Translation and cross-cultural adaptation of a mental health battery in an African setting

Background: Standardised measuring instruments are increasingly used in psychiatric research cross-culturally. These instruments are considered to be culturally equivalent when all forms of biases, or social norms specific to the culture of origin, have been removed. Objectives: To describe the qualitative process of selection, translation and cultural adaptation of a mental health battery for use in a Xhosa-speaking community that is, as far as possible, 'culture-free' or equivalent. Method: Informal discussions were held with key members in the community to determine what would be considered as appropriate for the community in respect of psychiatric screening instruments. Existing rating-scales for depression, alcohol abuse and posttraumatic stress disorder that would meet these criteria were identified and then translated from English into Xhosa. Cultural equivalence was achieved by combining methods of back-translation, committee consensus approach and decentering. Discussions during the committee consensus meetings were recorded and categorized into themes. Two themes emerged: (1) issues related to the attainment of semantic equivalence and (2) broader problems inherent in cross-cultural research. Results: Issues related to individual questionnaires included the use of terms to describe emotional distress cross-culturally. Broader issues related to the translation process itself included the form of language to be used, time-frames, and the use of Likert-scales. It also demonstrated the problems inherent in the categorization of emotions. Conclusion: A method of combining a group approach, back-translation, and decentering was effective and efficient in this context for establishing content and semantic equivalence. Cross-cultural adaptation can never completely remove all forms of bias from a research instrument, but such limitations should be acknowledged and openly discussed, rather than hidden or ignored.