Translation, Cultural Adaptation, and Validation of the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) in Chinese

Abstract

Background

Rhinoplasty requires balanced consideration of function and aesthetics, necessitating a precise evaluation tool. A reliable and validated patient-reported measure, the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) evaluates both aspects but was previously unavailable in Chinese. This study fills that gap by providing a Chinese version.

Objectives

In this study we aimed to translate, culturally adapt, and validate a Chinese iteration of the SCHNOS (C-SCHNOS) for appraising the functional and aesthetic outcomes among Chinese patients following rhinoplasty, furnishing a reliable and efficacious assessment tool for Chinese users.

Methods

Following international guidelines, the SCHNOS questionnaire was translated and culturally adapted for Chinese use. Its psychometric properties, including internal consistency, correlations, and reproducibility, were evaluated among Chinese natives in Sichuan Province from March 2022 to January 2023.

Results

The C-SCHNOS was administered to 110 Chinese natives, showing high internal consistency, with Cronbach's α of 0.81 for SCHNOS-O (obstructive domain) and 0.92 for SCHNOS-C (cosmetic domain). Spearman correlations for SCHNOS-O (0.36-0.65) and SCHNOS-C (0.51-0.74) were positive and significant. Test-retest reliability analyses revealed strong Spearman correlations for SCHNOS-O (r = 0.87) and SCHNOS-C (r = 0.90). Responsiveness was statistically significant for SCHNOS-O (P < .001) but not for SCHNOS-C (P = .222). Exploratory factor analysis and parallel tests indicated that C-SCHNOS maintained a single-factor structure, with eigenvalues exceeding the critical values (2.55 for SCHNOS-O and 4.35 for SCHNOS-C), reflecting excellent unidimensionality.

Conclusions

The SCHNOS questionnaire was successfully translated into Chinese and culturally adapted. The C-SCHNOS is a dependable and valid instrument for utilization in the Chinese population in patients undergoing functional or cosmetic rhinoplasty.

Rhinoplasty stands as the most prevalent surgical intervention in global facial plastic surgery and otolaryngology, serving to alter both the form and function of the nasal structure, whether undertaken for aesthetic refinement or to address functional requirements pertaining to nasal obstruction.^1,2 Given the intimate association between nasal functionality and aesthetics, procedures aimed at cosmetic nasal enhancement may impact nasal function and vice versa.³ Although numerous tools have been developed to assess postrhinoplasty aesthetic or functional outcomes, few encompass evaluations of both aspects simultaneously.⁴ Among these, the Standardized Cosmetic and Health Nasal Outcomes Survey (SCHNOS) emerges as a tool specifically designed to concurrently assess functional and aesthetic components in rhinoplasty, representing a reliable, consistent, and validated patient-reported outcome measure (PROM) tool.^5,6 Consequently, the widespread development of relevant PROMs in real-world research becomes imperative for evaluating the efficacy of rhinoplasty.⁷

The original version of SCHNOS has been validated in multiple languages, including Spanish, French, Turkish, Arabic, Persian, and Italian, with all these translated versions demonstrating as high levels of internal consistency, reliability, and validity as the original version.^8-13 Strikingly, although Chinese (Mandarin) boasts the largest number of native speakers globally, ranks among the most common second languages, and is an official working language of the United Nations, with over a billion native speakers worldwide, no Chinese adaptation of SCHNOS is yet available.¹⁴

To ensure semantic and conceptual equivalence in PROMs across diverse linguistic and cultural backgrounds, conducting sociocultural adaptation of such tools is recommended.¹⁵ This adaptation not only ensures effective assessment within the patient’s cultural context but also provides standardized tools for comparison across international populations.¹⁶

Against this backdrop, in our study we endeavored to translate the SCHNOS questionnaire into Chinese, adhering to the guidelines set forth by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), and to culturally adapt it for the Chinese population.¹⁷ Subsequently, validation will be conducted among Chinese-speaking populations in China who undergo functional rhinoplasty, cosmetic rhinoplasty, or both, to obtain a SCHNOS questionnaire applicable to the Chinese linguistic environment.

METHODS

The translation and cultural adaptation process of the SCHNOS questionnaire strictly adhered to the relevant guidelines of the ISPOR.¹⁷ This prospective validation study spanned from March 2022 to January 2023, encompassing 2 meticulous sequential phases. In the first phase, through steps such as bilingual expert translation, back translation, group discussions, and pretesting, the accuracy and adaptability of SCHNOS content in the Chinese environment were ensured. In the second phase, SCHNOS surveys were administered to selected rhinoplasty patients and control groups in the Chinese context. With psychometric methods, we thoroughly validated the internal consistency, stability, structural validity, content validity, and discriminant validity of SCHNOS. This research protocol was approved by the Ethics Committee of Sichuan Provincial People's Hospital (IRB NO.-2018-288), and all participants provided written informed consent.

Questionnaire Description

The SCHNOS comprises 10 items for self-assessment, including 4 items related to nasal functional improvement (SCHNOS-O) and 6 items assessing satisfaction with cosmetic outcomes (SCHNOS-C). Patients utilize a 0 to 5 rating scale similar to the Likert scale (“No Problem” to “Extreme Problem”) to respond to these questions. The questionnaire generates 2 scores, 1 for each domain (function and cosmesis), with a maximum total score of 100. Figures 1, 2 illustrate the structure and scoring system of both the Chinese and English versions of the SCHNOS.

Translation Process

Forward Translation and Back Translation

In this study, 2 independent bilingual translators, who were native Chinese-speaking plastic surgeons, initially translated the SCHNOS questionnaire from English to Chinese. Subsequently, 2 additional independent bilingual translators, who were English-native professional translators unfamiliar with the original questionnaire content, translated the Chinese version back into English to ensure the preservation of the original concepts and identify differences from the original English questionnaire. An expert panel of plastic surgeons coordinated and integrated the 2 initial Chinese versions, ensuring respect for the original meanings, to form a preliminary Chinese version of the questionnaire. A new native English independent bilingual translator was then hired to back translate the preliminary Chinese questionnaire into English to verify content fidelity. This back-translated English version was sent to experienced researchers for comparison against the original English questionnaire (Figure 3), ensuring the accuracy and integrity of the questionnaire content.

Cognitive Interviews

Following the aforementioned steps, co-first authors (M.C. and S.C.), fluent in both Chinese and English, conducted 15-minute individual interviews with 10 Chinese-speaking rhinoplasty patients. During the interviews, M.C. reviewed each item of the questionnaire with the patients one by one, aiming to identify potential ambiguities, validate patient understanding, and confirm questionnaire acceptability. Patients were encouraged and asked to orally express their understanding and perceptions about each item of the questionnaire, with detailed feedback recorded. After summarizing the interview data, the research team conducted a review of the translated versions and made necessary modifications to some contents. The revised results were approved by the team of plastic surgeons, who further reviewed the final confirmed Chinese version. After multiple rounds of proofreading and refinement, the translation and cultural adaptation process of SCHNOS from English to Chinese was completed, culminating in a definitive Chinese version of the SCHNOS questionnaire.

Patient Recruitment

The final version of the C-SCHNOS (Chinese iteration of the SCHNOS) questionnaire was given to 55 adult patients who underwent rhinoplasty and 55 control individuals from a provincial hospital in Southwest China. Specifically, the age distribution for our case group ranged from 25.7 to 45.9 years, whereas the control group's ages broadly spread from 28.7 to 56.3 years. Exclusion criteria included various conditions such as craniofacial syndromes, nasal septal perforation, history of head and neck radiation therapy, connective tissue diseases, sinusitis, uncontrolled asthma, sinus tumors, allergic rhinitis, concurrent sinus surgery, inability to understand the questionnaire, age under 18, and craniofacial trauma within the past 3 months. The control group consisted of adult patients without nasal deformities or symptoms such as dizziness, hearing loss, tinnitus, or gastroesophageal reflux disease.⁸ Written informed consent was obtained from all participants, who completed the SCHNOS questionnaire on the day of their visit.

Psychometric Validation and Statistical Analysis

To measure the internal consistency and overall stability of the Chinese SCHNOS-O and SCHNOS-C, Cronbach's α was calculated with single-sided 95% CIs. For Cronbach's α results, values were categorized as excellent (≥0.9), good (0.8-0.9), acceptable (0.7-0.8), questionable (0.6-0.7), poor (0.5-0.6), or unacceptable (<0.5).

To assess the validity and reliability of the questionnaire, test-retest reliability was examined in 110 patients, including 55 rhinoplasty patients and 55 control participants, over a 2-week interval. The distribution of the groups is illustrated in Table 1. Spearman's rank correlation coefficient and the paired-sample Wilcoxon signed-rank test were employed to compare the mean scores of SCHNOS-O and SCHNOS-C domains between the 2 time points (2-week interval). Spearman's rank correlation coefficient was applied to determine the correlation between different items in the Chinese version of SCHNOS-O and SCHNOS-C scales, as well as the reproducibility of scores at different time points, obtaining 2-tailed P values. Correlation coefficients were very weak (<0.19), weak (0.20-0.39), moderate (0.40-0.59), strong (0.60-0.79), or very strong (0.80-1.0). Additionally, we employed the Wilcoxon signed-rank test to compare the mean scores of SCHNOS-O and SCHNOS-C at the 2-week intervals to determine whether significant changes occurred. The significance level for all 2-tailed P values was set at ≤.05. Through these statistical analyses, the stability and consistency of SCHNOS questionnaire scores over the short term could be more accurately assessed.

When exploring the differences between the rhinoplasty group and the control group, we utilized the 2-sample Wilcoxon rank-sum test (also known as the Mann–Whitney U test) to examine whether significant differences existed between the 2 groups of participants in their initial SCHNOS questionnaire responses. The significance threshold level was set at a 2-tailed P of value ≤.05. If the P value was ≤.05, significant differences in scores between the 2 groups in that specific domain were considered.

Exploratory factor analysis (EFA) was conducted on the initial score data obtained from 110 respondents to reveal the underlying structure of the SCHNOS questionnaire and to identify the main factors or dimensions influencing patient experiences in both functional and cosmetic aspects following rhinoplasty. This EFA included quantitative analysis (unrotated principal component analysis and parallel analysis) and graphical analysis (scree plot along with parallel analysis line). The quantitative analysis identified which variables in the data could be grouped into common factors through unrotated principal component analysis and parallel analysis, estimating factor loadings to determine the factor structure. Graphical analysis, such as the scree plot, intuitively presented the magnitude of variability explained by each potential factor, aiding researchers in determining the reasonable number of factors to extract. Through these analytical methods, the structural validity of the SCHNOS could be evaluated, and its ability to effectively capture the core experiences of rhinoplasty patients in both functional and cosmetic aspects could be determined.

All statistical analyses described above were performed with IBM SPSS Amos version 25.0 software and its extension plug-ins (IBM Corporation, Armonk, NY).

RESULTS

Translation Process

Forward and Back Translations

Throughout the study, translators conducted the initial English-to-Chinese translation of the SCHNOS, resulting in discrepancies between the 2 versions. To ensure consistency between translation quality and original concepts, researchers coordinated and addressed these differences. Supplemental Table 1 (located online at www.aestheticsurgeryjournal.com) illustrates instances of this correction process. Upon back translation (ie, translating the preliminary Chinese version back into English), minimal discrepancies were found between the translated version and the original concept, indicating no further modifications were necessary. This iterative process and review enabled the research team to achieve precise translation and cultural adaptation of the SCHNOS, aligning closely with the original questionnaire concept.

Cognitive Interviews

In this study, the research team conducted interviews with 10 patients scheduled for rhinoplasty. These 10 patients had an equal gender distribution (50% female, 50% male) and an average age of 28.7 years. There is currently no consensus on the number of cognitive interviews that should be conducted.¹ The determination of interview quantity is based on the point of saturation, when no new information is obtained.

Based on the results of cognitive interviews, the translation version of the SCHNOS underwent 3 modifications. Initially, patients were prompted to focus on specific time frames. Researchers emphasized “the past month” in the questionnaire introduction because 3 patients misunderstood they should respond based on the past month, instead mistaking it for recent months or years. This was underscored and bolded to highlight the uniqueness of the time frame. Additionally, severity was emphasized in the introduction section to quantify the severity of issues.

For the C-SCHNOS, 7 patients expressed significant confusion regarding items 1 and 3 because these 2 items were nearly identical in meaning in the translated Chinese version, making it difficult for native Chinese-speaking patients to distinguish them. Consequently, “inflammation congestion” was appended to item 3 to distinguish it from item 1, focusing patient attention on the status of the nasal cavity. Two patients also found item 5 confusing, unsure whether it focused on nasal function or aesthetics. Therefore, the term “appearance” was added to item 5 to emphasize consideration of appearance issues.

Additionally, during the interviews, it was observed that 2 patients overlooked the requirement to evaluate the nose from the side rather than the front in item 8. To prevent patients from overlooking this item, “side view” was specifically marked in item 8. After these revisions, the revised version of the C-SCHNOS was administered to an additional 5 rhinoplasty patients, who did not encounter the issues mentioned in the previous interviews. Examples of these revisional details and results can be found in Supplemental Table 1 (located online at www.aestheticsurgeryjournal.com).

Psychometric Validation

Among the invited 110 patients, all participated in the study at a provincial hospital in Southwest China. All invited patients consented to participate. The study results indicated high internal consistency for both the SCHNOS-O and SCHNOS-C. The Cronbach's α coefficient for SCHNOS-O was 0.809 (95% CI, 0.744-0.862), for SCHNOS-C it was 0.924 (95% CI, 0.899-0.944), and for the entire SCHNOS it was 0.849 (95% CI, 0.800-0.888), demonstrating excellent internal consistency. Moreover, the removal of any single item did not significantly improve Cronbach's α values for the SCHNOS-O, SCHNOS-C, or the entire SCHNOS, and all items showed good or acceptable corrected item-total correlations.¹³

The Spearman correlation coefficients for all items of SCHNOS-O were positive and statistically significant. However, there were differences in correlation strength, for instance, the correlation coefficient between items 2 and 3 was 0.357, and between items 2 and 4 was 0.645 (Table 2). The Spearman correlation coefficients between items of SCHNOS-C were also positive and statistically significant, ranging from moderate (correlation of 0.509 between items 7 and 8) to strong (0.740 between items 6 and 10) (Table 2). All repeated measures correlations were consistently moderate to very strong.

During the evaluation of test-retest reliability in both patient and control groups, positive and statistically significant Spearman rank correlation coefficients (r) were noted for the SCHNOS-O and SCHNOS-C. In the obstruction domain, r = 0.857 (95% CI, 0.783-0.908), calculated from 55 observations. Furthermore, in the cosmetic domain, r = 0.890 (95% CI, 0.834-0.926), also derived from 55 observations. Additionally, Wilcoxon signed-rank tests indicated significant differences in test-retest results within both the obstructive and cosmetic domains (P value < .001).

Difference Between Cases and Controls

Wilcoxon signed-rank test results indicated significant differences between case and control groups for all items and total scores of the SCHNOS-O and SCHNOS-C (P < .0001). This suggests statistically significant differences between rhinoplasty and nonrhinoplasty control groups, whether in responses to specific questions or overall scores of obstructive symptoms and aesthetic satisfaction, indicating a significant impact of rhinoplasty on patients' quality of life and satisfaction.

Validity

In this study, the Kaiser-Meyer-Olkin (KMO) values for the SCHNOS-O and SCHNOS-C were both greater than 0.7, indicating suitability for EFA, and Bartlett's sphericity test was highly significant (P < .0001), further confirming good conditions for factor analysis. EFA confirmed a unidimensional characteristic for both SCHNOS-O (with 1 factor, eigenvalue = 2.54769) and SCHNOS-C (single factor, eigenvalue = 4.35319), well exceeding the critical threshold (Table 3). These results supported the good unidimensional characteristics of the SCHNOS-O and SCHNOS-C scores structurally, indicating that they primarily reflected a single core concept of nasal obstruction symptoms and aesthetic satisfaction. This suggested that, although these 2 scales contained multiple items, these items revolved closely around a core, namely, satisfaction with nasal function and appearance. This also provided strong theoretical support for the subsequent use of the SCHNOS to evaluate the effects of rhinoplasty.

DISCUSSION

In this study, we successfully translated the SCHNOS into a Chinese version suitable for Chinese patients, and as well conducted cultural adaptation and validation. The results demonstrated that this Chinese version was conceptually and psychometrically equivalent to the original English version. Following international standard guidelines, we meticulously followed a multistep process, encompassing forward translation, backward translation, and cognitive interviews, to ensure the development of a valid clinical assessment tool.^16,17 This multistep process ensured not only semantic equivalence but also that the original content and concepts were adapted to the cultural background of the target population.

As a reliable measurement tool, C-SCHNOS demonstrated high internal consistency in both the SCHNOS-O and SCHNOS-C, and removing any item did not significantly increase the Cronbach's α coefficient. These results closely resembled those of the original English edition.¹ Through Spearman correlation analysis and EFA between SCHNOS-O and SCHNOS-C, positive significant correlations between items within each domain and their unidimensional characteristics were confirmed, further demonstrating the validity of the C-SCHNOS. Through a series of rigorous steps, including translation, cultural adaptation, and cognitive interviews, the questionnaire remained conceptually and culturally consistent with the original version and adapted to the characteristics of the target population, ensuring that the C-SCHNOS possesses reliability, accuracy, content, and construct validity.

During the retest phase of our study, we demonstrated the good reproducibility of the instrument. Positive correlations were observed between responses to obstructive and cosmetic domains over a 2-week interval. Wilcoxon signed-rank tests revealed no significant differences between responses in the obstructive and cosmetic domains, robustly indicating the excellent reproducibility of the questionnaire. These results underscore the significant reliability and validity of C-SCHNOS among Chinese participants, with the potential for further enhancement of these correlations with an increased sample size. To strengthen and broaden the applicability of our study findings, expanding the sample size in future research is imperative.

Moreover, considering that participants in our study primarily hailed from Chengdu and its surrounding areas, and acknowledging potential discrepancies in education levels and reading comprehension across various regions in China, the translated and validated C-SCHNOS necessitates meticulous optimization and refinement on a larger scale. Therefore, we aim to validate and refine the questionnaire based on a larger sample size in China to furnish Chinese plastic surgeons with a precise and applicable patient assessment tool. This will ensure that C-SCHNOS accurately reflects the quality of life of patients undergoing nasal surgery nationwide. Such an initiative will not only contribute to a comprehensive understanding of postrhinoplasty patients' conditions across China but also significantly advance the improvement of medical service quality and the deepening of related research activities in our country.

To the best of our knowledge, this study marks the pioneering effort in developing a Chinese version of the SCHNOS. These adaptive questionnaires hold substantial significance in evaluating health-related quality of life. They not only effectively serve individual patient screening, dynamic monitoring, and health outcome quantification but also establish mutually comparable standards for health research globally.¹⁸ Through this approach, standardized questionnaires can be adopted by different countries and regions, fostering cross-cultural communication and international collaboration, thereby enabling accurate, equitable, and comparable assessments of the quality of life of rhinoplasty patients on a global scale.

CONCLUSIONS

In conclusion, we have successfully developed the C-SCHNOS, which has been confirmed as an effective and reliable tool for comprehensively assessing both functional and aesthetic aspects of rhinoplasty. We anticipate that this questionnaire will provide Chinese plastic surgeons with a precise patient assessment tool, enabling more personalized diagnosis and treatment methods for rhinoplasty patients in a Mandarin-speaking context and providing strong support for the scientific evaluation of their postoperative quality of life.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Acknowledgments

Dr Maohua Chen and Dr Siyuan Cai contributed equally to this work as co-first authors.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This research was funded by the Key R&D (Research and Development) project of Sichuan Provincial Department of Science and Technology (2023YFS0124), the Industry-University-Research innovation fund of the Science and Technology Development Center, Ministry of Education of China (2021JH011), the Medical-Industrial Crossover Joint Fund of Sichuan Provincial People’s Hospital (ZYGX2021YGLH002), and the Youth Talent Fund of Sichuan Provincial People’s Hospital (2022QN58).

REFERENCES

Author notes