Prior to conducting translation, we reviewed the latest guidelines for translating measures into different languages (Cao et al., 2017; Gjersing, Caplehorn, & Clausen, 2010; World Health Organization, 2018). Although there were diverse recommendations and guidelines for translating measures, the most common recommendations for the translation process consists of five steps:1) forward-translation; 2) experts’ panel review; 3) backward-translation; 4) pre-test measures and cognitive interview; 5) development of final version. Given some variations in available resources, each country followed or adapted the common recommendations.
- For China, two bi-lingual translators independently performed forward translation and then experts’ panel evaluated and resolved any discrepancies from different versions of translated measures. Then two different translators conducted backward translation. After the backward translation, independent researchers met to achieve consensus by resolving any discrepancies and developed the final version.
- In Korea, three bi-lingual researchers formed expert panels and translated measures into Korean as follows: Two translators independently translated each measure. Then, multiple consensus meetings were held to resolve discrepancies in translation and create the final versions for each measure.
- To translate measures into Taiwanese Mandarin, ten bi-lingual translators independently performed forward and backward translation on two measures (Chen, Chen, & Wong, 2014). After completing forward and backward translation, the ten translators met to achieve consensus by resolving any discrepancies. Then content validity was assessed by a different team of experts, including MD, Nurses, Junior High school Teacher, Nurse Scientists.
In each country, researchers focused on translating measures with enhanced cultural adaptation by emphasizing translating the main concepts of items in each measure rather than translating word-for-word (World Health Organization, 2018). Understanding the Western and Eastern cultural differences is critical in developing culturally appropriate measures (Cao et al., 2017; Epstein, Santo, & Guillemin, 2015). Therefore, cultural differences between Western and Eastern cultures were discussed in the regular AREA executive meetings. These rich conversations focused primarily on the differences in relationships within families, how individual family members communicate, and on perceptions of spiritual perspective. As the final step of translation, each country has conducted, or will conduct, a pilot test with adolescents and young adults with cancer to evaluate acceptability, reliability and validity of the translated measures.
Through these translation processes, we learned that measurement translation is not a simple word-to–word translation (Epstein et al., 2015; Geisinger, 1994; Villagran & Lucke, 2005). The process requires cultural and contextual understanding (Furukawa & Driessnack, 2016). In general, Asian culture is strongly influenced by Confucianism (Yum, 1988). As a result, Asian culture is characterized as hierarchies in interpersonal relationships and collectivism which emphasizes strong group affiliation and high harmony which contrasts with the Western culture wherein individualism is highly valued.
Cultural differences present several challenges when translating measures. First, cultural difference was found in interpersonal relationships, specifically, regarding how people differently define the definition or scope of family (e.g., “Members of my family get good ideas from me about how to do things or make things” from the measure titled Perceived Social Support from Family (Procidano & Heller, 1983). For example, considering that our target population is adolescents and young adults (AYA), it might be hard for AYA to envision that their family members, especially their parents, would ask for their advice or opinion. The difference in developing interpersonal relationship is also applied to relationship between healthcare provider and patients. As an example of hierarchy, there wereitems referring to healthcare providers as “myhealthcare providers” in the Perceived Social Support from Healthcare Providers (Procidano & Heller, 1983). In Asian culture, the concept of possession of healthcare providers as one’s own does not make sense because it is against cultural background of perceived hierarchies between healthcare providers, especially, physician and patients. So, it is common to express that patients belong to physician or healthcare providers, rather than they belong to patient.
The cultural difference between Western and Eastern produces linguistic difference, too. For example, in Korean culture, “my or mine” are rarely used; instead, Koreans usually say “our or us”. Thus, the Korean versions of measures changed “my healthcare” to “our healthcare provider”. Additionally, we faced challenges to find appropriate words that reflect the same meanings. For example, when we translate the words “companionship” into Korean, we found that there are many words that have similar meaning to companionship, but none that are a good fit. Therefore, when we simply changed word-for-word, back translations did not convey the meaning of the original items. We spent much time in our back translation discussions and also in the Executive Committee meetings to find conceptually similar word that reflect the culturally appropriate meaning that is closest to the original meaning.
Last, we found the generational gap was another important issue in translation. For example, to consider variations in vocabulary across generations, we needed to translate items into vocabulary that is most familiar to AYA. Therefore, in translating measures, translators should consider whether the vocabulary used among adolescents and young adults is reflected in the measures.
Suggestions for further cross-cultural works include the following. 1) Use at least two translators: one who is familiar with the terminology and the content of the area covered by the measures, and the second who is knowledgeable about the idiomatic expressions commonly used in targeted languages and target population (Hilton & Skrutkowski, 2002). 2) To resolve discrepancies and enhance cultural adaptation, work with a team that includes multiple expertise in linguistics and instrumentation, and individuals with diverse cultural backgrounds and from diverse disciplines (Epstein et al., 2015). 3) It is important to enhance cultural adaptation during the process of back translation. Although back-translation is a widely recommended method to enhance reliability and validity in translating measurements, employing back-translation receives critique in that it focuses on changing word for word without also focusing on enhancing cultural adaptation (Beck et al., 2003; Hilton & Skrutkowski, 2002). In this global era, increasing the number of cross-cultural research studies is necessary to solve demanding healthcare issues. Successfully translating measures with enhanced cultural adaptation will contribute current knowledge by providing reliable and valid measures through cost and labor effective method. To achieve this goal, researchers should focus on translating the underlying concepts of items rather than translating word-for-word.