METHODOLOGICAL ISSUES IN NURSING RESEARCH

Instrument translation process: a methods review

Wantana Maneesriwongul MPH DNSc RN
Chairman of Graduate Study in Community Health Nursing, Nursing Department, Ramathibodi Hospital Faculty of Medicine,
Mahidol University, Bangkok, Thailand

Jane K. Dixon PhD

Professor, Doctoral Program, Yale University School of Nursing, New Haven, Connecticut, USA

Submitted for publication 10 February 2004

Accepted for publication 15 March 2004

Correspondence: M A N E E S R I W O N G U L W . & D I X O N J . K . ( 2 0 0 4 ) Journal of Advanced Nursing

Wantana Maneesriwongul, 48(2), 175–186
Nursing Department, Instrument translation process: a methods review
Ramathibodi Hospital Faculty of Medicine,
Background. Cross-cultural and international collaborative studies are needed in
Mahidol University,
nursing research. Therefore, it is necessary to translate research instruments into the
270 Rama 6 Road,
Bangkok 10400, language of the culture being studied. In this methods review, different processes of
Thailand. instrument translation and evaluation of translation adequacy in published nursing
E-mail: rawlp@mahidol.ac.th research are described and classified into a hierarchy.
Methods. Studies including translation of quantitative research instruments were
reviewed. Forty-seven studies were included. These were classified into six categ-
ories.
Results. Studies were classified into categories as follows: forward-only translation
(2), forward-only translation with testing (7), back-translation (13), back-transla-
tion with monolingual test (18), back-translation with bilingual test (3), and back-
translation with both monolingual and bilingual test (4). Strengths and weaknesses
are analysed.
Conclusion. The studies reviewed used diverse methods of varying quality. There is
need for consensus among researchers in how to achieve quality of instrument
translation in cross-cultural research. Researchers should carefully attend to
achieving and reporting evidence of the accuracy and validity of instrument trans-
lation. When back-translation fails to achieve semantic equivalence, the instrument
development process should be replicated in the target language.

Keywords: instrument translation, back-translation, bilingual test, cross-cultural

research, nursing research, literature review

of people with diverse cultural backgrounds, research instru-

Background
Cross-cultural and international collaborative studies are
needed in nursing research. For studies in which quantitative
measures will be used, it is necessary to translate these
measures into the language of culture being studied. This is
not a simple process. The values reflected by an instrument
and the meanings of its component constructs may vary from
one culture to another. In order to study the health care needs
ments must be reliable and valid in each culture studied
(Munet-Vilar’o & Egan 1990).
Thus, quality of translation and validation of the translated
instrument plays a significant role in ensuring that the results
obtained in cross-cultural research are not due to errors in
translation, but rather are due to real differences or
similarities between cultures in the phenomena being
measured. However, while instrument translation and

2004 Blackwell Publishing Ltd 175

W. Maneesriwongul and J.K. Dixon
verification of adequacy of translation are important,
researchers approach this in a variety of ways.
Brislin et al. (1973) recommended one or more of the
following techniques: (1) back-translation; (2) bilingual
techniques; (3) committee approach; and (4) pretest. In
back-translation, a target language version is translated back
into the source language version in order to verify translation
of the research instrument. The bilingual technique involves
testing both source and target language versions among
bilingual respondents in order to detect items yielding
discrepant responses in the two versions. The committee
approach is the use of a team of bilingual people to translate
from the source to the target language. In pretest procedures,
a pilot study should be carried out after instrument transla-
tion is completed in order to ensure that future users of the
target language version can comprehend all questions and
procedures (Brislin 1970).
These techniques have been recommended, but none is
perfect. Each technique deals with one or two types of
equivalence and thus they are complementary to each other.
Although back-translation is highly recommended by experts
on cross-cultural research (Brislin 1970, Werner & Campbell
1970, Champman & Carter 1979), a target language version
resulting from poor translation might still retain much of the
source language’s structure, so that is easy to back-translate
correctly despite translation errors. In this case, although
back-translation is used, the target language version may not
be appropriate for use with the target population, especially
for cross-cultural research. As an aspect of the translation
process, it is also necessary that the versions of the instrument
be systematically compared (Tang & Dixon 2002). Compar-
ison between the original and back-translated versions (also
in the source language) is necessary, as is comparison
between source and target language versions. In the bilingual
technique, both source and target language versions are tested
among bilingual subjects. However, recall of one’s previous
answers may lead to response bias on whichever instrument is
done second. The committee approach, although useful, is
regarded as weak, because it does not necessarily control for
shared misconceptions. A committee participant may be
reluctant to criticize another participant’s suggestions. Mul-
tiple translators may work together or separately. A pretest is
essential, even when careful translation technique is used, in
order to reveal problems with clarity of the target language
version among the target population, and possibly to deter-
mine psychometric characteristics of the translated instru-
ment. However, use of pretesting alone cannot establish
equivalence between versions. Essentially, multiple tech-
niques should be used in all cross-cultural research (Brislin
et al. 1973).
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
Although previous scholars have reviewed and critiqued
literature on translation methods, these have not provided a
systematic examination of the full variety of approaches used
in instrument translation (Jones & Kay 1992, McDermott &
Palchanes 1994, Gilmer et al. 1995, Corless et al. 2001, Jones
et al. 2001). In this methods review, different processes of
instrument translation and evaluation of translation ade-
quacy in published nursing research are described and
classified into a hierarchy, and the strengths and weaknesses
of each are analysed.
Search methods
A search of the literature was conducted in order to identify
research articles including translation of quantitative research
instruments. This was done in an exploratory way and with
consultation from the librarian of the Yale University
Nursing Library. In early October 2002, a search with the
word ‘translation’ as subject heading or keyword yielded 947
citations in the CINAHL database. Perusal of these revealed
that a high proportion were off-topic, dealing with issues
such as ‘translation’ of research into practice, and language
translation of health education materials, or translation
methods as used in qualitative studies.
The next step was to combine this set of citations with a set
of subject headings focused on quantitative instruments. Four
subject heading terms were selected: ‘research instruments or
instrument construction or instrument scaling or instrument
validation’. Combining this set of citations with the connec-
tor ‘and’, the number of citations was reduced to 207. With
further limitations to articles in English language and
appearing in journals identified by CINAHL as ‘core nursing
journals’, the number of citations was further reduced to 69.
This list of citations was used to identify the five journals in
which such articles most often appeared. These were Journal
of Advanced Nursing, Cancer Nursing, Nursing Research,
Western Journal of Nursing Research, and Image/Journal of
Nursing Scholarship. These five journals each had a range of
six to 21 articles, and included 50 of the citations. This set of
major nursing journals seemed appropriate in representing
diverse journal types, including general scholarly journals, a
clinical specialty journal, and journals focusing on research.
No other core nursing journals had more than three such
citations.
These 50 citations were located and reviewed in relation to
additional criteria for inclusion: that the article described a
research study and that it indicated that a quantitative
research instrument was translated as a part of the described
study. (In some papers, conducting and evaluating the
translation was a major study purpose. In others instrument
Methodological issues in nursing research
translation was simply a step towards other study purposes.
Both types were included.) Nine articles were omitted for the
following reasons: use of instrument previously translated
and reported in literature (3), methods or literature review
paper not focused on a specific instrument translation (3),
duplicate publication about a single study (1), qualitative
study (1), and ‘translation’ of format, rather than from one
language to another (1). A decision was made to retain one
methods article because it included a detailed description of
the process used by the author for translation of a research
instrument. In all, 41 of the 50 articles met the criteria for
continued inclusion. In addition, manual review of the most
recent issues of the selected journals yielded six additional
articles, not yet listed in CINAHL database, which met the
criteria for inclusion. This set of 47 articles was then analysed
for elements of the instrument translation process, as
described below. The number of articles per journal in the
final set were as follows: Journal of Advanced Nursing (20),
Nursing Research (9), Cancer Nursing (8), Western Journal
of Nursing Research (6), and Image/Journal of Nursing
Scholarship (4). Although not a complete set of all published
articles including translation of a research instrument in the
nursing literature, it is felt that this is an adequate collection
of articles for examining commonalties and diversity in
approaches used.
All articles were reviewed by the first author. The second
author also reviewed a subset of these, including all those
identified as complex or unclear. These were discussed until
agreement was reached about the basic elements of the
translation process and testing presented in the article. Using
the information provided in the reviewed articles, a system
for categorizing the articles was developed.
Results
Forty-three of the 47 studies reviewed concerned translation
of instruments from English into other languages, including
Chinese (10), Spanish (8), Korean (5), Finnish (4) and other
languages. Twenty-five of the studies indicated that a major
purpose was to conduct and evaluate the instrument trans-
lation. Twenty-two did not indicate this as a purpose; thus, it
appears that the instrument translation was conducted as a
step in accomplishing other study purposes.
Of the 47 studies reviewed, 38 used forward- and back-
translation and the remaining nine used only forward-
translation. Thirty-two studies tested the translated instru-
ment either with monolingual subjects (24), bilingual subjects
(3), or both (5). Fifteen studies did not indicate that the
instrument was tested. Using these two key characteristics –
method of translation and method of testing – the studies

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
Instrument translation process
were classified into six categories. For studies with forward-
translation only, two categories were created to distinguish
those with no test of the translated instrument from those
with any kind of test. For studies with forward- and-back
translation, four categories were created to distinguish
between those with no test, monolingual test, bilingual test,
or both kinds of test. Thus, each category represents a specific
combination of characteristics relevant to instrument trans-
lation. Names of the categories, number of studies, and
category descriptions, along with strengths and weaknesses of
each, are presented in Table 1. Frequency of instrument
translation characteristics by category, are presented in
Table 2.
In all, 38 of the 47 studies reported that versions of the
instrument were compared, including 19 which compared
source language and target language versions, 13 which
compared the original and back-translated versions, and six
which reported conducting both types of comparison.
Fourteen studies reported use of multiple translators for
either forward- or back-translation or both. Forty studies
reported some types of reliability and/or validity from
instrument testing, or from a separate content validity
process. The remainder of this section reports results by
category.
Forward-only translation (category 1)
Two studies used only forward-translation, without back-
translation and without testing of the instrument in the
target language. Neither of these gave information about
who performed the translation or whether there was one
translator or more than one (Lauri et al. 1997, Lukkarinen
1998). In a study conducted by Lukkarinen (1998), the
Nottingham Health Profile (NHP) was translated into
Finnish. Although the use of back-translation was not
addressed, the Finnish version was approved by the
European NHP symposium. Lukkarinen et al. (1998)
indicated that the Finnish version of the NHP had been
translated and standardized in a previous study using a
large Finnish sample and that reliability and validity were
also established. However, there was no information that
pretests addressed semantic or conceptual equivalence
between versions. Lauri et al. (1997) developed an instru-
ment in Finnish to measure decision-making by public
health nurses. Reliability and validity was established based
on pretesting of the Finnish version. The authors translated
this instrument into English and Norwegian to describe the
decision-making of public health nurses in Canada,
Finland, Norway, and the United States of America (USA).
Although significant differences in decision-making process
177
178
Table 1 Descriptions of instrument translation categories

Category (No.) Descriptions Strengths Weaknesses

1. Forward-only Instrument used was translated from the source Applicable when only one translator is available. Equivalences between SL version and TL
translation (2) language (SL) into the target language (TL) Time and cost saving. version is not verified.
without using back-translation technique.

2. Forward Category 1 plus a pretest of the TL version. Applicable when only one translator is available. Equivalences between SL version and TL
translation with Time and cost saving. version is not verified.
W. Maneesriwongul and J.K. Dixon

testing (7) TL version can be tested for appropriate use in TL

(monolingual) subjects.

3. Back translation Instrument used was translated from the source
(13) language into the target language by a translator.
Then the target language version was translated
back into the source language by other translators.
Then, 2 source language versions were compared.
Semantic equivalence between SL version and TL Not possible when only one translator
version can be verified. is available.
Direct comparison of 2 source language versions Time and cost commitment.
provides additional evidence of quality. Discrepancies between SL & TL responses
are not detected.

4. Back translation Category 3 plus test of the target language version Semantic equivalence between SL version and TL Not possible when only one translator
and monolingual among monolingual (target language) subjects. version can be verified. is available.
test (18) Reliability and/or validity test of TL version is Time and cost commitment.
conducted among monolingual subjects. Discrepancies between SL & TL responses
TL version can be tested for appropriate use in TL are not detected.
(monolingual) subjects.

5. Back translation Category 3 plus test of the source and target Semantic equivalence between SL version and TL
and bilingual language versions among bilingual subjects. version can be verified.
test (3) Reliability and/or validity test of both SL and TL
versions is conducted among bilingual subjects.
Discrepancies between SL & TL responses
are detected.
Not possible when only one translator
is available.
Time and cost commitment.
TL version cannot be tested for appropriate
use in TL (monolingual) subjects.
Difficult to find enough bilingual subjects.

6. Back translation Category 3 plus test of the target language version Semantic equivalence between SL version and TL Not possible when only one translators
and monolingual & among monolingual (target language) subjects, and version can be verified. available.
bilingual tests (4) test of the source and target language versions Reliability and/or validity test of SL & TL version can Time and cost commitment.
among bilingual subjects. be conducted among both mono and Difficult to find enough bilingual subjects.
bilingual subjects.
TL version can be tested for appropriate use in TL
(monolingual) subjects.
Discrepancies between SL & TL responses
are detected.

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186

 Table 2 Frequency of instrument translation characteristics by category

Aspects of instrument translation processes

Translators Comparisons Testing methods

Methodological issues in nursing research

Category Single Multiple Single and Not Monolingual Bilingual Mono and Psycho-metric
(Number of studies) translator translators multiple* specified SL/TL SL/SL Both test test bi-lingual test evaluation 

1. Forward-only 0 0 0 2 2 0 0 N/A N/A N/A 2

translation (2)
2. Forward translation 2 3 0 2 6 0 0 6 0 1 5
with testing (7)
3. Back translation 4 4 1 4 1 6 2 N/A N/A N/A 9à
(13)
4. Back translation 9 3 2 4  6 7 1 18 N/A N/A 18à
with monolingual
test (18)
5. Back translation 2 1 0 0 0 2 1 N/A 3 N/A 3

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186

with bilingual
test (3)
6. Back translation 3 0 0 1 2 0 2 N/A N/A 4 4
with monolingual
& bilingual tests (4)

Total 20 11 3 13 19 13 6 24 3 5 40

*Studies used one translator for forward translation and more than one translators for back translation, or vice versa. **Some studies had a translator do forward translation, but provided
no information about back translator or vice versa.  This column refers to report of psychometric evaluation done as a part of instrument testing (i.e. one or more form of reliability or
validity). àSome studies mention only about content validity or face validity,
N/A ¼ not applicable.

179
Instrument translation process
W. Maneesriwongul and J.K. Dixon
between countries were revealed, these findings are question-
able, in that there is no indication that back-translation was
used. Without verification of translation adequacy, the
differences might be due to errors in translation, rather than
being true differences between countries. These two reports
did not give information about the translator, and did not
specify that a comparison of versions, bilingual technique or
pretest among target language subjects was conducted.
Forward-only translation with testing (category 2)
Seven studies used forward-translation followed by testing of
the target language version, either with monolingual or
bilingual subjects. Six of these indicated comparison of the
target and source language versions to allow identification
and correction of any discrepancies occurring during the
translation process (Arakawa 1997, Maggs & Abedi 1997,
Chan & Chang 1999, Clifford et al. 1999, Miller & Chandler
2002, Tafas et al. 2002). Three of the studies might have used
a committee approach to translate the instrument (Kotzabas-
saki et al. 1997, Clifford et al. 1999), but only one clearly
specified this (Miller & Chandler 2002). Miller and Chandler
(2002) used a focus group to address potential translation
and conceptual problems and establish a final version of the
target instrument, while Clifford et al. (1999) used a bilingual
technique to test both target and source language versions. In
addition to tests of clarity and appropriateness of the target
language version, psychometric characteristics including
internal consistency, reliability and indicators of validity
were calculated in five studies (Arakawa 1997, Kotzabassaki
et al. 1997, Maggs & Abedi 1997, Clifford et al. 1999, Tafas
et al. 2002).
Back-translation (category 3)
Thirteen studies used a back-translation technique without
indication that the translated instrument was tested before
further use. A key benefit of conducting a back-translation
is that this allows comparison of the original source
language version with the version which was back-transla-
ted into the source language. However, of the 13 studies
assigned to this category, only six specified that the source
language versions were compared (Lin & Ward 1995, Fry
& Nguyen 1996, Adams et al. 1997, Kuisma et al. 1997,
Murtonen et al. 1998, Shin 1998). Two compared both
source language versions, as well as comparing the source
language and target language versions (Yom 1998, Mikhail
& Petro-Nustas 2001). One specified that the source
language version and target language version were com-
pared, and that modifications were made before conducting
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
back-translation and then evaluating equivalence between
source language versions (Yom 1998).
There may be more than one iteration of forward- and
back-translation. In a study by Fry and Nguyen (1996),
translation and back-translation were repeated three times to
reduce discrepancies between source language and target
language versions. Lin and Ward (1995) did single iteration
for most of the items in their study, but three iterations were
performed for a few items presenting with some discrepan-
cies, and additionally a panel of experts conducted content
validation of the target language instrument.
It is implicit in back-translation that different translators
are used for the forward translation and back translation.
Five of the studies in this category used more than one
translator for either the forward or backward translation or
for both (Yamashita 1995, Adams et al. 1997, Mikhail &
Petro-Nustas 2001, Han et al. 2002, Heilemann et al. 2002).
Four studies did not provide information about the number
of translators (Kuisma et al. 1997, Shin 1998, Kim 1999,
Hakulinen et al. 1999).
Back-translation and monolingual test (category 4)
Eighteen studies were identified which used a back-transla-
tion technique along with a test of the target language version
with monolingual subjects. Among these, nine used only two
translators: one translator conducted forward translation,
and the other conducted back translation (Walker et al. 1990,
Jones & Kay 1992, Sherman et al. 1992, Kim et al. 1995,
Holroyd et al. 1998, Wells et al. 2001, Chen et al. 2002,
Idvall et al. 2002, Li et al. 2002), while five studies used
multiple translators for at least one of the translation
processes (Jones 1995, Kajermo et al. 1998, Yamashita
1998, Fu et al. 2002, Hilton & Skrutkowski 2002).
Information about the number of translators was not always
provided (Bernal et al. 1997, Kyngas et al. 2000, Haddad &
Hoeman 2001). Multiple iterations of translation were
conducted in six studies (Jones & Kay 1992, Sherman et al.
1992, Yamashita 1998, Kyngas et al. 2000, Wells et al. 2001,
Hilton & Skrutkowski 2002). Interestingly, a study of a
teaching inventory with deaf parents had two sign language
interpreters do forward and backward translations using a
counterbalanced technique: one translated the first half and
the other translated the second half of the source language
instrument into the target language. Consequently, discre-
pancies between source and target versions were identified
and the target version was modified. Back-translation was
then repeated until the investigator and interpreters were
satisfied with equivalence between source and target
languages (Jones & Kay 1992).
Methodological issues in nursing research
In addition to comparison between versions, seven studies
used a panel of experts to establish content validity (Sherman
et al. 1992, Yamashita 1998, Kyngas et al. 2000, Haddad &
Hoeman 2001, Wells et al. 2001, Chen et al. 2002, Li et al.
2002), and the Content Validity Index of the target language
version was calculated in two of these (Haddad & Hoeman
2001, Chen et al. 2002).
Most studies in this category tested the target language
instrument for clarity, comprehensiveness, appropriateness,
and/or cultural relevance among its monolingual subjects.
However, there was some variation in this pattern. In
addition to testing the target language instrument among
monolingual subjects, three studies tested the source language
version of the same instrument among source language
monolingual subjects (Sherman et al. 1992, Dijkstra et al.
2000, Hilton & Skrutkowski 2002). Two studies involved
translation into American sign language (Jones & Kay 1992,
Jones 1995). One tested the original and second source
language versions among source monolinguals, instead of
testing the target language instrument among target language
monolinguals (Jones & Kay 1992).
Back-translation and bilingual test (category 5)
Three studies used a back-translation technique, compared
the original and second source versions of the instrument, and
tested both source and target language versions among
bilingual subjects. The approach to data collection for the
bilingual test varied. In two of the studies bilingual subjects
completed both source and target language versions using a
cross-over design to control recall bias (Chang et al. 1999,
Chien et al. 2001). However, rather than use a cross-over
design, Son et al. (2000) had bilingual (Korean) subjects
complete the English version first, followed by the Korean
version, and they randomized items in the Korean version in
order to minimize a recall effect on the second test. Other
points of variation between studies included calculation of
psychometric characteristics of the target language instru-
ment (Son et al. 2000), having a panel of experts validate
content of the final target language version (Chang et al.
1999), and testing item equivalence using kappa statistics
(Chien et al. 2001).
Back-translation and monolingual and bilingual test
(category 6)
Four studies used a back-translation technique, tested the
target language version among monolingual subjects, and
tested both source and target language version among
bilingual subjects. Three studies had only two translators

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
Instrument translation process
translate the instrument: one conducted forward-translation,
and the other conducted back-translation (Dimmitt 1995,
Lin et al. 2001, Chou et al. 2002); one did not give
information about the translators (Lim et al. 1996). All
studies compared the source and target language versions of
the instrument, while two also compared the original and
second source versions (Dimmitt 1995, Lin et al. 2001),
and one had several raters examine all three versions (Chou
et al. 2002). In addition to testing the target language
version among target language monolingual subjects, in two
studies the source language version was also tested with
people who were monolingual in the source language
(Dimmitt 1995, Lim et al. 1996). Two studies also had a
panel of experts validate the target language instrument
(Lin et al. 2001, Chou et al. 2002). Internal consistency
reliability was calculated in all studies, supplemented by
other psychometric assessments. Studies classified into this
category used the most complete process for instrument
translation; however, there was still notable variation in the
processes used.
Discussion
A methods review of 47 articles revealed that information
about instrument translation processes provided in published
cross-cultural nursing research was often inadequate. This
may be due, in part, to varied purposes in the articles being
reviewed and also to editorial requirements of the journal
from which articles were selected.
Of 47 reviewed articles, conducting and evaluating the
translation was major purpose of 25 articles. More informa-
tion about translation processes were provided in these
articles. However, we recommend that all studies involving
instrument translation should include information to estab-
lish that translation processes were adequate. This informa-
tion is needed even when the study uses an instrument already
translated by other researchers, especially when this infor-
mation has not been previously published in an accessible
source.
We also found that there is no standard guideline for
instrument translation, and the quality of processes used for
instrument translation varied widely among these articles. The
six categories which we developed might be thought of as a
kind of hierarchy, with category 1 ‘Forward-only translation’
indicating a minimal level of effort, while category 6, ‘Back-
translation and monolingual and bilingual test’, indicates a
substantial effort to assure validity of the translation. The
following sections discuss the strengths, weaknesses and
appropriate applications of these categories. This supplements
the information presented in Table 1.
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W. Maneesriwongul and J.K. Dixon
Strengths, weaknesses and applications
Forward-translation should be carried out when only one
translator is available, as this is considered the least
thorough translation process. When forward-translation is
used, the target language version should always be
pretested with target language subjects. Despite pretesting,
cross-cultural comparisons should not be conducted,
because forward-translation cannot be used to ensure that
differences or similarities detected in phenomena were not
due to errors in translation. Thus, studies in which a
forward translation was used should not aim to make
cross-cultural comparisons. This approach can be streng-
thened by rigorous comparison between source language
and target language versions by independent judges if that
is feasible. Such a rigorous approach, using the Translation
Validity Index [an adaptation of Lynn’s (1986) Content
Validity Index], has been described by Tang and Dixon
(2002). However, with a forward-only translation, seman-
tic equivalence may not be established between target and
source language versions. Without back-translation, ade-
quacy of instrument translation cannot be verified and
should not be assumed.
If the purpose of the study is to make cross-cultural
comparisons, back-translation is necessary. Through this
process, comparison between source and target language
versions by bilingual judge(s), as well as of two source
language versions by monolingual judge(s), are made, in
order that discrepancies of translation can be identified and
corrected. However, it can be difficult to find more than
one bilingual translator and native source language speaker
[to serve as monolingual judge(s)] in the target language
community or country. Thus, some studies used bilingual
judges, or people who were not specified as native speakers
of the source language. In this review, eight studies
indicated that back-translation was done, without specify-
ing that the source language versions were compared. We
suspect that in at least some of these studies this compar-
ison was conducted, although it was not described in the
report.
In back-translation, modification of words and concepts
that have no clear equivalence in the other language is
allowed. This is particularly useful when one version has
ideas and words which, in the other language, seem socially
insensitive or can be expressed only with difficulty (Champ-
man & Carter 1979). The key to achieving semantic
equivalence is to retain the same meaning of each item after
translation into the language of each culture (Flaherty et al.
1988). This technique also helps to achieve conceptual
equivalence. In addition, instrument reliability is streng-
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
thened and the validity of the study and credibility of the
findings are simultaneously enhanced.
When a sufficient number of bilingual subjects is available,
back-translation can be combined with a bilingual technique.
This provides an opportunity to test both source and target
language versions among bilingual subjects, so that any
discrepancies can be detected. To minimize recall bias, a
cross-over design recommended by Prince and Mombour
(1967) was used in three studies (Chang et al. 1999, Clifford
et al. 1999, Chien et al. 2001). However, Son et al. (2000)
proposed a new approach for this technique by having
Korean subjects who could also read and understand English
complete the English version first and then subsequently
complete the Korean version. These researchers believed that
exposure to questions in a less familiar language was unlikely
to influence participants in responding to the same questions
in their own native language. They also placed items in the
Korean version in random order to reduce any recall effect.
Combining back-translation with testing of the target
language version among monolingual subjects is necessary to
test the clarity and appropriateness of the target language
version. Ideally, this should involve comprehensive psycho-
metric evaluation to assess reliability and validity, as would
be performed with any newly-developed instrument. Reliab-
ility and validity of the source language version should not
necessarily be assumed for the target language version. We
found that, among studies with back translation, 22 conduc-
ted some kind of testing with one or more monolingual
groups. Usually this was testing of the target language version
with subjects who know that language, but four of these
tested both source and target versions with monolingual
subjects in the source and target language respectively
(Sherman et al. 1992, Dimmitt 1995, Jones 1995, Lim et al.
1996, Hilton & Skrutkowski 2002). For example, Hilton and
Skrutkowski (2002) had 59 English speakers complete the
English language version, while 13 French speakers com-
pleted the French version of the instrument, and then
compared patterns of responses. In contrast, Jones and Kay
(1992) tested the original and second source language
versions as back-translated among source monolingual
subjects; this was characterized as a ‘triangulation strategy’
and was done because inadequate numbers of bilingual
subjects could be found. Two studies used qualitative
methods such as an interview (Kyngas et al. 2000) and a
focus group (Chen et al. 2002) along with a pilot test of the
target language version, while Miller and Chandler (2002)
used only a focus group.
Back-translation combined with both bilingual and mono-
lingual tests is the most complete instrument translation
process. This allows detection and correction of discrepancies
Methodological issues in nursing research
between source and target language versions, as well as a test
for clarity and appropriate use with subjects who are
monolingual in the target language. However, this requires
substantial commitment of time and resources, and is possible
only if enough bilingual subjects can be found. It is not
surprising that only four of 47 studies fitted this category.
Another approach to instrument translation, the com-
mittee approach, was not commonly used in the articles
reviewed. However, 11 indicated use of multiple transla-
tors: forward-translation (3) and back-translation (8). It
was not consistently clear to what extent translators
worked independently rather than in a ‘committee’ format.
In any case, translators working together may share
misconceptions and may compromise each other. Despite
using a committee approach, it is still necessary to combine
this with back-translation, a bilingual technique, and pre-
testing, as suggested by Brislin et al. (1973). Additionally,
descriptions and/or the qualifications of the translators
should be provided as an indicator of quality (Jones et al.
2001).
Several factors may influence the selection of these meth-
ods: (1) the objectives of the study; (2) the availability of
translators, judges and bilingual subjects; (3) the budget; and
(4) time. If an objective of the study is to make cross-cultural
comparisons, back-translation combined with both bilingual
and monolingual tests should be used. However, if sufficient
numbers of translators, judges and/or bilingual subjects
cannot be recruited, or time and/or budget is severely
restricted, the rigour of the instrument translation process
will inevitably be diminished.
Recommended minimum standards for applying an instru-
ment developed in another language should include back-
translation and testing (with an acceptable internal consis-
tency reliability) among target language subjects at least to
allow detection and correction of discrepancies of transla-
tion, as well as evaluation of clarity and appropriateness with
future subjects. Back-translation begins to provide an assur-
ance that the instrument is the same in the two languages, and
assessment of internal consistency gives an indication of
reliability of the target language version.
Limitations
This methods review of instrument translation process used
in nursing research is limited in two ways. First, the set of
studies reviewed does not reflect the total universe of relevant
studies involving translation of a quantitative instrument.
Specifically, we decided to limit the review to the five major
nursing journals with the highest frequency of such studies.
This enabled a focus on prominent journals with substantial

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
Instrument translation process
experience in studies of this type, and also made possible a
100% rate of study retrieval. However, it meant that studies
published in other journals, including an instrument transla-
tion study by one of us (Tang & Dixon 2002), were not
included. Second, in some of the articles reviewed, the
translation process was described in a cursory way, without
full information about what was done – reflecting an
observation made three decades ago that researchers often
provide only ‘scant’ information about instrument translation
and cross-cultural administration (Brislin et al. 1973). We
made no effort to obtain information beyond that which was
clearly stated in the research report. This may have led to
inaccurate characterization of some studies. For example, it is
quite possible that some studies involving back-translation,
but not specifying comparison between versions, actually did
such comparisons but this was not stated in the research
report.
Conclusions
Since there is no single perfect translation technique, we
suggest that multiple techniques should be used in all cross-
cultural research. However, there is no consensus among
researchers on how these techniques should be used or
combined. In the 47 studies reviewed, there was a wide
variety of techniques and operationalizations or combina-
tions, as well as variation in number and qualifications of
translators. The quality of an instrument used in cross-
cultural research is expected to vary with quality of the
translation method. Therefore, there is need for consensus on
how to achieve quality of instrument translation in cross-
cultural nursing research.
More detailed information about translation processes
should be provided in reports. This should be a requirement
of all journals in reviewing research studies involving
instrument translation. Likewise, studies that use an instru-
ment that was translated as part of a previous study should
provide background information concerning the translation
process previously used. Thus, reviewers and other readers
will be informed about the translation process, as well as
evidence of the adequacy of the resulting target language
instrument. Further, when back-translation or even multiple
back-translation methods are applied, but semantic equival-
ence cannot be achieved, researchers should consider repli-
cation of the instrument development process in the target
language, rather than using an instrument which will not
make sense in the target language. This is necessary because if
translation is not done well, this could lead to suspicious
research findings, which reflect systematic errors of transla-
tion rather than substantial differences between groups.
183
W. Maneesriwongul and J.K. Dixon
What is already known about this topic
• Cross-cultural research is becoming more popular in
nursing, but there is no standard guideline for instru-
ment translation.
• Back-translation is the most highly recommended tech-
nique for translation in cross-cultural research.
What this paper adds
• Information about instrument translation processes
provided in published cross-cultural nursing research is
often inadequate.
• The quality of processes used for instrument translation
in nursing research varies widely, and consensus on
standard guidelines for instrument translation is
needed.
• Instrument translation processes were classified into
hierarchy, with analysis of the strengths and weaknesses
of the approaches.
• Minimum standards for applying an instrument devel-
oped in another language should include back-transla-
tion and monolingual testing.
It is highly recommended that instrument translation
methods and issues related to cross-cultural instrument
equivalence should be included in nursing research courses.
In particular, many doctoral programmes in nursing require
students to take a course on measurement. Such a course
should include content on translation processes, and on
evaluating translation equivalence of a translated instrument.
Achievement of consensus standards for appropriate trans-
lation processes, adequate reporting about such processes,
and focused preparation of beginning researchers in these
processes would enhance the likelihood of high quality
instrument translation. This, in turn, would enhance the
potential for productive research with people of diverse
languages and cultures, and enable researchers around the
world to obtain results that accurately reflect the health
characteristics and needs of various cultural groups. Ideally,
this would lead to increased collaboration between research-
ers from various cultures and improved synergy of results,
through which researchers could build a base of knowledge
that applies across cultural groups.
Author contributions
WM took major responsibility for conceptualization of the
project, identification and collection of the articles used to
184
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(2), 175–186
provide data, extraction of data, analysis, and interpretation
of results. JD collaborated in all aspects of the project, with
particular emphasis on design of method and scholarly
presentation.
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