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Modification is an important process by which to adapt an instrument to be used for another culture. However, it is not fully understood how best to modify an instrument to be used appropriately in another culture.
This study aims to synthesize the modification strategies used in the cross-cultural adaptation process for instruments measuring health beliefs about cancer screening.
A systematic review design was used for conducting this study. Keywords including constructs about instrument modification, health belief, and cancer screening were searched in the PubMed, Google Scholar, CINAHL, and PsycINFO databases. Bowling’s checklist was used to evaluate methodological rigor of the included articles. Results were reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) approach with a narrative method.
A total of 1312 articles were initially identified in the databases. After removing duplications and assessing titles, abstracts, and texts of the articles, 18 studies met the inclusion criteria for the study. Based on Flaherty’s cultural equivalence model, strategies used in the modification process included rephrasing items and response options to achieve semantic equivalence; changing subjects of items, changing wording of items, adding items, and deleting items to achieve content equivalence; adding subscales and items and deleting subscales and items to achieve criterion equivalence. Solutions used to resolve disagreements in the modification process included consultation with experts or literature search, following the majority, and consultation with the author who developed the scales.
This study provides guidance for researchers who want to modify an instrument to be used in another culture. It can potentially give cross-cultural researchers insight into modification strategies and a better understanding of the modification process in cross-cultural instrument adaptation. More research could be done to help researchers better modify cross-cultural instruments to achieve cultural equivalence.
Cancer is one of the leading causes of death in the world [
Although cancer screening has proven to be an effective way to detect cancer at the early stage, the use of cancer screenings is not optimal among several populations [
Based on the health belief model, health belief of cancer screening can be measured by 6 constructs, including perceived severity and susceptibility of cancer, perceived benefits and barriers of cancer screening, self-efficacy, and cues to action of cancer screening [
Cross-cultural instrument adaptation includes 2 necessary steps, instrument translation and instrument modification [
Compared to a newly developed instrument, using various modification methods to adapt an existing instrument to be used in the target population is a cost efficient and time-saving choice [
The purpose of this systematic review was to synthesize the modification strategies used in the cross-cultural instrument adaptation process measuring health belief of cancer screening for another population/ethnicity based on Flaherty’s cultural equivalence model [
A systematic review design was used for conducting this study. Keywords including constructs about instrument modification, health belief, and cancer screening were searched in the PubMed, Google Scholar, CINAHL, and PsycINFO databases in June 2020. Detailed keywords from each construct included (1) instrument modification: instrument, modify, revise, adapt, adaptation, refinement, refine; (2) health belief: perception, attitude, belief, perspective; and (3) cancer screening: cancer, screening, prevent, prevention. Equivalent index terms with the same meanings were also searched. Inclusion criteria for the articles were (1) peer-reviewed articles, (2) reported instrument modification process about health beliefs toward cancer screening, and (3) published in the English language (which could be read by the authors). The exclusion criteria were (1) informal articles such as commentary, letter to the editor, and conference abstract and (2) constructs from the health belief model not included.
For identifying relevant studies, keywords were applied to search the full text of articles in the databases. Titles and abstracts of the articles were read further to exclude irrelevant studies. Articles in the reference list of selected articles were also searched. Inclusion and exclusion criteria were evaluated during the process. Information on the purpose, sample, setting, methods, results, and discussion of the included articles was extracted and entered into the table of evidence. Bowling’s checklist was used to evaluate methodological rigor of the included articles [
A total of 1312 articles were initially identified in the databases. After removing duplications, the titles and abstracts of the articles were assessed further, and 1293 articles were excluded in the process. Out of the 19 remaining articles screened, 1 article was further excluded because it focused on the cultural beliefs of cancer screening instead of health beliefs of cancer screening. In total, 18 studies met the inclusion criteria and were included in the study [
PRISMA flowchart documenting study selection process.
Among the 18 reviewed studies (
Study characteristics for the included articles.
Study authors and citation | Modification strategies |
Gozum and Aydin [ |
Rephrasing words in the items (Sa) |
Guvenc et al [ |
Adding items (Cb) |
Karayurt and Dramalı [ |
Rephrasing words in the items (S) |
Secginli and Nahcivan [ |
Rephrasing words in the items (S) |
Yilmaz and Sayin [ |
Rephrasing words in the items (S); deleting parts of the sentences in the items (C) |
Hashemian et al [ |
Deleting parts of the sentences in the items (C); deleting items (C); adding items (C) |
Kharameh et al [ |
Rephrasing words in the items (S); deleting items (C) |
Taymoori and Berry [ |
Rephrasing words in the items (S); deleting parts of the sentences in the item (C); changing the subject of the items (C); changing the response options (S) |
Lee and Lee [ |
Rephrasing words in the items (S); deleting parts of the sentences in the items (C); changing the response options (S) |
Medina-Shepherd and Kleier [ |
Rephrasing words in the items (S) |
Juárez-García et al [ |
Changing the response options (S); deleting items (C); adding items (C) |
Dewi [ |
Rephrasing words in the items (S); deleting subscales (Crc); adding subscales (Cr) |
Marmarà et al [ |
Rephrasing words in the items (S); changing the subject of the items (C); deleting subscales (Cr); deleting items (C); adding subscales (Cr) |
Lee et al [ |
Rephrasing words in the items (S) |
Mikhail and Petro-Nustas [ |
Minor changes in the wording of the items (S); adding items (C) |
Parsa et al [ |
Adding subscales (Cr) |
Zelviene and Bogusevicius [ |
Rephrasing words in the items (S); deleting parts of the sentences in the items (C) |
Tsangari and Petro-Nustas [ |
Minor changes in the wording of the items (S) |
aS: semantic.
bC: content.
cCR: criterion.
The quality of the reviewed articles was evaluated by the first author and verified by the second author using Bowling’s checklist (
During the data evaluation process, the first author extracted relevant data from the reviewed articles and entered data into the Excel (Microsoft Corp) table of evidence, summarized correlated information into themes, and classified data into different categories. The second author checked the data and categories to ensure the findings were synthesized in a reliable way.
Quantitative studies critical appraisal checklist [
|
Criteria | Yes | No |
1 | Aims and objectives clearly stated | 18 | 0 |
2 | Hypothesis/research questions clearly specified | 10 | 8 |
3 | Dependent and independent variables clearly stated | 3 | 15 |
4 | Variables adequately operationalized | 14 | 4 |
5 | Design adequately described | 12 | 6 |
6 | Method appropriate | 18 | 0 |
7 | Instruments used tested for reliability and validity | 18 | 0 |
8 | Source of sample, inclusion/exclusion, response rates described | 14 | 4 |
9 | Statistical errors discussed | 4 | 14 |
10 | Ethical considerations described | 13 | 5 |
11 | Study was piloted | 15 | 3 |
12 | Statistically analysis appropriate | 18 | 0 |
13 | Results reported and clear | 18 | 0 |
14 | Results reported related to hypothesis and literature | 18 | 0 |
15 | Limitations reported | 13 | 5 |
16 | Conclusions do not go beyond limit of data and results | 18 | 0 |
17 | Findings able to be generalized | 0 | 18 |
18 | Implications discussed | 18 | 0 |
19 | Existing conflicts of interest with sponsor identified | 0 | 18 |
20 | Data available for scrutiny and reanalysis | 0 | 18 |
According to Flaherty’s cultural equivalence model, strategies used in the modification process were categorized by the equivalence type, especially semantic, content, and criterion equivalence (
Modification strategies used in the studies.
Equivalence type | Strategies |
Semantic equivalence |
Rephrasing items Rephrasing response options |
Content equivalence |
Changing subjects of items Changing wording of items Adding items Deleting items |
Criterion equivalence |
Adding subscales and items Deleting subscales and items |
Semantic equivalence requires the meaning of each item in the adapted instrument to be similar to the meaning of the original item [
Upon reading expert and participant comments about the scales, the authors simplified and modified some wordings of items during the modification phase [
To reach cultural accuracy of items, some words in the items were replaced by other words. Following one participant’s suggestion, in the study to adapt a Korean version of Champion’s Health Belief Model Scale, the word “hok” was changed into “meongwooli.” Even though both words meant lump or mass in Korean, the authors asserted the modification helped the women in the study to better understand the content of the instrument [
Another strategy used to reach cross-cultural semantic equivalence was rephrasing medical terms to generally known terms. This strategy was used in the study conducted to measure health beliefs of colorectal cancer screening among Korean Americans [
To avoid causing misunderstanding, confusion, and anxiety, some instrument items were changed by reversing direction of the meaning. This strategy was used in one study conducted with Maltese women [
To increase clarity and achieve semantic equivalence, wordings of response options in the instruments may need to change. This strategy was used in 3 studies [
Content equivalence requires the content of each item in the adapted instrument to be relevant or appropriate to each cultural group or population under study [
This strategy was used to achieve content equivalence by making the meanings of the items relevant or appropriate. It could avoid arousing fatalistic thoughts that were commonly present among minority populations. This strategy was used in the study conducted with Maltese women [
To modify items measuring the sizes of breast lumps in Champion’s Health Belief Model Scale (“I am able to find a breast lump which is the size of a quarter/dime/pea”), different items or coins familiar to the target population were used. In the Indonesian Health Belief Model Scale, “quarter” and “dime” were changed to “walnut” and “hazelnut,” respectively, because the sizes of a walnut and hazelnut are commonly known in Indonesia [
To increase the cultural sensitivity of the adapted instrument, thus increasing the scale’s content equivalence, entire items or parts of items were added to the adapted instrument.
Adding entire items to the modified scale was a common strategy used in the reviewed studies. In the Iranian Health Belief Model Scale, the item “I am more likely than the average woman to get breast cancer” was added to the adapted instrument because this item was maintained in the previous version of Champion’s scale and also because of the special features of the participants in the study (who had a family history of breast cancer) [
To make the meaning of the items clear and easily understandable, additional words of explanation were added as part of some items. In the study conducted with Korean Americans, the explanation “not wanting to let other people know that you are doing the stool blood test or handling stool for the test” was added to the item “not having privacy would keep you from having a stool blood test,” since privacy could be interpreted as several different Korean words depending on the context [
Deleting entire items or parts of items was a common strategy used in the studies to achieve content equivalence. Entire items in the reviewed studies were removed due to redundancy, irrelevance, or inaccuracy or a low content validity index at the item level. In one study, the item “I am too old to need a routine mammogram” was deleted because the Iranian women (n=200) in the study were younger (mean age 46.15 [SD 7.26] years, range 28 to 69 years) than the participants in the original Champion study (aged 50 years and older) [
To reach cross-cultural content equivalence, parts of sentences in items from the original instruments were deleted. The terms “boyfriend” and “partner” in the item “Breast cancer would threaten a relationship with my boyfriend, husband, or partner” were deleted in 2 studies with Iranian women because sexual relationship outside the marriage is forbidden by Islamic rules and religious norm [
Criterion equivalence requires the interpretation of an instrument’s relationship to established independent criteria for a certain event to be the same across cultures. This type of equivalence was usually achieved by adding subscales or items and deleting subscales.
In the Maltese Health Belief Model Scale, the authors added subscales concerning the impact of sociodemographic and socioeconomic factors (eg, items about education level and income) on women’s breast screening behavior to acknowledge the contributions of those criteria to breast cancer screening [
In the reviewed studies, some subscales in the Health Belief Model Scale were deleted to increase cultural sensitivity. When the literature search indicated that most Maltese women perceived breast cancer to be a serious threat, the perceived severity scale was removed from the Maltese Health Belief Model Scale because the authors determined that perceived severity was not a criterion for examining the health belief of Maltese women toward breast cancer screening [
If a disagreement arose and panel members could not reach consensus on the translated items, solution strategies included consultation with experts, literature search, following the majority, and consultation with the author who developed the scales.
This strategy was used in one study aiming to measure the health belief of Korean Americans toward colorectal cancer screening [
This strategy was used in one study conducted with Hispanic women. The terms used for marital status aroused a disagreement over the comment from an expert panel member. The expert did not believe that every Hispanic would understand
When meanings of the items in the original scale were not stated clearly, consulting with the author who developed the scales may provide clarification. In a study conducted with Korean Americans, some participants did not understand the meaning of the term “privacy” in the barrier items. Hence, the primary investigator consulted with the author who developed the barrier scale. The author clarified the meaning of privacy, and the item was rephrased accordingly [
This study synthesized the modification strategies used in the instrument adaptation process to achieve cultural equivalence and provided solutions to the divergence in the instrument modification process. The instrument that measured health beliefs about cancer screening was used as an example in the study. To our knowledge, this is the first study to date investigating the modification strategies used in the adaptation process of instruments measuring health beliefs of cancer screening. The modification strategies to achieve cultural equivalence summarized in this study could help researchers gain insight into the instrument modification process.
To reach cross-cultural equivalence of the adapted instruments, modification is an essential step. According to Medina-Shepherd and Kleier [
According to the literature, the strategies used in the adaptation process generally included 3 types of modifications—changing, deleting, and adding—and 2 levels—scale level and item level, which consisted of modification of the question statement and response options).
First, rephrasing items or response options was a basic strategy in instrument modification to achieve semantic equivalence [
Second, changing subjects of items, changing wordings, and adding or deleting items could help the adapted instrument achieve content equivalence with the original items. Some item subjects may be not appropriate in the instrument due to fatalistic thoughts of participants, and the subjects may need to be changed. Adding relevant items and deleting irrelevant statements were also important strategies to reach content equivalence. In the literature reviewed in this study, items tended to be added to increase cultural sensitivity and clarity and deleted to decrease redundancy, irrelevance, or inaccuracy or increase the content validity index at the item level. In the instrument modification process, items in the original scale suitable to the initial cultural context may not be suitable to the other cultural context. Selecting relevant items and deleting irrelevant items could lessen confusion and make the scale more meaningful [
In addition, the strategies of adding and deleting subscales and items were often used to achieve cross-cultural criterion equivalence. In the literature reviewed in this study, the specific reason for adding and deleting subscales and items was to increase cultural sensitivity and clarity. This strategy should be used with careful consideration. Unless supported by a comprehensive literature review or updated theoretical framework that reflects a changed base of the instrument, adding or deleting subscales and items could significantly impact the validity of the adapted instrument.
Furthermore, disagreement solution strategies for the modification process included consultation with experts or literature search, following the majority, and consultation with the author who developed the scales. Using an appropriate solution strategy to solve a disagreement arising in the modification process can clarify the vague meanings of items and further increase the validity of the items. During the modification process, it is best to have a research team with bilingual professionals who are familiar with the cultures for which the instrument was originally developed and to which it will later be adapted. If it is possible, the primary investigators for the instrument modification should be the ones who are bilingual, bicultural, and familiar with the concepts measured in the instrument. This could facilitate the instrument modification process and help meet challenges that emerge during the process.
This systematic review has some limitations. First, we used a narrative rather than a meta-analysis method to summarize data. As such, our findings cannot be used to recommend the optimal strategies for modifying instruments used in the cross-cultural research. Second, we reviewed only articles written in English, which may have biased the data and restricted our findings. Limiting the review to English language articles may introduce a language bias and lead to erroneous conclusions [
Instrument modification is an important part of cross-cultural research. Adapting an instrument developed for another culture to be used in the target population can save time, add value to the original instrument, and promote science achievements to circulate around the world. With the development of science, factors impacting the cross-culture instrument modification change accordingly. For example, instruments used for online and offline cancer screening (eg, paper version, telephone assessment) may differ in wording, which may impact the technical equivalence of the instrument. A systematic review of the factors that may impact the instrument modification process in the new stage of science is necessary and can help cross-cultural researchers gain a comprehensive understanding of the modification process to achieve cultural equivalency. In addition, research to update the definition of cross-cultural equivalence and a clear gold standard checklist to evaluate cultural equivalence for the instrument modification should be established for cross-cultural researchers, since Flaherty’s approach was introduced several decades ago [
Instrument modification is a necessary process in cross-cultural instrument adaptation. This study summarized the modification strategies used to culturally adapt instruments measuring health beliefs of cancer screening to achieved cross-cultural equivalence. It can potentially give cross-cultural researchers more insight into the modification strategies and a better understanding the modification process in the cross-cultural instrument adaptation. More research needs to be done to help researchers better modify cross-cultural instruments and develop a checklist to achieve cross-cultural equivalence.
PRISMA checklist.
Preferred Reporting Items for Systematic Reviews and Meta-analyses
The authors would like to thank the participants in the study and the editors for their anonymous comments, which improved the quality of this paper.
FL collected and analyzed the data and wrote the manuscript. EL checked the data and data analysis process and revised the manuscript.
None declared.