METHODS
151 patients with oncologic diagnoses were included in the study. Sociodemographic Data Form, The
Basic Documentation For Psycho-Oncology (PO-BADO), Hospital Anxiety and Depression Scale
(HADS), Perceived Stress Scale (PSS), Karnofsky Performance Scale (KPS), and Cancer Coping Questionnaire
(CCQ) were conducted.
RESULTS
The PO-BADO scale demonstrated a high level of internal consistency, with Cronbach"s alpha of 0.826
for the overall scale, 0.792 for the physical symptoms subscale, and 0.749 for the mental symptoms subscale.
PO-BADO scores showed strong positive correlation with HADS and PSS scores (r=0.657, 0.769,
0.763 and 0.685), and moderate negative correlation (r=-0.527) with KPS scores. Confirmatory factor
analysis yielded an x2/sd value lower than 3, a CFI of 0.97, and an RMSEA of 0.034.
CONCLUSION
Our results indicate that the Turkish version of PO-BADO is a valid tool for evaluating mental health
issues, as well as the medical challenges experienced by Turkish cancer patients.
Keywords: Cancer; mental health; PO-BADO; psyhooncology; validation
The prevalence of psychiatric disorders in cancer patients
highlights the importance of routine psychiatric
evaluations when considering the impact of these disorders
on disease progression, quality of life, and treatment
adherence.[
Psychosocial screening aims to identify at-risk individuals
early and facilitate timely interventions. Morover,
this tailored approach can lead to more effective
psychosocial interventions that directly address the
individual's needs.[
Distinguishing between physical and psychological
distress is crucial in clinical practice. PO-BADO
aims to determine whether a patient's distress is primarily
physical or psychological. Rather than replacing
screening tools, it functions as an instrument that enhances
initial assessments made with such tools. When
a patient is identified as high-risk through a screening
questionnaire, the PO-BADO provides a more detailed
evaluation that complements self-report scales. With
its structured format, this form can be used by healthcare professionals from different disciplines, fostering
communication and a shared language among professionals
from various fields.[
To the best of our knowledge, no screening scale in
Turkish allows for the simultaneous evaluation of the
physical and psychological issues of cancer patients
by an expert. The primary objective of this research
is to adapt and validate the PO-BADO for assessing
psychosocial issues specific to cancer patients, thereby
addressing a critical gap in comprehensive cancer
care of Turkish cancer patients. By utilizing this tool,
healthcare professionals can efficiently assess the psychosocial
needs of cancer patients, allowing for more
targeted and personalized care.
The sample size was determined based on the commonly used 10:1 case-to-variable ratio in the literature, by using the data of the original scale as the reference. [12] Considering potential data loss, the study was conducted with 151 participants for the 12-item scale. Participants were randomly selected from individuals 18 years or older, had no intellectual disability or active psychotic disorder, were at least literate, had a general medical condition suitable for the interview, and consented to participate in the study.
During the interviews with 75 patients, a second evaluator was present as an observer, independently scoring responses without interfering with the application. Aiming for the inter-rater reliability testing, the primary interviewer and the second evaluator recorded their responses separately on different forms.
Before commencing the study, ethical approval was obtained from the Clinical Researches Ethics Committee of Istanbul University Istanbul Faculty of Medicine on March 8, 2023, with decision number 1672709. The study was conducted following the principles of the Helsinki Declaration. Informed consent was obtained from all participants before they completed the forms.
Measures
Volunteers who met the inclusion criteria were administered
a sociodemographic data form, Basic Documentation For Psycho-Oncology (PO-BADO), Hospital
Anxiety and Depression Scale (HADS), Perceived
Stress Scale (PSS), Karnofsky Performance Scale, and
Cancer Coping Scale (CCS).
1. Sociodemographic Data Form: This is a semistructured
interview form generated by the investigators
to collect detailed demographic information
such as age, gender, marital status, and educational
background. It also gathers data on patients" psychiatric
and medical history, family history, and
subjective experiences related to their illness. Cancers
classified as stage 3-4 and/or grade 2-4 were
categorized as advanced-stage cancers.[
2. The Basic Documentation For Psycho-Oncology
(PO-BADO): PO-BADO was developed by the
PO-BADO Working Group between 2000 and
2006, with the support of DAPO (German Psycho-
Oncology Working Group) and PSO (German
Cancer Society Psycho-Oncology Working Group).
[
• If the patient scores at least 4 on one of the physical
or psychological distress or at least 3 on two
different items,
• If the scores for physical and psychological distress
are below these criteria but there are at least
two "yes" answers on the additional distress items,
• If the score is at least 3 on one of the physical
or psychological distress and at least one "yes"
answer on the additional distress items, it can be
said that the patient requires psycho-oncological
support.[
3. Hospital Anxiety and Depression Scale (HADS):
Developed in 1983 by Zigmond and Snaith, this
scale is used to detect anxiety and depression
symptoms in non-psychiatric clinical settings.[
4. Perceived Stress Scale (PSS): The PSS is a tool measure
the degree to which individuals perceive various
situations they encounter in their lives as stressful.[
5. Karnofsky Performance Scale (KPS): Developed by
Karnofsky and Burchenal in 1949,[
6. Cancer Coping Scale (CCS): Based on cognitivebehavioral
therapy principles, the CCS is designed
to reflect patients" coping methods.[
Translation Process
Data Analyses
The validity and reliability study of the PO-BADO
scale was conducted according to international standards
after obtaining written permission from the authors
of the original scale. In the first phase, the translation
of the scale into Turkish was carried out by a
Turkish consultant psychiatrist working in Germany
over 10 years, who was proficient in German language.
The Turkish translated form was evaluated by the two
acamicians of the reseach team, for its linguistic and
cultural eligibility. In the following phase, the form was
back-translated by an other Turkish physician who was
fluent in the original language and blind to the original
document. In the third phase, the back-translation
was compared with the original by Dr. Birgitt Marten-
Mittag, one of the developers of PO-BADO, and the
Turkish form was revised based on her suggestions.
The Turkish form was found to be understandable by
patients, and the final version was created based on
feedback from the pilot application on 10 randomly
selected participants. Prof. Dr. Peter Herschbach and
Dr. Birgitt Marten-Mittag approved the final form.
For descriptive statistics, mean, median, and standard deviation
values were calculated. The internal consistency
of the scale was assessed using Cronbach"s alpha (α) value and item-total item correlation analysis. The suitability
of the Turkish form for the original factor structure was
evaluated through Bartlett"s test of sphericity and Kaiser-
Meyer-Olkin (KMO) sample adequacy measures. The reliability
of the PO-BADO scale was analyzed in terms of
item-total score correlations and internal consistency by
calculating the Cronbach α coefficient. The homogeneity
between evaluators was analyzed using the intra-class
correlation coefficient (ICC). Confirmatory factor analysis
(CFA) was performed to determine the construct validity
of the PO-BADO. For CFA, the following fit indices
were used: x2/df, Comparative Fit Index (CFI), Root
Mean Square Error of Approximation (RMSEA), and
Tucker Lewis Index (TLI). Convergent validity was assessed
by analyzing the correlation between PO-BADO
scores and HADS, PSS, KPS, and CCS scores. Statistical
analyses were performed using the Jamovi Version
2.2.5.0 and SPSS Statistics Version 26.0.[
Cronbach's ? reliability analysis was conducted to
determine the internal consistency of the PO-BADO.
The test results from 151 patients were used to calculate
the internal consistency coefficient. The overall Cronbach"s
? coefficient was found to be 0.826, indicating
high internal consistency for the PO-BADO. The itemtotal
score correlation ranged from a lowest value of
0.235 to a highest value of 0.628. The Cronbach"s ? for
the physical symptom subscale was 0.792, while the
Cronbach"s ? for the psychological symptom subscale
was 0.749. The item-total score correlations and the
changes in the Cronbach's ? reliability coefficient after
removing items from the scale are presented in Table
The KMO test value was found to be 0.839, indicating
that the data is suitable for factoranalysis. The results
of the CFA revealed that the factor loading values
for all items were greater than 0.30. It was determined
that the factor loading values for all items were above
0.30, the error variances were below 0.90, and all items
were statistically significant (p<0.001) (Table
The results of the CFA showed that for the scale administered by the other evaluator, the factor loadings for all items were above 0.30, and the error variances were below 0.90. Additionally, all items were found to be statistically significant (p<0.001).
When examining the CFA results, the x²/sd value
was 1.17, the CFI was 0.97, the TLI was 0.973, and
the RMSEA was 0.034. Based on these indices, it can
be concluded that the model showed good fit to the
data. In the French validity and reliability study of the
PO-BADO, the CFI was 0.950, the RMSEA was 0.055,
and the SRMR (Standardized Root Mean Square Residual)
was 0.057, all of which were found to be within
acceptable fit ranges.[
In the convergent validity analysis, the correlation
between PO-BADO scores and the Hospital Anxiety and
Depression Scale (HADS), Perceived Stress Scale (PSS),
Karnofsky Performance Scale (KPS), and Cancer Coping
Questionnaire (CCQ) scores was evaluated. Both
HADS-D, HADS-A and HADS-Total scores showed
strong correlation with PO-BADO Psychological and
PO-BADO Total scores; and moderate correlation with
PO-BADO Physical scores. PSS scores were strongly correlated
with PO-BADO Psychological and PO-BADO
Total scores and weakly correlated with PO-BADO Physical
scores. While KPS scores showed moderate negative
correlation with PO-BADO Physical subscale and POBADO
total scores; the correlation between PO-BADO
Psychological scores were found to be weak. CCQ scores
did not show significant correlation with PO-BADO Physical scores and only showed weak negative correlation
with PO-BADO Psychological and PO-BADO Total
scores. The correlation coefficients (r values) and the significance
evaluations are presented in Table
The homogeneity of the scales was demonstrated
through internal consistency. The internal consistency
coefficient is one of the key parameters in determining
the reliability of a scale.[
The reliability of the PO-BADO was assessed using
ICC. The ICC values for the total score of physical
symptoms were 0.93, and for psychological symptoms,
it was 0.98. The excellent range of the intra-class correlation
coefficient indicates that the evaluators had a high
level of agreement and that PO-BADO was rated similarly
among different practitioners. In a study by Knight
et al.,[
The KMO test was found to be 0.839, indicating that
our data is suitable for factor analysis. In our study, all
items had factor loadings above 0.30, and error variances
were below 0.90 (p<0.001). When examining
the factor loadings for the 12 items in our study, eight
items showed high factor loadings, while four items had
moderate loadings. In the psychometric evaluation of
the original German version of PO-BADO by Knight et
al.[
In our study, the TLI value was calculated to be
0.97, suggesting that the model has a good fit. Upon
examining the results of the confirmatory factor analysis
(CFA), the x²/df ratio was found to be below 3, with
CFI=0.97 and RMSEA=0.034. According to these indices,
it can be concluded that the model fits the data
well. In the French validity and reliability study of POBADO,
CFI=0.950, RMSEA=0.055, and SRMR=0.057
were within acceptable ranges.[
In the convergent validity analysis, we evaluated
the correlation levels between PO-BADO total and
subscale scores and HADS, PSS, KPS, and CCQ scores.
HADS scores showed a strong correlation with POBADO
psychological and total scores, while showing
moderate correlation with physical scores. This is an
expected outcome because HADS is not a scale that focuses
specifically on physical parameters. However, the
strong correlation with psychological and total scores
shows that PO-BADO is a valid tool for assessing psychological
difficulties such as anxiety and depression.
Similarly, PO-BADO physical scores showed weak
correlation with PSS scores, however the psychological
and total sections showed strong correlation. This result
is thought to stem from PSS not being a suitable test for
measuring physical parameters, but it shows that both
scales are similar in measuring psychological parameters.
The KPS is a test used to measure physical condition,
and it showed moderate correlation with the
physical section of PO-BADO, indicating that PO-BADO
can also provide an acceptable insight into physical
difficulties experienced by oncology patients in their
current medical condition. However, the correlation
between KPS and the psychological section of PO-BADO
was weak, which can be explained by the fact that
KPS does not focus on psychological parameters.
The CCQ scale did not show a significant correlation
with the physical section of the PO-BADO and showed
a weak correlation with the other sections. Although the
p-value appears statistically significant, the low r-value
indicates that PO-BADO does not provide an adequate
assessment of coping with cancer. From this perspective,
it can be said that BADO is a tool that focuses on
patients" recent psychosocial status and physical difficulties,
but is not a suitable tool for assessing coping skills.
The developers of the scale have not established a
cut-off score for referring patients for psychiatric evaluation.
However, as previously stated in the methods
section, they have identified three key criteria that indicate
a patient"s need for psycho-oncological support.
Likewise, we believe that as a screening tool, the same
criteria indicate a need for psychosocial support in
Turkish cancer patients, but do not point to a need for
the assessment of psychiatric disorders. In our opinion,
psycho-oncological support can be provided by mental
health professionals such as psychologists, psychological
counsellors, or psychiatric nurses who have received
specialized training in this field, and referral to
psychiatry departments may be considered in clinical
situations where mental disorders are suspected.
There are some limitations of our study. The first limitation
is conducting a single-center study, which may affect
the generalizability of our results. Secondly, we obtained
data from patients in stable stages of the disease
since many of the patients in the terminal stage did not
consent to participate in the interviews. When the psychosocial
status of patients with severe medical conditions
is not assessed, their needs may not be fully understood.
Finally, the scale administrators were a fourth-year
psychiatry resident and a psychologist with a master"s degree
in psycho-oncology. Both of these practitioners have
extensive experience in interviewing oncology patients.
However, PO-BADO is described as a tool that can be
used by all healthcare professionals involved in the treatment
process of oncology patients with just basic training.
Ethics Committee Approval: The study was approved by the Istanbul University Istanbul Faculty of Medicine Clinical Researches Ethics Committee (no: 1672709, date: 08/03/2023).
Informed Consent: Participants gave written informed constent.
Conflict of Interest Statement: The authors have no competing interests to declare that are relevant to the content of this article.
Funding: The authors did not receive financial support from any organization for the submitted work.
Use of AI for Writing Assistance: No AI technologies utilized. Author Contributions: Concept - U.B.N., D.A., I.P.; Design - U.B.N., D.A., I.P.; Supervision - I.P.; Data collection and/ or processing ? U.B.N.; Data analysis and/or interpretation - U.B.N., M.K., D.A., I.P.; Literature search - U.B.N.; Writing - U.B.N., I.P.; Critical review - M.Ö.
Acknowledgments: The authors would like to thank Mustafa Alican Dirican, M.D., for his contributions to the translation and back-translation process.
Peer-review: Externally peer-reviewed.
