The pitfalls of translation--a case study based on the translation of the EQ-5D into Xhosa.

There is an evident need for standardised, internationally recognised instruments to measure health-related outcomes that are also locally applicable. The European Quality of Life 5-Dimensions (EQ-5D) is a widely used measure of health-related quality of life (HRQoL) that was translated into Xhosa. This communication outlines some of the different cultural and linguistic issues that had to be addressed during the translation process. The translation guidelines provided by the EuroQol group were followed. This involved both forward and backward translations by Xhosa speakers, with consensus meetings after each. Thereafter, lay panel respondent testing of the consensus version was performed. Eventually a credible Xhosa version of the EQ-5D was produced. Concepts which proved surprisingly difficult to transfer across the languages and cultures included 'mobility', 'confined to bed' and the choice of word to denote 'male'. The translation process prompted lengthy discussion and proved more challenging than initially anticipated. Despite the rigorous process followed, later additions had to be made to the questionnaire after field testing. It would appear that extreme caution should be exercised when using a questionnaire in a culture and language different from the one in which it was originally developed and validated. If this is not done, the validity of cross-cultural research projects may be open to question.