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Year : 2012  |  Volume : 34  |  Issue : 2  |  Page : 149-152  

The process and challenges in the translation of World Health Organization Quality of Life (WHOQOL- BREF) to a regional language; Malayalam

1 Department of Psychiatry, Amrita Institute of Medical Sciences and Research Centre, Edapally, Cochin, Kerala, India
2 Department of Clinical Psychology, Amrita Institute of Medical Sciences and Research Centre, Edapally, Cochin, Kerala, India
3 Department of Community Medicine, Amrita Institute of Medical Sciences and Research Centre, Edapally, Cochin, Kerala, India
4 Department of Endocrinology and Diabetology, Amrita Institute of Medical Sciences and Research Centre, Edapally, Cochin, Kerala, India

Date of Web Publication28-Sep-2012

Correspondence Address:
Bindu Menon
Department of Psychiatry, Amrita Institute of Medical Sciences and Research Centre, Edapally, Cochin - 683 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7176.101783

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A lot of research has been directed on wellbeing and disability in many non-communicable disease conditions. In this context, health-related aspects of life and quality of life (QOL) are receiving a lot of focus. Many Quality of Health measures are available, of which World Health Organization Quality of Life (WHOQOL-BREF) is one of the most popular. Translating and adapting this tool is useful in view of research happening in a multicultural arena. Though translations into Hindi and other Indian languages including Tamil and Kannada have been done, a Malayalam version is not available. This paper discusses the steps adopted in this exercise and the challenges in translating WHOQOL-BREF to Malayalam from the original English version.

Keywords: Malayalam, quality of life, World Health Organization Quality of Life BREF

How to cite this article:
Menon B, Cherkil S, Aswathy S, Unnikrishnan A G, Rajani G. The process and challenges in the translation of World Health Organization Quality of Life (WHOQOL- BREF) to a regional language; Malayalam. Indian J Psychol Med 2012;34:149-52

How to cite this URL:
Menon B, Cherkil S, Aswathy S, Unnikrishnan A G, Rajani G. The process and challenges in the translation of World Health Organization Quality of Life (WHOQOL- BREF) to a regional language; Malayalam. Indian J Psychol Med [serial online] 2012 [cited 2020 May 25];34:149-52. Available from:

   Introduction Top

There has been an increase in the number of multinational and multicultural research projects, and with it the need to adapt health status measures for use in other than the source language has also grown rapidly. [1],[2],[3],[4] Most questionnaires are developed in English speaking countries [5] and hence there is a dearth of culturally validated health measures - both physical and psychological. This hampers meaningful research in many instances, especially for studies that assess health care utilization or QOL. [5],[6]

The term quality of life is used to describe the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare and politics. QOL is defined as individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns [7] The definition focuses on the impact of disease and effect of interventions on the QOL, rather than on the diseases and their associated symptoms. Standard indicators of the QOL include not only wealth and employment, but also the built environment, physical and mental health, education, recreation and leisure time and social belonging. [8]

Investigations into HRQL (Health-related Quality of Life) have led to instruments suitable for detecting minimally important effects in clinical trials, for measuring the health of populations and for providing information for policy decisions. [9] Widely valued aspects of life exist that are not generally considered as "health," including income, freedom, and quality of the environment. Although low or unstable income, the lack of freedom, or a low-quality environment may adversely affect health; these problems are often distant from a health or medical concern. Clinicians focus on HRQL, although when a patient is ill or diseased, almost all aspects of life can become health related. [8]

HRQL serves as an index for the impact of the chronicity of a given health condition. [10] The health condition itself is less distressing for patients as compared with the loss of functional capacity it produces. This in turn drastically reduces the sense of well-being, affects the interpersonal relations resulting in further reduction in well-being, leading into depression and exacerbation of existing health condition. This explains why lot of interest is taken in the QOL of the patient. We (the authors) decided to translate QOL-BREF into a regional Indian Language; Malayalam, because there are very limited instruments available in Malayalam to measure the QOL.

The first and major step in the process of cultural equivalence is the translation, which determines the usefulness, reliability and validity of the instrument in the new cultural context. In order to validate health status measures for cross-cultural use a number of criteria are required [2],[11] namely content equivalence; semantic equivalence; technical equivalence; criterion equivalence and conceptual equivalence.

The authors have translated WHOQOL-BREF from the original English version and tried to establish the content and semantic equivalence of the Malayalam version

   About the Instrument Top

The WHOQOL-BREF instrument comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships and environment. [7] The WHOQOL-BREF is a shorter version of the original instrument that may be more convenient for use in large research studies or clinical trials. [12] It is a generic instrument which includes physical, psychological, social and environmental profiles. Its psychometric properties were analyzed using cross-sectional data from 23 countries. [13] Among Indian languages, it has been translated into Hindi, Tamil and English. [14] Sick and well respondents were sampled from the general population, as well as from hospital, rehabilitation and primary care settings, patients with physical and mental disorders and with respect to quotas of important socio-demographic variables. Analyses of internal consistency, item-total correlations, discriminant validity and construct validity through confirmatory factor analysis indicate that the WHOQOL-BREF has good to excellent psychometric properties of reliability and performs well in preliminary tests of validity.

   Process Top

The guidelines in translation that have been chalked out by the WHO were followed. The translation methodology recommended by WHO has two features, which give it an advantage over straightforward forward/backward translation in the inception of a bilingual group doubling as a review panel that discusses and resolves issues around the translation process and a monolingual group that reads the translated document and comments on the qualitative and semantic aspect of the language used.

   Steps Involved Top

Initial forward translation
A four-membered bilingual panel was constituted of professionals with background in Sociology, Community Medicine and Psychiatry and from Psychology. All the members were familiar with the design and methodology of the project. All the four members were native speakers of Malayalam but proficient in English as well. By the virtue of their profession and experience, all the four members who constituted the bilingual panel had a good understanding of the target population in which the instrument would be used.

All the four members worked together on the first forward translation of the tool to Malayalam. The rough draft was then circulated among the members for comments and revision. Following two sittings, a consensus was arrived at on the first draft of initial forward translation.

This first draft was then discussed with the monolingual panel, which constituted of persons who spoke only Malayalam and who were the representatives of the target population. Their feedbacks were included in the draft. This group was moderated in a non-directive, information gathering approach by two members of the bilingual panel.

Back translation
Back translation was done by a professional translator.

   Synthesis Top

The original English version of the tool, translated version and the back translated version are then reviewed by the group of bilingual experts to determine the accuracy and equivalence of the translation process. Further refinement was done on the translation by synthesizing feedbacks from the above-mentioned sources after arriving at a consensus by the bilingual panel on the same.

   Challenges Top

Semantic equivalence requires each item or statement to retain its meaning as in the original version and this turned out to be the biggest challenge. The fact that there is no semantic equivalence in Malayalam for an expression like blue mood made the task difficult and approximate words which convey the same import were used. The same difficulty arose while trying to find equivalent Malayalam words/usage for the expression 'get around'. The item 'how safe do you feel in your daily life' proved a little difficult to translate, since in Malayalam the same word is used to refer to safety and security.

Content equivalence pertains to the examination of each item to establish whether the concept it measures is relevant to the cultural setting in which it is to be used. In this context, difficulty was experienced in translating the item 'Are you able to accept your bodily appearance', since too much of importance attached to ones physical aspects is frowned upon in Indian culture. The translation of the item which asks about sex life was also debated upon, since the panel felt the question might be inappropriate and insensitive when asked to people who have lost their spouses or are old.

In the mono-linguistic panel it was found the socioeconomic and educational status played an important role in the understanding of more complex constructs like meaning in life or being satisfied with oneself, with those educated to high school level, understanding it to have a more multi-dimensional percept than those with lesser education. All the members however perceived QOL as an important determinant of a productive life

   Discussion Top

Translation of a tool is a labor intensive task involving multiple discussions to reach consensus. It includes much individual work and lengthy group discussions to ensure that consensus decisions resulted in the most appropriate terms being used in the translated instrument. [15]

Establishing semantic equivalence was the most difficult since cultural differences make it difficult to capture certain nuances of expression in English. However it is noteworthy that 80% of the items could be translated and back translated with the same meaning without any difficulty. Also many English words are incorporated into the local usage and are routinely used, sometimes more than the original Malayalam It is therefore safe to conclude that despite the difficulties and challenges pertaining to certain words and expressions, the WHOQOL-BREF was quite amenable to translation from English into Malayalam.

For the research to progress in a multicultural mileu, it is essential to have basic research tools which are culturally adapted and which satisfy all the criteria of equivalence. Quality of Life Scales are used in the psychiatric, social and medical research, and are thus, likely to have a wide utility. This effort at the Malayalam translation of the WHOQOL-BREF (the gold standard amongst the Quality of Life Scales) is an important step in bringing a locally adapted tool for the benefit of researchers from this part of the world.

   References Top

1.Anderson RT, Aaronson N, Wilkin D. Critical review of the international assessments of health related quality of life generic instruments. In: The International Assessment of Health Related Quality of Life: Theory, Translation, Measurement and Analysis. Oxford, UK: Rapid Communication of Oxford; 1995. p.11-37.  Back to cited text no. 1
2.Bullinger M, Alonso J, Apolene G, Leplège A, Sullivan M, Wood-Dauphinee S, et al. Translating health status questionnaires and evaluating their quality: The IQOLA Project Approach. International Quality of Life Assessment. J Clin Epidemiol 1998;51:913-23.  Back to cited text no. 2
3.Wiesinger GF, Nuhr M, Quittan M, Ebenbichler G, Wölfl G, Fialka-Moser V. Cross-cultural adaptation of the Roland- Morris questionnaire for German speaking patients with low back pain. Spine (Phila Pa 1976)1999;24:1099-103.  Back to cited text no. 3
4.Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross cultural adaptation of self report measures. Spine (Phila Pa 1976) 2000;25:3186-91.  Back to cited text no. 4
5.Guillemin F, Bombardier C, Beaton D. Cross cultural adaptation of health related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol 1993;46:1417-32.  Back to cited text no. 5
6.Gonzalez-Calvo J, Gonzalez VM, Lorig K. Cultural diversity issues in the development of valid and reliable measures of health status. Arthritis Care Res 1997;10:448-56.  Back to cited text no. 6
7.World Health Organization. WHOQoL Study Protocol. Geneva: WHO; (MNH7PSF/93.9). 1993  Back to cited text no. 7
8.Derek G, Johnston R, Pratt, G. "Quality of Life". Dictionary of Human Geography (5th ed.). Oxford: Wiley-Blackwell; 2009 ISBN 978-1-4051-3287-9  Back to cited text no. 8
9.Guyatt GH, Feeny DH, Patrik DL. Measuring Health-Related Quality of Life. Ann Intern Med 193:118:622-9.  Back to cited text no. 9
10.Patrick DL, Erickson P. Health status and health policy: quality of life in health care evaluation and resource allocation. New York: Oxford University Press; 1993.  Back to cited text no. 10
11.Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA, et al. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis 1988;176:257-63.  Back to cited text no. 11
12.Murphy B, Herrman H, Hawthorne G, Pinzone T, Evert H. Australian WHO QoL instruments: User's manual and interpretation guide. Australian WHO QoL Field Study Centre, Melbourne, Australia: 2000.  Back to cited text no. 12
13.Skevington SM, Lotfy M, O'Connell KA. The World Health Organization's WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial A Report from the WHOQOL Group. Qual Life Res 2004;13:299-310.  Back to cited text no. 13
14.Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. Natl Med J India 1998;11:160-6.  Back to cited text no. 14
15.Bhui K, Mohamud S, Warfa N, Craig T, Stansfeld S. Cultural Adaptation of Mental Health Measures: Improving the quality of clinical practice and research. Br J Psychiatry 2003;183:184-6.  Back to cited text no. 15

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