Keywords

It is true and widely acknowledged that there are diverse languages and cultures across the world, with unique languages and cultures specific to particular countries. Such diversity is further complicated by the ever-growing trend of immigration, which is a reality across the world. Immigrants bring their native languages, customs and cultures to the hosting countries (Sidani et al., 2010), resulting in increased diversity of languages and cultures within the boundaries of these receiving countries, including the United States and Australia. For example, the linguistic and cultural diversity within America is wide and constantly expanding (Black, 2018). With the ever-changing ethnic and cultural composition of American communities, the mental health needs among American populations are changing (Shrestha & Heisler, 2011) and becoming increasingly diversified. This is true for Australia and other developed countries, which have become ideal immigration destinations, leading to increased linguistic and cultural diversity and thereby diversified health needs of subgroups of populations within these societies. There is, therefore, a pressing need for relevant cross-cultural studies to handle numerous problems among these multinational and multicultural populations (Sousa & Rojjanasrirat, 2011). Development of mental health initiatives has been called for at national and international (e.g., UNICEF, 2014; WHO, 2013) levels to address cultural diversities and the needs of local populations. In this context, researchers are being propelled by such diversities to make research findings more applicable to various sub-populations, and health professionals are being required to deliver culturally and linguistically responsive care in different settings (Sidani et al., 2010). “If people do not identify with the materials, they will reject it. If people do not see themselves in the message, they will not listen. If people do not understand the message, they will not respond.” (Watters, 2003).

Health care researchers engaging in cross-cultural studies need to gain access to reliable and cross-validated measures in other languages and cultures (Beaton et al., 2000; Sousa et al., 2005). Since administering quality care is based on accurate measurement and better understanding of the linguistic, cultural and ethnic backgrounds of individuals, cross-cultural research findings can provide physicians, nurses and other health care professionals with essential clinical implications with regard to how to deliver care to diverse populations. As measurement of people’s health conditions is a core component of health care (Sidani et al., 2010), various assessment tools specific to the diversified languages and cultures of people living in different countries and within multicultural communities are required to capture the varying physical and mental health needs of individuals from various language and cultural backgrounds. In short, the global population diversity suggests a pressing need for cross-culturally validated research scales or tools to enable researchers and clinicians to access reliable and valid instruments that capture concepts of interest unique to their particular languages and cultures and thereby to carry out cross-cultural studies and administer quality patient care (Sousa & Rojjanasrirat, 2011).

Cultural beliefs and values can shape individuals’ understanding of health, interpretation of changes of health conditions and perceived acceptability of health interventions (Givens et al., 2007; Killoran & Moyer, 2006). As a result, people’ perspectives on health vary from culture to culture, and health-related concepts are conceptualized and operationalized differently across cultures, resulting in varying health needs among people from diverse cultural contexts. The perception and interpretation and the indicators of particular health concepts in one culture may not necessarily make any sense in another culture (Banville et al., 2000; Yam et al., 2005). Health instruments are developed based on specific beliefs and values reflecting the dominant culture (Sidani et al., 2010) where these tools are designed and intended to be used, which impacts individuals’ ability to understand and respond to these measures (Warnecke et al., 1997). People are, therefore, most likely to respond to items on assessment tools from their own perspectives, which may not necessarily be congruent with the intent underlying the scales, undermining the validity or accurate interpretation of the responses (Sidani et al., 2010). A good case in point is the idiom of “feeling blue,” which is semantically equivalent to “depression” in the culture prevalent in North American. This culturally-loaded expression is included in many instruments for academic and clinical purposes, including Center for Epidemiologic Studies-Depression Scale (Radloff, 1977). The color blue, however, symbolizes “joy” in some Latin American cultures (Streiner & Norman, 2008) and “vigor and vitality,” “peace,” “hope,” “tranquility,” etc., in Chinese culture. Responses of people from the latter cultural settings may be congruent with their understanding of the cultural connotation of the scale item involving “feel blue,” but their responses would be misinterpreted by health professionals or researchers from North American cultures. Such misinterpretations are likely to incur inaccurate measurement of individuals’ health status and health care needs, which potentially jeopardizes the appropriateness and safety of health interventions and health care services. As such, it is imperative to translate and adapt health-related instruments to secure valid responses (Banville et al., 2000) capturing people’s perspectives on health that are specific to the target culture. Translated measures that are fully adapted to the language, beliefs and values of the target culture are the prerequisite for the accurate and comprehensive measurement of individuals’ health conditions, the selection of appropriate interventions, and thereby the support of culturally appropriate, understandable and relevant health care.

“The lack of culturally appropriate mental health assessment instruments is a major barrier to screening and evaluating efficacy of interventions. Simple translation of questionnaires produces misleading and inaccurate conclusions.” (Kaiser et al., 2013, p. 532) To be effective in assessing the physical and mental health of individuals from different language and cultural backgrounds, instruments must be translated and adapted to accurately measure their health status, avoiding limiting the meaningfulness of collected data (Sidani et al., 2010). In the context of language and cultural diversities across countries and the increased language and cultural diversities within some countries, like Australia and America, due to immigration, langue barriers and diverse cultural beliefs and values highlight the significance of achieving cultural equivalence in the process of translating and adapting health-related scales. The achievement of cultural equivalence in such a process not only entails the understanding of varying health needs of people from different cultures but also facilitates capturing their diverse health needs through instruments tailor-made to specific cultures.

To meet the diversified health needs of multicultural populations, merely translating previously developed assessment tools is far from sufficient. A growing literature shows that the “single forward and back-translation” technique has been proven inadequate in ensuring the quality of translation, potentially resulting in a poorly-translated version (Brislin et al., 1973; Hambleton, 2001). Cross-cultural adaptation needs to go hand-in-hand with translation to make translated scales specific to the multiple health needs of people from multiple cultural settings. Adaptation is oriented towards producing an equivalent measure adapted to the target culture, which is a prerequisite for the investigation of cross-cultural differences (Guillemin et al., 1993). The complex, challenging translation and adaptation task calls for a combination of approaches (Hambleton, 2001). Only when the quality of translation and adaptation has been ensured and the corresponding process involved has been reported, is it possible that comparisons are made across studies and datasets, conclusions are drawn on the constructs assessed, or statements are made about culture differences (van Widenfelt et al., 2005), for the benefit of understanding and meeting the varying health needs of people from multiple cultural backgrounds. To the best of our knowledge based on literature review, cross-cultural adaptation in the translation of mental health instruments has not yet attracted close attention from the international academic community. Hopefully, through our current research, this domain of study will receive adequate attention to help address diversified mental health needs and deliver tailored quality mental health care and services among different populations across national boundaries and within multicultural communities. To these ends, translated health-related materials must be relevant to the cultural beliefs and values of the target social settings and culturally comprehensible and acceptable to the target readers.

Presentations of mental disorders vary according to settings, particularly where somatic, emotional or psychological expressions are crucially important (Desjarlais et al., 1995). Recognition of mental disorders is further complicated by diverse expectations of normal or acceptable behavior (Desjarlais et al., 1995; Good et al., 2007). As a result, many important terms in mental health, including labels for affective states, are considerably challenging to translate directly, considering the lack of direct, available translations, the nuances of language evolution and the considerations of popular usage of particular terms (Barger et al., 2010). “Translation for mental health materials should be consistent with clients’ multicultural background and context, and should not assume the target text audience’s worldview to be identical or inferior to that of the source text audience.” (Black, 2018, p. 8) As a result, strict translation of tools has been proven insufficient in multiple settings (Betancourt et al., 2009; Kohrt & Hruschka, 2010). To address such insufficiency, we propose that translated instruments should be adapted to the target culture to capture cultural understandings and constructs (Allden et al., 2009), thereby becoming culturally relevant, comprehensible and acceptable in the target social settings. The rationale for our proposal can be found in previous studies (Baorong, 2009; Jabir, 2006; Nord, 1997; Vermeer, 2000). Advocating functional approaches to translation theories, Nord (1997) asserts that different settings require different renderings of the source text. Vermeer (2000) and Baorong (2009) both uphold “skopostheorie” that takes “skopos” (purpose) as the fundamental principle underlying translation. In other words, what drives the approach to the translation of any text is none other than the intent underlying the text rather than full faithfulness to the original text in terms of the word-for-word structure or the extra-lingual communicative effect (Jabir, 2006). Applying functional translation approaches, or specifically skopostheorie, to translation in the domain of mental health, van Ommeren et al. (1999) proposes an approach to the cross-cultural translation of mental health scales developed in different cultural settings, which focuses on three dimensions of equivalence: the relevance, comprehensibility, and acceptability of items on the instrument. These dimensions will be presented in Chaps. 3, 4, and 5, respectively.