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Cross-cultural Adaptation of the Health Sciences Evidence-based Practice Questionnaire into Japanese and Its Test–Retest Reliability in Undergraduate Students

ABSTRACT Objectives: The Health Sciences Evidence-Based Practice (HS-EBP) questionnaire was recently developed for measuring five constructs of evidence-based clinical practice among Spanish health professionals by applying content and construct validity investigation. The current study aims to undertake a cross-cultural adaptation of the HS-EBP into Japanese and to investigate the internal consistency and test–retest reliability of the Japanese HS-EBP among undergraduate students of nursing and physical and occupational therapies. Methods: Cross-cultural adaptation was undertaken by following Beaton’s five-step process. Subsequently, the Japanese HS-EBP test–retest reliability was assessed with a 2-week interval. Participants were recruited from among third and fourth grade undergraduate students of nursing and physical and occupational therapies with clinical training experience. Results: Pilot testing included 30 participants (11 nursing students, 11 physical therapy students, 8 occupational therapy students). Consequently, we developed the Japanese HS-EBP to be understandable for undergraduate students of nursing and physical and occupational therapies. Data from 52 participants who completed test–retest reliability questionnaires demonstrated adequate test–retest reliability in the total scores of Domains 1, 3, 4, and 5 [intraclass correlation coefficients were (ICC)=0.74, 0.70, 0.75, and 0.74, respectively]; the exception was Domain 2, which had an ICC of 0.66. Internal consistency (Cronbach’s α) was adequate for Domains 1–5, for which α was 0.87, 0.94, 0.86, 0.93, and 0.95, respectively. Conclusions: This study developed the Japanese version of HS-EBP and provided preliminary evidence of adequate internal consistency and test–retest reliability in most domains for undergraduate students of nursing and physical and occupational therapies.


INTRODUCTION
The importance of evidence-based practice (EBP) is recognized by healthcare professionals worldwide, and many tools exist to evaluate its adherence and compliance. A recent systematic review found that no measure provided adequate construct validity. 1) Based on the five steps of EBP processes, 2) the five-domain Health Sciences EBP (HS-EBP) questionnaire was established to evaluate adherence to, and compliance with, EBP among Spanish health professionals. The HS-EBP was developed by applying content validity investigation using the Delphi technique 3) and statistical ex-amination for the construct validity. 4) Criterion-related and convergent validity of the HS-EBP has also been confirmed with other measures such as dispositional resistance to change and intrinsic motivation. 4) Cross-cultural adaptation of the HS-EBP has been initiated worldwide. For example, in the Chinese version, preliminary evidence of the content validity has been established. The five-factor structure and adequate internal consistency have been confirmed among nurses in Taiwan. 5) However, the Japanese version has not yet been developed, and its testretest reliability has not been examined in languages other than Spanish.
Regarding EBP in Japanese rehabilitation medicine, Fujimoto et al. 6) reported that most physical therapists recognized its importance (83.3% of the 384 participants) and usefulness for clinical decision-making (77.1%). However, only 11% of the participants reported a history of EBP education. In nursing, only 29% of 472 nurses in two university-affiliated hospitals in Tokyo reported a history of EBP. 7) Therefore, facilitating EBP education is necessary in undergraduate and postgraduate rehabilitation medicine training in Japan. The HS-EBP questionnaire can be used as a useful training guide.
The current study aims to undertake a cross-cultural adaptation of the HS-EBP questionnaire into Japanese and to investigate the internal consistency and test-retest reliability of the Japanese HS-EBP among undergraduate students of nursing and physical and occupational therapies.

Design
The Institutional Research Committee of Saitama Prefectural University approved this study (#20011), and written informed consent was obtained from each participant before data was collected. First, approval for translation of the HS-EBP into Japanese was obtained from the original developer, current coauthor (JCF). Cross-cultural adaptation was undertaken based on the five steps of the Beaton guidelines 8) : (1) forward translation (two independent versions), (2) synthesis of the two translations, (3) backward translation (two independent versions), (4) expert committee review, and (5) pilot testing. Subsequently, the test-retest reliability of the HS-EBP was assessed.

Cross-cultural Adaptation
For the forward translations, two Spanish-Japanese bilingual translators (YK and KY) independently translated the HS-EBP into Japanese. One translator was a physical therapist who was aware of the aims of the HS-EBP. The other was a professional Spanish translator, not a healthcare provider, who was unaware of the aims of the HS-EBP. In the synthesis meeting to conflate the two forward translations, a combined Japanese draft was developed through discussions among the two forward translators and a current author (HT). Modifications to ensure semantic, idiomatic, experiential, and conceptual equivalences were recorded. 8) In the backward translation, the combined Japanese draft was then translated into Spanish independently by two professional translators (HU and SN) who were not healthcare providers and were unaware of the aims of the HS-EBP. An expert committee review was held with eight members, namely, the translators of the forward and backward translations and four current coauthors (HT, KK, HC, and YH). Finally, a provisional draft questionnaire to be assessed by pilot testing was reviewed by the developer to confirm its conceptual equivalences to the original. For pilot testing, third and fourth grade undergraduate students (n=30) of nursing and physical and occupational therapies with clinical training experience were recruited in March 2021 by advertisements placed in Saitama Prefectural University, Saitama, Japan. Data collection was executed through online survey (SurveyMonkey, San Mateo, CA, USA). After the participants' demographic data (age, sex, grade, and discipline) were gathered, they were asked, "Did you understand the sentence?" The participants rated their understanding of each item, including the instructions, on a five-point numerical rating scale: 1="I could not understand the sentence at all" and 5="I understood it completely." 9) For items with a score of <4, reasons for modification and suggestions were requested. Considering these suggestions, the items were modified without changing their meaning by four coauthors (HT, KK, HC, and YH). Appendix 1 shows the resulting Japanese HS-EBP questionnaire, with the URL of an English version of the HS-EBP for reference. The details of the point-by-point modifications of the draft Japanese HS-EBP are shown in Appendix 2.

Reliability
Participants were recruited in March 2021 via advertising in Saitama Prefectural University, Saitama, Japan. Included were third and fourth grade undergraduate students of nursing and physical and occupational therapies with clinical training experience. Exclusion criteria were those participants who had their last clinical training experience more than 6 months previously and those who did not take the second test within 2 days of the target time.
Data were collected twice with a 2-week interval (the second testing survey link was e-mailed to each participant) following the suggestion of the Consensus-based Standards for the Selection of Health Measurement Instruments (COS-MIN). 10) At initial testing, after collection of demographic data, participants completed the Japanese HS-EBP questionnaire with reference to experience of their last clinical training period; the time taken to complete the HS-EBP questionnaire was measured. At the second testing, the participants completed the HS-EBP without seeing or trying to recall the responses of the initial testing; participants were asked to take roughly same amount of time as for the initial testing. The Japanese HS-EBP has 60 items, which the participants rated according to their degree of agreement using a ten-point numerical rating scale (1=the lowest agreement; 10=the highest agreement). The Japanese HS-EBP has five domains: (1) Beliefs-Attitudes (12 items with total scores ranging from 12 to 120), (2) Results of scientific research (14 items with scores ranging from 14 to 140), (3) Development of professional practice (10 items with scores ranging from 10 to 100), (4) Assessment of results (12 items with scores ranging from 12 to 120), and (5) Barriers-Facilitators (12 items with scores ranging from 12 to 120). Higher scores indicate greater supporting attitudes or behavior toward the application of EBP in clinical practice.
Participant recruitment continued until a sample size of 50 was achieved for the second testing, a number that was rated as adequate by COSMIN. 11) Test-retest reliability was assessed using ICC for each item and domain; ICC values ≥0.7 were considered adequate. 12) Further, the minimum detectable change (MDC) for each domain was calculated using the following formulas: where SD is the standard deviations of combined data samples in the initial and second testing, and the MDC is the smallest integer. Internal consistency was assessed using data from the initial testing in each domain, considering Cronbach α ≥0.7 to be adequate. 10) Data distributions were assessed using data from the initial testing for each item and domain, considering floor or ceiling effects when >15% of the responses were the minimum or maximum score. [13][14][15] Furthermore, Spearman's ρ was calculated using data from the initial testing across each domain to examine each domain's similarity because of uncertainty about the normal distribu-tion of all datasets; inter-domain correlation ρ ≥0.3 10) was considered adequate, as reported in the original HS-EBP. 4) Statistical analysis was conducted using the Statistical Package for the Social Sciences (version 21.0, IBM Corporation, New York, USA) with statistical significance set at 5%. Table 1 presents a summary of the 30 participants involved in the cross-cultural adaptation of the HS-EBP. During pilot testing with the 30 participants, we obtained 1-6 comments/ suggestions per item that had a score <4 for understanding on a 5-point numerical rating scale; 28 of the 60 items and 3 instructions (Domains 1, 2, and 5) had at least one understanding score <4. Appendix 2 summarizes the modifications to the translation made as a result of the pilot testing and shows the resulting changes to the Japanese HS-EBP.

RESULTS
In the reliability assessment, 53 participants completed the initial test questionnaire, and 52 completed the second questionnaire. Consequently, data for 52 participants were analyzed; the demographic data for the 52 participants are summarized in Table 1. The mean (standard deviation) time to complete the Japanese HS-EBP was 11.0 (5.7) min. The ICC values and the ceiling and floor effects are summarized in Table 2

DISCUSSION
In the current study, a Japanese version of the HS-EBP questionnaire was developed, based on Beaton's guidelines. 8) that was applicable to both professionals and undergraduate students. The HS-EBP is superior to other EBP participant-reported outcome measures (PROMs) because of its more rigorous development process, including content validity considerations. 3) Therefore, the Japanese HS-EBP is expected to be a foundation for investigating solutions aimed at enhancing EBP in clinical practice in Japan. Further, items of the Japanese HS-EBP can act as reference points for training to enhance EBP adherence and compliance among undergraduate students and rehabilitation professionals in Japan.
Reliability assessments confirmed adequate internal consistency and inter-domain correlations, consistent with the findings of a previous study using the original Spanish HS-EBP and including 869 professionals in medicine (55%), nursing (14%), physical therapy (20%), and psychology (9%) in Spain. Further, adequate test-retest reliability was observed in the total scores in four domains; the exception was the 14-item Domain 2 (Results of scientific research) (ICC=0.66). However, the ICC values in the current study are comparable to, or better than, those of the previous study, 4) whose ICC values (95% confidence intervals) were 0.53 (0.5-0.55), 0.63 (0.61-0.65), 0.35 (0.32-0.37), 0.57 (0.54-0.60), and 0.47 (0.44-0.49) for Domains 1-5. These findings support the reliability of the Japanese HS-EBP among undergraduate students of nursing and physical and occupational therapies.
Cronbach's α for the internal consistency was greater than 0.90 in Domains 2, 4, and 5. However, scales with α >0.9 are known to include redundant items. 16) Further, the average time to complete the Japanese HS-EBP was 11.0 min, with a median of 10 min being feasible for a web survey. 17) Nonetheless, there were items with inadequate test-retest reliability. Potential reasons for such low ICCs may include problems in the item's comprehensibility and the psychometric property of the content validity, 18) which indicate that the participants might have had difficulty in correctly understanding items with low ICCs. Another potential reason could be a problem with the ten-point scale: Simms et al. 19) suggested that an optimal scale for a PROM is a 6-point Likert scale rather than the 0-10 scale for PROMs. The Japanese HS-EBP is expected to be used with other PROMs to explore strategies to enhance EBP in clinical practice. Therefore, it would be useful to make a shorter version of the Japanese HS- These findings indicate that the Japanese version of the HS-EBP may have responsiveness concerns among undergraduate students of nursing and physical and occupational therapies. However, such a biased response may also be a feature of a small cohort of undergraduate students. In the future, with a far larger cohort that includes professionals, Rasch analysis will be required for targeting evaluation to investigate each item's appropriateness and the appropriateness of the 0-10 scale.
The current study's possible limitations include the sampling process, since participation was voluntary. Therefore, those with low and high confidence levels toward EBP might have chosen not to participate in the study (self-selection bias); however, some of those with particularly high confidence toward EBP might have participated (self-serving bias). These factors might help to explain why more ceiling effects were observed than floor effects in each item across each domain. However, the effect of these potential limitations on the current findings of adequate reliability in most domains is uncertain. Further investigations using more robust sampling methods are required to comprehensively establish the reliability of the Japanese HS-EBP.
In conclusion, this study developed the Japanese version of the HS-EBP. We found preliminary evidence of adequate internal consistency and test-retest reliability in most domains for undergraduate students of nursing and physical and occupational therapies. The need for further investigations to develop a shorter version with higher test-retest reliability   was also considered.

CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.
Copyright © 2021 The Japanese Association of Rehabilitation Medicine APPENDIx Appendix 1. The Japanese Health Sciences Evidence-based Questionnaire (Japanese HS-EBP) An English version of the Health Sciences Evidence Based Questionnaire is available for reference: (https://doi.org/10.1371/ journal.pone.0177172.s002).

Japanese HS-EBP
The questionnaire you are about to answer is designed to collect information on the use of Evidence Based Practice in Health Sciences in Spain.
Expressions were shortened to enhance readability. For the purpose of generalizability, "Spain" was omitted. To enhance readability, the abbreviation "EBP" was used because "Evidence Based Practice" was repeatedly used.
(Evidence Based Practice: EBP) Domain 1 (Beliefs-Attitude) This part of the questionnaire aims to find out your OPIN-ION concerning different aspects related to the paradigm of Evidence Based Practice. Rate on a scale of 1 to 10 the level of agreement you have with the following statements (where 1 corresponds to the lowest and 10 the highest).
The word "paradigm" was considered difficult for students to understand; consequently, an explanation was given in parentheses. "Practice" was translated as "clinical practice" throughout the questionnaire as it was considered more natural to say "CLINICAL practice" than "practice" as far as EBP is concerned in Japanese.

NO CHANGE (n=2) EBP
Item 1-3. EBP must play a positive role in my professional practice.

MINOR (n=1) EBP
Item 1-4. I consider EBP improves the quality and results of interventions.

MINOR (n=2) EBP
Item 1-5. In professional practice, EBP is a helpful tool for decisionmaking.

EBP
Item 1-6. EBP involves getting more efficient results. Item 2-9. I usually assess the quality of the methodology used in the research studies I find.

EBP
We added "when I read research papers" to enhance readability in Japanese.

MINOR (n=1)
Item 2-10. I recognize the possible bias or confusion factors and limitations of the studies selected.
We added "when I read research papers" to enhance readability in Japanese.

MINOR (n=2)
Item 2-11. I am capable of interpreting the practical implications of statistical results. The same scoring information was used as the instruction in Domain 1 to enhance readability.

MINOR (n=1)
Item 5-2. In my workplace there are documents that guide interventions towards EBP.