Review Article
A review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus

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Abstract

Objectives

The aim of cross-cultural adaptation (CCA) of a questionnaire is to achieve equivalence between the original and adapted questionnaire. Here, we aimed to review the state of the art in CCA methods.

Study Design and Setting

We reviewed cross-disciplinary bibliographic databases for articles on methods and guidelines for CCA of questionnaires. Articles were first selected by their abstract and title, and then, we retrieved full-text English articles. References of selected articles were searched for additional relevant studies.

Results

We identified 31 guidelines and found no consensus in CCA methods. Most methods included use of committees, focus groups, and back translations. Evidence for the best methods is lacking, although clues indicate that back translation may not be mandatory.

Conclusion

Several methods are available for CCA of questionnaires. According to experts only, most would achieve comparable results, and choosing one is a matter of preference and logistic. More evidence is needed to support recommendations. Adaptation and validation of a questionnaire are two different processes that should be distinguished and undertaken with care.

Introduction

What is new?

Key findings

  1. The concept of equivalence between languages in cross-cultural adaptation (CCA) of questionnaires in the literature involves different definitions and frameworks. The most comprehensive definition can be useful as a reference.

  2. We identified 31 different CCA methods in a review of the literature.

What this adds to what was known?
  1. The methods of CCA can differ by their main focus (technical translation, focus groups, concepts, and so forth), but we lack evidence of the superiority of one method over another.

What is the implication and what should change now?
  1. CCA of questionnaires is a delicate process. Any validated method can be used as long as its process is rigorous enough to achieve equivalence between the original and the translated questionnaire. More research is needed to provide evidence to support current guidelines.

Over the last decades, the number of self-report questionnaires, used in multiple fields of science, has increased exponentially. Often these questionnaires are meant to explore a construct that cannot be measured directly, quality of life being one example among patient-reported outcomes. These questionnaires are composite measurement scales (CMSs). A CMS consists of items or questions that assess one or several attributes scored by a scale. A construct consists of several attributes that are evaluated by a number of selected elementary criteria or items, each scored on a scale [1]. For clarity, we use the term questionnaire, which implies a CMS, in this article.

Creating a questionnaire implies expenditure of time and money, first to develop the questionnaire and choose domains and items that will best explore the construct of interest and second to validate the questionnaire, ensuring that it actually measures what it is intended to measure.

Cross-cultural research can be conducted to explore the same question in several cultures or measure differences across cultures. For either goal, researchers need the same questionnaire in different languages. If the questionnaire is available in another language, researchers should adapt a questionnaire with documented validity rather than create a new one because the cross-cultural adaptation (CCA) is faster and is assumed to produce equivalent measure [2]. This situation is true under the condition that the construct exists in the target culture and that the existing instrument measures it appropriately.

However, CCA of one questionnaire for another culture can be problematic. First, the translation can involve linguistic problems because two languages can have nonequivalent words or idiomatic expressions. For example, the word “fair” in English, which is often used in questionnaires, has no fixed equivalent in French and can be translated in two slightly different ways: “moyen” or “mediocre,” which would not elicit the same answer [3]. Second, the adaptation itself in another culture can be the problem because one item can have a very different meaning or no meaning at all in a specific cultural background. For example, in the Health Assessment Questionnaire (HAQ), people are asked if they can sit in their bathtub. For the Thai version of the HAQ [4], the adapter replaced the action of sitting in a bath by sitting to pay homage to a sacred image because in the Thai culture, people do not use bathtubs. Finally, the cultures can be so far apart that the way of thinking can be different [5].

A clear distinction should be made between translation, adaptation, and cross-cultural validation. Translation is the single process of producing a document from a source version in the target language. Adaptation refers to the process of considering any differences between the source and the target culture so as to maintain equivalence in meaning. This adaptation is referred to CCA. The cross-cultural validation of a questionnaire is a different process from the CCA. Cross-cultural validation aims to ensure that the new questionnaire functions as intended and has the same properties as the original and functions in the same way [6]. The adaptation and validation of a questionnaire are two different steps but can be part of an iterative process because if the questionnaire is not valid, the adapted version must be changed.

Many different methods of CCA exist, but none are considered the gold standard. Thus, reviewing the state-of-the-art methods of CAA and their respective level of evidence is useful.

Section snippets

Equivalence

Many authors have worked on the concept of equivalence [7], [8], [9], [10]. Herdman et al. [11] defined three approaches: absolutist, relativist, and universalist. Many CCA articles and most current guidelines follow a universalist approach [12], which considers that a person's culture can affect how people answer any given question depending on the concept explored.

Equivalence has been divided into different categories, with the number varying depending on the author [13], [14], [15]. With a

Achieving equivalence

The ways to achieve equivalence first depend on the stage at which the question of equivalence is encountered.

  • -

    Before the original questionnaire is developed: some authors proposed to develop questionnaires for different cultures at the same time [17], [18], [19], [20], [21].

  • -

    At the beginning of the CCA process, before any translation, the potential conceptual equivalence should be evaluated. This case corresponds to the recommendation by Herdman et al. [16]. This evaluation is rarely performed

Literature review of guidelines and methods for CCA

We aimed to identify potentially relevant articles concerning methodological approaches to CCA published between 1970 (the model by Brislin) [24] and mid-2014. We used search strategies [25] for the databases MEDLINE via PubMed, EMBASE, PsycINFO, and the Web of Science with the terms “cross-cultural” and “adaptation or translation or validation” combined with “questionnaire or instrument.” The results of the searches were combined by use of EndNote X7 (Thomson Reuters).

Articles were selected on

Adaptation and validation

Adaptation specifies that the underlying concept and hypotheses of the adapted questionnaire are those of the original questionnaire. In theory, an adapted questionnaire should have the same properties as the original, so if the properties of the original are poor, the adapted questionnaire will also have poor properties. In any case, the adapted questionnaire should always be validated by means of proper statistical tools. The COSMIN group provided recommendations and a checklist to verify a

Conclusion

Many different recommendations for CCA exist; some are quite different and most differ by their focus (technical translation, focus group, concepts, and so forth). However, only two experimental studies [36], [38] and two quasi-experimental studies [34], [35] compared different methods of adaptation. Studies comparing methods suggest that the back translation should not be mandatory but can be useful as a communication tool with the author of the original questionnaire. As well, expert

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