Our results corroborate this line of argument. Even though the validity of an instrument has been documented by a single study and published in one academic journal, there are no set standards for validation. Cultural adaptation of an instrument should be an ongoing process in order to ensure its validity. This view is supported by a review article that points out the necessity of continuing the validation process (30).
Using a professional for the back-translation
International translation procedures set as a standard that a professional translator be used when translating back to the original language (22). Some studies refer specifically to the back-translation and comment on linguistic challenges (33, 34). To our knowledge, the use of a professional translator as a language expert after completion of the first back-translation has not been described previously.
By using an authorised translator in the process of argumentation in a Norwegian context, the researchers will be able to ensure validation of the language used and thus also the validity of the instrument’s content. If no authorised translator is used in the dialogue with the instrument developer, the expert panel risks accepting the instrument developer’s response to the translator’s version without question.
In our study, the user representative emphasised that the word ‘ekstrem’ (‘extremely’), which was one of the end points of the scale, should not be used. In the quality-of-life instrument RAND-36, the end point of the scale in the Norwegian version is ‘ekstremt mye’, which is a direct translation of ‘extremely’.
It is questionable whether responding that ‘... physical health or emotional problems have extremely affected daily activities with family, friends, neighbours or other groups of people’ (... ekstremt mye’) is as common in Norway as it is in the USA. Boel and collaborators point out that attention must be paid to the end points of the scale, giving a Danish version of ESAS as an example, in which ‘unconscious’ is one of the end points (32).
Linguistic challenges in translation
The pilot test of AFI that was undertaken once the expert panel and the instrument developer had reached agreement showed that the instrument was easy to complete. The vast majority answered all questions. There were, however, objections to one question in particular: ‘La være å si eller gjøre noe du ikke vil’ (‘Keeping yourself from saying or doing things you did not want to say or do’). The translator and the instrument developer had previously discussed this question, and the psychologist and other members of the expert panel had commented on it.
The expression ‘keeping yourself from’ has no obvious Norwegian translation. The expert group assessed the input conceptually, culturally and in terms of language. In particular, we discussed whether ‘la være’ (‘refrain from’) is a negation or not. After thorough consideration the expert panel chose not to change the wording.
The results from the pilot test showed that the question ‘La være å si eller gjøre noe du ikke vil’ had the most missing scores and most comments in the questionnaires. Eight persons did not answer the question, and 18 others had entered comments. Since this applied only to this question, one possible explanation could be that that the respondents simply failed to understand what was asked.
This discussion illustrates that translating an American instrument into Norwegian, in terms of language as well as culture, may involve challenges. If the argumentation on which a translation is based is made available to those who want to use the instrument, this will increase the understanding of the choices made and the changes that can be made, if any are called for.
It is interesting to note that on the whole, the standard deviations for the four last questions in the AFI are higher than for the other questions. The same tendency is reported from a sample of young women with breast cancer, for whom the same instrument was used (5).
We cannot know for certain whether this is due to the content of the questions or a larger variation in the responses. We may speculate, though, that this is a result of the reversal of the scales, when compared to the preceding questions.
On the other hand, the use of reversed scoring may indicate the respondent’s level of attention, since this instrument also measures any attention deficit in the respondents (35). Results from the participants in our study are comparable to those in a study undertaken among women and men aged 65–87 who were living at home (36).
However, they had better cognitive function than women aged 27–86 with breast cancer (5). Since the sample in our study included persons older than 60 years, without any known cancer diagnosis as an inclusion criterion, this may indicate that the instrument functioned well.
One of the strengths of this study is its use of an expert panel with a user representative and a professional translator. Moreover, the participants in the pilot study had the opportunity to provide feedback on the design of the instrument. We might have wished for a representative sample of the general population, but this was impossible for practical, ethical and financial reasons.
Use of snowball sampling may be another strength, since large parts of the country were included. On the other hand, this methodology may have a weakness in causing sampling bias, nor do we have any information about the participants’ condition of health.
Translation and cultural adaptation of an instrument is a comprehensive process. It is appropriate to make each step of the translation procedure available, thus to enable researchers to assess the choices that have been made. Including user representatives in an expert panel may help improve the validation of a questionnaire. In collaboration with the expert panel, the dialogue between the translator and the instrument developer may help ensure that the intention behind the instrument is maintained.
The Norwegian version of the AFI which is now available must be tested on a larger sample of cancer patients aged 60 and above before we can draw any final conclusions regarding its intercultural validity. Accordingly, this study does not permit any conclusions regarding the reliability, validity and responsiveness of this instrument.
1. Cancer in Norway 2015 – Cancer incidence, mortality, survival and prevalence in Norway. Oslo: Cancer Registry of Norway; 2016.
2. Mandelblatt JS, Hurria A, McDonald BC, Saykin AJ, Stern RA, Vanmeter JW, et al. Cognitive effects of cancer and its treatments at the intersection of aging: what do we know; what do we need to know? Seminars in Oncology. 2013;40(6):709–25.
3. Anderson-Hanley C, Sherman ML, Riggs R, Agocha VB, Compas BE. Neuropsychological effects of treatments for adults with cancer: a meta-analysis and review of the literature. Journal of the International Neuropsychological Society. 2003;9(7):967–82.
4. Ahles TA, Root JC, Ryan EL. Cancer- and cancer treatment-associated cognitive change: an update on the state of the science. Journal of Clinical Oncology. 2012;30(30):3675–86.
5. Cimprich B, Visovatti M, Ronis DL. The Attentional Function Index – a self-report cognitive measure. Psycho-oncology. 2011;20(2):194-202.
6. Von Ah D, Storey S, Jansen CE, Allen DH. Coping strategies and interventions for cognitive changes in patients with cancer. Seminars in Oncology Nursing. 2013;29(4):288–99.
7. Cimprich B. A theoretical perspective on attention and patient education. Advances in Nursing Science. 1992;14(3):39–51.
8. Jurado MB, Rosselli M. The elusive nature of executive functions: a review of our current understanding. Neuropsychology Review. 2007;17(3):213–33.
9. Engstad RT, Engstad TT, Davanger S, Wyller TB. Eksekutiv svikt etter hjerneslag. Tidsskrift for Den norske legeforening. 2013;133(5):524–7.
10. Cimprich B. Attentional fatigue following breast cancer surgery. Research in Nursing & Health. 1992;15(3):199–207.
11. Cimprich B, So H, Ronis DL, Trask C. Pre-treatment factors related to cognitive functioning in women newly diagnosed with breast cancer. Psycho-oncology. 2005;14(1):70–8.
12. Jansen CE, Dodd MJ, Miaskowski CA, Dowling GA, Kramer J. Preliminary results of a longitudinal study of changes in cognitive function in breast cancer patients undergoing chemotherapy with doxorubicin and cyclophosphamide. Psycho-oncology. 2008;17(12):1189–95.
13. Merriman JD, Jansen C, Koetters T, West C, Dodd M, Lee K, et al. Predictors of the trajectories of self-reported attentional fatigue in women with breast cancer undergoing radiation therapy. Oncology Nursing Forum. 2010;37(4):423–32.
14. Shih J, Leutwyler H, Ritchie C, Paul SM, Levine JD, Cooper B, et al. Characteristics associated with inter-individual differences in the trajectories of self-reported attentional function in oncology outpatients receiving chemotherapy. Supportive Care in Cancer. 2017;25(3):783–93.
15. Visovatti MA, Reuter-Lorenz PA, Chang AE, Northouse L, Cimprich B. Assessment of cognitive impairment and complaints in individuals with colorectal cancer. Oncology Nursing Forum. 2016;43(2):169–78.
16. Cimprich B. Development of an intervention to restore attention in cancer patients. Cancer Nursing. 1993;16(2):83–92.
17. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. Journal of Clinical Epidemiology. 2010;63(7):737–45.
18. Mokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL, et al. The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Medical Research Methodology. 2010;10:22.
19. Verdens helseorganisasjon (WHO). Process of translation and adaptation of instruments. 2016. Available at: http://www.who.int/substance_abuse/research_tools/translation/en/(downloaded 14.12.2017)
20. Utdanningsdirektoratet. Det felles europeiske rammeverket for språk. 2011. Available at: https://www.udir.no/Upload/Verktoy/5/UDIR_Rammeverk_sept_2011_web.pdf?epslanguage=no(downloaded 14.12.2017).
21. Gonzalez MT, Hartig T, Patil GG, Martinsen EW, Kirkevold M. Therapeutic horticulture in clinical depression: a prospective study. Research and Theory for Nursing Practice. 2009;23(4):312–28.
22. Polit DF, Beck CT. Essentials of nursing research : appraising evidence for nursing practice. 8. ed.Philadelphia, PA: Wolters Kluwer / Lippincott Williams & Wilkins; 2014.
23. Polit DF, Yang FM. Measurement and the measurement of change. Philadelphia, PA: Wolters Kluwer / Lippincott Williams & Wilkins; 2015.
24. Christoffersen L, Johannessen A, Tufte PA, Utne I. Forskningsmetode for sykepleierutdanningene. Oslo: Abstrakt forlag; 2015.
25. Polit DF, Beck CT. Nursing research : generating and assessing evidence for nursing practice. 10. ed. Philadelphia, PA: Wolters Kluwer; 2017.
26. Miki-Rosario N, Garcia Filho RJ, Garcia JG, Dini GM, Bottomley A, Chow E, et al. Translation into Portuguese, cross-cultural adaptation and validation of «The European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire-Bone Metastases-22». Annals of Palliative Medicine. 2016;5(3):190–5.
27. Reinertsen H, Christophersen K-A, Helseth S. Vurdering av postoperativ smerte hos barn (0-5 år): Validering og reliabilitetstesting av smertevurderingsverktøyet FLACC. Sykepleien Forskning. 2014;9(2):136–44. Available at: https://sykepleien.no/forskning/2014/02/validering-og-reliabilitetstesting-av-smertevurderingsverktoyet-flacc(downloaded 15.12.2017).
28. Sjetne IS, Tvedt C, Squires A. Måleinstrumentet ʻThe Nursing Work Index-Revisedʼ – oversettelse og utprøvelse av en norsk versjon. Sykepleien Forskning. 2011;6(4). Available at: https://sykepleien.no/forskning/2011/11/maleinstrumentet-nursing-work-index-revised-oversettelse-og-utprovelse-av-en-norsk(downloaded 15.12.2017).
29. Johnson TP. Methods and frameworks for crosscultural measurement. Medical Care. 2006;44(11 Suppl 3):S17–20.
30. Nekolaichuk C, Watanabe S, Beaumont C. The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991–2006). Palliative Medicine. 2008;22(2):111–22.
31. Bergh I, Aass N, Haugen DF, Kaasa S, Hjermstad MJ. Symptom assessment in palliative medicine. Tidsskrift for Den norske legeforening. 2012;132(1):18–9.
32. Boel K, Haaber K, Byskov, L. Dansk versjon av ESAS – symptomregistrering. Omsorg. 2009(1):41–6.
33. Beck CT, Bernal H, Froman RD. Methods to document semantic equivalence of a translated scale. Research in Nursing & Health. 2003;26(1):64–73.
34. Yu DS, Lee DT, Woo J. Issues and challenges of instrument translation. West J Nurs Res. 2004;26(3):307–20.
35. Podsakoff PM, MacKenzie SB, Podsakoff NP. Sources of method bias in social science research and recommendations on how to control it. Annual Review of Psychology. 2012;63:539–69.
36. Jansen DA. Attentional demands and daily functioning among community-dwelling elders. Journal of Community Health Nursing. 2006;23(1):1–13.