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 Table of Contents  
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 173-178

Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain

Department of Musculoskeletal Physiotherapy, MGM College of Physiotherapy, Navi Mumbai, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Vrushali P Panhale
Department of Musculoskeletal Physiotherapy, MGM College of Physiotherapy, Sector 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_41_18

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Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK (r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS (r = 0.48, P = 0.00) and between FABQ-M and RMDQ (r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population.

Keywords: Fear-Avoidance Beliefs Questionnaire, low back pain, Marathi version, translation, validation

How to cite this article:
Panhale VP, Gurav RS, Suradkar K. Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain. Indian J Pain 2018;32:173-8

How to cite this URL:
Panhale VP, Gurav RS, Suradkar K. Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain. Indian J Pain [serial online] 2018 [cited 2020 Jul 13];32:173-8. Available from: http://www.indianjpain.org/text.asp?2018/32/3/173/249103

  Introduction Top

Patient is considered as the highlight for any health-care system. The Institute of Medicine defines the patient-centered health care as providing the care that is respectful of and responsive to individual patient preferences, needs, and values ensuring that patient values guide all clinical decisions.[1] Nowadays, there is growing realization for the patient-centered health-care system.[2] The outcomes of a clinical intervention obtained by the patient, that is, patient-reported outcomes (PROs) seem to be of equal importance to outcomes such as clinical, physiological, or caregiver-reported. Patient-reported outcome measures (PROMs) are questionnaires measuring the patients' views of their health status. Patients' own perceptions of their health and experiences are key to providing excellent patient-centered care.[3] As per studies, enhanced treatment adherence and outcomes can be obtained by giving attention to patient feedback on health-care outcomes and patient behavior change.[4]

Nonspecific chronic low back pain (CLBP) has adverse effects on the human body. Its effects are adverse leading to restrictions in daily activities, can cause disability, and also affect the quality of life of patients. The factors influencing disability include not only the pain related to the condition but also the psychosocial factors. Psychosocial factors such as, fear of pain, activity avoidance behavior, and beliefs about the potential effect of pain on work activity (WA) and physical activity (PA) have been shown to influence disability.[5] Fear-avoidance beliefs describe patients' worries that their pain/injury will be exacerbated by certain activities and these should be avoided. These beliefs often cause such individuals to avoid engaging in PAs for fear of more pain or further injury. This can result in increased disability, work absenteeism, heavy reliance on medications, and excessive use of medical services.

To assess the fear-avoidance behavior, Waddell et al. developed a Fear-Avoidance Beliefs Questionnaire (FABQ) in English language, which is widely used to test the behavioral components in LBP patients.[6] FABQ has been in use in different populations. It has been translated to German, Dutch, Swiss-German, French, Brazilian Portuguese, Norwegian, Spanish, Greek, Chinese, Arabic, Italian, and Hausa.[5],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17]

India is diverse nation with varying cultures and languages. Marathi is the language that is spoken widely along the Western coastal region in the state of Maharashtra. However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use.

The translation and cultural adaptation of instruments is an internationally recognized and valid method. The process involves translation of instrument from one language to another, synthesis, back translation, expert committee review to finalize the pilot testing version, pretesting (pilot-testing), feedback, and psychometric evaluation.[17]

Therefore, the present study had two objectives. In the first phase, cultural adaptation and translation of the FABQ into Marathi were performed. In the second phase, preliminary assessment of the reliability and validity was conducted for the final version of the FABQ-Marathi (FABQ-M) in patients with CLBP.

  Materials and Methods Top

After seeking permission from the Institutional Research Review Committee, the study was conducted in two phases.

Phase 1 involved translating the original FABQ into Marathi using forward-backward translation process given by Beaton.[18] The process comprised five stages explained in detail as follows:

  • Stage I: Initial translation – The first stage in adaptation is the forward translation. Two forward translations were made from the original language (English) to the target language (Marathi). In this way, the translations were compared for discrepancies. It is necessary for the bilingual translators to have the target language as their mother tongue. The two translators had different profiles and backgrounds. One of the translators was aware of the concepts being examined in the questionnaire being translated. The other translator was not aware of the concepts being quantified and had nonmedical background.
  • Stage II: Synthesis – The two translators and a senior physiotherapist synthesized the results of the translations. With the use of the two forms, a single questionnaire was formulated adjusting the discrepancies between the two.
  • Stage III: Back translation – Totally blind to the original version, a translator then translated the FABQ of Marathi back into the original language (English). This is a process of validity checking to make sure that the translated version is reflecting the same item content as the original versions.
  • Stage IV: Expert committee review – The composition of this committee is crucial to achievement of cross-cultural equivalence. The committee consisted of four translators and two senior physiotherapists. Committee reviewed all the translation and reached a consensus on discrepancies. This formed the prefinal version.
  • Stage V: Pilot testing – A group of patients (total of 5) with LBP were selected for pretesting the prefinal version. These patients spoke and understood both English and Marathi languages equally well. Patients were interviewed to assess their interpretation of each question and their chosen response. This was checked to know missing responses and presence of difficulty in understanding the meaning of words. Each of them were given the newly translated FABQ-M and FABQ English. They were also asked for their general comments on the questionnaire. They showed no difficulty in understanding the newly developed version and so this formed the final FABQ-M [Annexure 1].

Phase 2 consisted of testing the reliability and validity of the FABQ-M.

A study population of 100 participants with chronic nonspecific mechanical LBP (pain lasting for >12 weeks of period) participated in the study. Informed consent was obtained from each participant. Participants with acute LBP, acute malignant conditions in LBP, pregnant women, traumatic cases, and congenital conditions of the spinal cord were excluded. Sociodemographic details of the participants were collected such as age, gender, academic level, and pain duration. Pain intensity was measured by the Numerical Rating Scale (NRS). Disability in daily activities was measured by the Roland–Morris Disability Questionnaire (RMDQ). The fear of movement was assessed by the Tampa Scale of Kinesiophobia (TSK). To assess the test–retest reliability FABQ-M was administered twice, the repeat administration being after 24 h in order to minimize the clinical and cognitive changes.

Outcome measures

Fear-Avoidance Beliefs Questionnaire

The FABQ consists of two subscales. The first subscale (items 1–5) is the PA subscale (FABQ-PA), and the second subscale (items 6–16) is the WA subscale (FABQ-WA).[6] Each subscale is graded separately by summing the responses of respective scale items (0–6 for each item); for scoring purposes. Only 4 of the PA scale items (24 possible points) and only 7 of the work items (42 possible points) are scored. The score range is 0–96, with a higher value reflecting a higher degree of fear-avoidance beliefs. A higher score indicates more strongly held fear-avoidance beliefs.

Numeric Rating Scale

This widely used measure of pain intensity ranged from 0 (no pain at all) to 10 (the worst possible pain) and was self-administered.[19]

Roland–Morris Disability Questionnaire

This is a specific outcome measure designed to be completed by patients with physical disability caused by LBP. It consists of 24 items, and the total score may vary from 0 (no disability) to 24 (maximum disability). We used Marathi version of the RMDQ.[20],[21]

Tampa Scale of Kinesiophobia

This assesses pain beliefs and pain-related fear of movement/reinjury in participants with musculoskeletal complaints and consists of a 17-item self-report questionnaire in which each question is scored using a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree); the total score is calculated by adding the scores of the individual items and ranges from 17 to 68. In this study, we used the English 17-item version.[22]

Statistical analysis

The Statistical Package for the Social Sciences (SPSS), version 16.0 (SPSS Inc., Chicago, IL, USA), was used to analyze the data.

Test–retest reliability or reproducibility was tested in a test–retest design and was evaluated using the intraclass Correlation Coefficient (ICC). The ICC was interpreted as follows: <0.40, poor reliability; 0.40–0.75, moderate reliability; 0.75–0.90, substantial reliability; and >0.90, excellent reliability. The internal consistency (homogeneity) was evaluated by Cronbach's α coefficient, which is considered statistically significant when between 0.70 and 0.95. Potential ceiling-and-floor effects were considered present if >15% of respondents achieved the lowest or highest possible total scores (ceiling-and-floor effects were not related to individual items). Construct validity was assessed by Pearson's correlation coefficient in numerical scales. The relationships were interpreted as highly correlated for r ≥ 0.60, moderately correlated for r = 0.30–0.60, and weakly correlated for r ≤ 0.30. Convergent validity was assessed by correlating the FABQ-M with TSK. Divergent validity was assessed by correlating FABQ-M with NRS for pain and RMDQ.

  Results Top

The study included a total of 100 participants with 55 men and 45 women with a mean age of 33.97 years (SD = ±11.54). The other sociodemographic characteristics are as shown in [Table 1]. FABQ was successfully translated in Marathi version using forward-backward translation. It took 40 days to complete a culturally adapted version. At the end of the pilot study, results from the interview showed that the patients understood the meaning of all questions properly. No help was required for interpretation of the questions. Time taken to complete the questionnaire was 7.25 ± 1.5 min.
Table 1: Sociodemographic characteristics of the participants

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The reliability was tested by measuring internal consistency and test–retest method. The Cronbach's alpha for FABQ = 0.860, Cronbach's alpha for PA = 0.731, and Cronbach's alpha for WA = 0.822. Correlation between FABQ-M on day 1 (test) and day 2 (retest) were highly significant. The intraclass coefficient was 0.976. The ICC values for it subscales were FABQ-PA = 0.95 and FABQ-WA = 0.95.

The convergent validity was assessed by correlating FABQ-M with TSK. Divergent Validity was assessed by correlating FABQ-M with NRS and RMDQ as shown in [Table 2].
Table 2: Convergent and divergent validity

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There were no ceiling-and-floor effects for the FABQ total scores as none of the participants achieved the lowest possible score and only one patient achieved the highest score.

  Discussion Top

To the best of our knowledge, this is the first study to translate, culturally adapt, and validate the FABQ for Marathi speaking patients with chronic nonspecific LBP. The translation and cross-cultural adaptation of the FABQ-M was successfully carried out by the forward-backward translation process, which is a recommended guideline given by Beaton. The pilot testing showed us that all the translated questions were properly understood without any difficulties. Hence, it was finalized without the need for any modifications. The Marathi version of the FABQ requires only 7.25 min to be completed making it appropriate for use in routine clinical setup. Despite patients having to fill out the questionnaires with a time gap of 1 day, no patient left the questionnaire unanswered.

FABQ-M was further administered on 100 participants to assess the reliability and validity of the questionnaire. A good internal consistency (0.86) was found for FABQ-M which is consistent with other reports. The correlations among the items showed that the Marathi FABQ-WA and PA subscales were internally consistent and results were similar to the original English version. Our findings are in line with the German (FABQ-WA 1: 0.89; FABQ-WA 2: 0.94; and FABQ-PA: 0.64), Italian (FABQ-I was 0.822; FABQ WA: 0.892, and FABQ PA: 0.739), Swiss-German (FABQ-WA: 0.89 and FABQ-PA: 0.82), Portuguese (FABQ-WA: 0.80 and FABQ PA: 0.90), Norwegian (FABQ-WA: 0.90 and FABQ-PA: 0.79), Spanish (0.93), Greek (FABQ-WA 1: 0.86; FABQ-WA 2: 0.90; and FABQ PA: 0.72), and Chinese results (0.90). FABQ-M demonstrated good test–retest reliability when the instrument was administered to participants a day apart. The ICC scores fell within the excellent reliability range of 0.90–1.00. This is similar to the validation studies of other translated versions.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] Test–retest reliability was found to be (r = 0.970) that indicates it is highly significant correlation between results of FABQ obtained on day 1 and day 2.

The convergent validity of FABQ-M was analyzed by comparing it with the TSK, which measured the same conceptual construct. The moderate correlations between FABQ-M (and its subscales) and TSK suggest that the constructs measured by the two scales are not completely the same. Different researchers have found varied results, Portuguese researchers found a higher correlation with the TSK (0.86), whereas poor-to-moderate correlations (r = 0.25–0.55) were found by Greek researchers. Divergent validity was analyzed by comparing the FABQ-M (and its subscales) with measures of pain (NRS) and disability (RMDQ). There was moderate correlation with pain and RMDQ. Overall, these results suggest that the construct assessed by the FABQ differs from these variables and are in line with most other reports regarding the construct validity of the FABQ.

Using PROMs to assess psychosocial factors in the patients' mother tongue helps to get the accurate response. Cultural adaptation further makes the tool acceptable and increases its usability.

The limitation of the study was that it being a cross-sectional study using PROMs, no physical assessment tests were included. Further studies can be performed to establish relationship between the newly translated FABQ and physical performance.

  Conclusion Top

This study showed that the FABQ-M is cross-culturally adapted and is a reliable and valid questionnaire. This newly formulated questionnaire can be used to determine fear-avoidance beliefs related to PA and WA by clinicians to assess kinesiophobia in all age groups. It is easy to administer and can be recommended for use in routine clinical practice in Marathi-speaking population.


We gratefully acknowledge the support of experts and translators involved in the translation process of the tool. We express our gratitude toward patients who participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Annexure Top

  References Top

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.  Back to cited text no. 1
International Alliance of Patients' Organizations. What is Patient-Centered Health Care? A Review of Definitions and Principles. 2nd ed. London: International Alliance of Patients' Organizations; 2007. p. 1-34.  Back to cited text no. 2
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Institute of Medicine. Crossing the Quality Chasm-A New Health System for the 21st Century. 1st ed. Washington, DC: National Academies Press; 2001.  Back to cited text no. 4
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  [Table 1], [Table 2]


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