Translation
Twenty-nine phrases were translated from the English source questionnaire to German, of which sixteen phrases corresponded to the questions comprising the final OxCAP-MH instrument. Two phrases were additional questions not included in the final score, four were instructions (e.g. “Please tick one”), six were different response options, and one was an explanatory sentence included at the beginning of the questionnaire, i.e. “This questionnaire asks about your overall quality of life.”
Following the formal steps of the translation process (Fig.
1), three German versions of the questionnaire were developed with the third version being the final approved translation of the OxCAP-MH. First, two independent forward translations were conducted and Version 1 of the German questionnaire was created. After conducting two independent back translations of Version 1 and carrying out the back translation review, nine out of 29 phrases (31%) were changed (seven based on the suggestions of the professional translators and two based on feedback from the in-country investigator in Austria and mental health specialists from Germany) and Version 2 was developed (Table
1).
I0 | Explanation | L | 2 | + | L | 2 | + | N |
Q1 | Daily activities | | | | I | 3 | + | Y |
I1 | Instruction 1 | | | | | | | |
R1–4 | Response option 1 | I | 1 | + | | | | Y |
Q2 | Social networks | | | | | | | |
Q3 | Losing sleep | I | 1 | + | | | | Y |
Q4 | Enjoying recreation | | | | | | | |
Q5 | Suitable accommodation | | | | | | | |
R5 | Response option 2 | | | | | | | |
Q6 | Neighbourhood safety | | | | | | | |
R6 | Response option 3 | | | | | | | |
Q7 | Potential for assault | | | | I | 2 | – | N |
R7–8 | Response option 4 | | | | | | | |
Q8 | Discrimination | | | | | | | |
I2 | Instruction 2 | I | 1 | + | | | | Y |
Q8a | Additional question | I | 1 | + | | | | Y |
I3 | Instruction 3 | | | | | | | |
R8a | Response option 5 | | | | P | 2, 3 | + | Y |
Q9 | Additional question | | | | | | | |
I4 | Instruction 4 | | | | I | 2 | + | Y |
R9 | Response option 6 | I | 1 | + | | | | Y |
Q9a | Influencing local decisions | L | 2 | + | S | 2 | – | Y |
Q9b | Freedom of expression | | | | | | | |
Q9c | Appreciating nature | | | | | | | |
Q9d | Respect and appreciation | I | 1 | + | | | | Y |
Q9e | Love and support | | | | I | 3 | + | Y |
Q9f | Planning one’s life | | | | | | | |
Q9g | Imagination and creativity | | | | | | | |
Q9h | Access | I | 1 | + | I | 2 | – | Y |
Number of accepted changes (%) | 9 (31%) | 5 (17%) | 12 (41%) |
Cognitive debriefing
Eight women and four men participated in the pilot testing of the German OxCAP-MH questionnaire (Version 2). The mean age of study participants was 37 years (range 24–62 years). The most common diagnosis was depression (
n = 5). The average duration of the interviews including both the times for completion and cognitive debriefing was 16 min (range 5–40 min) (Table
2).
Table 2
Cognitive debriefing (pilot study) sample characteristics
001 | 24 | Male | 7 | Schizophrenia |
002 | 28 | Male | 10 | Paranoid schizophrenia |
003 | 36 | Female | 9 | Depression, panic disorder |
004 | 34 | Female | 10 | Depression, panic disorder |
005 | 26 | Female | 11 | Borderline personality disorder |
006 | 27 | Female | 5 | Depression, panic disorder |
007 | 32 | Male | 6 | Depression, mental and behavioural disorders due to use of alcohol |
008 | 62 | Female | 26 | Schizoaffective disorder |
009 | 50 | Male | 30 | Depression, anxiety disorder |
010 | 31 | Female | 23 | Posttraumatic stress disorder |
011 | 50 | Female | 20 | Bipolar disorder |
012 | 41 | Female | 40 | Schizoaffective disorder |
As the cognitive debriefing sessions revealed, neither patients nor carers experienced any major difficulties with understanding the individual item concepts or answering them. For patients, nine (56%) out of the 16 questions were entirely clear and six questions were easy to understand. Only one item referring to “influencing decisions in the local area” proved problematic to interpret (Table
3). Carers considered potential difficulties with six questions (Table
3).
Table 3
Results of the cognitive debriefing
Q1 | Daily activities | Y (1) | Y |
Q2 | Social networks | Y (3) | Y |
Q3 | Losing sleep | Y (3) | Y |
Q4 | Enjoying recreation | N | Y |
Q5 | Suitable accommodation | N | Y |
Q6 | Neighbourhood safety | Y (1) | N |
Q7 | Potential for assault | Y (1) | N |
Q8 | Discrimination | N | N |
Q9a | Influencing local decisions | Y (8) | N |
Q9b | Freedom of expression | Y (1) | N |
Q9c | Appreciating nature | N | N |
Q9d | Respect and appreciation | N | N |
Q9e | Love and support | N | Y |
Q9f | Planning one’s life | N | N |
Q9g | Imagination and creativity | N | N |
Q9h | Access | N | N |
Based on the qualitative analysis of the cognitive debriefing sessions, another six change suggestions were brought forward by the in-country investigator and three by the patients and/or carers (Table
1). Following careful linguistic and construct considerations including preserving the integrity of the instrument and focusing on common concerns, five of the suggested changes were implemented at this stage (Table
1).
Overall, 14 out of the 17 suggested changes were accepted (82%) resulting in a total of 12 changed phrases out of the 29 originally translated phrases (41%) in the final German version of the OxCAP-MH instrument (Table
1). The majority of the proposed changes (12 out of 17; 71%) referred to ambiguous wording and the possibility of different interpretations. One suggested change (6%) was due to a politically unacceptable expression, and one due to differences in political and social systems (6%). Three changes were suggested and implemented due to need for harmonisation for cross-country language differences between Austria and Germany (18%) (Table
1).
While professional translators were able to discuss changes that referred to pure linguistic issues, feedback from the in-country investigator, mental health specialists, and patients and carers resulted in modifications in wording mostly due to cultural and political differences between the countries (UK and Austria/Germany) as well as cross-country differences between Austria and Germany (Table
1). Response option 5 (R8a in Table
1) serves as an example of a change necessary due to the politically and culturally differential meaning of a word in the German language. The direct translation of “race” to “Rasse” had to be removed from the final German version, as “Rasse” is a term considered politically incorrect in the German language due to historical reasons. Changes to Question 9a were necessary due to relevant terminology differences between Austria and Germany. The word “local area” was initially translated as “Ortsgebiet” which was expected to be difficult to interpret for psychiatric patients according to the feedback from the in-country investigator and the mental health specialists from Germany. Consequently, the wording “Wohngebiet” (living area) was adopted in the final version of the questionnaire (Additional file
1).
Differences in cultural and political concepts between the UK and Germany/Austria were also reflected in the translation of Question 9a which asks about the ability to influence decisions affecting the local area, i.e. if patients have a ‘voice’ in their local area. At first glance this question seemed to be unclear to most participants in the pilot study (Table
3). Qualitative analysis revealed that this is likely to be due to the fact that the concept of participation in decision making at the community level seems more relevant in the Anglo-Saxon culture. Nevertheless, as many study participants were able to come up with accurate exemplifications, the question was left unchanged to protect the instrument’s integrity (Additional file
1).
As a result of cognitive debriefing, Question 9e was also modified. Originally phrased, the question asked if patients “find it easy to enjoy the love, care and support of [their] family and friends”. It was easy to understand but considered problematic by both carers and some patients, since the expression implies that someone has a supporting family to begin with. “Family? In the old days, yes …” (ID 007), “If I actually got [support] from my family, I would gratefully accept it …” (ID 008) and “Sure, but to this end [support] would actually need to exist to begin with” (ID 009) were three of the (translated) comments hinting a potential deficit experienced by people with mental health conditions in this respect and showing a very important dimension of quality of life in the context of mental disorders. In the final translation the linking word “and” was therefore replaced with “and/or” (“Mir fällt es leicht, die Liebe, Fürsorge und Unterstützung meiner Familie und/oder Freunde anzunehmen und zu genießen.”).
Contrary to the English language, the use of masculine and feminine forms is inherent in the German language, especially in written communication. The text of the questionnaire, however, only contained one word where this issue was relevant, i.e. ‘Freunde/
Freundinnen’ meaning ‘friends’. In order to keep the questionnaire easy to read, only the male version was included in the translation (‘Freunde’). Neither carers nor patients noted or brought this issue up at the piloting stage and therefore no changes were deemed necessary.
Another characteristic of the German language is the use of “Du/Sie” forms. While the English “you” is used in both formal and informal communication, in German two variants are used for this personal pronoun: “Du” in informal and “Sie” in formal language. In line with German cultural standards, the “Sie” form was used throughout the questionnaire. No relevant concerns were raised.
Additional file
1 presents the full details of the translation process based on one sample item from the OxCAP-MH questionnaire.