Keywords

1.1 Mental Health Worldwide

Population mental health is integral to population health (Susser & Patel, 2014), and there could be “no health without mental health” (Prince et al., 2007). Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organization, 2007). Such a state is, however, disrupted in at least one out of three people over their lifetime (Ginn & Horder, 2012; Steel et al., 2014). According to Mental Health Foundation (2015), 25% of adults and 10% of children are likely to suffer from mental illness every year. Mental illness has, therefore, become a growing public health concern globally (Mental Health Foundation, 2016), significantly impacting the life of millions of people and profoundly impacting the community and economy.

Global mental health, by definition, examines factors impacting health across national boundaries, promotes health equity within and among countries, addresses prevention and clinical care, and values mutual exchange of knowledge in partnerships among countries of different income levels (Koplan et al., 2009). One main objective of global mental health is to ascertain and meet the most glaring unsatisfied needs for mental health care in low- and medium-income countries (Collins et al., 2011; Horton, 2007; Lancet Global Mental Health Group, 2007; Menezes, 2014; Patel & Prince, 2010; Pike et al., 2013). Various other goals are also widely shared in the global mental health domain (Becker & Kleinman, 2013; Menezes, 2014; Pike et al., 2013), including “promoting social inclusion and civil rights of people with mental illness, combating stigma and discrimination, involving service users in shaping the care they receive and building regional and local capacity for mental health research” (Susser & Patel, 2014).

Regarded as one of the most common causes of disability, mental health disorders can impair the quality of life (Whiteford et al., 2015). Individuals with severe mental health disorders represent a socially vulnerable and excluded group (Funk et al., 2010). Their lives are more likely to be subject to poverty, discrimination, human rights violation and increased morbidity and mortality rates (Susser & Patel, 2014). Mental disorders are considered a major driver of the growing overall morbidity and mortality worldwide (Alonso et al., 2013; Prince et al., 2007). The socially disadvantaged groups of individuals with mental disorders tend to have less access to environments that stimulate social, emotional and cognitive development in early life, and these early disadvantages are associated with a range of worse mental health and social outcomes across their life course (Susser & Patel, 2014). However, individuals living with mental illness are largely neglected globally (Saxena et al., 2007).

It has been estimated that mental disorders may cost the global economy $16 trillion from 2011 to 2030 through lost labor and capital output (Jones et al., 2014). The average annual mental health burden for each of these twenty years may be equivalent to 1% of the 2012 global GDP (World Bank, 2023). From the broadest perspective, mental disorders are detrimental to “human capital” as the most valuable resource of modern societies and “human development” as the benchmark of progress because mental health is fundamental to both (Sen and Anand, 1990; Heckman, 2006; Jenkins et al., 2008; Sen, 1999).

In the context of the widely perceived negative impacts of mental health disorders on individual lives and society, the worldwide magnitude of mental disorders has been underscored by studies on their global burden (Lopez & Murray, 1998). However, despite the considerable worldwide burden and the associated adverse human, economic and social impacts, priority has not been given to the treatment and care of individuals with mental illness by policy makers and funders across the world (Bloom et al., 2011; Saxena et al., 2007) and by health professionals and providers worldwide. One underlying overriding cause is the lack of high quality translated materials related to mental disorders worldwide. Such translated materials can help fill the language gap that prevails in the mental health domain (Black, 2018), especially in the context that the growing perception of core symptoms of common mental disorders worldwide has greatly driven campaigns for addressing mental disorders in developing countries (Patel & Prince, 2010; World Health Organization (WHO), 2008).

1.2 Variations in the Expression of Mental Disorders

As is shown by large-scale epidemiological studies, mental disorders are prevalent in diverse societies and cultures (Flaherty et al., 1988). However, different global prevalence rates of major mental health disorders imply that there are variations in how these disorders are expressed (Flaherty et al., 1988; Draguns & Tanaka-Matsumi, 2003). These variations may partly be explained by the fact that people living in diverse social contexts experience and communicate emotional distress in different ways (Ballenger et al., 2001). As such, psychiatric disorders can be seen as cultural conventions, which mainly define appropriate forms and expressions of suffering (Kirmayer, 2002), resulting in largely variable manifestations, diverse presentations and unique illness categories across cultural settings (Desjarlais et al., 1995; Kirmayer, 2007). For example, Kirmayer (2002) has identified several different forms of mental illness specific to particular cultural settings that are expressed by means of idioms of distress.

Investigating mental health disorders in different cultures is controversial and can best be explained by two positions embedded in cross-cultural psychiatry: the universalistic position versus the relativistic position (Smit et al., 2006). The former holds that emotions result from neurophysiologic processes in the limbic system and are thus biological phenomena, and that there is a limited repertoire of universal emotional experiences (Panksepp, 1998). Advocated in biomedicine, this position highlights categorizing and labeling syndromes (Kleinman & Good, 1985). By contrast, the relativist position argues that emotional expression is socially constructed and thus specific to a given historical, societal and cultural system (Lutz, 1985). Held by ethnographic and anthropological studies, this position asserts that tools developed in one cultural setting may fail to capture the idiosyncratic ways that emotional distress is expressed in other cultural settings because the context within which people from other cultures live and experience the world may be ignored (Kleinman & Good, 1985).

Both positions have been criticized for their limitations. The universalistic position runs the risk of being imperialistic because it ignores cultural differences and insists on using concepts developed in a Western context as a blueprint for perceiving other cultures (Kleinman & Good, 1985). The relativistic position risks concretizing dissimilarities by ignoring the impacts of acculturation and cultural assimilation (Swartz, 1998), therefore revealing little about similarities (Kirmayer, 2001).

The relativistic position and the universalistic position align respectively with the emic and etic approaches, two traditional methods of observation adopted in cross-cultural research (Flaherty et al., 1988). These orientations are concerned with the origin of concepts in question (Draguns & Tanaka-Matsumi, 2003; Kinzie & Manson, 1987). As “an insider’s view of culture,” the emic approach, comparable to the relativistic position, aims at the description of the language and customs of the culture at a specific time by using “culturally defined, within-group independent and dependent (outcome) variables” to gain a granular understanding of concepts relevant to one cultural setting but possibly irrelevant to other cultural settings (Flaherty et al., 1988, p. 257). This approach can enable us to give a fine-grained description of behaviors within a particular culture at a given time, allowing for descriptively comparing particular phenomena between two cultures and theories to explain observed phenomena. In contrast, within the paradigm of the etic approach, comparable to the universalistic position, the concept of a behavior and techniques for measuring this behavior in one culture is applied to another culture, shedding little light on cultural disparities in the purpose and meaning of behavior (Flaherty et al., 1988). As a result, signs and symptoms of a prevalent disorder (i.e., depression) specific to a particular culture will be overlooked if diagnostic criteria established in a specific Western culture is applied to a non-Western cultural context (Kleinman, 1977). In brief, the emic approach focuses on the meaning that a specific cultural group attaches to a particular notion while the etic approach focuses on the description of phenomena that is independent of meaning (Kinzie & Manson, 1987).

In the final analysis, the nature of emic and etic approaches could largely be revealed by Murphy’s (1969) claim that culture enters psychiatric inquiry in two ways: as a distortion and as an object of research. Specifically, the emic approach is adopted when one aims to compare the symptoms of commonly occurring syndromes, such as depression, cross-culturally; on the other hand, the etic approach is used when one seeks to identify the impact of acculturation on depressive symptoms across two particular cultures, and the objective of this approach is to minimize the distortion by culture to make cross-cultural comparisons meaningful (Flaherty et al., 1988).

Attempts have been made to integrate the relativistic and universalistic positions through combining the emic and etic approaches (Smit et al., 2006), with concepts and descriptions that are derived from anthropological studies (an emic orientation) being incorporated into measuring scales, an etic orientation (Draguns & Tanaka-Matsumi, 2003). Such integration finds its full expression in the process in which cultural equivalence is established through the cross-cultural adaptation of psychiatric research instruments (Smit et al., 2006).

In the context of a growing number of populations who could benefit from mental health materials written in their native language, it is necessary to determine an approach to language translation that prioritizes the world view of the target readers (Black, 2018). Such an approach is most likely to identify the variations in how mental disorders are expressed in the target language and cultural settings.

1.3 Translating and Cross-Culturally Adapting Mental Health Scales: A Pressing Need

Translation is essentially a multilingual and multicultural endeavor that can provide far-reaching implications for the growth and development of the mental health domain worldwide (Black, 2018). Culture can play a substantial role in variations in behaviour, and measurement of behavior in a cross-cultural context calls for the use of adapted instruments (Herdman et al., 1997). The global population (cultural) diversity entails a pressing need for cross-culturally validated measures or scales (Sousa & Rojjanasrirat, 2011), which can be used to ascertain the varying mental health needs of diverse populations from multicultural societies. This need necessitates the translation and cross-cultural adaptation of mental health scales. “Translation, adaptation and validation of an instrument or scale for cross-cultural research is time-consuming and requires careful planning and adoption of rigorous methodological approaches to derive a reliable and valid measure of the concept of interest in the target population.” (Sousa & Rojjanasrirat, 2011) Mental health materials thus translated, adapted and validated are most likely to identify the variations in how mental health disorders are expressed in diverse language and cultural settings and therefore capture the varying health needs of multicultural populations across national boundaries and within multicultural communities. To facilitate comparability and deliver appropriate interventions, the best way to identify and assess mental disorders is likely to be an integration of adapting Western instruments (van Ommeren et al., 1999), exploring additional symptoms and expressions that would not be captured through an adaptation-only approach (Kohrt & Hruschka, 2010), and investigating far-reaching influences, including function impairment (Bolton & Tang, 2002).

When reviewing the literature on and proposing guidelines for cross-cultural adaptation of health-related quality of life measures, Guillemin et al., (1993, p. 1417) observe that “With a few exceptions, all the measures so far developed are in the English language and are intended for use in English-speaking countries.” This is also true for other health-related materials, including various instruments like mental health scales. It is, therefore, necessary to have materials available in languages other than English for comprehensive and accurate cross-cultural research, assessment, and education (Johnson & Cameron, 2001; Miranda et al., 2002) in non-English-speaking countries and among a growing number of immigrants in English-speaking communities. Such necessity confirms the settings for cross-cultural adaptation of scales identified by Guillemin et al. (1993). The degree of adaptation depends on similarities and disparities between the languages and cultures of the populations concerned (Brislin et al., 1973). Immigrants recently settled in a host culture may have a low level of acculturation and thus need a measure that is cross-culturally adapted to their native language and culture. For example, immigrants living in America or Australia may encounter specific problems in communicating their needs in English with regard to health-related issues, and they may also assess their health status and perceive health materials of various types based on their language and cultural origin and the degree of being assimilated into the host language and culture. Besides, a scale to be administered in a country other than that where it has been developed may necessitate cross-cultural adaptation since different cultural beliefs have been imprinted in the mind of the people concerned, who are accustomed to referring to their native culture when assessing their health conditions and understanding health materials.

A huge range of English health-related measures have been developed and validated to administer various health-related assessment, screening, interventions, and education. “There is nonetheless a need for measures specifically designed to be used in non-English-speaking countries and also among immigrant populations, since cultural groups vary in disease expression and in their use of various health care systems.” (Guillemin et al., 1993, p. 1417). To meet this need, two approaches can be adopted: developing new tools and using tools already developed in another language. Developing new scales is time-consuming (Shan et al., 2023), with the bulk of the effort made to conceptualize the scale and select and reduce its items (Guillemin et al., 1993). When previously developed measures are transposed through simple translation from their source cultural settings to target cultural contexts, they are most unlikely to be successful due to language and cultural differences (Berkanovic, 1980) and to cultural variations in the perception of particular concepts and constructs and the ways that health issues are expressed (Kleinman et al., 1978). Success in this approach calls for a systematic toolkit that can entail the effective cross-cultural adaptation of original English measures.

Cross-cultural adaptation consists of two essential components: the translation of the measures under investigation and its adaptation. It requires “a combination of the literal translation of individual words and sentences from one language to another and an adaptation with regard to idiom, and to cultural context and lifestyle” (Guillemin et al., 1993, p. 1421). The quality of an adapted instrument is then subjected to assessment with regard to its sensibility, the essential elements of which include the designed purpose, comprehensibility, content and face validity, replicability and suitability of the scale studied (Feinstein, 1987).

The individuals’ perceptions of the scales studied and the ways that health problems are expressed and health situations are assessed vary from culture to culture (Guillemin et al., 1993; Kleinman et al., 1978). As a result, translating and adapting previously developed instruments cross-culturally may most likely accommodate the varying needs of the populations studied in the target language and culture. This is particularly true for the cross-cultural translation and adaptation of already developed mental health scales, given the growing global prevalence and magnitude of mental health disorders and the resulting burdens on and negative outcomes for the individual and society, as reviewed in Sect. 1.1. Trans-culturally adapting and validating previously developed instruments can facilitate communicating research findings to international audiences who are likely to fund mental health service development (Kohrt et al., 2011). Besides, adapting standardized measures for depression and anxiety can be beneficial with regard to administering treatment approaches tailored to such disorders (WHO, 2008). Filling the written language gap in mental health through translation and adaptation not merely helps increase the availability of multi-language written materials, but also helps open educational opportunities that are conventionally delivered through psychoeducation, parenting, preparedness workshops or other oral means (Black, 2018). Additionally, culturally and linguistically appropriate written educational materials promise not only to offer essential information, but also to reduce stigma socially attached to mental health concerns and relevant help-seeking (Black, 2018). One of the objectives of this work is to use cross-cultural adaptation as a means to contribute to the worldwide mental health stigma reduction initiatives. Section 1.5 will deal with this topic by focusing on the stigma attached to mental disorders and the role of language (translation), or more specifically, the power of language in the cross-cultural translation and adaptation of mental health scales.

1.4 Cultural Adaptation in the Translation of Mental Health Scales

“Research in the area of translation methodology has been largely overlooked in the mental health field” (Black, 2018). It is essential to cross-culturally adapt health-related instruments to obtain valid responses (Banville et al., 2000). Cultural adaptation of research scales is designed to produce culturally equivalent research materials. Translated and adapted scales catering to the cultural beliefs of the target language are key to accurately and comprehensively assessing individuals’ health status, delivering tailored interventions, and therefore facilitating culturally appropriate and relevant health care (Banville et al., 2000). As such, we can say that “translation is, at its core, a multicultural and multilingual endeavor with profound implications for the growth and development of the mental health field on a global scale” (Black, 2018, p. 9).

An adapted tool may be deemed culturally equivalent when all types of biases or social norms unique to the source culture have been eliminated (Van de Vijver & Poortinga, 1997). According to Van de Vijver and Poortinga (1997), three categories of biases are likely to influence cross-cultural research, including construct bias, method bias and item bias. Construct bias may occur when the concept under discussion is substantially different cross-culturally. Method bias may occur when the methods adopted to investigate a construct are unfamiliar or inappropriate in the target culture. Item bias may occur when a particular item fails to fit the description of a concept under discussion in the target culture. Cultural adaptation is an effective approach to getting rid of these biases.

Cultural adaptation aims to achieve cultural equivalence, which consists of five major mutually-exclusive dimensions: content equivalence, semantic equivalence, technical equivalence, criterion equivalence, and conceptual equivalence (Flaherty et al., 1988, p. 258).

  • Content equivalence. The concept of each item of the instrument is relevant to the phenomena of each culture being studied.

  • Semantic equivalence. The meaning of each item is the same in each culture after translation into the language and idiom (written or oral) of each culture.

  • Technical equivalence. The method of assessment (e.g., pencil and paper, interview) is comparable in each culture with respect to the data that it yields.

  • Criterion equivalence. The interpretation of the measurement of the variable remains the same when compared with the norm for each culture studied.

  • Conceptual equivalence. The instrument is measuring the same theoretical construct in each culture.

According to Flaherty et al. (1988), any item or measure may be cross-culturally equivalent on one or more of these five dimensions but not equivalent on other dimensions. For example, semantically equivalent instruments may not necessarily be conceptually equivalent ones. Figure 1.1 (Flaherty et al., 1988, p. 258) below can vividly illustrate these five dimensions of cultural equivalence.

Fig. 1.1
figure 1

Taxonomy of issues in designing instruments for cross-cultural validation in psychiatric research

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As illustrated in Fig. 1.1, the 45° line represents a “culture-free” instrument, one that is equivalent on all five dimensions across culture A and culture B. Such cultural freedom or universality of measures is not a rule but an exception. In reality, instruments are culture-bound, as shown by the two 90° lines pointing to culture A and culture B in Fig. 1.1. The actual adaptation of scales across cultures, in effect, yields an oscillating line around the 45° line rather than a straight line at 45° for each tool adapted for study. The objective of this taxonomy is to facilitate designing a measure that is cross-culturally equivalent in all five dimensions. In what follows, these five dimensions of equivalence will be described in detail in the light of Flaherty et al. (1988), if not specified otherwise.

1.4.1 Content Equivalence

For cross-cultural research, each item of the scale needs to be examined with fine granularity to ascertain whether the phenomenon described is relevant to each culture or not. When content validity has been established in the source culture, the relevance of each item to the target culture needs to be reexamined by determining whether the item, or rather the phenomenon the item describes, actually occurs in the target culture and is recognized by the members of the target culture.

A content expert team comprising social scientists and psychiatrists from both source and target cultures assesses the content equivalence of each instrument item by rating it as relevant, irrelevant, or questionably relevant to each target culture under investigation. Items rated as irrelevant by one expert or questionably relevant by two or more experts need to be directly removed; items rated as questionably relevant by one expert need to be reconsidered for inclusion.

When any item is crossed out, the modified tool needs to be scrutinized once more to determine internal consistency and reliability. To this end, standardized alpha coefficients are usually measured, with an alpha coefficient greater than 0.60 showing that a given instrument is acceptable. When many items are removed from a measure, its internal consistency may be so diminished that it could not be used in cross-cultural studies. If the variable assessed by the tool is essential to the research, new items need to be added to achieve content equivalence and restore internal consistency. Sometimes, we would modify some items by finding equivalent content areas in the source and target cultures on an item-by-item basis to yield two different scales that are equivalent in content. Modifications of tools by adding items for one culture produce tailor-made scales relevant to each culture, though not directly comparable any longer (Brislin, 1970).

1.4.2 Semantic Equivalence

Semantic equivalence is achieved when the meaning of each item remains unchanged after being translated into the language of each culture. It is particularly challenging to achieve semantic equivalence in cross-cultural studies. The usual practice in cross-cultural research is that a scale developed for use in one (source) culture and language is translated into another (target) language and culture. However, it is incorrect to assume that the translated scale would naturally be reliable and valid in the target culture.

Back-translation proposed by Brislin (1970) is generally acknowledged as the key to achieving semantic equivalence. A measure is forward-translated from a source language to a target language by one or more bilingual persons before being back-translated from the target language to the source language by another bilingual person or team. And then, a team of bilingual experts scrutinizes these two versions by rating each item on a 3-point Likert scale, with 3, 2, and 1 indicating “exactly the same meaning in both versions,” “almost the same meaning in both versions,” and “different meaning in each version.”

Items rated as “different meaning in each version” by all raters need to be removed; items receiving a mix of ratings of “exactly the same meaning in both versions” and “almost the same meaning in both versions” need to be reconsidered. In many cases, rewording is not sufficient enough to allow an item or items to be included. Any reworded items need to be reexamined through back-translation. It is essential to reword rather than eliminate items if possible so as not to disturb the psychometric properties of the translated scale. Nevertheless, it is impossible to realize semantic equivalence on an item, particularly when translating either idioms or adjectives and terms that describe personal or emotional states.

Back-translation turns far more intricate when more than two cultures are being investigated and especially when merely an oral version of the language exists in a culture. Semantic equivalence calls for equivalence both to the source culture and to all target cultures under investigation.

1.4.3 Technical Equivalence

What really matters in technical equivalence is whether the data collection method impacts the research results differently in the source and target cultures. Some data collection methods regarded as natural in Western culture may be considered as uncomfortable or unfamiliar in some other cultures. For example, as pointed out by Vernon and Roberts (1981), the technical equivalence of a paper-and-pencil test is always compromised in cross-cultural research because this data collection method is unfamiliar to many countries in the third world. Similarly, private interviews of females by male interviewers are generally regarded as a taboo; the questionnaire formats of repeated questioning and probing prevalent in Western society may be deemed forcible in countries of the third world. A panel of experts familiar with the methods of data collection in both cultures needs to determine whether the data gathering method for each scale is consistent with the target culture.

1.4.4 Criterion Equivalence

In cross-cultural studies, criterion equivalence is designed to assess the capacity of the scale to evaluate the variables in both source and target cultures under investigation. Criterion equivalence is established when the interpretation of the results from the source tool and the target tool is the same in both cultures.

A scale developed in one culture is designed to differentiate individuals who are independently assessed as having a trait or diagnosis from those who are independently assessed as not having this trait or diagnosis. Ideally, the adapted tool has equally high levels of sensitivity or specificity when it is applied to the target culture. If not, it is most likely that a different cutoff score is needed in the target culture although the adapted scale is able to distinguish individuals with the trait from those without it.

As with criterion equivalence, what is at issue is not whether particular phenomena or symptoms occur, but whether the diagnostic criteria actually assess the same phenomena in both cultures.

1.4.5 Conceptual Equivalence

Conceptually equivalent scales assess the same basic construct (concept) in different cultures. “Conceptual equivalence refers to the validity of the concept explored and the events experienced by people in the target culture, since items might be equivalent in semantic meaning but not conceptually equivalent” (Guillemin et al., 1993, p. 1423). For example, “Physical therapist” may be translated perfectly from English into Chinese semantically, but have a different conceptual meaning in the Chinese culture. Vernon and Roberts (1981, p. 1240) claim that a direct measurement of conceptual equivalence is usually impossible in psychiatry, and other less direct techniques are needed, including “examining the correlations among the items on the questionnaire in the study population and analyzing the relationship of responses to other variables in each study population.”

The method usually adopted to determine conceptual equivalence is to examine the relationship between constructs as measured by the scale and to compare this relationship with their known relationship (Cronbach & Meehl, 1955). For example, if stressful life events are found to be positively correlated with psychophysiological symptoms in both cultures under study and if there exists a cross-culturally valid method to measure these symptoms, the finding of significant correlations between stressful life events and such symptoms could establish the conceptual equivalence of the life events tool cross-culturally (Baratta et al., 1985).

Health-related concepts are conceptualized and operationalized differently in different languages and cultures, highlighting the significance of exploring conceptual equivalence in the translation and adaptation of instruments (Sidani et al., 2010). Conceptual equivalence means the “existence, relevance, and acceptability of the concept and its indicators across cultures”: the meaning, perception, and indicators of the concept in the source culture are similar to those in the target culture (Sidani et al., 2010, p. 134). It is reflected through recognizing and perceiving the concept and relevant indicators in the source and target cultures (Johnson, 2006; Stewart and Napoles-Springer, 2000). It is necessary to determine conceptual equivalence to minimize the risk of imposing a concept prevailing in one culture upon another culture where it is unfamiliar or irrelevant and the risk of failing to identify relevant indicators specific a concept in another culture (Brislin et al., 1973). Underlying the cultural validity of measures designed to assess health-related concepts (Leplege & Verdier, 1995), conceptual equivalence needs to be examined before translating instruments from the source language and culture to the target language and culture.

Although there are recommendations and guidelines with regard to translating, adapting and cross-validating instruments using a comprehensive multi-step process, researchers fail to put them into practice (Sousa & Rojjanasrirat, 2011). This failure is most possibly attributable to unspecified, user-unfriendly methodologies presented in previous studies, making it challenging for researchers to utilize these methodological approaches (Sousa & Rojjanasrirat, 2011). This background of research warrants the examination of cultural adaptation in the translation of health scales using a specified, use-friendly, comprehensive approach, which we will present in the translation of various genres of mental health materials.

The objective of translation is to achieve equivalence between the scale in the source language and the scale in the target language (Sperber, 2004). To this end, the symmetrical translation is a better choice, compared with the asymmetrical translation. The symmetrical translation is the most recommended approach because it attaches great importance to faithfulness of meaning and colloquialness of expression in both the source and target languages rather than to literal translation (Jones & Kay, 1992). It is the only approach that facilitates comparing responses from individuals of one culture with those of another (Jones & Kay, 1992; Jones et al., 2001) and determining the most relevant types of cross-cultural equivalence (semantic, conceptual, content, technical, and criterion) (Hilton & Skrutkowski, 2002). The process of translation, adaptation, and cross-cultural validation of a measure for use in other languages, cultures, and countries calls for well-considered planning and appropriate application of comprehensive, rigorous, and well-established methodologies (Chapman & Carter, 1979; Brislin, 1970, 1986; Jones, 1987; Jones & Kay, 1992; Guillemin et al., 1993; McDermott and Palchanes, 1994; Beaton et al., 2000, 2002; Jones et al., 2001; Sperber, 2004; Shan et al., 2023).

1.5 Cultural Adaptation in Mental Health Translation as One Means to Reduce Stigmatization of Mental Illness

Individuals with mental illness are far more intensely stigmatized than those suffering from other medical conditions, which frequently gives rise to unfavorable social, political, economic and psychological consequences (Baumann, 2007; El-Badri & Mellsop, 2007; Marwaha & Johnson, 2005). People are less likely to relate to those with mental illness (Halter, 2008). Stigmatizing attitudes lead to discriminatory practices in daily settings, limiting private and public institution opportunities (Pingani et al., 2012). Afraid of stigmatization, people with mental illness are likely to disengage themselves from society, therefore worsening their clinical conditions and prognosis (Mojtabai, 2010; Vauth et al., 2007; Yap et al., 2010). Pervasive stigma and discrimination contributes, to some extent, to the imbalance between the global burden of disease caused by mental disorders and the attention paid to these conditions (Vigo et al., 2016). Stigma is reflected in discriminating social structures, policy and legislation, resulting in lower availability, accessibility and quality of services geared to mental health, compared with physical health (Giesecke et al., 2004). Fewer job opportunities and social exclusion or bullying are typical examples of stigmatization (Pingani et al., 2012).

From the perspective of conceptualization, stigmatization may entail intricate cognitive-behavioral interactions between individuals and social settings (Norman et al., 2010). Two leading theoretical explanatory conceptualizations can well elucidate the complex social construct of stigma: Corrigan et al. (2003) and Link and Phelan (2001). According to Corrigan et al. (2003), public stigma can be conceptualized as status loss and discrimination attributable to prejudices towards individuals with mental illness held by people around them. Link and Phelan (2001) conceptualize self-stigma as the reactions of those belonging to a stigmatized population when coming face to face with stigmatizing attitudes that they apply to themselves. These two conceptual constructs consist of three components: the cognitive component of stereotypes, the emotional component of prejudice and the behavioral component of discrimination. Stereotypes can be defined as negative beliefs, attributed to other for public stigma (e.g., being dangerous or incompetent) or to self for self-stigma (e.g., belief of being dangerous or incompetent); stereotypes lead to prejudice as their cognitive and emotional reaction (e.g., fear or anger for public stigma, and low self-esteem for self-stigma) and subsequently to the behavioral response of discrimination (e.g., avoidance or withholding employment and housing opportunities for public stigma, and failure to pursue work for self-stigma) (Corrigan & Watson, 2002). Studies have identified a direct link between these three dimensions and recovery from psychiatric disorders: low levels of knowledge, stigmatizing attitudes and discriminatory behaviors are correlated with social exclusion and lower rates of help-seeking and medication compliance, all of which hamper care and treatment and thus prevent recovery (Evans-Lacko et al., 2012; Rüsch et al., 2005; Thornicroft, 2008). As with public stigma, two more concepts need to be described: the concept of responsibility and the concept of dangerousness. Responsibility is based on the attribution theory (Weiner, 1995): when individuals with mental disorders are regarded as being responsible for their disorders, the public may be angry with them and will not assist them; when individuals with mental disorders are deemed as a victim of mental disorders, feelings of pity and readiness to help will be evoked in the general public. The conceptualization of dangerousness asserts that people perceiving individuals with mental illness as dangerous will fear and thus avoid them (Edwards & Endler, 1989).

Studies have been conducted to diminish stigma attached to mental illness. In addition to a wide range of public health campaigns launched to reduce stigma attached to mental disorders, such as the Changing Mind Campaign by The Royal College of Psychiatrists in the UK (Crisp, 2000), the advocacy of the review of language used about people with mental disorders needs to be noticed and enhanced. For example, a review of the language used about people living with dementia has been advocated for inclusion, stigma reduction and the increase of education and awareness as the way to reduce stigma (Bartlett, 2014). The power of language has also been highlighted by Alzheimer’s Australia (2009) in their Dementia Friendly Language Position Paper 4:

Language is a powerful tool. The words we use can strongly influence how others treat or view people with dementia. For example referring to people with dementia as ‘sufferers’ or as ‘victims’ implies that they are helpless. This not only strips people of their dignity and self esteem, it reinforces inaccurate stereotypes and heightens the fear and stigma surrounding dementia.

Inspired by such activism, we propose that the tool of language be harnessed to combat mental illness-related stigma. In this respect, the power of language can never be overemphasized, as we will illustrate in the following chapters of this book.

Language is a powerful tool (Cayton, 2006; Sabat, 2001). Words reflect thoughts and feelings, displaying respect or disrespect (Swaffer, 2014). As advocated by Swaffer (2014), the words that we use not merely considerably impact how others perceive or treat individuals living with dementia, but also, perhaps more importantly, affect how people with dementia view themselves and interact with others, which may adversely influence their abilities to be empowered. Language can “promote and empower, enable and increase self-esteem, and encourage one’s ability to self-help, or it can demean, devalue, disrespect and offend those we refer to” (Swaffer, 2014, p. 711). Thus informed, we propose that the language used about individuals with mental disorders should be “normal, inclusive, jargon-free, non-elitist, clear, straight-forward, non-judgmental,” and centering on “the person not the disease or social care system, or language trends that come and go” (Swaffer, 2014, p. 711). As argued by Hughes et al. (2006), “Language creates the particularly human kind of rapport, of being together, that we are in a conversation together.” Accordingly, it is imperative and pressing to adopt “inclusive, non-offensive language that supports the whole person positively, rather than negative demeaning language that stigmatizes and separates us” (Swaffer, 2014, p. 711).

Cultural stigma attached to mental illness (Gary, 2005), the lack of culturally specific instruments and the resulting risk of misdiagnosis (Johnson & Cameron, 2001) and language (Garcia & Duckett, 2009) have been listed as barriers to seeking mental health services and care. Among them, language has been identified as “the most common barrier in any health care setting” and “a risk factor with adverse outcomes” (Aboul-Enein & Ahmed, 2006, p. 168). To attend effectively to the mental health needs of individuals with mental illness and to reduce stigmatization of mental disorders, we need to translate mental health scales previously developed in English into other languages and pay close attention to cross-cultural adaptation in the translation process.

1.6 Summary and Goal of This Book

Our book investigates the necessity and effectiveness of cultural adaptation in the translation of mental health scales. In what follows, we will present the principles of culturally effective adaptation in the translation of mental health scales before dealing with different genres of mental health materials and the effective implementation of cultural adaptation in the translation of these genres.

While methodologies for translating, adapting and validating measures for use in cross-cultural health care studies have been well established (Brislin, 1970, 1986; Chapman & Carter, 1979; Guillemin et al., 1993; Jones, 1987; Jones & Kay, 1992; Jones et al., 2001; Wild et al., 2005), variations in the use of these methodological approaches are constantly prevalent in the literature on health care. As a result, there is a lack of apparent consensus among researchers on how to use or combine these approaches, a great variation in the essential qualifications translators need to have, and a scarcity of detailed information on the forward-translation, back-translation, validation, modification and refinement of scales (Sousa & Rojjanasrirat, 2011). This background of research warrants further examination of cross-cultural translation and adaptation of health assessment tools to meet the varying health needs of individuals from diverse language and cultural settings and thereby deliver quality care targeted at mental health disorders across the world, and to add to the literature.