Keywords

Culture is defined as systems of meaning, knowledge and action (Nastasi & Hitchcock, 2016). According to Nastasi et al. (2017, pp. 137–138), culture, when perceived as a system of meaning, facilitates individuals and communities organizing the multiple components of their world into a coherent whole in a process of co-construction via social interaction; culture, when considered as a system of knowledge, “sanctions normative behaviors and other socially acceptable ways of acting, so that the constructed ‘meaningful’ world is consolidated, reinforced, transmitted, and maintained over generations”; as a system of action, culture is dynamically constructed, that is, its members can negotiate new meanings by acting upon their world. Culture is, therefore, not merely a shared system of meaning, but an individual system for interpreting the world and guiding action and an interpersonal system to aid communication (Nastasi et al., 2017, p. 138). Since culture reflects a set of people’s shared beliefs, values and behavioral expectations, the individual’s interpretation of these shared systems may be impacted by their experiences in multiple settings with varying cultural meanings. It can be seen that culture is co-constructed by its members in given contexts.

In addition to linguistic validity and psychometric validity, cultural is another highly influential factor that strongly impacts the achievement of an equivalent translation (Kuliś et al., 2011). Therefore, cultural differences need to be considered in the process of translating instruments not only when different languages are spoken in multiple countries, but also when one language is spoken in more than one country or in various regions within a single country (Kuliś et al., 2011). Taking cultural differences into consideration, Nastasi et al. (2017) argue that the aim of cultural co-construction applied to school mental health programming is the development and planned adaptation of culturally-relevant interventions. Thus informed, we propose that mental health scales, cross-culturally translated and adapted ones in particular, must be relevant to the target culture, especially considering the fact that the global psychological knowledge is derived primarily from research on populations from North America and Western Europe, thereby representing merely 5% of the world’s population and neglecting the remaining 95% (Arnett, 2008). Specifically, the goal of cross-culturally translating and adapting previously developed mental health instruments is to make these tools culturally valid, or specifically “relevant to systems of meaning, knowledge, and action for the target cultural group and local context” (Nastasi et al., 2017). To this end, the development of cross-culturally adapted scales involves a process of modifying existing measures to ensure cultural relevance, technically termed “cultural grounding,” or “evidence-based cultural adaptation” (Barrera et al., 2013; Colby et al., 2013). Thus, cross-cultural adaptation needs to be informed by knowledge of target populations and contexts, and it is ideally achieved through a systematic data collection process that leads to evidence-based cultural grounding (Nastasi & Hitchcock, 2016).

Cultural relevance is closely associated with content equivalence. When showing content equivalence, an instrument item is relevant to local experiences (van Ommeren et al., 1999). When asking a question about phenomena that have nothing to do with the underlying construct, an instrument item is irrelevant to the target culture (Manson, 1997). Assessing cultural relevance entails comparing the content of the items on mental health-related scales with the popular beliefs about and indicators of the concept that are prevalent in the target culture (Sidani et al., 2010). Items whose content is consistent with the cultural beliefs and manifestations of the target societies are deemed culturally relevant (Sidani et al., 2010). The assessment of cultural relevance is designed to identify: (1) items on the source scales that are relevant to the target culture; (2) items on the source scales that need to be modified to make them more relevant to the target culture; and (3) manifestations that capture the concept prevalent in the target culture but are not embodied in any of the items on the source scale (Sidani et al., 2010). Based on such identifications, modifications need to be made as follows: (1) items or expressions in items that are irrelevant to the target culture need to be removed from the translated scale; (2) culturally appropriate or colloquial expressions of the same idea need to be used in the target scale; (3) items that reflect indicators of the concept specific to the target culture need to be added to the translated scale; and (4) specific, culturally relevant indicators that are commonly manifested in the target culture but not captured by any item on the source scale need to added to the translated scale.

When the definitions and indicators of some concepts expressed in the items on the original scales cannot be captured in the target language and culture, these concepts or even the entire items involving these concepts need to be removed from the translated and adapted scales. For example, we removed the item “To what extent do you think it is likely that Personality Disorders are a category of mental illness” from the Mental Health Literacy Scale (O’Connor & Casey, 2015) when translating and adapting this measure from English into Chinese, considering that most Chinese people would not understand the Chinese translation of “Personality Disorders” into “人格障碍.” This is because the concept of “Personality Disorders” is largely irrelevant to the Chinese culture and almost never talked about among Chinese populations. The decision of removal was made by a panel of researchers consisting of bilingual translators, bilingual mental health professionals and mental health content experts based on discussion and the bilingual mental health professionals’ clinical experience and practice. Similarly, when translating and adapting the item “People with [mental illnesses] need to take better care of their grooming (bathe, clean teeth, use deodorant)” on Day’s Mental Illness Stigma Scale (Day et al., 2007), we deleted “deodorant” from this item due to the fact that “deodorant” is irrelevant to the Chinese people’s daily living experiences. Chinese populations never use “deodorant” after a bath or a shower, which is contrary to Western culture where it is commonly used. If translated into “除臭剂” and retained in the translated Chinese scale, this term is most likely to cause confusion among Chinese people and even stigmatize individuals with mental illness due to the possibly perceived association between odor and those suffering mental disorders. As the examples above indicate, removing items from and adding items to adapted scales entail carefully weighing the “trade-off” between making scales conceptually equivalent in the source and target languages and improving their cultural validity or relevance (Leplege & Verdier, 1995).

Some items on the source scales call for modifications to be more culturally relevant to the target social context. In this case, culturally appropriate or colloquial expressions of the same idea need to be used in the translated and adapted scale. A good case in point is the term “Agoraphobia” in the item “To what extent do you think it is likely that the diagnosis of Agoraphobia includes anxiety about situations where escape may be difficult or embarrassing” on the Mental Health Literacy Scale (O’Connor & Casey, 2015). “Agoraphobia,” the fear of open or public places, is translated into “广场（或旷野）恐怖（症）,” “恐旷症,” or “公共场所恐惧症” in the dictionary, but not all these three translated versions are culturally appropriate from the perspective of the intended Chinese readers. We chose “广场恐惧症” as the final translation of “Agoraphobia” after consulting with several psychiatric professionals working in Qilu Hospital of Shandong University, China, who voted “广场恐惧症” as the most culturally appropriate or colloquial expression of the same idea as “Agoraphobia” in the original English item. Likewise, in cultural settings where some people in a particular ethnic group are not willing to acknowledge their condition of depression, “stressed” is a better wording in the adapted interventions (Conner & Grote, 2008). Different ethnic groups may have varying conceptualizations of mental disorders relative to the standard, established views of mental health professionals (Conner & Grote, 2008), which calls for linguistic modifications of certain terms or expressions in particular items on the translated and adapted scales to make them more culturally relevant.

To assess the cultural relevance of translated and adapted instruments, Sidani et al., (2010, p. 138) proposed the following questions: “Do you and people in your community believe and/or experience what this item reflects? How important is the idea or indicator reflected in this item in representing the concept as understood by you and people of your community? Is the content of the item offensive to people of your community? What words in your language can be used to express the same idea or indicator as in this item?” These questions can serve as specific indicators and yardsticks of cultural relevance in the translation and adaptation of mental health scales.