Keywords

1.1 Variations in How Mental Disorders Are Expressed

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 disorders imply that there are variations in how these disorders are expressed (Flaherty, 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: 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.

1.2 Pressing Need to Translate and Cross-culturally Adapt Mental Health Scales

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: 1417) observes 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 wide 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: 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: 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. 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 regarding 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).

1.3 Prevalence of Mental Disorders in China and Translation of Mental Health Scales into Chinese

In the early 2000s, approximately 17% of adults in China were found to have a mental disorder (Phillips et al., 2009), making China one of the most mentally ill countries worldwide (Demyttenaere et al., 2004). As many as 92% of individuals with mental disorders in China had never sought any type of professional help for their disorder (Phillips et al., 2009). In this background, it is necessary to use scales to assess people’s beliefs about, attitudes towards, and knowledge and literacy about mental disorders and to rate and screen mental disorders. However, such scales are very few in China. Therefore, there is a pressing need for the Chinese translation of mental health scales developed in other languages to conduct tailor-made assessment, screening, education, intervention, prevention and treatment in mainland China and possibly in Chinese-speaking communities worldwide.