Table 1 shows a suggested sequence of the cross-cultural adaptation process. The first stage is to assess if there is the same relationship between the questionnaire and underlying concept in both the original and target setting [2 (link),3 (link)]. In addition it is important to assess that items within the instrument are equally relevant and acceptable in the target population as they are in the original population [2 (link)]. Both conceptual and item equivalence can be assessed through a literature review [2 (link),3 (link)]. Findings from the literature review should be discussed with experts in the field and members of the target population [2 (link),3 (link)].
The original instrument should thereafter be translated from the original language into the language of the target population [2 (link)-5 (link)]. At least two persons should produce the initial translations independently [4 (link)-6 (link)]. The translators should be fluent in the language of the target population with a good understanding of the original language [2 (link)-5 (link)]. The translated versions should be synthesized into one version by a third independent translator [4 (link),5 (link)]. Thereafter the synthesized version should be back-translated independently by at least two different persons [4 (link)-6 (link)]. The back-translators should be fluent in the original language with a good understanding of the language in the target population [2 (link)-5 (link)]. Thereafter the synthesized translated version and the synthesized back-translated version should be reviewed by an expert committee [4 (link),5 (link)].
The expert committee should comprise of methodologists, health professionals, language professionals, and the translators (forward and back-translators) [4 (link)]. The expert committee assesses if a word or several words reflect the same ideas or subjects in both the original and adapted versions of the questionnaire [2 (link)-5 (link)]. This assessment ensures that items are translated correctly and are relevant in the new setting [4 (link)-6 (link)]. If there are uncertainties around the meaning of specific words or items, the developer of the original instrument can be contacted for clarifications [2 (link),4 (link)]. It is also suggested to return to the target population and have experts in the field discuss subtleties brought out by the various translation proposals [3 (link)]. The instrument should be adjusted accordingly after a consensus is reached [4 (link),5 (link)].
Thereafter the instrument should be pretested [4 (link)]. Between 30 and 40 respondents are viewed as appropriate in the pretest [3 (link),4 (link)]. Respondents are probed for their understanding, acceptability and emotional impact of the items in order to detect confusing or misleading items [3 (link),4 (link)]. To ask respondents to rephrase each item is one technique that can identify whether an item is understood or not [3 (link)]. Reichenheim (2007) suggests that interviews are conducted until a pre-established percentage of understanding is achieved for all items (e.g. ≥ 90%) [3 (link)]. A final semantic adjustment should be made by the research group based on the evidence from the pilot study [3 (link)-5 (link)].
The operational equivalence of the instrument should be evaluated after the semantic adjustments [2 (link),3 (link)]. Operational equivalence means that it is possible to use similar questionnaire format, instructions, mode of administration and measurement methods in the target populations as was used in the original setting [2 (link)]. A literature review may give information regarding the use of instruments in the target setting [2 (link)]. It is also possible to contact experts in the field and members of the target population to assess if format, instructions, mode and administration and measurement methods are appropriate [2 (link)]. Once consensus is reached in regards to operational equivalence, the methods are incorporated into the study [3 (link)].
Finally, the instrument should be administered to participants in a formal study. On the basis of the results from this study the psychometric properties of the instrument should be tested using recognized statistical methods [4 (link),5 (link)].
The original instrument should thereafter be translated from the original language into the language of the target population [2 (link)-5 (link)]. At least two persons should produce the initial translations independently [4 (link)-6 (link)]. The translators should be fluent in the language of the target population with a good understanding of the original language [2 (link)-5 (link)]. The translated versions should be synthesized into one version by a third independent translator [4 (link),5 (link)]. Thereafter the synthesized version should be back-translated independently by at least two different persons [4 (link)-6 (link)]. The back-translators should be fluent in the original language with a good understanding of the language in the target population [2 (link)-5 (link)]. Thereafter the synthesized translated version and the synthesized back-translated version should be reviewed by an expert committee [4 (link),5 (link)].
The expert committee should comprise of methodologists, health professionals, language professionals, and the translators (forward and back-translators) [4 (link)]. The expert committee assesses if a word or several words reflect the same ideas or subjects in both the original and adapted versions of the questionnaire [2 (link)-5 (link)]. This assessment ensures that items are translated correctly and are relevant in the new setting [4 (link)-6 (link)]. If there are uncertainties around the meaning of specific words or items, the developer of the original instrument can be contacted for clarifications [2 (link),4 (link)]. It is also suggested to return to the target population and have experts in the field discuss subtleties brought out by the various translation proposals [3 (link)]. The instrument should be adjusted accordingly after a consensus is reached [4 (link),5 (link)].
Thereafter the instrument should be pretested [4 (link)]. Between 30 and 40 respondents are viewed as appropriate in the pretest [3 (link),4 (link)]. Respondents are probed for their understanding, acceptability and emotional impact of the items in order to detect confusing or misleading items [3 (link),4 (link)]. To ask respondents to rephrase each item is one technique that can identify whether an item is understood or not [3 (link)]. Reichenheim (2007) suggests that interviews are conducted until a pre-established percentage of understanding is achieved for all items (e.g. ≥ 90%) [3 (link)]. A final semantic adjustment should be made by the research group based on the evidence from the pilot study [3 (link)-5 (link)].
The operational equivalence of the instrument should be evaluated after the semantic adjustments [2 (link),3 (link)]. Operational equivalence means that it is possible to use similar questionnaire format, instructions, mode of administration and measurement methods in the target populations as was used in the original setting [2 (link)]. A literature review may give information regarding the use of instruments in the target setting [2 (link)]. It is also possible to contact experts in the field and members of the target population to assess if format, instructions, mode and administration and measurement methods are appropriate [2 (link)]. Once consensus is reached in regards to operational equivalence, the methods are incorporated into the study [3 (link)].
Finally, the instrument should be administered to participants in a formal study. On the basis of the results from this study the psychometric properties of the instrument should be tested using recognized statistical methods [4 (link),5 (link)].
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