R E S E A R C H A R T I C L E A B r i d g e B e t w e e n C u l t u r e s : A R e p o r t o n t h e P r o c e s s o f T r a n s l a t i n g t h e EQ-5D I n s t r u m e n t i n t o S h o n a A B S T R A C T : There is an increasing need in medical research fo r outcome measures that are both locally applicable and internationally recognised. The European Quality o f Life 5-dimensions (EQ-5D) has been fo u n d to be a valid and reliable instrument f o r describing health related quality o f life in Western societies. The p a p er describes the process o f translating the EQ-5D into Shona, the language spoken by the majority o f Zimbabweans. The EuroQoL group has developed a protocol f o r trans­ lation that was fo llo w e d rigorously. Issues such as conceptualisation o f health concepts cross-culturally, semantic equivalence (the transfer o f meaning across languages) and specific idiomatic expressions are discussed. It is concluded that i f the translation process is not adequately addressed, researchers may be guilty o f sim ply imposing notions o f health and quality o f life across cultures. Consequently, the results will not provide m eaningful insights into the cultures under study. KEYWORDS: TRANSLATION, SHONA, Q U ALITY O F LIFE, CULTURE JELSMA j'; CHIVAURA V2; DE WEERDT W3; DE COCK P4; 1 Department o f Rehabilitation, University o f Zim b ab w e. Faculteit Licham elijke O p vo e d in g en Kinesitherapie, Katholieke Universiteit Leuven, Belgium. 2 Department o f English, University o f Zim b ab w e. 3 Faculteit Licham elijke O p vo e d in g en Kinesitherapie, Katholieke Universiteit Leuven, Belgium. 4 Centrum v o o r O ntw ikkelingsstoornissen, Faculteit G eneeskunde, Katholieke Universiteit, Leuven, Belgium. INTRODUCTION W ith the growing international colla­ boration in clinical research, there has been an increasing need for international instruments to assess outcomes (Bullinger e ta l 1998). Health related quality o f life (HRQoL) measures are im portant out­ com e measures that are often used in international studies either to evaluate change over time o r to discrim inate betw een two groups at a specific point in time (Beaton et al 1996). The majority o f esta b lish e d m easu res stem from A nglo-A m erican literature (Bullinger et al 1998) and in Southern Africa, research is often undertaken w hich requires the use o f these in strum ents. H ow ever, health status m easures developed in one country cannot sim ply be translated for use in a different cultural context (W agner et al 1998). T he translation process should ensure that, the target version is not. only sem antically equi­ valent to the source version but also conceptually equivalent. In other words, the translation should not only reflect the correct linguistic interpretation of the source but, if the instrum ent is to be useful, it should reflect the dom ains that the target culture regards im portant (H erdm an 1998). O ne o f the m ost com m only used m ea­ sures o f HRQoL is the European Quality o f Life - 5 dim ensions or EQ-5D. It is a generic single index measure, validated in several European countries w hich has been used to m easure health for both clinical and econom ic appraisal (Bakker and van der Linden 1995). The EQ-5D is a decep tiv ely sim ple in stru m en t w hich includes a description o f the respondents ow n health with regard to five domains o f function; rating o f own health by m eans o f a visual analogue scale, and background information about the respondent (Brooks and EuroQ ol 1996) (See Table I). The EuroQ ol Group has developed a strict protocol to guide those who w ish to translate the instru­ m ent from E nglish into other languages (EuroQol). A t present, there are many E uropean lan g u ag e versions o f the EQ -5D and a Japanese version. This report describes the first attem pt to pro­ duce an officially approved version in the language o f an A frican country. T he aim o f this paper is to docum ent the difficulties encountered in translating the EQ -5D into Shona, the language o f the m ajority o f the citizen s o f Zimbabwe. It is likely that sim ilar pro­ blem s are encountered in translating W estern developed instrum ents into the local Southern African languages and it is hoped that our experience will assist others in the developm ent o f locally valid translated instruments. BACKGROUND INFORMATION Zim babw e is a country o f approximately 12 million people. There are two main language groups, Shona and Ndebele. Shona speakers com prise the majority language group. English is the official language. Since Independence in 1980, there has been free com pulsory primary education (seven years o f schooling) and the adult literacy rate is high, 91% (com pared to 84% in South Africa) (Tandon 2000). Both Standard Shona and N debele are taught at schools and exam ined at both ‘O ’ and ‘A’ level. CORRESPONDENCE: Jelsm a J D epartm ent o f Rehabilitation, U niversity o f Zimbabwe, Box A178, Avondale, Harare, Zimbabwe. Tel: 263-4-791631. Fax: 263-4-724912. Email: jjelsm a@ healthnet.zw SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:jjelsma@healthnet.zw However, standard Shona is academic and elitist and no one in fact speaks it. There are several dialects, including M anica, Zezuru and Kalangu. Prior to this translation, w ork had been done to establish the reliability o f the EQ-5D in a high-density area in H arare (Chim era and Jelsm a 1999). A translation o f the EQ -5D had been car­ ried out but the translation protocol had not been adequately follow ed to justify recognition as an official translation by the EuroQ oL Group. As the EQ-5D was to be used as a m easurem ent instrum ent in ongoing research on HRQoL, it was decided to redo the translation accord­ ing to the protocol prescribed by the EuroQol Group. METHOD The protocol was followed as closely as possible. This entailed i) F o rw a rd tra n s la tio n c a rrie d o ut independently by two native Shona speakers and a m eeting to gain consensus on the first draft. ii) Backw ard translation by two trans­ lators w orking independently and a m eeting to gain consensus. iii) Testing o f the instrum ent on a lay panel o f 18 participants. A t each stage o f the process, reports o f the m eetings were sent to the EuroQol Group and com m ents and suggestions w ere m ade and im plem ented before progressing to the next phase. The two forw ard translators were lecturers in the Departm ent o f English, one o f w hom spoke the Zezuru dialect and the other the Ndau dialect. It was agreed that the translation would be produced in standard Shona. Standard Shona is the meeting point o f all dialects, equivalent to BBC English. It is the local lingua franca and suppresses the variance o f different dialects. Sim ilar to all standardised languages the dif­ ference betw een the use o f different dialect speakers when speaking standard Shona lies not in expressions or choice o f words but m ore in pronunciation: phonology and inflections, e.g. American English and B ritish English. The two forward translators w orked independently o f each other to produce a draft version. Translator 1 produced a more direct, literal translation. Translator 2 used more colloquial and natural oral discourse. He translated the content into the idiom and conceptual fram ew ork o f the respondents to a greater extent. The problem with this translation was that back-translation into English m ight have produce unrecognisable results. These versions were extensively discussed and a consensus version agreed upon. The Translation Protocol requires that the back translators be native English speakers and the EuroQol Group sug­ gested that they did not necessarily have to be fluent in Shona but should have a reasonable com m and o f Shona. H ow ­ ever, we argued that we were not ju st addressing language issues but trying to interface com pletely different cultures and worldviews. Consequently, we felt that if we asked a native English speaker who w ould likely represent the Western Judeo-Christian point o f view on illness and disability, we w ould lose out on the specific cultural nuances that are present in the choice o f alm ost all the words. The translation w ould end up being a technically correct, but essentially for­ eign instrument. The other argum ent that we put for­ ward for the services o f native Shona speakers as back translators was that E nglish is the official lan g u ag e o f Zim babw e and that the back translators had not only com pleted B ritish set and m arked ex am in atio n s b u t had also com pleted honours degrees in English. In contrast, in European and other coun­ tries, national languages are all spoken officially and at school. Any English speaking person living in these European countries would be forced to learn to speak these national languages. Similarly the nationals o f these countries would not be constantly exposed to English. The EuroQ ol G roup accepted these argum ents and the back tran slato rs a p p ointed w ere then nativ e Shona speakers, both o f whom were lecturers in the English L anguage at the Open U niversity o f Zim babwe. Once again, one translator was asked to produce a literal, direct translation and the other a more idiom atic translation. The process took many hours o f dis­ cussion. A t each stage o f the process, feedback was received from the EuroQol T ranslation Group and suggested m odi­ fications were im plem ented RESULTS AND DISCUSSION OF THE PROCESS The results o f the back translation are presented in Table I. Conceptual aspects: It was apparent from the outset o f the translation process that the concepts described by the EQ -5D do not sit com fortably in the Shona worldview. For exam ple, the English concepts o f health sound inappropriate when trans­ lated because som e health states are seen to have a spiritual rather than a physical origin. M ararike (1999) states that ill­ nesses may be normal (i.e. an illness with an im personal cause) or abnormal (an illness with interpersonal causes.) A bnorm al diseases can only be treated by traditional healers because m odem m edicine cannot address the ultimate cause o f the illness, namely witches or the various types o f spirits. (M ararike, 1999). A ttitudes towards these health states are th erefo re und ersto o d and interpreted differently in Shona culture and experience. The traditional Shona w ay o f life is largely spiritual and hum anistic, within the group and less m aterialistic and individualistic than, perhaps, that o f western capitalist socie­ ties (Mararike 1999). People define them­ selves in terms o f the group and their health or illness is actualised within that context. The contrast to Western indivi­ dualism and em phasis on self-deter­ m inism im plies that independence in functioning is not w eighted as heavily as it w ould be in W estern cultural contexts and concepts related to personal care and usual activities are understood dif­ ferently. In the next stages o f validation o f the instrum ent it might be necessary to establish the relative item weights (m easurem ent equivalence) as these can be expected to reflect the com parative im portance given to different item s in different cultures (H erdm an 1998). Semantic Equivalence: Several p roblem s w ere enco u n tered with achieving sem antic equivalence, w hich is concerned w ith the transfer 4 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table I: Results of the back translation ORIGINAL EQ - 5D Health Questionnaire (Shona version) By placing a tick (thus) in one box in each group below, please indi­ cate which statements best describe your own health state today. Mobility I have no problems in walking about. I have some problems in walking about. I am confined to bed. Selfcare I have no problems with self-care. I have some problems in washing and dressing. I am unable to bath or dress myself. Usual activities (e.g. work, study, housework, family or leisure activities) I have no problems performing my usual activities I have some problems with performing my usual activities. I am unable to perform my usual activities. Pain/discomfort I have no pain or discomfort. I have moderate pain or discomfort. I have extreme pain or discomfort. Depression/anxiety I am not anxious or depressed. I am moderately anxious or depressed. I am extremely anxious or depressed. FIRST TRANSLATOR (LITERAL) E Q - 5 D Health questionnaire In each set of the following responses insert a tick in th box at the end like this [✓ ] against one answer only which you think is the one that explains your health today. Being able to walk/move I have no difficulty in walking/ moving. Walking/moving is difficult for me. I cannot even walk/move. Keeping/taking care of myself I am able to keep myself. I am not really able to wash myself or dress myself. I am not able to wash or dress myself. Everyday tasks (For example: working, reading/studying, doing work in the house or around the house, relaxing or spending leisure time with the family) I have no problems doing the tasks I normally do every time. I have problems doing tasks I normally do every day. I can no longer do the tasks I used to do every day. Pain/being unsettled I am not feeling pain. I feel pain a little myself. I feel pain very much. Having trouble with the brain/thinking/being depressed I have nothing that troubles the brain. I have many things that trouble me. I am being troubled very much. SECOND TRANSLATOR (ENGLISH IDIOM) EQ -5 D Questionnaire on Health Choose one response, from each of the following sets, which most accu­ rately describes the state of your health today. Place a tick in the box [✓] against your chosen response. Movement I feel no pain when I walk/move. I feel pain when I walk. I am unable to walk. Personal Hygiene I can look after my personal hygiene without any problem. I have difficulties in bathing or dressing. I am unable to wash or dress myself. Performance of day to day tasks (for example, work, studying, domestic work, entertaining family) I have no problems in doing my day to day duties. I have problems in doing my day to day duties. I am unable to do my day to day duties. Physical pain/discomfort I feel no pain or discomfort. I feel moderate pain or discomfort. I have severe p ain/ discomfort. Mental problems and anxieties I have no mental problems or anxieties. I suffer from moderate stress/anxiety. I suffer from severe stress/anxiety. SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table I: Results of the back translation (continued) ORIGINAL EQ - 5D Health Questionnaire (Shona version) Compared with my general health over the last 12 months my present state of health today is: Better, Much the same, worse. Instructions for VAS Your own health state today. Best imaginable health state. Worst imaginable health state Because all replies are anonymous, it will help us to understand people's answers better if we have a little background data from everyone, as covered in the following questions: Have you experienced serious illness? Yes [ ] No [ ] In yourself? FIRST TRANSLATOR (LITERAL) E Q - 5 D Health questionnaire When I am comparing my health in the last twelve months and today, I can say myself today: It is now better. It is the same. It is worse. So that we can help people to see how good or bad their health is today, we have given you a scale to measure (it looks like a thermometer used to measure body temperature), it has numbers starting from 0 up to 100. 0 shows the poor health of someone who is very ill. 100 shows the very good health of someone who is not ill. We ask you to point at the number on the scale that you think is the one that shows exactly where your health is today. Do this by drawing a line starting from the box that is below to your right, where the scale is, until you end where exactly the number you have chosen which you think is the one that shows where your health is today. Your health today Very good health Very bad health Because your answers will not have your names, we kindly ask you to tell us something about how you live your life from what follows. Insert a check in the box like this [✓ ] on each answer that you will have chosen Have you ever seen someone very, very ill? Yes [ ] No [ ] Are you the one yourself? SECOND TRANSLATOR (ENGLISH IDIOM) E Q -5 D Questionnaire on Health When I look back at my health during tfie last twelve months, I would say that at present: I feel better than I have felt during the last twelve months. My state of health has not changed throughout the period. I feel worse that I have felt in the last twelve months. To help respondents to accurately estimate their state of health, we have provided a scale (similar to a thermometer measuring body temperature) which ranges from 0 to 100. 0 represents a very poor state of health, while 100 represents the height of good health. Mark on this scale the level at which you estimate your health to be. Draw a line from the box labelled "Your state of health today" to the number on the scale that most accurately reflects your state of health. The state of your health at this moment Very good health Very bad health Since this questionnaire will not carry your names, we ask you to provide us with additional informa­ tion about your health which you may regard as confidential. Place a tick in the box against the most suit­ able response Have you ever seen a very ill person? Yes [ ] No [ ]. Was this person yourself? 6 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table I: Results of the back translation (continued) ORIGINAL FIRST TRANSLATOR SECOND TRANSLATOR (LITERAL) (ENGLISH IDIOM) EQ - 5D Health Questionnaire E Q - 5 D EQ -5 D (Shona version) Health questionnaire Questionnaire on Health In your family. Is it another member of your family? Was the sick person a member of your family? In caring for others. Is it someone you saw in your work Did you see the person while carry­ for health and helping people that you were doing? ing out health or social work? What is your age in years? How many years do you have? How old are you? Are you Male Female? Are you; Are you a man or a woman? Are you male or female? A current smoker Do you smoke? Do you smoke? An ex-smoker Did you use to smoke? Did you smoke in the past? Never smoked Have you never smoked? Have you ever smoked in your life? Do you now or did you ever, Do you work now, or have you Are you involved or have you been work in health or social services? ever worked as a health worker or involved in health or social work. someone who helps people? If so, what was your particular If so, in what capacity?' If that is true, what was your position? designation? Which of the following best O f the following, tell us what you From the following indicate your describes your main activity? can say is exactly something that you are doing: main/major occupation: In employment or self-employment Job that you do yourself or that you are employed to do Self employed or formally employed Retired On pension Pensioner Housework Domestic work Domestic Work Student School child Student Seeking work Looking for work/employment Seeking employment Other (please specify) Any other that we have left out Any other occupation (not included (tell us what it is) above): Specify. Did your education continue after Have you done further studies since Did you further your education the minimum school leaving age? you left/finished school? after leaving school? Do you have a degree or Do you have a degree or any other Do you have a degree or it's professional equivalent? course similar to a degree? equivalent? If you know your postcode would If you know your address, please If you know it, please indicate you please write it here? write it here. your address here. o f meaning across languages and with achieving a similar effect on respondents in different languages (Herdm an 1998). Shona does not separate an abstract concept from the context in which it is experienced. E.g. The concept “pain” is not separate from the person who is experiencing the pain. A bstract concepts require either a subject or an object. Sim ilarly causation is part o f Shona idiom and it is difficult to simply say, “I have some problem s with w alking” w ithout identifying the som ething which is giving me problem s with walking. This is evidenced by the inclusion o f “p a in ” in T ranslator 2 ’s version (“I feel pain when I. walk”). The panel con­ cluded that pain was not inherent in the w ords used and that the final condition (confined to bed) changes the im plica­ tion from pain causing t h e , problems to unspecified problem s. Sim ilarly it is difficult to say “Confined to bed” w ith­ out stating the agent that is responsible. SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Quantification of degree of problem: The quantification o f degree o f problem was also difficult, a problem also expe­ rien ced in the tran slatio n o f SF-36 from A m erican English into European languages (Wagner et al 1998) and exam ­ ined further by K eller et al (1998). For exam ple, a literal translation o f “I have some problems with w alking” is possible but the expression is unnatural in Shona. One is either m obile or immobile. The Shona would say, “I can w alk a little” not “I have some problems with walking” . The latter would imply som e other kinds o f problem s with mobility, such as not having a car. Eventually the phrase was translated as “I can w alk but I have some problems with doing so” or “Walking gives me problem s” w hich implies abi­ lity to walk but with difficulty. The innate modesty o f the language also makes definitive statem ents unac­ ceptable in Shona idiom. It implies arro­ gance to say, “I have no problem s...” F or exam ple, the words used to translate “I have no problems with self-care” come across as arrogant, “I d o n ’t need anyone to help me” . However, a slightly apolo­ getic tone is introduced by the insertion of “zvangu” - “m y se lf’ which softens the statem ent and im plies more modestly, “me, myself, I have no problem s” . Similarly people would hesitate to say that their health state approxim ates the “Best im aginable health state” or “Worst im aginable health state” and these words were replaced with “Very good health” and “Very bad health” . Different domains: M obility: Problem s with the translation o f m obi­ lity concepts have been discussed above. The translating o f “confined to bed” presented two problems. A s m entioned above, Shona requires an agent - who or what has confined the person to bed? Secondly, not everyone sleeps in a bed. In the end an idiom atic Shona expres­ sion was used w hich im plies being unable to m ove out o f bed. Literally the expression means “I cannot even walk at all” but it implies other problem s apart from w alking about and can be used m etaphorically for a day in bed with an acute illness as well as a m ore perm a­ nent health state. It encom passes the idea o f both short-term illness (e.g. flu) and long term paralysis. A m ore direct translation o f the English “Confined to bed” implies that the person is moribund and about to die. S elf care: Possible options included “kuzvibatsira” (to help oneself) o r “kuzviitira” (to carry out tasks for oneself) or “kuzvishandira” (to w ork for oneself) or “kuzvionera” (to look after oneself). “K uzvibatsira” was chosen as being closest to the origi­ nal in im plying some disability when difficulty is encountered with the tasks. This was literally back translated as “I am able to keep m y s e lf’. The poten­ tial confusion betw een the w ider sense o f taking care o f oneself (i.e. fending for oneself) is lim ited to personal care by the inclusion o f “w ashing and dressing” in the next question. Pain/discom fort D iscom fort was difficult to translate and expressions such as “I cannot even stay in one place” were considered. Another issue is that in Shona, discom fort is not a sensation separate from pain. Once the idea o f discom fort has been included, the word pain in the rest o f the questions “kurw adziw a” includes the concept o f discomfort. D epression/ anxiety O f all the EuroQol concepts, the idea o f depression and anxiety are most difficult to capture in Shona. There is no specific w ord for depression, it is usually implied from sym ptom s rather than self report. A nxiety and depression are the m ean­ ings o f the same word, “kurem erw a” . Depression is seen to be caused by some life experience and is not described as a psychological state in isolation. W hile both anxiety and depression may cause sadness, they do not necessarily incor­ porate sadness in them selves. Anxiety and depression becom e prem onitions w here the causes are n ot palpable. A nxiety and depression are not, there­ for health states in Shona. They are understood as occasional psychological (social/alienation) or spiritual (religious) states. In addition, severe anxiety is seen to border on a psychiatric state know n as “m hopu” . A fter extended discussion, the words literally translated as “I have nothing that troubles the brain” or idiomatically translated into the English “I have no m ental problem s o r an x ieties” w ere accepted. Courtesy: T he question relating to the age o f the respondent also posed a problem as in normal social discourse it would be extrem ely discourteous to ask such a question o f an adult. The m ore usual fram ing o f this question would be “In w hat age bracket do you belong?” which is in fact a socialisation question. The answers w ould then be in the twenties or thirties, adult teenager or even married that would im ply adult. Contextual issues: Although not dealt with directly in the translation process, issues such as the setting o f the interview, as well as the gender and ages o f the interview er and resp o n d en t resp ectiv ely can have a m ajor im pact on the outcom e o f the qu estio n n aire and these issues need careful consideration. CONCLUSION A lthough it is likely that the Shona respondents will identify it as a foreign instrum ent, Shona is able to capture the EQ -5D concepts. The respondents will be able to recognise the concepts and respond appropriately, while maintaining the awareness that the questions do not relate directly to “their w orld” . The translation attem pted to make the sense, meaning, spirit and practice, w hich the concepts and expressions in English signify, understood by target language speakers in Shona, as clearly and natu­ rally as possible. However, it is conceded that the target speakers might see, expe­ rience and practice them quite differently. A ccu rate tran slatio n o f the source instrum ent is only the first stage o f the process o f developing a com parable version in the target language. The Shona EQ -5D still needs to be validated in term s o f psychom etric criteria o f reliability, validity and responsiveness (B ullinger et al 1998). The relative advantages o f develop­ ing a hom egrow n instrum ent and o f 8 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No A R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) translating existing instrum ents would need to be exam ined in every research context. H ow ever a strong argum ent for the translation o f standardised instru­ ments was made at a regional workshop on research inform ed rehabilitatio n planning in which it was stated “An issue o f regional concern is that the lack o f standardised methods and terminology make it virtually impossible to validate the different results and cer­ tainly makes it impossible to compare the results o f the different regional studies.” (Ferrinho and Cornielje 1998) O ur experience supports H erdm an’s contention that conceptual equivalence should not be assum ed on the basis of measurem ent properties and correlations obtained using translated questionnaires, but also by evaluating the questionnaires them selves in the light o f knowledge regarding the H RQ oL concept in the target culture (Herdman 1998). We con­ clude that if an instrum ent is to be used in a culture, which differs widely from the source culture, extensive discussion needs to take place at every stage o f the translation process. Both forward and back translators should be native speak­ ers o f the target language, particularly if English is the official language o f the target population (as is the case in , Southern Africa). The utilisation of translators from outside the m edical field contributed to a more natural and idiom atic version o f the instrument. In addition the extensive know ledge o f the target cu ltu re th at the translators enjoyed, resulted in a culturally more acceptable translation. At the initiation o f the project, the EQ -5D was chosen as a suitable instru­ m ent fo r m easu rem en t o f H R Q oL because it had been v alidated over a wide range o f conditions and it is sim ­ ple and easy to understand. In the light o f the difficulties involved in trans­ lating what appears to be a short and rela­ tively straightforw ard instrum ent, we would advise researchers to think very carefully about choosing instrum ents that are longer and more complex. The more com plex the instrum ent is, the more difficult it will be to develop a local translation that is co n cep tu ally and semantically equivalent. In conclusion, time spent in follow ­ ing a stringent translation protocol, such as developed by the EuroQ ol Group, is time well spent. In Southern Africa, there is an exciting interface betw een cultures, languages and worldviews. If relevant research is to be done in the sub-conti­ nent, a meeting place between English and the local languages, between Anglo- American culture and traditional ways o f living and b etw een the W estern M edical model o f health and traditional cultural beliefs needs to be established and nurtured. The developm ent o f accu­ rate and culturally sensitive instruments, e ither through careful translation o f ex istin g in stru m en ts o r through the developm ent o f locally relevant m ea­ sures, can be an im portant em barkation point. If the translation process is not taken seriously, we may be guilty o f simply im posing notions o f health and quality o f life across cultures (Herdman 1998) and our results will not provide m eaningful insights into the cultures that we are studying. ACKNOWLEDGEMENTS: The com m ents and su g g estions by M ichael Herdman at each stage o f the translation process are gratefully acknowledged. Funding for the project was made available by the Zim babwe National Burden o f D isease Steering C om m ittee funded by the DANIDA, D anish D evelopm ent Agency and DFID, the B ritish D evelopm ent Agency. REFERENCES B akker C, van der Linden S 1995 Health related utility measurement: An introduction. Journal o f Rheumatology 22: 1197-1199 Beaton DE, Bombardier C, Hogg-Johnson SA 1996 Measuring health in injured workers: A cross-sectional comparison o f five generic health status instrum ents in workers with musculo-skeletal injuries. American Journal o f Industrial Medicine 29: 618-631 Brooks R, EuroQol G 1996 EuroQol: the current state o f play. Health Policy 37: 53-72 Bullinger M, Alonso J, Apolone G, Leplege A, Sullivan M 1998 Translating health status questionnaire and evaluating their quality: T he IQ oLA project approach. Journal o f Clinical Epidemiology 51: 913-923 Chimera J, Jelsma J 1999 The reliability o f the EuroQol in a high-density suburb in H arare, Zim babw e. BSc. (H ons.) thesis. University o f Zimbabwe EuroQol Undated. Translation guidelines for the EuroQol EQ-5D, EuroQoL Group, Rotterdam Ferrinho P, C ornielje H 1998 Towards consensus on research-based disablem ent policies for Southern Africa. Proceedings of the Workshop “Towards Research Informed Rehabilitation Planning in Southern Africa”, H arare, Zim babw e. B ulaw ayo, SAFOD 117-123 Herdman M 1998 A model o f equivalence in the cultural adaptation o f HRQoL instruments: the universalist approach. Quality o f Life Research 4: 323-335 K eller S, Ware JE, Gandek B, Aaronson N, A lonso J 1998 Testing the equivalence o f translations o f widely used response choice labels: R esults from the IQ oLA Project. Journal o f Clinical Epidemiology 54: 933-944 M ararike CG 1999 Survival strategies in rural Zimbabwe. Harare: M ond Books , . 1 Tandon Y. 2000. Human Development Report 1999 - Zimbabwe, United Nations Develop­ ment Programme, Poverty Reduction Forum, Institute o f Development Studies, University o f Zimbabwe, Harare W agner A K, G andek B, A aronson N, Acquadro C, Alonso J 1998 Cross-cultural comparisons o f the content o f SF-36 transla­ tions across 10 countries: Results from the IQoLA project. Journal o f Clinical Epidem io­ logy 51: 925-32 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )