As evidence-based practice gains momentum in hearing-related disciplines and as hearing devices become more popular across the world, developing appropriate tools to assess outcomes is paramount. Recent efforts have been seen in adapting questionnaires developed in English-speaking countries to another language so it can be used in different cultures. These questionnaires include, but are not limited to, the International Outcomes Inventory for Hearing Aids and the Speech, Spatial and Qualities of Hearing Scale (Int J Audiol. 2002;41(1):3; Int J Audiol. 2004;43(2):85).
Two approaches have been taken to adapt hearing-related questionnaires. The first focuses on maintaining the nuances of the original version and sometimes adapting the items to suit the target culture without paying attention to the appropriateness of the language and validity of the translation. Psychometric equivalence may be assumed rather than formally evaluated. As such, findings may be invalid when outcomes of those translated questionnaires are compared with norms obtained using the source-language questionnaire.
The second approach carefully translates items based on published good practice guidelines on translating health care-related questionnaires and may adapt some items to make them relevant to the target culture (J Clin Epidemiol. 2015;68(4):435). As these published guidelines do not directly address issues specific to audiology (e.g., importance attributed to listening ability and geographical variations in a listening environment and social culture), researchers or clinicians may make decisions based on their best judgement. While the second approach is superior to the first one in ensuring the functional equivalence between the translated and source-language versions, a review of relevant publications suggests a lack of full documentation of the translation/adaptation process, making comparison across studies difficult.
Hall, et al., recently published a new set of guidelines for questionnaire adaptation based on a comprehensive review of existing guidelines and expert input (Int J Audiol. 2017 Nov 21:1).
The new guidelines incorporated opinions of researchers who led projects in adapting questionnaires to other languages and cultures. Members of two international organizations, the International Collegium of Rehabilitative Audiology (ICRA) and the TINnitus Research NETwork (TINNET), were consulted to ensure that the guidelines not only follow conventional practice but also reflect contemporary issues affecting different cultures across the globe. Specific attention was paid to adapt questionnaires for people (e.g., immigrants) of different cultural backgrounds who live in a second-language environment and those who speak different languages in different cultures (e.g., different ethnic groups in a country). Other factors considered in developing the guidelines include differences in living environment (e.g., metropolis versus rural), implications of language and culture on listening needs (e.g., participation of family members in communication interchange), and the need to adapt the rating scales (e.g., certain rating scales may not be appropriate in some cultures). The members debated various issues and agreed on a best practice standard whenever possible.
The guidelines recommend six methodological steps to adapt a selected questionnaire:
- Preparation, which includes involving and obtaining permission from the source language questionnaire developer;
- Forward translation to the target language while accounting for cultural, language, and lifestyle differences;
- Back translation to the source language to check whether the nuances of the source-language questionnaire have been maintained;
- Committee review of the outcomes of the previous steps to ensure that the purposes are met;
- Field test to evaluate the possibility of unexpected issues and help resolve issues for which no prior consensus has been reached; and
- Review and finalize the translation.
To address these six steps, the step-by-step guide has 22 items that lead the reader through all the procedures necessary to be confident that the translated questionnaire is functionally equivalent to the original while accounting for any cultural differences. Short descriptions of each of these steps are provided. To facilitate a better understanding of how these steps should be followed and reported, examples were published as supplementary materials along with the guidelines (Int J Audiol. 2017 Nov 21:1).
The guidelines also highlighted the importance of involving the source language developer to ensure the nuances of the original questionnaires are maintained and avoid duplication of efforts. Another emphasis of the guidelines is proper documentation and reporting, including justifications when the guidelines could not be followed. Finally, a checklist is included to help researchers and clinicians make informed choices about conducting or omitting any items and reporting the process.
Although these procedures may seem labor-intensive, they are believed to result in high-quality adaptation and translation of questionnaires that will best suit the target population. These guidelines are accessible for free online.