Cross-cultural Adaptation of the Arabic Positive and Negative Syndrome Scale in Schizophrenia: Qualitative Analysis of a Focus Group

The Positive and Negative Syndrome Scale (PANSS) is a 30-item clinical scale that provides information on the positive and negative symptoms of schizophrenia.¹ It is a validated and reliable scale.¹ The PANSS contains 3 subscales measuring positive symptoms, negative symptoms, and general psychopathology, which includes anxiety, depression, and insight.² Taken together, these 30 items create a total severity score.

The PANSS is a standardized instrument widely used in clinical research for schizophrenia.² The PANSS allows clinicians to measure a patient’s clinical response to pharmacologic treatment and is commonly used for assessing antipsychotic treatment efficacy.³ Clinical scales must be validated for each new population to which they will be applied. This article looks at the validation of this tool in an Arab population. It is important to consider the whole patient when utilizing clinical scales or creating management strategies. This includes consideration not only of a patient’s language but also of their culture and of the community norms that may affect them. 

Why was this research needed?

Studies looking at the diagnosis of schizophrenia are often completed in Western countries.² In the research we highlight here, the PANSS was evaluated in a population of patients of Arab descent with schizophrenia with the goal of understanding how to best utilize and adapt the scale.² Four main areas were explored in assessing the cultural competence and appropriateness of this scale in the population of interest. The authors examined issues related to translation, interview structure, cultural sensitivity, and rating the scale.²

The PANSS has been translated into more than 30 languages.² An Arabic translation of the PANSS was validated in 2016 in Arab patients with schizophrenia.² Validation of scales across cultures is important because patients with schizophrenia may exhibit different symptoms in different cultural environments. For example, studies have shown that in Western countries, patients with schizophrenia are more likely to have depressive symptoms, delusions, and thought insertions, while in non-Western countries, patients with schizophrenia are more likely to experience visual and directed auditory hallucinations.² Additionally, inadequate translation can affect a scale’s reliability.² Thus, the PANSS was tested in the population of interest and adapted to suit these patients.

What did the researchers do?

The PANSS had been previously translated to Arabic using the back-translation method by 3 bilingual psychiatrists and 2 professional translators.² This method involves re-translating content from the target language back to its source language to ensure that it has retained important points.

The authors of this paper translated, culturally adapted, and validated the Arabic version of the PANSS in patients with schizophrenia in Qatar.² The study population for the validation project was Arab schizophrenia patients attending the Department of Psychiatry at Rumailah Hospital, Hamad Medical Corporation (HMC), and Weill Cornell Medicine – Qatar from 2013 to 2014.² Semi-structured focus groups were held, including the clinical research coordinators (CRCs) and the principal investigator, all of whom were fluent in English and Arabic. The CRCs were trained in the administration of PANSS and attended an intensive training course held by the PANSS Institute.² All participants had medical backgrounds and some level of experience in mental healthcare.² During these sessions, particular attention was paid to whether there were domains that should be added to, removed from, or modified in the Arabic PANSS.²

A thematic analysis approach was used to clarify emerging themes. This approach consisted of 6 steps.²

1. Materials underwent multiple revisions to extract relevant data.
2. Initial observations from transcripts were coded.
3. Initial comments and codes were then analyzed to identify themes.
4. Themes were organized into groups, and a thematic chart was created.
5. These organized themes were defined according to their overall cultural significance.
6. Emerging themes were supported by participant quotes and divided according to their relevance to the study’s goals.
   
   

What were the main results of the study?

PANSS interview and rating

The authors determined that the formal Arabic translation of the PANSS did not match up with all Arabic dialects. For example, the Arabic word for “delusion” is not commonly used in Qatar. Therefore, CRCs would substitute words in interviews based on a patient’s understanding, local culture, education level, and Arabic dialect.²

Differences in spoken language, methods of communication, and presentation of psychiatric symptoms among different communities may impact the findings of the adapted PANSS.² Certain words have different meanings based on the particular Arabic dialect spoken in the area in which a patient resides. Such differences in meaning were identified and considered in PANSS administration for Arabic-speaking patients.² For example, the CRCs replaced “carrying a chip on your shoulder” with “coming with trouble on his face.”²

Specific cultural themes

In addition to the semantic constructs discussed above, specific cultural themes identified in this study included religion, beliefs, and gender.²

In Qatar, the Islamic religion is a central pillar of life. CRCs agreed that some questions in the PANSS were, when applied to individuals within Islamic culture, insensitive and required changing.²

Per the authors, Arabs firmly believe in the existence of supernatural forces and that psychiatric illness is somehow related to these forces.² This belief could make it difficult to determine if certain thoughts or behaviors were psychotic features or simply due to cultural norms.²

There are also differences in perceptions of and ways of coping with mental illness between male and female patients.² Families of female patients were more likely to attempt to shield the patient and not bring them in for treatment. Thus, male and female individuals in this cultural setting may not receive equal care.² Additionally, female patients may not be free to interact with a male rater in the same manner as a male patient may, thus creating inequalities in administration across genders.

Why were these results important?

This qualitative study explored the use of the translated PANSS scale in Arab patients with schizophrenia. It identified 2 main issues in administration and scoring of this scale: differences in dialect among communities of Arab patients and differences in religious and cultural beliefs and norms.² The authors concluded that appropriate training of CRCs can address the differences in dialects among different patient groups. They also stated that cultural differences could influence patients’ and family members’ beliefs and if, how, and when they would seek medical care for symptoms of schizophrenia.²

In general, psychiatric scales should be culturally adapted to and appropriately translated for the specific population of intended use before being utilized in clinical practice in that population.² Additionally, it is important that those administering the scales have some familiarity with the patient’s culture and language or dialect.²

Limitations

The heterogeneity of the population studied may make it difficult to best understand necessary changes to the administration of the scale within smaller, more homogenous groups.² Such factors include differences in local dialects and regional differences in culture and community beliefs. Thus, word choice may need to be modified or patient responses individually interpreted.

What’s next?

Clinicians administering the PANSS scale in Arabic should be trained to consider the effects of local dialects, religion, and social constructs.² Larger studies of patients and caregivers are needed to improve the process of refining the translations as well as for training raters to administer the PANSS.²  

This summary was prepared independently of the study’s authors.

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.   

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