Cross-cultural adaptation of AD-8 into Amharic for operationalizing the detection of cognitive impairment in a primary care setting of Ethiopia

doi:10.21203/rs.3.rs-1820446/v1

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Research Article

Cross-cultural adaptation of AD-8 into Amharic for operationalizing the detection of cognitive impairment in a primary care setting of Ethiopia

https://doi.org/10.21203/rs.3.rs-1820446/v1

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Background

Cross-Cultural adaptation of a cognitive screening instrument requires careful planning and its implementation is complex, expensive and time consuming. This study aims to cross culturally adapt AD8 using the WHO translation and adaptation process guidelines in preparation for the development of a mobile health based dementia screening app at the primary care center of Ethiopia.

Methods

The panel discussed forward and backward translated AD8 instrument items alongside with the original English version of AD8 and Lawshe’s CVR _critical value to adapt them to the interim final and the reconciled Amharic versions of AD8 respectively. The reconciled Amharic version was pilot tested, a cognitive interview was conducted, and the results were analyzed and a summary report was generated to adapt it to the final Amharic version of AD8.

Results

The Lawshe’s CVR value was less than the expected CVR _critical value (0.75) for all of the forward translated items of AD8 except for the ‘Question items # 3 &7’. The panel substituted words and/or phrases in the title, instructions and ‘Question items # 1 & 6’; and added ‘Radio’ to the Question item # 4. The Lawshe’s CVR value (1.0) was greater than the expected CVR _critical value (0.75) for all of the backward translated instrument items of AD8. The internal reliability of the reconciled Amharic version of AD8 was very good with a Cronbach’s alpha value of 0.875. Cognitive interview study participants verbalized lived experiences to reason and explain the way the reconciled Amharic version of AD8 question items was understood. The reconciled Amharic version was adapted without any modification as the final Amharic version of AD8.

Conclusion

changes made, reasons for change, and a vote of consensus for each question item of AD8 was documented at every step of deliberations of the panel. The Amharic version of AD8 demonstrated a very good internal reliability with strong item correlation. The Amharic version of AD8 fulfills the perquisite for the development of mobile health based AD8 dementia screening at primary care settings of Ethiopia and aligns with the WHO task-shifting strategy of dementia screening.

Cross-cultural adaptation

cognitive screening

Eight-item Interview to Differentiate Aging and Dementia (AD8)

Ethiopia

Sub-Saharan Africa

Globally the number of people living with dementia is projected to triple to more than 152 million by 2050, rising, particularly in eastern Sub-Saharan Africa, North Africa and the Middle East (1). In Sub-Saharan Africa over 2 million people live with Alzheimer disease and this number is projected to rise to 7.6 million by 2050(2). In Ethiopia people over 60 years of age are projected to double from 5.2 million in 2015 to 10.4 million in 2050(3).

The 2017 WHO Global Plan of Action on Dementia aims to diagnose at least 50% of people with dementia by 2025(4). Ethiopia has not yet ratified a national policy to support people with dementia or their families(5) but has approved a National Social Protection Policy for the vulnerable and poor in 2014(6) and ratified the African Union Protocol on the Rights of Older Persons in 2020(7). These legal frameworks serve as a foundation to implement the 2017 WHO Global Plan of Action on Dementia.

Eleven percent of 65 years and older and 32% of 85 years and older are expected to have dementia in primary care settings (8). The 2016 Alzheimer report identifies dementia screening and task-shifting as important strategies to establish and effectively run dementia care in primary care settings(8). The Alzheimer’s Association Annual Wellness Visit Algorithm recommends AD8 “ Eight-item Interview to Differentiate Aging and Dementia” as one of the brief informant cognitive impairment screening tools in a primary care setting(9). The AD8 tests for memory, orientation, judgment and function. It has demonstrated excellent concurrent validity and internal, interrater and intrarater reliabilities(10). The AD8 is also validated as a self-rating tool to detect dementia(11) and has been successfully adapted into different languages (12–16).

Cross-Cultural adaptation of cognitive screening instruments requires careful planning and its implementation is complex, expensive and time consuming. (17–29) Psychometric properties of measures developed for use in public health and community settings rarely describe the five domains recommended by Consolidation Framework for Implementation Research (CFIR)(30). To date, the AD8 has not been adapted for use in Ethiopia. Cross cultural adaptation of AD8 creates an opportunity to understand the incidence and prevalence of dementia, to device task-sharing strategies and utilize mobile health (mHealth) based dementia screening platform at primary care level. This study aims to adapt AD8 using the WHO translation and adaptation process guidelines in preparation for the development of mHealth based dementia screening app at primary care centers of Ethiopia.

The WHO translation and adaptation process guidelines constituted forward translation, back translation, pilot testing and cognitive interviewing, and final documentation.

Forward translation

college-preparatory school Amharic teacher with a master’s degree in the field was recruited and trained on WHO translation and adaptation guidelines to forward translate AD8 into Amharic.

Expert Panel

The investigators formed an expert panel composed of 3 Psychiatrist (two professors and one assistant professor), 3 neurologists (one associate professor and two assistant professors), a professor in epidemiology and 2 public health experts (a professor and an associate professor) with experience in cross-cultural adaptation of instruments. A chairperson and a secretary were nominated to organize and document the proceedings of meetings. A half-day workshop was organized to brief expert panel on the WHO translation and adaptation process guidelines, and on how to interpret Lawshe’s content validity ratio (CVR) and content validity index (CVI). The panel agreed on standard operation procedure, received the forward translated Amharic version via email; independently rated each instrument item of the forward translated Amharic version of AD8 on Epicollect5; received Lawshe’s CVR and CVI of the forward translated Amharic version of AD8 via email; identified and resolved inadequate expressions/concepts of translation of the forward translated Amharic version of AD8; documented changes made to the forward translated Amharic version to produce the interim final Amharic version of AD8; received the backward translated English version of AD8; independently rated each instrument item of the backward translated English version of AD8 on Epicollect5; received Lawshe’s CVR and CVI of the backward translated English version of AD8; reconciled the backward translated and original English versions of AD8; documented changes made to the interim final Amharic version to produce the reconciled Amharic version of AD8; received summary report findings from the pilot-testing and cognitive interviewing; and documented changes made to the reconciled Amharic version of AD8 to develop the final Amharic version of AD8.

Back translation

An architect and former Ethiopian Reporter English newspaper editor was recruited and trained on WHO translation and adaptation guidelines to back translate interim final Amharic version of AD8 into English.

Data collection and statistical analysis of Lawshe’s content validity ratio and content validity index

the panel was virtually trained how to navigate, identify, complete, save and upload data on a demo Epicollect5 project. The panel serially accessed Epicollect5 created projects for the forward and backward translated versions of AD8. The panel independently rated each instrument item of the forward translated and back ward translated versions of AD8 as “Essential,” “Useful but not essential” or “Not necessary” on Epicollect5. Additional information regarding answer choice translation, structure and format of the instrument, presence of missed items and/or misplaced items, and overall quality of the forward and back translated Amharic and English versions of AD8 was collected on Epicollect5. The data acquired via Epicollect5 was downloaded into an Excel workbook, cleaned and transformed into an ‘x’ when the response was “Essential,” and into “blank” when the responses were “Useful but not essential” or “Not necessary.” Lawshe’s CVR and CVI was calculated using 3.3.B Lawshe CVR Worksheet for Dispositions Survey - UAH (www.uah.edu/images/Education/caep_2019/3.3.b_lawshe_cvr_worksheet_for_dispositions_surv.) The Lawshe’s CVR and CVI were serially provided to the expert panel to identify, resolve and reconcile inadequate expressions/concepts of translations of the forward translated Amharic version of AD8 and backward translated English versions of AD8.(31, 32)

Pilot-testing and cognitive interviewing

Data collection instrument and data collection procedure for the pilot –testing

Two data collectors with master’s degrees in public health were hired and trained about the objectives of the study. The data collectors assumed a role play and administered Epicollect5 created AD8 questionnaire to each other and identified technical glitches that required modification. A total of 33 study participants, older than 50 years of age, were randomly selected from Coronavirus Disease (COVID) vaccine registration log books of Abinet, Teklehaimanot, Beletech, woreda 8 and Yeka health centers in Lideta and Yeka Sub-Cities of Addis Ababa, Ethiopia. The study participants were explained about the objectives of the study verbally consented and interviewed using an AD8 questionnaire created on Epicollected5. The questionnaire comprised of the reconciled Amharic version of AD8, demographic variables and lists of chronic health problems. Two PhD candidate project coordinators supervised the data collection process, and the PI daily monitored data collection progress and data completeness on Epicollect5.

Statistical analysis for the Pilot –testing

Epicollect5 collected pilot-test data was downloaded into an Excel workbook, cleaned and exported to SPSS version20.0 for statistical analysis. Demographic variables were categorized and frequencies calculated. Internal reliability of AD8 was checked using Cronbach’s alpha. The validity of AD8 was assessed using Person’s correlation coefficient. The calculated Person’s correlation coefficient value of each question item was compared against the Person’s critical value (0.3440) at p < 0.05 for 33 study participants at 2 degrees of freedom. The principal axis factoring method was used to explore factor loadings and extract Eigenvalues from the AD8 pilot-testing data. Preconditions for exploratory factor analysis were assessed by: inspecting correlation matrix ( 2.93 to 7.64), Kaiser-Meyer-Olkin Measure of Sampling Adequacy ( 0.763), Bartlett's Test of Sphericity ( 0.0001), and extraction item communality was 0.245 for ‘less interest in hobbies and activities,’ and 0.353 to 0.832 for rest of the items.(33, 34) SPSS extracted Eigenvalues were compared with a Parallel Analysis Engine generated random Eigenvalues at 95th percentile and determined the number of factors retained.(35)

Cognitive interviewing

data collectors approached pilot-study participants and asked for their willingness to participate in cognitive interviewing. Eight participants volunteered to participate in the focus group discussion (FGD), and their mobile phone numbers were registered and called a day before the FGD. The data collectors, who previously had conducted FGD, were trained about the objectives of the AD8 cognitive interviewing, how to use the AD8 FGD guideline, and on how to facilitate FGD and probe FGD participants. Seven FGD participants showed up at Abinet health center where the FGD was held. FGD facilitator and field note taker welcomed and briefed FGD participants about the objectives and standards of operation. Participants verbally consented, and the facilitator interviewed them separately using the reconciled Amharic version of AD8. Study particpants introduced themselves and were assigned an identification number by the facilitator to keep them anonymous. Before pitching into the main AD8 questionnaire, participants were asked about their understandings of dementia, whether or not they were screened for dementia before, the types of questions they were asked when screened or what they expected to be asked if not screened before. Participants were then handed out the reconciled Amharic version of AD8 and read aloud each question item and responded in turn to each question item. Whenever required the moderator read the questions aloud and probed particpants either concurrently or retrospectively. Participants were probed for difficult to understand questions, presence of unfamiliar words or phrases, presence of abusive words, and length of time required to complete the questionnaire.

Statistical analysis for the cognitive interviewing

the FGD was conducted at Abinet health center in Lideta Sub-City, Addis Ababa. Data was audio recorded, transcribed and translated into Amharic by FGD moderator. Field observations were made and reported, and a PhD candidate project coordinator supervised the progress of FGD. The transcript and translated transcript were read and audio recordings listened to, and an insight into FGD participant’s perspectives was gained. The formatted AD8 FGD transcript and translated transcript and audio recordings were exported to atlas.Ti version 7.1 for analysis. Field notes, transcripts and audio recording were explored for deductive coding schemes using Presser and Blair emotional and cognitive coding sets.(25, 36–38) Hearing problems necessitated question items and probes to be repeated over and again to the participants that made emotional coding a nonviable option. Participants were also unable to rephrase and explain how each AD8 question item was understood and answered; rather they preferred to verbalize their lived experiences suggesting difficulty with cognitive response tasks but not with the survey response task. Cognitive coding was again deferred but instead in vivo quotations from verbalized experiences’ of participants were used to describe AD8 question item responses.

Forward translation

The original English version of AD8 was forward translated by a college preparatory Amharic teacher who had a master’s degree in the field.

Lawshe’s CVR and CVI for the forward translated Amharic version of AD8

The forward translated Amharic version of the AD8 instrument items were independently rated by the expert panel as “Essential”, “Useful but not essential” and “Not necessary” on Epicollect5. The calculated Lawshe’s CVR values of the AD8 instrument items were (-0.5 to -0.25 ) for the ‘administration guidelines’, ‘instructions’, and ‘Question items # 1, 2, 4 and 5’; and 0 for the ‘score interpretation guidelines’ and ‘Question items # 6 & 8’ of AD8 instrument items. The Lawshe’s CVR values of the AD8 instrument items (-0.5, -0.25 and 0) were less than the expected CVR _critical value (0.75) for a panel size of 8. The calculated Lawshe’s CVR value of the forward AD8 instrument items were 0.75 for the ‘title’ and ‘Question items # 3 &7’; and 1 for the ‘answer choice translation’, ‘structure and format,’ ‘presence of missed item/s,’ and ‘misplaced item/s.’ The Lawshe’s CVR values (0.75 and 1) of the forward translated Amharic version of AD8 were greater than or equal to the expected CVR _critical value (0.75) for a panel size of 8 Table 1.

Table 1

Lawshe's content validity ratio and content validity index for back ward translated English version of AD8 in Addis Ababa, Ethiopia, 2021.
lists of instrument items independently rated by experts	Expert Identification Number									CVR
lists of instrument items independently rated by experts	1	2	3	4	5	6	7	8		CVR
Amharic version of title and identification section	x	x	x	x	x	x	x			0.75
Amharic of version of detailed AD8 Administration guideline	x			x	x					-0.25
Amharic version of AD8 score interpretation guideline	x				x	x		x		0
Amharic version of brief AD8 administration instruction	x				x	x				-0.25
Amharic version of AD8 Question # 1	x					x				-0.5
Amharic version of AD8 Question # 2	x	x						x		-0.25
Amharic version of AD8 Question # 3	x	x	x		x	x	x	x		0.75
Amharic version of AD8 Question # 4	x							x		-0.5
Amharic version of AD8 Question # 5	x	x					x			-0.25
Amharic version of AD8 Question # 6	x				x	x		x		0
Amharic version of AD8 Question # 7	x	x	x	x	x	x	x	x		1
Amharic version of AD8 Question # 8	x	x			x		x			0
Amharic version of answer choices	x	x	x	x	x	x	x			1
Structure and format of Amharic version AD8	x	x	x	x		x				1
Missed items from Amharic version of AD8		x				x				1
Misplaced items from Amharic version of AD8	x	x	x	x		x	x	x		1
CVR (Critical) for a panel size (N) of 8 is 0.75.									CVI	0.281

Expert panel decision vote for the forward translated Amharic version of the AD8

The panel discussed the forward translated Amharic version of AD8 item by item alongside with the original English version of AD8 and Lawshe’s CVR _critical value of the forward translated version of AD8. The panel documented changes made, reasons for change and a decision vote for each item of the forward translated Amharic version of AD8. The panel substituted a word to better represent ‘dementia’ in the title; added a word to better represent ‘ID’ in the identification column; substituted a phrase to better represent ‘cognitive problem’ in the instruction; substituted a phrase to better represent the phrase ‘problem with judgment’ in Question # 1; added the word ‘radio’ in Question # 4 because it was known (owned) by most people in rural and urban settings; and substituted a phrase to better represent the phrase ‘balancing check book’ in Question # 6 because ‘balancing check book’ was hardly known by ordinary Ethiopians. The panel had rephrased all instrument items except Question # 7 and the reference. Finally, the panel unanimously endorsed changes made to the forward translated Amharic version of AD8 and adapted it as an interim final Amharic version of AD8 Table 2.

Back ward translation

the interim final Amharic version of AD8 was back translated by an Architect and a former editor of the Reporter English Ethiopia newsletter.

Lawshe’s CVR and CVI for the backward translated English version of AD8 instrument

the instrument items of the backward translated Amharic version were independently rated by the panel as in the forward translated Amharic version. The calculated Lawshe’s CVR value was 1.0 for all instrument items of the backward translated Amharic version of AD8 which was greater than the expected CVR _critical value (0.75) for a panel size of 8 Table 3.

Table 2

Expert panel decision vote for changes made and reasons for change to the forward translated Amharic version to adapt it to the interim final version of AD8 in Addis Ababa, Ethiopia, 2021.
Translated section	Expert opinion			Decision: Vote of experts
Translated section	Forward translated version	Changes made after experts discussion	Reasons for the changes	Decision: Vote of experts
Title	AD8 የመርሳት በሽታ ምርመራ ቃለ መጠይቅ	AD8 የመጃጀት በሽታ መለያ መጠይቅ	መጃጀት better represent Dementia than የመርሳት በሽታ	9/9
	ሲ ኤስ ቁጥር	ሲ ኤስ መለያ ቁጥር	መለያ represent “ID” which was missed in forward translation	9/9
Instruction	ማሳሰቢያ- ፣ “አዎ ፣ ለውጥ አለ ማለት” በአለፉት በርካታ ዓመታት በእውቀት (በአስተሳሰብ እና ትውስታ) ችግር መኖሩን ይገልጻል::	ያስታውሱ፣ “አዎ ፣ ለውጥ አለ” ማለት በአለፉት በርካታ ዓመታት በግንዛቤ ችግር ምክንያት ለውጥ መኖሩን ይገልጻል (ማሰብ እና ማስታወስ):	Cognitive problem is better expressed by the word ግንዛቤ ችግር	9/9
Question 1	የመወሰን ችግር /በገንዘብ አጠቃቀም ችግሮችን ለመፍታትና የመሳሰሉትን የግል ውሳኔ አሰጣጥ	የማመዛዘን ችግር (ለምሳሌ ውሳኔ ለመስጠት መቸገር ፤የገንዘብ አጠቃቀም ችግር፤ የማሰብ ችግር)	Problem with judgment is better expressed by the word የማመዛዘን ችግር	9/9
Question 2	የተለመዱ /ዘወትር / ተግባሮችንና አንቅስቃሴዎችን የማከናወን ያነሰ ፍላጎት	የሚያስደስትዎት ነገር/ የሚያዘወትሯቸዉ አንቅስቃሴዎች ፍላጎት ማነስ	Rephrased	9/9
Question 3	ነገሮች መደጋገም/ ጥያቄዎችን፤ታሪኮችን፤አረፍተ ነገሮችን ወዘተ/	ነገሮችን ይደጋግማሉ (ጥያቄዎችን፤ ታሪኮችን፤ዐረፍተ ነገሮችን ወዘተ)	Rephrased	9/9
Question 4	በቤት ውስጥ ያሉትን መሣሪያዎች እንዴት እንደሚጠቀሙበት መማር ችግር ፣ (ለምሳሌ ፣ሪሞት ኮንተሮል፤(ማይክሮዌቭ) ማሞቆያዎችን፤ ኮምፒወተሮችንና ሞባይሎችን ወዘተ	በቤት ውስጥ ያሉትን መገልገያ መሣሪያዎች እንዴት እንደሚጠቀሙበት ለመማር መቸገር ፣ (ለምሳሌ ፣ራድዮ፤ ሪሞት ኮንተሮል፤(ማይክሮዌቭ)፤ ኮምፒውተሮችንና ሞባይሎችን ወዘተ	Radio was added, as it’s a commonly known in rural and urban settings	9/9
Question 5	ትክክለኛ ወሮችን፤ ቀኖችን፤ ዓመተ ምህረቶቸን መርሣት	ትክክለኛውን ወር ወይም፤ ዓመተ ምህረትን መርሳት	Rephrased	9/9
Question 6	የተወሳሰቡ የገንዘብ/ ሂሳብ ሰነዶችን አያያዝ ችግር (ለምሳሌ ፤ የባንክ ቼክ ደብተርን ማመጣጠን ፤ የገቢ ግብር ፣ የፍጆታ ክፍያን መክፈል) ወዘተ መርሳት	ከበድ ያለ የገንዘብ ጉዳዮች አያያዝ ችግር/ሂሳብ ሰነዶችን አያያዝ ችግር (ለምሳሌ ፤ የባንክ ሂሳብን ማመጣጠን፤ የገቢ ግብር ፣ የፍጆታ ክፍያን መክፈል)	Rephrasing የባንክ ቼክ ደብተርን with የባንክ ሂሳብን; as the former is barely known by ordinary Individuals.	9/9
Question 7	ቀጠሮዎችን የማስታወስ ችግር	ቀጠሮዎችን የማስታወስ ችግር	No change was made	9/9
Question 8	የዕለት ተዕለት የአስተሳሰብ እና / ወይም የማስታወስ ችግር	የዕለት ተዕለት የማሰብ እና/ ወይም የማስታወስ ችግር	Rephrased	9/9

Table 3

Lawshe's content validity ratio and content validity index for back ward translated English version of AD8 in Addis Ababa, Ethiopia, 2021.
lists of items independently rated	Expert Identification number									CVR
lists of items independently rated	1	2	3	4	5	6	7	8		CVR
Back translate version of title	x	x	x	x	x	x	x	x		1
Back translate version of administration	x	x	x	x	x	x	x	x		1
Back translate version of score interpretation	x	x	x	x	x	x	x	x		1
Back translate version of instruction	x	x		x	x	x	x	x		1
Back translate version of AD8 Question # 1	x	x		x	x	x	x	x		1
Back translate version of AD8 Question # 2	x	x		x	x	x	x	x		1
Back translate version of AD8 Question # 3		x		x	x	x	x	x		1
Back translate version of AD8 Question # 4	x	x		x	x		x	x		1
Back translate version of AD8 Question # 5	x	x	x	x	x	x	x	x		1
Back translate version of AD8 Question # 6	x	x		x	x	x	x	x		1
Back translate version of AD8 Question # 7	x	x		x	x	x	x	x		1
Back translate version of AD8 Question # 8	x	x		x	x	x	x	x		1
Back translate version of answer choices	x	x	x	x	x	x	x	x		1
Structure and format of back translate version	x	x	x	x	x	x	x	x		1
Missed items of back translate version		x	x	x	x		x	x		1
Misplaced items of back translate version	x	x	x	x	x	x	x	x		1
Overall quality of back translate version	x	x		x	x	x	x	x		1
CVR(Critical) for a panel size (N) of 8 is 0.75.									CVI	1

Expert panel suggested changes to the interim final Amharic version of AD8

The panel discussed the backward translated English version of AD8 item by item alongside with the original English version and Lawshe’s CVR _critical value of the backward translated version of AD8. The panel substituted ‘respondent’ for ‘patient’ in the 2nd paragraph of ‘Administration and scoring guidelines’ of the interim final Amharic version of AD8.There were no other changes made to the interim final Amharic version of AD8 Table 4.

Table 4

Expert panel suggested changes to the interim final Amharic version for discrepancies identified between the original and the backward translated versions of AD8 in Addis Ababa, Ethiopia, 2021.
Translated section	Expert opinion
Translated section	Original English Version	Back translated English version	Discrepancies detected	Suggested change
AD8 Dementia Screening Questionnaire
Item 2	Less interest in hobbies/activities	Lack of interest in hobbies/ regular activities	Back translation was not correct but the Amharic was good so no changes made
The AD8 Examination interview procedure and grading guideline second paragraph	The questions are given to the respondent on a clipboard for self– administration or can be read aloud to the respondent either in person or over the phone.	The questions are given to the patient to complete on their own or can be read aloud to the respondent in person or over the phone	Patient should be changed to respondent in the Amharic	ጥያቄዎቹ ተሳታፊዉ በራሳቸው እንዲሰሩ ሊሰጡ ይችላል፤ አልያም ጮክ በማለት ለምላሽ ሰጭው በፊት-ለፊት ወይም በስልክ ይነበብላቸዎል፡፡
AD8 examination interview procedure and grading guideline 4th paragraph			Back translation was not correct but the Amharic was good so no change was made
	• Sensitivity > 84% • Specificity > 80% • Positive Predictive Value > 85% • Negative Predictive Value > 70% • Area under the Curve: 0.908; 95%CI: 0.888–0.925	• Sensitivity > 84% • Difference > 80% • Positive prediction value > 85% • Negative prediction value > 70% • Area under the curve: 0.908; 95% CI: 0.888–0.925	Agreed to put the English versions in a bracket since this is for the rater	• ትብነት(Sensitivity) > 84% • ልዩነት (Specificity) > 80% • አዎንታዊ ትንበያ እሴት ( Positive Predictive Value ) > 85% • አሉታዊ የትንበያ እሴት ( Negative Predictive Value ) > 70% • በኩርባ ስር ያለ ቦታ( Area under the Curve): 0.908; 95%CI: 0.888–0.925

Pilot-testing

A total of 33 study participants took part in the pilot-testing of AD8. Study participants were females (78.8%) and widows (54.5%), and had a median age of 65 years (interquartile range of 20 years). Two-third (63.6%) did not have any formal education. High school certificate (12.4%) was the highest attained educational level while primary education (21.2%) was the most commonly attained educational level. Hypertension (70.6%), diabetes (23.5%), and depression (23.5%) were the most common self-reported illnesses Table 5. Shapior-Wilks test (p < 0.05) and inspection of skewness and kurtosis measures showed that the total score is not approximately normally distributed for both males and females. The median AD8 score was 1 (interquartile range of 3), the minimum and maximum AD8 scores were 0 and 8, and the median time required to complete an interview with AD8 was 2 minutes (interquartile range of 1.67 minutes). Fifty four percent of study participants scored 0 or 1, and the remaining 45.6% scored 2 to 8.

Table 5

Self-reported illnesses by AD8 pilot study participants in Addis Ababa, Ethiopia, 2021.
Self-reported illnesses	Responses
	N	Percent	Percent of cases
Hypertension	12	41.40%	70.60%
Diabetes	4	13.80%	23.50%
Dyslipidemia	2	6.90%	11.80%
Heart disease	1	3.40%	5.90%
stroke	1	3.40%	5.90%
Depression	4	13.80%	23.50%
HIV	3	10.30%	17.60%
Hearing or visual problem	2	6.90%	11.80%
Total	29	100%	170.60%

The internal reliability of the Amharic version of AD8 was very good with a Cronbach’s alpha value of 0.875 (95% CI 0.798 to 0.930) and there was no need to remove an item to improve the reliability of the tool Table 6. The calculated Pearson’s values for the Amharic version of AD8 ranged from 0.634 to 0. 835. The calculated person’s values for the Amharic version of AD8 were greater than Pearson’s critical value [(0.3440) at p < 0.05 for 33 study participants and 2 degrees of freedom] for all questions.

Table 6

AD8 Cronbach's alpha coefficients in Addis Ababa, Ethiopia, 2021.
	Corrected Item-Total Correlation	Cronbach's Alpha if Item Deleted
Problems with judgment	0.709	0.851
Less interest in hobbies/activities	0.486	0.879
Repeats the same things over	0.782	0.846
Trouble learning how to use a tool	0.595	0.864
Forgets correct month or year	0.641	0.858
Trouble handling complicated financial	0.719	0.850
Trouble remembering appointments	0.567	0.866
Daily problems with thinking	0.651	0.858

SPSS generated Eigenvalues from the AD8 pilot-testing data set was greater than to only one of the Parallel Analysis Engine generated random Eigenvalues Table 7. Hence, a single factor was retained explaining 55.25% of the total variance. The factor loadings of the Amharic version of AD8 was strong (> 0.4) for all items and ranged from 0.49 to 0.863. The lowest factor loadings were to Question # 2 ‘Less interest in hobbies/activities’ (0.491) and to Question # 7 ‘Problem remembering appointments’ (0.590) of AD8. The highest factor loadings were to Question # 3 ‘Repeats the same thing over and over’ (0.863) and to Question # 6 ‘Trouble handling complicated financial affaires’ (0.805) of AD8.

Table 7

Comparison of AD8 initial Eigenvalues with the Parallel Analysis Engine generated random Eigenvalues in Addis Ababa, Ethiopia, 2021.
Component or Factor	1	2	3	4	5	6	7	8
Initial Eigenvalues	4.413	1.002	0.904	0.708	0.397	0.276	0.177	0.122
Percentile Eigenvalue	2.101	1.672	1.381	1.138	0.980	0.835	0.681	0.524

Cognitive interviewing for the FGD

Study participants were females (5/7) and had elementary level education (6/7). Hearing problems necessitated the facilitator to repeat questions and probes over and again. Participants preferred to verbalize their lived experiences to reason and explain the way the AD8 question item was understood and answered Table 8. When a respondent was asked, “What she understood for question item ‘Less interest in hobbies/activities;’ the respondent (R1) replied, “I used to enjoy shopping for holidays… I can’t afford it now.”

Table 8

Cognitive interview particpants’ lived experiences to explain the way AD8 question items were understood in Addis Ababa, Ethiopia, 2021.
Question Items	Respondents’ answers	Facilitator’s probe	Respondents’ answer
Problems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking	I don’t think spending money has relationship with problem of reasoning. I spend money like, I used to.	Are you suggesting removing ‘difficulty of spending money’ from the question?	The question is about how and when I should spend my money… I don’t think it has anything to do with Alzheimer.
Less interest in hobbies/activities	I am reserved from things that make me happy.	Why?	Due to aging.
Repeats the same things over and over	Do I repeat sentences? I don’t repeat sentences!!	Is the question clear?	Yes, it is clear. It says,” Do you repeat questions?” Assume I am talking with you now, did I repeat what I have already told you.
Trouble learning how to use a tool, appliance, or gadget	I only have a radio and I don’t have difficulty using it.	Does any one of you know microwave?	What is it?
Forgets correct month or year	(In Ethiopia) months of the year starts in September (Meskerem) and ends in August (Pagume)…	Is it clear? Anyone with different opinion?	No
Trouble handling complicated financial affairs	I pay my “Ider” bill (a type of social insurance) ... I pay my rent every year or month.	Do you have any idea to add?	No
Trouble remembering appointments	…. I don’t have this problem.	I am asking you to know how you understand this question	Some people forget appointments, they may have dementia.
Daily problems with thinking and/or memory	Not to forget things, “I write on my notebook and tell my families to remind me.” This helps me to remember (not to forget).	Is it clear? Anyone with different opinion?	No

Expert panel suggested changes to the reconciled Amharic version of AD8

the panel received summary report findings from pilot-testing and cognitive interviewing. The panel did not find it necessary to make changes to the reconciled Amharic version of AD8, and hence adopted it as a final Amharic version of AD8.

Dementia is under recognized by primary care physicians.(39, 40) The WHO identifies task-shifting and integrating dementia care at primary care centers as a strategy to scale up dementia care in LMIC;(8) a view shared by mental health policy advisors and investigators of Ethiopia.(41–44) The American Alzheimer’s Association recommends AD8 as one of the dementia screening instruments in a primary care setting.(9) Cross cultural adaption is a well-recognized strategy to ensure the psychometric equivalence of an instrument.(17–21, 23, 26–30, 45) The content validity and face validity equivalences of the Amharic version of AD8 should be determined before utilizing it as a dementia screening tool in primary care centers.(25, 30–32, 36, 38, 46–48) We employed the WHO translation and adaptation process to adapt and document the cross-cultural adaptation processes of AD8 into Amharic, a national language of Ethiopia.

AD8 is translated into different languages and is in use by different countries.(14–16, 49–51) Nevertheless, the content and face validities of AD8 are rarely reported by investigators; a fact that has made comparison difficult. To our knowledge this is the first cross-cultural adaptation study that has described the methodological details used to determine the content and face validity equivalence of the Amharic version of AD8. The following steps were adhered to minimize subjectivity in the adaptation process of AD8: set a standard operation procedure for the panel; independently rate each question item via Epicollect5; Lawshe’s CVRs and CVI were calculated for each question item to identify areas of disagreement and to determine focus of deliberations;(31, 32) the panel was provided with summary reports of the pilot-testing and cognitive interviewing; and the panel has documented the changes made, the reasons for change, and vote of consensus for each question item at every step of panel deliberation. These sets of procedures enabled us to independently monitor, evaluate and ensure the quality of adaptation processes. As observed in other studies, the Amharic version of AD8 dementia screen demonstrated a very good internal reliability with strong item correlation, and scaled into a single factor.(10, 52)

Field notes, transcripts and audio recordings accessed from cognitive interviewing were explored for deductive coding schemes using Presser and Blair emotional and cognitive coding sets.(25, 36–38) In our study the field note taker and FGD moderator felt participants had hearing problems and the PIs perceived FGD particpants had difficulty with the cognitive response task but not with the survey response task. Hence, we deferred emotional and cognitive coding schemes and opted for in vivo coding to capture the essence of the survey response task.(25) The majority of our cognitive interviewing study particpants had attained elementary level education which imparts a high level of functional illiteracy.(53) Illiterate and functionally illiterate individuals are reported to have deficits in their language, cognition and numerical abilities that potentially limit their ability to meaningfully engage in the think aloud verbal protocol analysis.(25, 53)

The Amharic version of AD8 fulfills the perquisite for the development of mobile health based AD8 dementia screening at primary care settings of Ethiopia and aligns with the WHO task-shifting strategy of dementia screening.

AD8 “ Eight-item Interview to Differentiate Aging and Dementia”
Consolidation Framework for Implementation Research (CFIR)
Content validity ratio (CVR)
Content validity index (CVI)
Coronavirus Disease (COVID)
Epicollect5 ( mobile and web application for free data collection)
Focus group discussion (FGD)
WHO (world health organization)

Ethics approval and consent to participate: The College of Health Sciences Institutional Review Board approved the study proposal (Protocol Number 08/20/Neuro) and Addis Ababa City Administration Health Bureau gave permission (Ref No AA13680/227) to access facilities and conduct pilot-testing and cognitive interviewing in ten health centers of Yeka and Lideta Sub-Cities of Addis Ababa, Ethiopia. Furthermore, all methods were performed in accordance with the guidelines and regulations of the College of Health Sciences Institutional Review Board, and an informed consent was obtained electronically and/or in person from all study subjects and/or their legal guardian(s).
Consent for publication: Not applicable.
Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due lack of clear policy by Addis Ababa university for data sharing but available from the corresponding author on reasonable request.
Competing interest: The authors declare that they have no competing interests.
Funding: This research was funded by administrative supplements to existing NIH grants and cooperation agreement for a project titled Health Professionals Education Partnership Initiative Ethiopia. The grant identification number was R25TW011214-02 and the requested supplement period was from 09/01/2020 to 08/31/2021. The funding organization did not have any role in the design of the study and data collection, analysis, and interpretation of data and in writing the manuscript.
Authors contribution: Seid Ali Gugssa,Yared Zenebe, Susanne Seeger Dawn Comeau and Miliard Derbew contributed to the conception, design, acquisition, analysis, and interpretation of the data. All authors have approved the submitted version and agreed to be accountable to for authors own contribution.
Acknowlegment: We would like to acknowledge Professors Mesfin Araya, Atalay Alem, Jemal Haidar, Ahmed Ali, and Doctors Mitike Molla, Hanna Demissie, Binyam Alemayehu, Abenet mengesha and Ribka Birhanu for their priceless service as expert panel. We would like to extend our heartfelt appreciations to all study participants, coordinators, data collectors and to the office of Medical Education Partnership Initiative Ethiopia. Finally, we would like to acknowledge and thank NIH for funding this work.

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No competing interests reported.

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Cross-cultural adaptation of AD-8 into Amharic for operationalizing the detection of cognitive impairment in a primary care setting of Ethiopia

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