDICINA El instrumento La terapia 42. ANEMIA sangre nervio ANEMIJA Krv Živac ANEMIJA Krv Živac LA ANEMIA La sangre El nervio 43. INTESTINOS digestión sudor CRIJEVA Probava Znoj CRIJEVA Probava Znoj LOS INTESTINOS La digestión El sudor 44. POTASIO mineral proteína KALIJ Mineral Protein KALIJ Mineral Protein EL POTASIO El mineral La proteína 45. COLITIS intestino vejiga KOLITIS Crijevo Mokraćni mjehur KOLITIS Crijeva Mjehur EL COLITIS Los intestinos La vejiga 46. OBESIDAD peso altura PRETILOST Težina Visina PRETILOST Težina Visina LA OBESIDAD El peso La altura 47. HEPATITIS pulmón hígado HEPATITIS Pluća Jetra HEPATITIS Pluća Jetra LA HEPATITIS Los pulmones El hígado 48. VESÍCULA BILIAR arteria órgano ŽUČNI MJEHUR Arterija Organ ŽUČNI MJEHUR Arterija Organ LA VESÍCULA BILIAR La arteria El órgano 49. CONVULSIONE S mareado tranquilo GRČEVI, KONVULZIJE Bolestan od morske bolesti Miran EPILEPSIJA Padavica Smirenost LA EPILEPSIA La epilepsia La calma 50. ARTRITIS estómago articulació n ARTRITIS Želudac Zglob ARTRITIS Želudac Zglob LA ARTRITIS El estómago La articulación SEEMEDJ 2020, VOL 4, NO. 2 Croatian Translation of SAHLSA-50 127 Southeastern European Medical Journal, 2020; 4(2) Conclusion The translation of SAHLSA-50 from Spanish into Croatian was done using the standard validated procedure. The terms were modified in only several items, in order to adapt the Croatian version to the most similar sense in Croatian. 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Acquisition of data: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Administrative, technical or logistic support: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Analysis and interpretation of data: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Conception and design: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Critical revision of the article for important intellectual content: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Drafting of the article: Berlančić T, Kuharić M, Janković D, Zibar L Final approval of the article: Berlančić T, Kuharić M, Janković D, Milić J, Badak K, Zibar L Guarantor of the study: Berlančić T, Zibar L Provision of study materials or patients: Berlančić T, Badak K, Zibar L