ARTICLE IN PRESS

Social Science & Medicine 57 (2003) 1289–1306

A systematic and critical review of the process of

translation and adaptation of generic health-related
quality of life measures in Africa, Asia, Eastern Europe,
the Middle East, South America
Annabel Bowden, Julia A. Fox-Rushby*
Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

Abstract

In recent years there has been a worldwide increase in demand for subjective measures of health-related quality of life
(HRQL). Researchers have the choice of whether to develop a new measure or whether to adapt an existing measure in
another language. This review evaluates the processes used in translating and adapting nine generic HRQL instruments
(15D, Dartmouth COOP/WONCA Charts, EuroQol, HUI, NHP, SIP, SF-36, QWB, WHOQOL) for use in Africa,
Asia, Eastern Europe, the Middle East, and South America. The review adopts a universalist model of equivalence,
outlined by Herdman, Fox-Rushby, and Badia (Qual. Life Res. 7 (1998) 323), to judge the 58 papers reviewed. Research
spans 23 countries and is dominated by research in the East Asia and Pacific region and the SF-36. Results are reported
for conceptual, item, semantic, operational, measurement and functional equivalence. It is argued that currently there is
a misguided pre-occupation with scales rather than the concepts being scaled and too much reliance on unsubstantiated
claims of conceptual equivalence. However, researchers using the WHOQOL approach are more likely to establish
reliable conclusions concerning the equivalence of their instrument across countries. It is a key conclusion of this review
that research practice and translation guidelines still need to change to facilitate more effective and less biased
assessments of equivalence of HRQL measures across countries.
r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Health-related quality of life; Translation; Adaptation; Equivalence; Cross-cultural

Introduction increasingly global dissemination of knowledge through

Demand for subjective measures of health-related
quality of life (HRQL) is increasing worldwide. This is
due to several factors, including the rising burden of
chronic disease; the desire to measure the impact of
health interventions beyond the absence of disease; the
requirements of international organisations to estimate
the impact of a wide variety of interventions to aid
resource allocation (Bobadilla & Cowley, 1995); and an
*Corresponding author. Tel.: +44-20-7927-2267; fax: +44-
20-7637-5391.
E-mail address: julia.fox-rushby@lshtm.ac.uk
(J.A. Fox-Rushby).
academic journals and international societies.
Most generic measures of HRQL have been developed
in English, leaving researchers working in other lan-
guages with two options; either to develop a new
measure and/or to translate an existing measure. There
is increasing concern about the relevance of translated
versions of HRQL instruments (Fox-Rushby & Parker,
1995). Criticisms have focussed on the quality of the
translation process (Anderson, Aaronson, Bullinger, &
McBee, 1996) and because cultural differences are not
‘accounted for’ during the translation and adaptation
process (Hunt, 1994). Guidelines for translating HRQL
questionnaires have been developed (Guillemin, Bom-
bardier, & Beaton, 1993; Bullinger et al., 1998; Sartorius

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0277-9536(02)00503-8
 ARTICLE IN PRESS
1290 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306

Table 1
Summary of the Herdman et al. (1998) definitions for each type of equivalence

Equivalence Definition

Conceptual Achieved when the questionnaire has the same relationship to the underlying concept in both cultures, primarily in
terms of the domains included and the emphasis placed on different domains.
Item ‘‘Item equivalence exists when items estimate the same parameters on the latent trait being measured and when
they are equally relevant and acceptable in both cultures’’ (p. 325).
Semantic The transfer of meaning across languages, achieving a ‘‘similar effect’’ on respondents who speak different
languages.
Operational ‘‘the possibility of using a similar questionnaire format, instructions, mode of administration and measurement
methods’’ (p. 329).
Measurement The psychometric properties of the adapted version of the HRQL measures are equivalent.
Functional ‘‘...the extent to which an instrument does what it is supposed to do equally well in two or more cultures’’ (p. 331).
This is demonstrated by being able to state how the ‘‘underlying trait’’ is defined or conceptualised, how well the
instrument design reflects that underlying trait, and how the results compare across cultures. This is assessed by
examining the degree to which the other five types of equivalence summarised above have been achieved.

& Kuyken, 1994) and the meaning of ‘equivalence’
debated, with confusion shown to abound (Herdman,
Fox-Rushby, & Badia, 1997, p. 234). Notions of
equivalence depend on the viewpoint taken (absolutist,
universalist, relativist) and a model has been developed
to examine equivalence between source and target
language versions of an HRQL measure from a
universalist perspective (Herdman et al., 1998). This
model defined six types of equivalence (see Table 1),
proposed strategies for their evaluation and suggested
an order in which testing should take place. However,
this model has not yet been operationalised.
This paper reports the results of a systematic and
critical review of the literature to establish how nine1
generic measures of HRQL have been translated and
applied amongst populations in Africa, Asia, Eastern
Europe, the Middle East, and South America based on
an operationalisation of the Herdman et al. (1998)
model of equivalence. A fuller technical report is
available from the corresponding author.
Methods
Literature search and selection
The first stage of the literature search took place in
mid-1999 using Medline, Embase, Psychological Ab-
stracts, Social Science and Psychological Abstracts and
ADIS. Search terms focussed on generic HRQL instru-
ments (n ¼ 9) and developers (n ¼ 17) (see Appendix A)
with no restrictions on language, country or time period.
1
The nine measures are: 15D; Dartmouth COOP Charts;
EuroQol (EQ5D); Health Utilities Index (HUI); Nottingham
Health Profile (NHP); Short-Form 36 (SF-36); Sickness Impact
Profile (SIP); Quality of Well-Being Index (QWB); and the
WHOQOL.
This search generated a total of 1347 papers. All titles
and available abstracts were downloaded and reviewed
to select full papers that used or adapted at least part of
one of the nine generic HRQL (15D, Dartmouth COOP/
WONCA Charts, EuroQol, HUI, NHP, SIP, SF-36,
QWB, WHOQOL) measures in the geographical areas
of interest.
Of the 62 papers identified, 24 were later rejected for
review for the following reasons: paper was unavailable
despite considerable attempts to retrieve it (n ¼ 9); not
in country/region of interest (n ¼ 9); added no new
information relative to other papers (n ¼ 3); reported on
an HRQL measure not selected for this review (n ¼ 1);
and only a published abstract was available (n ¼ 2).
With the remaining 38 papers, a second search involved;
an iterative search of the references from the 38, which
identified a further eight papers; adding three papers
known to the authors; and contacting the developers
of each measure, which identified an additional six
papers. Finally, in March 2000, a web-page search of the
nine generic HRQL measures identified three further
papers2. Of the 58 papers selected for full review
2
The corresponding web pages visited are as follows. 15D:
http://www.uku.fi/~sintonen/; Dartmouth COOP Charts:
http://home.fnxnet.com/FNX/home and http://www.dart-
mouth.edu/~coopproj/publications.html; EuroQol: http://
www.eur.nl/bmg/imta/eq-net/eq5d/translat.htm, (now moved
to http://www.euroqol.org/); Health Utilities Index: http://
www.fhs.mcmaster.ca/hug/index.htm; Nottingham Health Pro-
file: http://www.atsqol.org/nott.html; Quality of Well-Being
Scale: http://www/outcomes-trust.org/catalog/qwb.htm and
http://www.atsqol.org/qwb.html; Short Form 36: http://
www.sf-36.com, http://www.outcomes-trust.org/catalog/SF-
36.htm and http://www.atsqol.org/SF-36.html; Sickness Impact
Profile: http://www.outcomes-trust.org/catalog/sip.htm, http://
www.qlmed.org/SIP/bulletin.html, and http://www.atsqol.org/
sick.html; and WHOQOL: http://www.who.int/msa/mnh/mhp/
ql.htm.
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
(see Appendix B), ten were translated into English (six
from Japanese, two Polish, one Arabic, and one Spanish).
Developing the review criteria
The review criteria were developed based on a model
developed by Herdman et al. (1998) although we are
aware that our experiences developing an HRQL
measure in Kenya (Bowden, Fox-Rushby, Nyandieka,
& Wanjau, 2002; Fox-Rushby, 2000 for the KENQOL
Group) and the EQ5D (Fox-Rushby & Selai, in press;
Herdman, Fox-Rushby, Rabin, Badia, & Selai, in press;
Rabin Rabin, Herdman Fox-Rushby, & Badia, in press)
influenced our thinking. Each paper included was
systematically reviewed using a standard set of questions
based on the Herdman et al. model. Early piloting of the
questions by both authors on four papers led to further
discussion and revision. The revised questions were
piloted again and were also critically reviewed by two
external reviewers.3
The questions used to review each paper covered the
following: background details (such as location of
research, language used and funders); methodological
aspects (such as characteristics of the samples, purpose
of paper, other instruments used, and translation
processes); and the extent to which a paper covered
methods suggested by Herdman et al. for each part of
the universalist model of equivalence (see Appendix C).
For each of the six types of equivalence we also
categorised each paper into one of three categories,
depending on the level of reporting (none/minimal;
partial; and extensive) and whether specific issues had
been covered. Details of the exact criteria are provided
in Table 2.
Results
Background
All papers were published between 1990 and 1999,
despite searches being conducted to identify papers prior
to this date. The SF-36 dominates the literature (40%)
followed by the WHOQOL (19%), Dartmouth COOP
Charts (14%), EQ5D (9%), NHP (7%), SIP (5%), 15-D
(3%), and HUI (3%). No papers were identified for the
QWB, and it is therefore excluded from further analysis.
The papers spanned 23 countries, falling into six of
the nine World Bank regions.4 There is a fairly even
3 5
Michael Herdman (Catalan Agency for Health Technology
Assessment and Research) and Maria Watson (GlaxoSmithK-
line).
4 6
Americas: Argentina, Brazil, Colombia, Mexico, Panama.
East and Southern Africa: South Africa, Tanzania, Zimbabwe.
East Asia and Pacific: China, Hong Kong, Japan, Singapore,
1291
spread across these six regions, except for the East Asia
and Pacific region where there are three times as many
papers (37 of the 58 papers reviewed). Noticeably, 30 of
the 37 papers for the East Asia and Pacific region
reported research carried out in Japan. All eight HRQL
measures have been used in the East Asia and Pacific
Region, whereas four or fewer measures had been used
in other regions (see Table 3). Research has been
conducted in 20 different languages with the dominant
language being Japanese (30 papers). Eight languages5
were represented in six to 11 papers each, and the
remaining 116 languages in five or fewer papers each.
Two papers described research with people suffering
from communicable disease (HIV and Hepatitis),
whereas 19 papers focused on people suffering with
non-communicable disease (e.g. cancer, and depression).
Only one paper reported on injuries (Wrzesniewski,
1997). The majority of research (n ¼ 38) was non-disease
specific.
Conceptual equivalence
Table 4 reveals that 65.5% of papers did not report or
only made a minimal investigation of conceptual
equivalence. A partial report was provided in 17 papers
(29.3%), and an extensive report in three papers (5.2%).
All of the extensive reporting were by researchers using
the WHOQOL (e.g. Szabo, 1996). There was no research
on conceptual equivalence for the 15-D, HUI or SIP.
The majority for the East Asia and Pacific region
(67.6%) failed to report on conceptual equivalence.
Nineteen papers (32.8%) provided some form of
theoretical argument. Examples include vague argu-
ments that consider the differences in experiences,
understanding, and conceptualisation of health, quality
of life, or aspects of health (e.g. Westbury et al., 1997)
and discussion of the conceptual basis of the HRQL
instrument (e.g. Wang & Chen, 1999). Authors using the
15-D and the SIP did not present any theoretical
arguments accepting or rejecting conceptual equiva-
lence. Research in the Americas and the East Asia and
Pacific region was more likely to present a theoretical
argument than other regions.
In total only 24.2% of the papers provided any
information about the assessment of local conceptions
(footnote continued)
Thailand. Eastern Europe: Croatia, Russian Federation, Po-
land. Middle East: Israel, Jordan, Saudi Arabia. South Asia:
India, Nepal, Pakistan, Sri Lanka.
Hebrew (n ¼ 11), Spanish (n ¼ 8), Croatian (n ¼ 8), Rus-
sian (n ¼ 7), Hindi (n ¼ 7), Cantonese (n ¼ 7), Tamil (n ¼ 6),
and Shona (n ¼ 6).
Arabic (n ¼ 3), Kiswahili (n ¼ 3), Thai (n ¼ 3), Polish
(n ¼ 2), Portuguese (n ¼ 2), Afrikaans (n ¼ 1), Malay (n ¼ 1),
Nepali (n ¼ 1), Putonghua (n ¼ 1), and Xhosa (n ¼ 1).
 ARTICLE IN PRESS
1292 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
Table 2
Criteria for deciding whether translation/adaptation process had followed Herdman et al.’s model
None/minimal adherence
Conceptual No mention of any issues related to
conceptual equivalence, or a
cursory mention of ‘‘cultural bias’’
or similar statement.
Item No mention of any issues related to
conceptual equivalence, or a brief
mention in the text relating to any
of the issues relating to item
equivalence.
Semantic No mention of any issues related to
semantic equivalence, or a brief
mention in the text about who was
involved in the translation of the
HRQL measure.
Operational No mention of any issues related to
operational equivalence.
Measurement No mention of any issues relating
to measurement equivalence.
Functional Papers not assessed for reporting on functional equivalence.
of health and quality of life. Research with the SIP,
NHP, and the WHOQOL were the most consistent in
providing this information. Approaches adopted in-
Partial adherence
At least a mention of one of more of
the following: (1) an assessment of
the local populations
conceptualisation of health or quality
of life, or (2) an assessment of the
appropriateness of the measure in the
target setting or (3) theoretical
arguments questioning or accepting
conceptual equivalence. Can also
include any of the other points listed
under conceptual equivalence.
Description of the assessment of
either (1) life style patterns in the
target population, or (2) the
relevance or acceptability of
individual items to the target
population, or (3) quantitative
assessment of item equivalence. Can
also include details about judgements
and changes made.
Description of at least one of the key
issues related to semantic
equivalence: (1) an assessment of
types of meaning, (2) an assessment
of key words and phrases, (3) who
was involved in translation of the
measure, (4) who was involved in
judging the quality of the
translations, (5) a description of any
problems encountered.
A description of at least one or two
of the key issues listed under
operational equivalence: (1) an
assessment of response options, (2)
an assessment of missing data, (3)
discussion on time frames, (4) a
discussion on instructions and
format. Can also include other issues
listed under operational equivalence.
A description of one or two of the
following: (1) reliability, (2) validity,
(3) sensitivity, scoring norms, or
effect size, (4) association and nature
of relationship between socio-
economic and demographics, clinical
characteristics and HRQL scores, (5)
item weighting. Can also include
other issues listed under
measurement equivalence.
cluded discussion among researchers (e.g. Lam, Van
Weel, & Lauder, 1994) and involvement of local people
(n ¼ 6) (e.g. WHOQOL Group, 1995). Users of the
Extensive adherence
Explicit details about at least
two of the three issues listed
under ‘‘partial’’. Can also
include any of the other points
listed under conceptual
equivalence. Should also be
information or each of the
other points listed under
conceptual equivalence.
Explicit details about at least
two of the three issues listed
under ‘‘partial’’. Should also
include details about
judgements and changes
made.
Extensive details about at
least 3 of the key items listed
under ‘‘partial’’. Should also
include information about the
other issues listed under
semantic equivalence.
An extensive description of at
three or more of the key issues
listed under ‘‘partial’’. Should
also include other issues listed
under operational
equivalence.
A detailed description of at
least three of the five issues
listed under ‘‘partial’’. Should
also include other issues listed
under measurement
equivalence.
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306 1293

Table 3
Number of references reporting research in each World Bank regiona for each HRQL instrument

East and East Asia and South Asia Eastern Europe Middle East Americas Total
Southern Pacific and Central number of
Africa Asia regions

WHOQOL (n ¼ 11) 6 7 7 8 6 5 6
SF-36 (n ¼ 23) 4 12 - 2 4 1 5
COOP (n ¼ 8) — 6 2 — 3 1 4
NHP (n ¼ 4) — 2 - 1 1 — 3
SIP (n ¼ 3) — 2 1 — — 1 3
HUI (n ¼ 2) — 1 — — — 1 2
15D (n ¼ 2) — 2 — — — — 1
EQ (n ¼ 5) — 5 — — — — 1
a
References can fall into more than one region in instances where research was conducted in more than one World Bank region. No
papers were identified for West Africa and North Africa regions.

WHOQOL adopted the widest range of methods for
assessing the local population’s conceptualisation of
health or quality of life, and are most active in making
this assessment.
Each paper was reviewed to establish what kinds of
people were asked to judge the appropriateness of the
instrument in the target setting. Forty-nine papers
(84.5%) gave no information at all. Some studies used
the author’s judgement or that of the original developers
of the instrument (n ¼ 2), others (n ¼ 8) used members
of the general population, health care users, and health
care workers.
Each paper was reviewed for conclusions, judgements
and justifications made by researchers concerning
conceptual equivalence. Only 10 papers provided this
information. The outcomes given were grouped into five
categories:
discussions) or quantitative evidence (e.g. analysis of
norms).
Item equivalence
Thirty-one papers (53.4%) did not report, or only
reported a minimal investigation into item equivalence.7
A partial report was provided in 23 papers (39.7%), and
an extensive report in four papers (6.9%). The extensive
reporting can be attributed equally to the WHOQOL
(e.g. Szabo, 1996) and the SF-36 (e.g. Lam et al., 1998).
By region most reporting occurred in South Asia and
least in Eastern Europe/Central Asia.
Only six papers addressed the issue of whether life
style patterns differed in source and target countries: SF-
36 (n ¼ 3), SIP (n ¼ 2), Dartmouth COOP Charts
(n ¼ 1). Examples include:

1. No changes were made and the conceptual basis

of the HRQL measure was accepted (n ¼ 3) (e.g.
Mitchell, Nahas, Shukri, & Al-ma’aitah, 1995).
2. The conceptual basis of the measure was questioned
but no changes were made to the measure (n ¼ 2)
(e.g. Shmueli, 1998).
3. The conceptual bases of measures were questioned
and changes were made to the measure as a result
(n ¼ 5) (e.g. Saxena, Chandiramani, & Bhargava,
1998).
4. Implications of the decision made were discussed
(n ¼ 1) (Westbury et al., 1997).
5. Recommendations for further research provided in
detail (n ¼ 1) (Lam, Gandek, Ren, & Chan, 1998).
* Discussion in the text (n ¼ 3) (e.g. Brena, Sanders, &
Motoyama, 1990).
* Reporting a discussion amongst the researchers
(n ¼ 2) (e.g. Landgraf & Nelson, 1992).
* Quantitative evidence (n ¼ 2) (Fukuhara, Ware,
Kosinski, Wada, & Gandek, 1998a).
In all cases there was an emphasis on the target
culture rather than a comparison of target and source
cultures. In general, the papers did not reflect on
implications of the evidence presented.
Items in the questionnaire must be both relevant and
acceptable to the target population. In this context there
was considerable variation by HRQL measure, but the

None of the papers reviewed considered that the 7

instrument might or would not work in the target
culture as a result of conceptual differences. All but one
of the 10 papers provided justification for the outcome,
which was based on qualitative (e.g. focus group
Herdman et al. (1998) referred to quantitative analysis to
assess item equivalence. However, in this review, any quanti-
tative analysis of item equivalence will be discussed within
measurement equivalence. The rationale and implications of
this decision are considered in the discussion section.
 1294
Table 4
Results of systematic review for each equivalence (%)

By HRQL instrument By World Bank Region

15D COOP EQ5D HUI NHP SF-36 SIP W’ QOL E and S E Asia S Asia E Middle Americas
(n ¼ 2) (n ¼ 8) (n ¼ 5) (n ¼ 2) (n ¼ 4) (n ¼ 23) (n ¼ 3) (n ¼ 11) Africa and (n ¼ 10) Europe East (n ¼ 10)
(n ¼ 10) Pacific and C (n ¼ 14)

A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306

(n ¼ 36) Asia
(n ¼ 11)

Conceptual equivalence None 100 75.0 80.0 100 50.0 69.6 100 27.3 50.0 67.6 30.0 40.0 57.1 33.3
Partial 0 25.0 20.0 0 50.0 30.4 0 45.5 20.0 24.3 40.0 30.0 14.3 33.3
Extensive 0 0 0 0 0 0 0 27.3 30.0 8.1 30.0 30.0 28.6 33.3

Assessment of local conceptions of 0 37.5 0 0 50.0 8.7 66.7 54.5 40.0 25.0 70.0 54.5 42.9 60.0

ARTICLE IN PRESS
health and QoL (n ¼ 15)
Appropriateness of HRQL measure 0 37.5 20.0 0 25.0 4.3.0 0 18.2 20.0 22.2 30.0 9.1 7.1 20.0
(n ¼ 9)
Author’s location (n ¼ 56) 100 75.0 100 100 75.0 91.3 100 100 100 89.1 80.0 90.9 100 88.9
Theoretical arguments (n ¼ 19) 0 50.0 20.0 100 75.0 30.4 0 18.2 20.0 36.1 20.0 9.1 14.3 30.0
Outcome, judgements and 0 12.5 20.0 0 50.0 8.7 0 36.4 30.0 19.4 50.0 18.2 28.9 30.0
justifications (n ¼ 10)

Item Equivalence None 50.0 62.5 100 50.0 75.0 47.8 66.7 20.0 30.0 48.6 20.0 54.5 50.0 22.2
Partial 50.0 37.5 0 50.0 25.0 43.5 33.3 60.0 50.0 40.5 60.0 27.3 35.7 55.6
Extensive 0 0 0 0 0 8.7 0 20.0 20.0 10.8 20.0 18.2 14.3 22.7

Life style patterns (n ¼ 6) 0 12.5 0 0 0 13.0 66.7 0 0 16.7 10.0 0 0 20.0

Relevance and acceptability of items 50.0 37.5 40.0 50.0 0 30.4 0 72.7 60.0 44.4 70.0 45.5 50.0 60.0
(n ¼ 23)
Outcomes of any quantitative or 0 12.5 0 0 0 0 0 0 0 4.3 10.0 0 0 10.0
qualitative analysis
Judgements about item equivalence 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Identifying non-equivalent items 0 12.5 0 0 0 34.8 0 18.2 40.0 22.2 30.0 18.2 21.4 20.0
(n ¼ 11)

Semantic equivalence None 100 62.5 60.0 50.0 50.0 60.9 100 81.8 70.0 67.6 60.0 70.0 64.3 44.4
Partial 0 37.5 20.0 50.0 50.0 26.1 0 18.2 30.0 21.6 40.0 30.0 35.7 55.6
Extensive 0 0 20.0 0 0 13.0 0 0 0 10.8 0 0 0 0

Types of meaning (n ¼ 13) 0 25.0 20.0 50.0 75.0 26.1 0 9.1 20.0 22.2 20.0 27.3 21.4 30.0
Original questionnaire meaning 0 12.5 20.0 50.0 0 13.0 0 9.1 10.0 16.7 10.0 9.1 7.1 20.0
(n ¼ 5)
Semantic re-writes 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Contact with developers (n ¼ 20) 0 12.5 20.0 100 0 34.8 0 72.7 70.0 27.8 10.0 0 0 20.0
Translation guidelines (n ¼ 14) 0 25 20.0 50.0 0 34.8 0 18.2 20.0 25.0 30.0 18.2 14.3 30.0
Meaning of key words and phrases 0 0 20.0 0 25.0 4.3 0 9.1 10.0 5.6 0 9.1 0 0
(n ¼ 4)
Lexical relationships 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Translators (n ¼ 19) 0 50.0 40.0 50.0 50.0 39.1 0 9.1 20.0 32.4 30.0 18.2 35.7 44.4
Judging the translation quality 0 0 40.0 100 50.0 43.5 0 9.1 20.0 24.3 10.0 27.3 28.6 33.3
(n ¼ 17)

A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306

Translation problems and difficulties 0 0 20.0 0 25.0 26.1 0 0 10.0 13.9 0 0 14.3 10.0

Operational None 50.0 62.5 60.0 50.0 100 69.6 33.3 45.5 60.0 51.4 40.0 70.0 71.4 33.3
equivalence
Partial 50.0 37.5 40.0 50.0 0 30.4 66.7 36.4 20.0 43.2 40.0 10.0 14.3 44.4
Extensive 0 0 0 0 0 0 0 18.2 20.0 8.7 40.0 20.0 14.3 22.2

Questionnaire format and instructions 0 12.5 0 0 0 2.8 66.7 27.3 10.0 50.0 0 0 0 0

ARTICLE IN PRESS
(n ¼ 6)
Literacy rates (n ¼ 1) 0 12.5 0 0 0 0 0 0 0 2.8 0 0 0 0
Addressing respondents (n ¼ 1) 0 12.5 0 0 0 0 0 0 0 2.8 0 0 0 0
Missing data (n ¼ 1) 0 0 0 0 0 2.8 0 0 0 2.8 0 0 0 0
Response options (n ¼ 14) 50.0 12.5 20.0 0 0 13.9 0 54.5 30.0 25.0 10.0 0 14.3 0
Literature reviews (n ¼ 1) 0 0 0 0 0 0 0 9.1 10.0 0 0 0 0 0
Time frames (n ¼ 8) 0 25.0 0 0 0 8.7 0 36.4 30.0 7.7 10.0 9.1 0 0
Pre-testing (n ¼ 4) 0 12.5 0 50.0 0 17.4 0 18.2 30.0 7.7 0 0 14.3 10.0
Comparative response bias (n ¼ 2) 0 12.5 20.0 0 0 0 0 0 0 7.7 0 0 0 0

Measurement None 0 37.5 40.0 50.0 25.0 21.7 66.7 54.5 50.0 37.8 50.0 60.0 57.1 66.7
equivalence
Partial 100 37.5 40.0 0 50.0 30.4 33.3 18.2 20.0 29.7 20.0 20.0 21.4 11.1
Extensive 0 25.0 20.0 50.0 25.0 47.8 0 27.3 30.0 32.4 30.0 20.0 21.4 22.2

Reliability testing (n ¼ 24) 100 12.5 0 0 25.0 65.2 0 45.5 30.0 33.3 40.0 45.5 35.7 20.0
Validity testing (n ¼ 25) 100 25.0 20.0 100 25.0 60.9 33.3 18.2 40.0 47.2 40.0 18.2 14.3 20.0
Relationship between HRQL and 0 62.5 60.0 50.0 75.0 56.5 33.3 36.4 60.0 47.2 20.0 27.3 50.0 30.0
respondent characteristics (n ¼ 30)
Item weighting (n ¼ 6) 100 0 40.0 0 25.0 4.3 0 0 0 13.9 0 0 1 0

Functional equivalence Papers not assessed for reporting on functional equivalence.

1295
 ARTICLE IN PRESS
1296 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
WHOQOL stands out because 73% of papers made an
assessment using at least one of the three approaches
described below:
* Consultation with experts (n ¼ 11): e.g. physicians
(Shigemoto, 1990), translators (Fukuhara, Bito,
Green, & Kurokawa, 1998b) and public health nurses
(Hisashige, Mikasa, & Katayama, 1998).
* Post hoc analysis of the HRQL questionnaire results
(n ¼ 9): e.g. analysis of the time taken to complete
the questionnaire (Watanabe, 1995).
* Qualitative research techniques with ‘non-experts’
(n ¼ 6) (Lam, Van Weel, & Lauder, 1994).
Very few papers provided details about any outcomes
or judgements8 as a result of identifying non-equivalent
items. Eleven papers highlighted items that were not
considered equivalent. Eight of these papers were for the
SF-36 and the remaining papers utilised the Dartmouth
COOP Charts and the WHOQOL. Only two of the
papers attended to this issue in any detail: Lam et al.
(1998) and Skevington, Bradshaw, and Saxena (1999).
In general, there is limited information about how items
were dealt with once they were identified as not
equivalent.
Semantic equivalence
Thirty-nine papers (67.2%) did not report or gave a
minimal report of investigations into semantic equiva-
lence. A partial report was provided in 15 papers
(25.9%), and an extensive report in four papers (6.9%).
Both the 15-D and the SIP failed to report on semantic
equivalence. Users of the EQ5D (Japanese EurQol
Translation Team, 1998) and the SF-36 (e.g. Fukuhara
et al., 1998b) were the only groups to provide an
extensive report. By region, the only extensive reporting
of semantic equivalence assessment has been completed
in East Asia and Pacific regions, and on closer
examination, all of this research is within Japan.
Although none of the papers addressed the types of
meaning presented in Herdman et al. (1998), 13 papers
(22.4%) did consider other issues of semantic impor-
tance, although none addressed this issue in any detail
and in most cases very general comments were made.
For example Mitchell et al. (1995) and Fukuhara et al.
(1998b) mentioned literal meaning and Szecket, Medin,
Furlong, Feeny, and Barr (1999) discussed idiomatic
expressions.
Each paper was examined to identify how the authors
and translators knew the meaning of the questionnaire
in the source language, and only six papers (10.3%)
8
Those judgements about item equivalence based on assess-
ment of the items post-translation are covered in the semantic,
operational or measurement equivalance sections.
Table 5
People selected to translate HRQL instruments and to judge the
translation quality
Translator Judged
(n=) translation
quality (n=)
Authors or researchers 8 6
Other professionals 6 1
Unspecified 6 4
Health care professionals 5 3
Professional translators 4 5
(including bilingual and
linguistic experts)
Members of the general 3 10
population
Original developers of the — 7
instrument
addressed this issue. In all cases the information was
fairly limited with Wagner et al. (1998) using the SF-36
providing the most thorough assessment of this. Twenty
papers (34.5%) had at least some contact with the
original developers who should have had the potential to
inform the researchers about the original questionnaire
meaning. The majority of these papers included at least
one of the original developers amongst the authors.
Only one paper described an assessment of key words
and phrases in the target language. Wrzesniewski (1997)
mentioned that three people directly connected with the
adaptation discussed the translation of every point in the
questionnaire. No paper described an assessment of the
lexical relationship9 between key words and phrases.
Nineteen of the papers provided information about
who translated the HRQL measure during the adapta-
tion process and these are listed in Table 5. Seven of the
papers used translators from more than one of the
categories listed. Seventeen papers provided information
about who made judgements about the translated
instrument (see Table 5), and ten of these used people
from more than one of the categories listed. Those using
the EQ5D, HUI, and NHP did not favour a type of
person to judge the translation. The SF-36 favoured the
general population and the developers to make the
judgement, although several of the SF-36 papers used
professional translators and the authors or researchers.
Fourteen papers (24.1%) made reference to translation
guidelines or protocol. There was considerable variation
by HRQL measure but less variation by region. Of
these, 11 papers (78.6%) used the guidelines recom-
mended by the developers and three (21.4%) used other
guidelines.
9
The relation of a particular word to other words that have
some aspects in common with it.
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
Herdman et al. (1998) identified three outcomes of
assessing semantic equivalence where items are either
easy, difficult or impossible to translate. However, only
eight papers identified any problems during the transla-
tion exercise, how any problems were dealt with and
whether or not items (questions) were considered easy/
difficult, or impossible to translate, e.g. Japanese EurQol
Translation Team (1998).
Operational equivalence
Thirty-six papers (62.1%) did not report or gave a
minimal report of investigation into operational equiva-
lence. A partial report was provided in 20 papers
(34.5%), and an extensive report in two papers (3.4%)
(WHOQOL Group, 1998a; Szabo, 1996). Only the
WHOQOL provides an extensive description of inves-
tigation into operational equivalence. Each of the six
World Bank regions has a reference that made an
extensive assessment, and this can be attributed entirely
to researchers using the WHOQOL.
Only Lam et al. (1994) provided information regard-
ing the literacy rates. Several papers provided informa-
tion about the educational level of the respondents. Only
Westbury et al. (1997) acknowledged how important it is
for researchers to be aware of the customs of addressing
people, and appropriate ways of framing questions, by
stating that written instructions were given to the
patients explaining the research to them.
Seven (12.1%) papers reported on whether or not the
same instructions and format were used in the source
and target versions of the instrument. Fourteen papers
(24.1%) provided information about the assessment of
response categories10 to establish if they were equivalent
in the source and target countries. Several of these
papers (n ¼ 4) provided very detailed descriptions of
how the equivalence of response options was examined,
e.g. Tsuchiya (1999).
Nine of the papers used only qualitative methods to
assess the equivalence of response options, three used
only quantitative methods, and two papers described
how both quantitative and qualitative methods were
employed, e.g. Keller, Ware, Gandek, Aaronson,
Alonso, Apolone et al. (1998). Only one paper (Szabo,
Orley, & Saxena, 1997) consulted literature about
appropriate response modes. Qualitative methods in-
cluded discussions between the authors or researchers
(Landgraf & Nelson, 1992) and extensive interviews with
people from the general population (Szabo et al., 1997).
Quantitative methods included Thurstone scaling ex-
ercises (Gandek et al., 1998) and Time Trade Off
techniques (Tsuchiya, 1999).
10
Response categories can be dichotomous (e.g. yes or no),
likert scales (e.g. excellent, very good, good, fair, poor), points
on a visual analogue scale (e.g. EQ-VAS) etc.
1297
Seven papers (12.1%) provided information about the
HRQL instrument’s time frame. For example, four
WHOQOL papers described that the time frame is 2
weeks prior to the administration of the questionnaire
and two SF-36 papers describe how the time frame was
changed (see Wagner et al., 1999).
Eight papers (13.8%) described pre-testing activities.
The information was very limited in all papers and for
four it is not clear whether issues surrounding opera-
tional equivalence were covered in the pre-testing.
Examples include Fukuhara et al. (1998b), who exam-
ined the response choices in pre-testing, and Szecket et al.
(1999) tested the skip-patterns on the questionnaire.
Herdman et al. (1998) identified three possible out-
comes of assessing operational equivalence: the same
methods can be used, some aspects of operational
equivalence need to be different; or it is impossible to
achieve operational equivalence. None of the papers
made a judgement of this nature, although it is clear
from the descriptions above that there are examples of
both the first and second outcomes. None of the papers
stated that the methods could not be transferred to the
target setting.
Measurement equivalence
There is an increased level of reporting of measure-
ment equivalence compared with conceptual, item,
semantic, and operational equivalence. All of the eight
HRQL measures have some papers that fall into the
partial and/or extensive categories. In fact, all of the
HRQL measures, except for the WHOQOL and the SIP,
have at least 50% of their papers in the partial and/or
extensive categories. The SF-36 and the NHP are both
noted for reporting most frequently. By region, the
combined percentage of papers in the extensive and
partial categories ranges from 33% (Americas) to 62.1%
(East Asia and Pacific).
Twenty-five papers (43%) reported assessments of
reliability. Internal consistency (using Cronbach Alpha)
was the most popular (n ¼ 15). Of these, 80% utilised
the SF-36 (e.g., Gandek & Ware, 1998). Test–retest
reliability was assessed in eight papers, with five using
the SF-36 (e.g., Al Abdulmohsin, Coons, Draugalis, &
Hays, 1997). Other forms of reliability testing included
equivalent forms using Pearson correlation coefficient
(Coons, Al Abdulmohsin, Draugalis, & Hays, 1998) and
item to scale correlation (Lewin-Epstein, Sagiv-Schifter,
Shabtai, & Schumeli, 1998).
Of the 23 papers (43%) that reported validity tests,
most concerned the SF-36. Tests included construct
validity (e.g. Thomas, Ruby, Peter, & Cherian, 1995),
face validity (e.g. Lam et al., 1994) and convergent
validity (Thumboo et al., 1999). It is difficult, in practice,
to separate the assessment of scoring norms with the
assessment of the relationship between questionnaire
 ARTICLE IN PRESS
1298 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
scores and socio-economic, demographic, and clinical
characteristics, and again with an assessment of known
(or extreme) group validity. The analysis of variation in
HRQL scores by socio-economic, demographic, and
clinical characteristics was by far the most common
analysis reported in the studies reviewed. Many studies
(n ¼ 10) referred to this as discriminant validity, of
which the SF-36 was included in seven. However, the
same analytical approach was used by others to establish
population norms (Ikeda and Ikegami, 1999; Mitchell
et al., 1995; O’Keefe & Wood, 1996), and many others
considered simply considered this an assessment of the
variation in scores by demographic and socio-economic
characteristics. The most popular characteristics for
analysis were age (n ¼ 12 papers) and gender (n ¼ 10
papers), whereas others described relationships between
HRQL scores and clinical characteristics. Examples
include analysis for those suffering with major and
minor depression (Froom, Aoyama, Hermoni, Mino, &
Galambos, 1995; Mino, Aoyama, & Froom, 1994).
The majority of the papers (63.3%) compared findings
with studies elsewhere. Several made comparisons with
studies from different countries that were part of the
same research project, but not with scores from the
instrument’s country of origin (e.g., Westbury et al.,
1997; Lam et al., 1994; WHOQOL Group, 1998a).
However, in most cases, the comparison is with data
from studies on populations from the source country
(e.g., Tsuchiya et al., 1998; Mitchell et al., 1995; Lam
et al., 1998).
Six papers provided information about the weighting
of items, four of these detailed the process of obtaining
new weightings for the HRQL measure in the target
country (Watanabe, 1995; Watanabe et al., 1996;
Hisashige et al., 1998; Lewin-Epstein et al., 1998).
Others suggested that weights should change but did not
use a different weighting scheme (e.g., Mitchell et al.,
1992).
Functional equivalence
Functional equivalence is the combined effect of
assessing for conceptual, item, semantic, operational,
Table 6
Extent of equivalence reporting in Japan by HRQL measure
Concept Item Semantic
15D None/minimal Partial None/minimal
COOP Partial Partial Partial
EQ5D Partial Partial Extensive
SF-36 Partial Extensive Extensive
SIP None/minimal Partial None/minimal
WHOQOL Extensive Extensive Partial
and measurement equivalence. Since functional equiva-
lence was a concept introduced by the Herdman et al.
(1998), and the majority of papers reviewed in this paper
were published prior to this date, it is a little premature
to examine reporting on functional equivalence. How-
ever, it is possible to provide an indication of whether
researchers have enough information to make an
assessment of functional equivalence. We selected Japan
as a focus because the majority of HRQL research
reviewed has taken place here, involving six of the nine
HRQL measures. Table 6 shows the HRQL instruments
in the first column and lists each equivalence across the
top row. The table gives an indication of the extent to
which each equivalence has been reported for the
Japanese version of each HRQL instrument. The
equivalence of the Japanese version of the WHOQOL
has been more extensively reported on than any other
Japanese versions of the HRQL measures. It also shows
that the Japanese version of the SF-36 has been well
documented in terms of equivalence. However, this table
reveals the focus on semantic and measurement equiva-
lence issues, and the lack of reporting on conceptual,
item, and operational issues.
Discussion
The discussion addresses the current state of translat-
ing and adapting generic HRQL measures, followed
by a reflection on the value of the Herdman et al.
(1998) model, and our attempt to operationalise this
model.
How widespread is the ‘‘international’’ field of generic
HRQL assessment?
This review has identified an increasing number of
adaptation studies outside of North America and
Northern Europe. Although the adaptation process
is increasingly widespread, it is uneven, with an absence
of activity in two of the World Bank regions (West
Africa and North Africa) and a preponderance of
activity in the East Asia and Pacific region, and
specifically in Japan.
Operational Measurement Functional
Partial Partial N/A
Partial Extensive N/A
Partial Extensive N/A
Partial Extensive N/A
Partial None/minimal N/A
Extensive Extensive N/A
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
The HRQL instruments reviewed in this paper, except
for the WHOQOL, were all developed in countries
where non-communicable, as opposed to communicable,
diseases are prevalent. The World Health Organization
reports11 that 6% of mortality in Europe can be
attributed to communicable disease whereas it is
71% in Africa and 39% in South East Asia. However,
only 3.4% of the papers reviewed focused on commu-
nicable disease and a mere 1.7% on accident and
injury. Thus, the current application of HRQL instru-
ments may not accurately reflect the disease profile or
benefits of appropriate health interventions. However,
whether researchers consider existing measures less
relevant for assessing the HRQL of people suffering
from communicable diseases is not known. Another
possible explanation is that researchers are keen to
compare their findings with results elsewhere and so
research interests from North America and Europe
dominate.
How well are generic measures of HRQL being assessed
for ‘‘equivalence’’ during the translation and adaptation
process?
Few studies consider each type of equivalence, as set
out in Herdman et al. (1998), and none in any detail.
The majority of papers only considered measurement
equivalence to any degree. This reveals a pre-occupation
in this field with scales rather than concepts. Indeed, it
confirms Herdman et al.’s earlier view that research in
this field either implicitly or explicitly adopts an
‘‘absolutist’’ conception of health (Herdman et al.,
1997), where health is conceived of in the same way
across the world and that all that differs is the value
attached to its component parts.
This review has allowed us to go beyond this broad
criticism and show how researchers evaluated the
translated questionnaires in detail and in practice.
Overall, there was a lack of published evidence for the
assessment of conceptual equivalence. It was disappoint-
ing to see quantitative analysis as the preferred approach
when qualitative procedures would certainly prove to be
equally, if not more, rewarding. It is notable that
developers and those translating and adapting instru-
ments rarely draw on theoretical positionings in this
research (Albrecht & Fitzpatrick, 1994) or question the
nature of their own beliefs—both of which affect
interpretations of whether instruments in source and
target languages are considered conceptually equivalent.
The majority of papers also failed to report, either
partially or extensively, on item equivalence. Semantic
equivalence was outlined in considerable detail by
11
http://www3.who.int/whosis/menu.cfm?path=whosis, bur-
den, burden gbd2000, burden gbd2000 subregion & langua-
ge=english (accessed 3 December 2001).
1299
Herdman et al. (1998), but the majority of papers failed
to report partially or extensively on this area. There
appears to be increasing contact with the original
developers of instruments, and it is not unusual to find
one among the authors of papers using translated
versions of an instrument. The advantage of this is that
translators are more likely to understand the aims and
intended meanings of the source instrument. The
disadvantages could include the unwillingness of origi-
nal developers to ‘‘allow’’ changes to be made, and the
need for greater compromise by translators as devel-
opers are able to ‘‘withhold’’ official ‘‘approval’’ of the
newly translated instrument without necessarily under-
standing anything about the target culture.
In terms of operational equivalence, there is a focus
on equivalence of response options, with an emphasis on
the placing of words on scales. In general, researchers
using the SF-36 have frequently examined validity and
reliability, although good practice is not restricted to
research using the SF-36.
It was surprising to see the ease with which those
translating/adapting HRQL measures accept the target
measure with unjustified assertions about cultural
applicability. Too much emphasis is being placed on
establishing the psychometric properties of an adapted
instrument. Researchers are generally too happy to
accept confirmation of validity and reliability as
sufficient evidence that the adapted measure is suitable
for use in the target culture. This is not a comment that
can be pinned to all the research examined. There were
some good examples of critical assessment of the
findings, often voiced as concerns over the applicability
of the HRQL measure in the target population.
However, the field can be characterised by statements
of concern about equivalence between source and target
versions of an instrument, followed by a sweeping
summary from authors that a measure is suitable for use
in the target population and, at most, a cautious
suggestion that further research might be needed to
confirm this.
The processes involved in developing and testing
the WHOQOL have more rigorously evaluated equiva-
lence. Therefore, conclusions about the use of the
WHOQOL are more likely to provide reliable and
valid interpretations across countries. Drawing together
papers from Japan for each HRQL instrument
demonstrated this. The WHOQOL researchers have
provided a greater amount of information to facilitate
an assessment of functional equivalence. However,
despite this, there are still concerns regarding its use:
for example, it uses an imposed concept of health
and further investigation of its psychometric properties
is needed. It would be unfair to identify an HRQL
measure that was the ‘‘least useful’’, as each measure
has shown good and bad practice in terms of
adaptation.
 ARTICLE IN PRESS
1300 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
How well was and can the Herdman et al. (1998) model
be operationalised?
The Herdman et al. (1998) model of equivalence is
unusual in its attempt to relate a philosophical
positioning to a working model of equivalence as well
as some practical examples of how to examine each type
of equivalence. It was particularly helpful in guiding our
examination of the processes through which the generic
measure of HRQL have been translated and applied
amongst our populations of interest. However, the
review also allowed us to re-examine the model,
particularly with respect to practical applications and
the delineation between alternative types of equivalence.
Overall, the model allowed us to develop a structured
checklist for each type of equivalence in some detail.
Also useful was the suggested order for which the
equivalences should be tested. The ordering worked well
in this review and helped identify situations where
researchers had claimed to address (for example)
functional equivalence, when in fact they had assessed
measurement equivalence. However, we did experience
some difficulties trying to operationalise the model as
not all types of equivalence were addressed in the same
level of detail in the Herdman et al. (1998) paper: for
example, semantic equivalence compared to item
equivalence. We also started to consider whether
response options (operational equivalence) should actu-
ally be part of measurement equivalence. The most
difficult distinction to make was to try to establish the
difference (if any) between quantitative assessment for
item equivalence, and methods used to establish
measurement equivalence. Herdman et al. (1998) de-
scribe how item equivalence should first be assessed
using qualitative approaches as well as assessing the
psychometric properties of the item in the target culture,
and gives examples of techniques such as Cronbach’s
alpha and Rasch analysis. However, within measure-
ment equivalence, Herdman et al. also refer to Cronba-
ch’s alpha as a method for assessing measurement
equivalence. Thus, information gathered during mea-
surement equivalence can be used to interpret item
equivalence, and the difference between the two
equivalences are not made clear. One potential solution,
and the one used in this review, is to strictly follow the
assertion that the equivalences should be tested in the
following order: conceptual; item; semantic; operational;
and measurement. But in fact, Herdman et al.’s model
recognises that assessing equivalence is a circular process
allowing a second assessment of (for example) item
equivalence at a later stage in the adaptation process.
The implications of our approach to solving this
problem is that we may have underreported the extent
to which researchers have assessed item equivalence by
classifying it all as an assessment of measurement
equivalence.
Whilst our operationalisation of the Herdman et al.
(1998) paper may assist those seeking to test translations
and adaptations of HRQL measures, we suggest the
following changes to our operationalisation:
* More extensive use of local literature reviews for
investigating other types of equivalence, not just
conceptual equivalence.
* Asking the following question for all types of
equivalence, not just conceptual equivalence: ‘‘Do
the authors highlight any areas where {operational}
equivalence has not been achieved?’’ to encourage
greater questioning and discussion of results.
* Include a question regarding what authors recom-
mend when a particular type of equivalence is not
achieved.
* Supplement with methods for assessing validity and
reliability, as these are not covered in any detail in
our operationalisation or in Herdman et al.’s paper.
* Draw on a wider range of information than provided
by Herdman et al.’s paper, e.g. participatory rural
appraisal techniques (Chambers, 1997), cognitive
assessment of survey methodology (Forsyth &
Lessler, 1991), or through an exercise using the
Herdman et al. paper to guide the translation/
adaptation of a generic measure in practice.
Finally, neither the Herdman et al. model nor our
operationalisation allows any statement to be made
concerning the degree to which source and target
questionnaires are equivalent per se. They only provide
methods through which processes are examined. At
present, the conclusions are left entirely to the judge-
ment of the individual researcher(s). Herdman et al. do
not suggest who should assess how far equivalence has
been achieved. For this review, we felt unable to make
such judgements, not only because the quality of the
evidence was weak, but also because we are not
sufficiently knowledgeable about the source and target
cultures within which HRQL instruments were being
used. This view is quite challenging because of the way
in which developers of existing HRQL instruments seek
to control the quality of translated/adapted HRQL
instruments. Perhaps the only people ever capable of
judging will comprise those research teams whose
members have each worked in both (or all) countries
of interest.
There are limitations to this study. The literature
searches were predominantly based on international
databases which have a bias against literature from
developing nations (Aronson & Bertrand, 1993). Adap-
tation procedures may not always be published,
especially where researchers have encountered problems
in their adaptation. In fact, it would be very useful to see
such material. It is also apparent that the Herdman et al.
model is only one model among many.
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306 1301

Conclusion SF20
SF12
Translation of HRQL instruments can be charac- SF6
terised to date by their focus on non-communicable SF 20
diseases in Southeast Asia rather than, for example, SF 12
communicable disease in Africa. Of the current instru- SF 6
ments available, the WHOQOL has evaluated equiva- SF 6D
lence most rigorously and is therefore more likely to Short Form 36
provide valid scores for comparison across settings, Short Form 12
although further psychometric testing is still needed and Short Form 20
concerns about the imposed definition of health and lack Short Form 6
of an index exist. Our conclusions are dependent on Medical Outcomes
accepting the Herdman et al. (1998) model, which we Survey
operationalised for the first time. In doing so, we found
Sickness Im- Sickness Impact Profile
more guidance for assessing particular types of equiva-
pact Profile
lence and we have suggested a number of additions to
SIP
the model to improve future reviews and translations.
However, such guidelines would ideally need testing. Nottingham Nottingham Health
Health Profile Profile
NHP
Acknowledgements
Quality of Quality Well-Being Scale
Well-Being
The authors would like to acknowledge Glaxo Well-
Scale
come for the financial support for this research including
Quality Well-Being Scale
providing a translation service where needed and the
Quality Well-Being Index
Health Economics and Financing Programme at
Quality Well-Being Index
LSHTM who provided funding for the preparation of
QWB Scale
this article. We thank Sarah Payne and Keiko Tsune-
QWB Index
kawa for their support and assistance and also gratefully
acknowledge Ann Ward, Richard Suchett-Kaye and Dartmouth Dartmouth COOP
Annette Cleary for their help with the literature search COOP
and obtaining papers. We also thank Suzanne Skeving- 15-D 15 Dimensional
ton, Cindy Lam, Michael Herdman, Virginia Wiseman Questionnaire
and Mercy Mugo for their comments on earlier drafts of 15Dimensional
this paper. Any errors are the fault of the authors. Questionnaire
Regarding any conflict of interest, both authors have 15 D Questionnaire
been members of the KENQOL group since 1995. In 15D Questionnaire
addition, Julia Fox-Rushby has been a member of the
EuroQol since 1987 and was one of many external Health Utili- Health Utilities Index
advisors to the WHOQOL in 1993/4. ties Index
HUI
WHOQOL WHOQOL
Appendix A. Literature search terms WHOQOL 100
WHOQOL BREF
Instrument Search terms
EuroQol EuroQol Authors and Anderson RT McKenna S
EQ 5D Instrument
EQ 5D Developers
EQ 5D Bergner M Nelson EC
Euro Qol Bice TW Olweny C
Deyo RA Orley J
Short Form SF-36 Feeny D Patrick D
36 Gandek B Sartorius N
SF 36 Hunt S Sintonen H
MOS 36 Kaplan RM Ware J
Rand 36 Marquis P
 ARTICLE IN PRESS
1302 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
Appendix B. Papers reviewed
Al Abdulmohsin, S.A., Coons, S.J., Draugalis, J.R.,
&Hays, R.D. (1997). Translation of the RAND 36-item
health survey 1-0 (AKA SF-36) into Arabic. Santa
Monica: RAND.
Amir, M., Roziner, I., Knoll, A., Neufold, M.Y. (1999).
Self-efficacy and social support as mediators in the
relation between disease severity and quality of life
patients with epilepsy. Epilepsia, 40(2), 216–224.
Bito, S., Fukuhara, S. (1998). Validation of interviewer
administration of the Short Form 36 Health Survey, and
comparisons of health-related quality of life between
community-dwelling and institutionalized elderly peo-
ple. Japanese Journal of Geriatric Medicine, 35(6),
458–463.
Bobak, M., Pikhart, H., Hertzman, C., Rose, R.,
Marmot, M. (1998). Socioeconomic factors, perceived
control and self-reported health in Russia. A cross-
sectional study. Social Science & Medicine, 47(2),
269–279.
Brena, S.F., Sanders, S.H., Motoyama, H. (1990).
American and Japanese chronic low back pain patients
cross-cultural similarities and differences. The Clinical
Journal of Pain, 6(2), 118–124.
Bullinger, M., Alonso, J., Apolone, G., Leplege, A.,
Sullivan, M., Wood-Dauphinee, S., et al. (1998).
Translating health status questionnaires and evaluating
their quality: The IQOLA project approach. Clinical
Journal of Epidemiology, 51(11), 913–923.
Coons, S.J., Al Abdulmohsin, A., Draugalis, J.R., Hays,
R.D. (1998). Reliability of an Arabic version of the
RAND-36 health survey and its equivalence to the US-
English version. Medical Care, 36(3), 428–432.
Froom, J., Aoyama, H., Hermoni, D., Mino, Y.,
Galambos, N. (1995). Depressive disorders in three
primary care populations: United States, Israel, Japan.
Family Practice, 12(3), 274–278.
Fukuhara, S., Hino, K., Kato, K., Tomita, E., Yuasa,
S., Okushin H. (1997). Health-related quality of life in
patients with chronic liver disease type-C. Kanzo, 38(10),
587–595.
Fukuhara, S., Ware, J.E., Kosinski, M., Wada, S.,
Gandek, B. (1998a). Psychometric and clinical tests of
validity of the Japanese SF-36 health survey. Journal of
Clinical Epidemiology, 51(11), 1045–1053.
Fukuhara, S., Bito, S., Green, J. A. H., Kurokawa, K.
(1998b). Translation, adaptation, and validation of the
SF-36 health survey for use in Japan. Journal of Clinical
Epidemiology, 51(11), 1037–1044.
Gandek, B., Ware, J.E., Aaronson, N.K., Alonso, J.,
Apolone, G., Bjorner, J., et al. (1998). Tests of
data quality, scaling assumptions, and reliability of the
SF-36 in eleven countries: Results from the IQOLA
project. Journal of Clinical Epidemiology, 51(11),
1149–1158.
Gandek, B., & Ware, J.E. for the IQOLA Project Group
(1998). Methods for validating and norming translations
of health status questionnaires: The IQOLA project
approach. Journal of Clinical Epidemiology, 51(11),
953–959.
Hisashige, A., Mikasa, H., Katayama, T. (1998).
Description and valuation of health-related quality
of life among the general public in Japan by the
EuroQol. The Journal of Medical Investigation,
45(1–4), 123–129.
Ikeda, S., Ikegami, N. (1999). Health status in Japanese
population: Results from Japanese EuroQol study.
Journal of Health Care and Society, 9(3), 83–92.
Jarema, M., Bury, L., Konieczynska, Z., Zaborowski,
B., Cikowska, G., Kunicka, A., et al. (1995). Compar-
ison of quality of life of schizophrenic patients in
different forms of psychiatric care. Psychiatria Polska,
31(5), 585–594.
Japanese EurQol Translation Team. (1998). The devel-
opment of the Japanese EuroQol instrument. Iryo to
Shakai, 8(1), 109–117.
Keller, S.D., Ware, J.E., Gandek, B., Aaronson, N.K.,
Alonso, J., Apolone, G., et al. (1998). Testing the
equivalence of translations of widely used response
choice labels: Results from the IQOLA project. Journal
of Clinical Epidemiology, 51(11), 933–944.
Lam, C.L., Van Weel, C., Lauder, I.J. (1994). Can the
Dartmouth COOP/WONCA charts be used to assess the
functional status of Chinese patients? Family Practice,
11(1), 85–94.
Lam, C.L.K., Gandek, B., Ren, X.S., Chan, M.S.
(1998). Tests of scaling assumptions and construct
validity of the Chinese (HK) versions of the SF-36 of
health survey. Journal of Clinical Epidemiology, 51(11),
1139–1147.
Landgraf, J.M., Nelson, E.C. (1992). Summary of the
WONCA/COOP international health assessment field
trial. Australian Family Practice, 21(3), 255–269.
Lewin-Epstein, N., Sagiv-Schifter, T., Shabtai, E.L.,
Schumeli, A. (1998). Validation of the 36-item
short form health survey (Hebrew version) in the
adult population of Israel. Medical Care, 36(9),
1361–1370.
Li, J., Fielding, R. (1995). The measurement of current
perceived health among Chinese people in Guangzhou
and Hong Kong, southern China. Quality of Life
Research, 4(3), 271–278.
Mino, Y., Aoyama, H., Froom, J. (1994). Depressive
disorders in Japanese primary care patients. Family
Practice, 11(4), 363–367.
Mitchell, R.A., Imperial, E., Zhou, D., Lu, Y., Watts,
G., Kelleher, P., et al. (1992). A cross-cultural assess-
ment of perceived health problems in the elderly.
Disability and Rehabilitation, 14(3), 133–135.
Mitchell, R.A., Nahas, V., Shukri, R., Al-ma’aitah, R.
(1995). Perceived health problems in elderly residents of
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
Jordan. Journal of Cross-Cultural Gerontology, 10(4),
307–314.
O’Keefe, E.A., Wood, R. (1996). The impact of human
immunodefficiency virus (HIV) infection on quality
of life in a multiracial South African population. Quality
of Life Research, 5(2), 275–280.
Pibernik-Okanovic, M., Szabo, S., Metelko, Z. (1996).
Quality of life in diabetic, otherwise ill and healthy
persons. Diabetologia Croatia, 25(3), 117–121.
Pibernik-Okanovic, M., Szabo, S., Metelko, Z. (1998).
Quality of life following a change in therapy for diabetes
mellitus. Pharmacoeconomics, 14(2), 201–207.
Sanders, S.H., Brena, S.F., Spier, C.J., Beltrutti, D.,
McConnell, H., Quintero, O. (1992). Chronic low back
pain patients around the world: Cross-cultural simila-
rities and differences. The Clinical Journal of Pain, 8(4),
317–323.
Saxena, S., Chandiramani, K., Bhargava, R. (1998).
WHOQOL-Hindi: A questionnaire for assessing quality
of life in health care settings in India. The National
Medical Journal of India, 11(4), 160–165.
Shigemoto, H. (1990). A trial of the Dartmouth COOP
charts in Japan. In: W.C. Committee (Ed.), Functional
status measurement in primary care (pp. 181–187). New
York: Springer.
Shumueli, A. (1998). The SF-36 profile and health-
related quality of life: An interpretative analysis. Quality
of Life Research, 7, 187–195.
Skevington, S.M., Bradshaw, J.,Saxena, S. (1999).
Selecting national items for the WHOQOL: Conceptual
and psychometric considerations. Social Science &
Medicine, 48, 473–487.
Szabo, S. (1996). The World Health Organization
Quality of Life (WHOQOL) assessment instrument. In:
B. Spilker (Ed.), Quality of life and pharmacoeconomics
in clinical trials (pp. 355–362). Philadelphia: Lippincott-
Raven.
Szabo, S., Orley, J., Saxena, S. (1997). An approach to
response scale development for cross-cultural question-
naires. European Psychologist, 2(3), 270–276.
Szecket, N., Medin, G., Furlong, W.J., Feeny, D.H.,
Barr, R.D. (1999). Preliminary translation and cultural
adaptation of Health Utilities Index questionnaires for
application in Argentina. International Journal of Cancer
Supplement, 12, 119–124.
Tazaki, M., Nakane, Y., Endo, T., Kakikawa, F., Kano,
K., Kawano, H., et al. (1998). Results of a qualitative
and field study using the WHOQOL instrument for
cancer patients. Japanese Journal of Clinical Oncology,
28(2), 134–141.
Thomas, K., Ruby, J., Peter, J.V., Cherian, A.M. (1995).
Comparison of disease-specific and a generic quality of
life measure in patients with bronchial asthma. The
National Medical Journal of India, 8(6), 258–260.
Thumboo, J., Fong, K.Y., Ng, T.P., Leong, K.H., Feng,
P.H., Boey, M.L. (1997). Initial construct cross-cultural
1303
validation of the Short Form 36 for quality of
life assessment of systemic lupus erythematosus patients
in Singapore. Annals Academy of Medicine, 26(3),
282–284.
Thumboo, J., Fong, K., Ng, T., Leong, K., Feng, P.,
Thio, S., et al. (1999). Validation of the MOS SF-36 for
quality of life assessment of patients with systemic lupus
erythematosus in Singapore. The Journal of Rheumatol-
ogy, 26(1), 97–102.
Tsuchiya, A. (1999). Estimating a EuroQol tariff: The
case of Japan. Barcelona, Spain: EuroQol Plenary
Meeting.
Tsuchiya, A., Hasegawa, T., Nishimura, S., Hisashige,
A., Ikegami, N.,Ikeda, S. (1998). A validity study of
the Japanese EuroQol instrument. Iryo-To-Shakai, 8(1),
67–77.
Wagner, A.K., Gandek, B., Aaronson, N.K., Acquadro,
C., Alonso, J., Apolone, G., et al. (1998). Cross-cultural
comparisons of the content of the SF-36 trans-
lations across 10 countries: Results from the IQOLA
project. Clinical Journal of Epidemiology, 51(11),
925–932.
Wagner, A.K., Wyss, K., Gandek, B., Kilima, P.M.,
Lorenz, S.,Whiting D. (1999). A Kiswahili version of the
SF-36 health survey for use in Tanzania: Translation
and tests of scaling assumptions. Quality of Life
Research, 8, 101–110.
Wang, Q., Chen, G. (1999). The health status of the
Singaporean population as measured by the Health
Utilities Index Mark III system. Singapore Medical
Journal, 40(6), 389–396.
Watanabe, Y. (1995). Tests of the weighting and usage
of a quality of life (QOL) questionnaire. Annual Report
of Research Committee on Epidemiology of Intractable
Diseases (pp. 137–139). The Ministry of Health and
Welfare of Japan.
Watanabe, Y., Ozasa, K., Higashi, A., Hayashi, A.,
Taneike, R., Kudoh, A., et al. (1996). Tests of the
weighting and usage of a quality of life (QOL)
questionnaire (report 2). Annual Report of Research
Committee on Epidemiology of Intractable Diseases (pp.
318–326). The Ministry of Health and Welfare of Japan.
Westbury, R.C., Rogers, T.B., Briggs, T.E., Allison,
D.J., Gervas, J., Shigemoto, H., et al. (1997). A
multinational study of the factorial structure and other
characteristics of the Dartmouth COOP Functional
Health Assessment Charts/WONCA. Family Practice,
14(6), 478–485.
WHOQOL Group. (1995). The World Health Organiza-
tion Quality of Life assessment (WHOQOL): Position
paper from the World Health Organization. Social
Science & Medicine, 41(10), 1403–1409.
WHOQOL Group. (1998a). The World Health Organi-
zation Quality of Life assessment (WHOQOL):
Development and general psychometric properties.
Social Science & Medicine, 46(12), 1569–1585.
 ARTICLE IN PRESS
1304 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306
WHOQOL Group. (1998b). Development of the World
Health Organization WHOQOL-BREF Quality of Life
Assessment. Psychological Medicine, 28, 551–558.
Wikblad, K., Smide, B., Bergstrom, A., Kessi, J.,
Mugusi, F. (1997). Outcome of clinical foot examina-
tion in relation to self-perceived health and glycaemic
control in a group of urban Tanzanian diabetic
patients. Diabetes Research and Clinical Practice, 37(3),
185–192.
Wrzesniewski, K. (1997). Study of quality of life using a
Polish adaptation of the Nottingham Health Profile. In:
J.B. Karski, H. Kirschner, &J. Leowski (Eds.),
Contemporary needs and ways of measuring health
(pp. 37–41). Warsaw: Ingis.
Wyss, K., Wagner, A.K., Whiting, D., Mtasiwa, D.M.,
Tanner, M., Gandek, B., et al. (1999). Validation of the
Kiswahili version of the SF-36 health survey in a
representative sample of an urban population in
Tanzania. Quality of Life Research, 8, 111–120.
Yodfat, Y. (1991). Functional status in the treatment of
health failure by Captopril: A multicentre, controlled,
double-blind study in family practice. Family Practice,
8(4), 409–411.
Yodfat, Y. (1995). A multicentre study of lisinopril in
the treatment of mild to moderate hypertension.
Harefuh, 129(1–2), 26–29.
Zuniga, M.A., Carillo-Jimenez, G.T., Fos, P.J., Gandek,
B., Mdeina-Moreno, M.R. (1999). Health status
evaluation with the SF-36 survey: Preliminary
results in Mexico. Salud Publica de Mexico, 41(2),
110–117.
Appendix C. Review criteria operationalised from Herd-
man et al. (1998)
C.1. Background details
* Publication authors and date.
* Journal title.
* Location of research.
* Funders of research.
* Disease and intervention studied.
* HRQL measure used.
* Source and target languages.
C.2. Methodological details
* Sample characteristics: number, sampling frame, and
method of selection.
* Sample characteristics: socio-demographic and eco-
nomic variables.
* Aims of study and hypothesis: specific to trial.
* Aims of study and hypothesis: specific to use of
instrument.
* Other disease specific and generic measures used
alongside instrument.
* Details of other clinical or behavioural measures used
alongside instrument.
* Listing of any other variables on which data was
collected.
* Method of using measure.
* Details of translation process.
C.3. Conceptual equivalence
* In what ways were the local populations conceptua-
lisation of health/QOL assessed?
(a) review local literature,
(b) review local questionnaires/instruments,
(c) discussion amongst researchers,
(d) involvement of anthropologists, sociologists, etc.,
(e) involvement of local people: (i) participant obser-
vation (ii) questionnaires,
(f) other.
What kind of people were asked to help judge the
appropriateness of the instrument in the target setting?-
Who was involved in the research?Were any theoretical
arguments presented questioning or accepting concep-
tual equivalence?What were the outcomes of the above?
And how were judgments made and justified?Do the
authors claim conceptual equivalence?
C.4. Item equivalence
* What evidence was presented to suggest that lifestyle
patterns were the same/similar in the source and
target countries?
* How was the relevance or acceptability of individual
items/questions to the target population addressed?
* What quantitative analysis of items equivalence was
undertaken?
* What were the outcomes of any quantitative or
qualitative analysis?
* What judgements were made about item equivalence?
* Do the authors claim item equivalence?
C.5. Semantic equivalence
What types of meaning were addressed in assessing
semantic equivalence? How were authors/translators
sure about what was meant by the original questionnaire
in the source language? Was a semantic re-write of the
original used? Were the original developers of the source
version contacted and what was the nature of the
contact? Were translation guidelines referred to? (a)
instrument guidelines (b) any other guidelines? How was
the meaning of keywords/phrases investigated in the
target language? Was the lexical relationship between
words established? What kind of people did the
translations? Who was in involved in judging the quality
of the translations? Was a translation protocol followed?
 ARTICLE IN PRESS
A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306 1305

What problems were identified in the translation exercise References

and how were they dealt with? Were items considered
easy/difficult/impossible to translate? Any other Aronson, B., & Bertrand, I. (1993). Letter. International Journal
evidence presented about semantic equivalence? Do the of Clinical Epidemiology, 22(1), 172.
authors claim semantic equivalence? Albrecht, G. L., & Fitzpatrick, R. (1994). A sociological
perspective on health-related quality of life research.
Advances in Medical Sociology, 5, 1–1721.
C.6. Operational equivalence Anderson, R. T., Aaronson, N. K., Bullinger, M., & McBee, W.
L. (1996). A review of the progress towards developing
* Were the same instructions and format used in the health-related quality-of-life instruments for international
source and target versions of the instrument? clinical studies and outcomes research. Phamacoeconomics,
* What are the literacy rates in the source and target 10(4), 336–355.
countries? Bobadilla, J. L., & Cowley, P. (1995). Designing and
* What issues of how to address respondents were implementing packages of essential health services. Journal
considered/reported? of International Development, 7(3), 543–554.
Bowden, A., Fox-Rushby, J. A., Nyandieka, L., & Wanjau, J.
* What was the % of missing data (by question) in the
(2002). Methods for pre-testing and piloting survey ques-
source and target data?
tions: Illustrations from the KENQOL survey of health-
* How were the response modes considered? related quality of life. Health Policy and Planning, 17(3),
* Were the same time frames used in the source and 322–330.
target questionnaires, and was the time frame Bullinger, M., Alonso, J., Apolone, G., Leplege, A., Sullivan,
investigated? M., & Wood-Dauphinee, S., et al. (1998). Translating health
* Were any reviews in the literature consulted about status questionnaires and evaluating their quality: The
appropriate response modes? IQOLA project approach. Clinical Journal of Epidemiology,
* How were issues pre-tested? 51(11), 913–923.
* Was there any analysis of comparative response bias Chambers, R. (1997). Whose reality counts? Putting the first last.
between source and target versions? London: Intermediate Technology Publications.
Forsyth, B. H., & Lessler, J. T. (1991). Cognitive laboratory
* Was the questionnaire considered to be operationally
methods: A taxonomy. In P. P. Biemer, S. M. Groves, L. E.
equivalent?
Lyberg, N. A. Mathiowetz, & S. Sudanudan (Eds.),
* Was any other evidence presented about operational Measurement errors in surveys (pp. 393–418). New York:
equivalence? Wiley.
* Do the authors claim operational equivalence? Fox-Rushby, J. (2000). Operationalising conceptions of ‘health’
amongst the Wakamba and Maragoli of Kenya: The basis
C.7. Measurement equivalence of the kenqol instrument. Quality of Life Research, 9(3),
316.
* How were the following issues investigated in the Fox-Rushby, J., & Parker, M. (1995). Culture and the
measurement of health-related quality of life. European
target setting:
Review of Applied Psychology, 45(4), 257–263.
Guillemin, F., Bombardier, C., & Beaton, D. (1993). Cross-
(a) reliability, cultural adaptation of health-related quality of life mea-
(b) validity, sures: Literature review and proposed guidelines. Journal of
(c) sensitivity, Clinical Epidemiology, 46(12), 1417–1432.
(d) scoring norms, Herdman, M., Fox-Rushby, J., & Badia, X. (1997). ‘Equiva-
lence’ and the translation and adaptation of health-related
(e) effect size,
quality of life questionnaires. Quality of Life Research, 6,
(f) socio-economic and demographic relationships
237–247.
with the instrument. Herdman, M., Fox-Rushby, J., & Badia, X. (1998). A model of
equivalence in the cultural adaptation of HRQoL instru-
ments: The universalist approach. Quality of Life Research,
* Were items weighted differently in the source and 7, 323–335.
target versions? Herdman, M., Fox-Rushby, J., Rabin, R., Badia, X., & Selai
* Any other evidence presented about measurement (forthcoming). Developing and translating different lan-
equivalence? guage versions of the EQ-5D. Brooks, R., Rabin, R., & de
* Do the authors claim measurement equivalence? Charro, F. (Eds.), The measurement and valuation of health
status using the EQ-5D: European perspective (Evidence
from the EuroQol BIOMED research program). Dordrecht:
C.8. Functional equivalence Kluwer Academic Publishers.
Do the authors claim functional equivalence? Hunt, S. M. (1994). Cross-cultural comparability of quality of
Refer to Herdman et al. (1998) for descriptions and life measures. International Symposium on Quality of Life
definitions of each criterion. and Health (pp. 25–27). Blackwell Verlag, Berlin.
 ARTICLE IN PRESS
1306 A. Bowden, J.A. Fox-Rushby / Social Science & Medicine 57 (2003) 1289–1306

Rabin, R., Herdman, M., Fox-Rushby, J., & Badia, X.
(forthcoming). Exploring the results of translating the EQ-
5D into 11 European languages. In: R. Brooks, R. Rabin, &
F. de Charro (Eds.), The measurement and valuation of
health status using the EQ-5D: European perspective
(Evidence from the EuroQol BIOMED research program).
Dordrecht: Kluwer Academic Publishers.
Sartorius, N., & Kuyken, W. (1994). Translation of health
status instruments. In J. Orley, & W. Kuyken (Eds.),
Proceedings of the joint meeting organized by the World
Health Organization and the foundation IPSEN (pp. 3–18).
Paris: Springer.