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Cross-Cultural Adaptation of Measures of Childhood Functioning for Low- and Middle-Income Countries: A Process Description in a Northern Indian Context

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Title: Cross-Cultural Adaptation of Measures of Childhood Functioning for Low- and Middle-Income Countries: A Process Description in a Northern Indian Context
Language: English
Authors: Minal Abhilashi (ORCID 0009-0000-5068-7822), Sanchita Johri, Gitanjali Lall, Sonakshi Pandey, Reetabrata Roy, Divya Kumar, Saani Shakeel, Sheffali Gulati, Monica Juneja, Jonathan Green, Gauri Divan, Kathy Leadbitter
Source: Focus on Autism and Other Developmental Disabilities. 2025 40(4):220-229.
Availability: SAGE Publications and Hammill Institute on Disabilities. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 10
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, Adjustment (to Environment), Behavior Rating Scales, Autism Spectrum Disorders, Media Adaptation, Semantics, Language Patterns, Punctuation, Sentence Structure, Instruction, Layout (Publications)
Geographic Terms: India
Assessment and Survey Identifiers: Vineland Adaptive Behavior Scales, Communication and Symbolic Behavior Scales
DOI: 10.1177/10883576251349216
ISSN: 1088-3576
1538-4829
Abstract: Measures assessing childhood functioning are often developed in high-income countries and need to be adapted for use in low and middle-income countries where the constructs they measure may not be relevant in their original form. This study describes the framework of cross-cultural adaptation of three measures, viz. Vineland Adaptive Behavior Scales--Third Edition; Communication and Symbolic Behavior Scales--Developmental Profile Caregiver Questionnaire and Child Health Utility-9D, followed in the Communication-centered Parent-mediated treatment for Autism Spectrum disorder in South Asia trial. The primary objective was to adapt these measures using a stepwise process while establishing semantic, idiomatic, conceptual, experiential, and technical equivalence between the original and adapted versions. Resulting items of each measure conveyed the same meaning and intent in both the original and adapted versions. The adapted versions had grammar, punctuation, sentence structure, instructions, layout and format, and mode of administration as they were in the original measures.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1490896
Database: ERIC
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  Value: <anid>AN0189133594;fdd01dec.25;2025Nov10.01:40;v2.2.500</anid> <title id="AN0189133594-1">Cross-Cultural Adaptation of Measures of Childhood Functioning for Low- and Middle-Income Countries: A Process Description in a Northern Indian Context </title> <p>Measures assessing childhood functioning are often developed in high-income countries and need to be adapted for use in low and middle-income countries where the constructs they measure may not be relevant in their original form. This study describes the framework of cross-cultural adaptation of three measures, viz. Vineland Adaptive Behavior Scales-Third Edition; Communication and Symbolic Behavior Scales-Developmental Profile Caregiver Questionnaire and Child Health Utility-9D, followed in the Communication-centered Parent-mediated treatment for Autism Spectrum disorder in South Asia trial. The primary objective was to adapt these measures using a stepwise process while establishing semantic, idiomatic, conceptual, experiential, and technical equivalence between the original and adapted versions. Resulting items of each measure conveyed the same meaning and intent in both the original and adapted versions. The adapted versions had grammar, punctuation, sentence structure, instructions, layout and format, and mode of administration as they were in the original measures.</p> <p>Keywords: cross-cultural adaptation; low- and middle-income country; Vineland Adaptive Behavior Scales–Third Edition; Communication and Symbolic Behavior Scales–Developmental Profile CSBS-DP; Child Health Utility-9D (CHU-9D)</p> <p>Research in child development often involves the assessment of diverse aspects of child functioning through verbal and performance based measures assessing various parameters such as their developmental or intellectual level, acquisition of skills, presence or absence of certain behaviors, or the physical and mental well-being of the child. Most pediatric measurement tools that use direct assessment methods have been developed within high-income countries (HICs) with western cultures and may need to be adapted for use within non-HIC contexts where children might be unfamiliar with the testing materials and procedures, such as lack of familiarity with pictures and stories in cognitive tests requiring interpretation of these ([<reflink idref="bib9" id="ref1">9</reflink>]). Even with measures not directly administered with children but based rather on parent report, concepts may differ across cultures, constructs may be culturally unfamiliar and direct translations can be unclear and ambiguous ([<reflink idref="bib23" id="ref2">23</reflink>]). Developing new measures from scratch for a specific culture and language requires significant effort, time and money ([<reflink idref="bib2" id="ref3">2</reflink>]). Adaptation ensures that accessibility and measurement validity are maintained, whilst avoiding the demands of generating new measures, and is therefore a robust and cost-effective solution when there is a paucity of home-grown measurement tools.</p> <p> <emph>Cross-cultural adaptation</emph> addresses both translation and cultural relevance to "fit the needs and preferences of a particular cultural group or community" ([<reflink idref="bib15" id="ref4">15</reflink>], p. 7). It is important to emphasize that adaptation goes beyond the single process of translation from the source to target language, by considering the differences between the source and target culture as well ([<reflink idref="bib18" id="ref5">18</reflink>]). Thus, it maintains the characteristics and meaning of the items as may be relevant to each culture ([<reflink idref="bib10" id="ref6">10</reflink>]).</p> <p>Frameworks for adaptation usually involve a stage-wise process, with the aim of achieving equivalence between the source version and the target version of the measure in the new culture, thereby allowing the measure to function in the way it was originally intended ([<reflink idref="bib1" id="ref7">1</reflink>]; [<reflink idref="bib5" id="ref8">5</reflink>]). Studies reporting the cultural adaptation of measures use different frameworks and define equivalence in different ways. Commonalities have also been observed in all these processes, specifically concerning translation: the use of forward translations, back translations, review by expert committees, synthesis of different translations obtained and pretesting the translated version with a group of respondents ([<reflink idref="bib1" id="ref9">1</reflink>]; [<reflink idref="bib5" id="ref10">5</reflink>]; [<reflink idref="bib8" id="ref11">8</reflink>]; [<reflink idref="bib10" id="ref12">10</reflink>]; [<reflink idref="bib21" id="ref13">21</reflink>]; [<reflink idref="bib25" id="ref14">25</reflink>]). However, there is no agreement on the best practice for qualitative cultural adaptation ([<reflink idref="bib4" id="ref15">4</reflink>]; [<reflink idref="bib9" id="ref16">9</reflink>]). Similarly, the types of <emph>cross-cultural equivalence</emph> achieved also differ from one study to another ([<reflink idref="bib5" id="ref17">5</reflink>]; [<reflink idref="bib6" id="ref18">6</reflink>]; [<reflink idref="bib8" id="ref19">8</reflink>]; [<reflink idref="bib10" id="ref20">10</reflink>]; [<reflink idref="bib25" id="ref21">25</reflink>]; [<reflink idref="bib28" id="ref22">28</reflink>]). The key types of equivalence described across studies have been defined as follows:</p> <p></p> <ulist> <item> Semantic equivalence: the "equivalence in the meaning of words, and achieving it may present problems with vocabulary and grammar." ([<reflink idref="bib5" id="ref23">5</reflink>], p. 1423)</item> <p></p> <item> Idiomatic equivalence: "since idioms and colloquialisms are rarely translatable, equivalent expressions have to be found or items have to be substituted." ([<reflink idref="bib5" id="ref24">5</reflink>], p. 1423)</item> <p></p> <item> Conceptual equivalence: "refers to the validity of the concept explored and the events experienced by people in target culture, since items might be equivalent in semantic meaning but not conceptually equivalent." ([<reflink idref="bib5" id="ref25">5</reflink>], p. 1423)</item> <p></p> <item> Experiential equivalence: "the situations evoked and depicted in the source version should fit the target cultural context and this may result in modification of an item..." ([<reflink idref="bib5" id="ref26">5</reflink>], p. 1423)</item> <p></p> <item> Technical equivalence: "refers to the requirement that the original and translated versions must yield comparable data when used in the different cultures." ([<reflink idref="bib10" id="ref27">10</reflink>], p. 297)</item> </ulist> <p>Despite the fact that numerous conventional approaches for the translation-adaptation process are available, each cross-cultural study has its own challenges. Challenges described include: the inefficiency of establishing clear consensus amongst experts during the expert committee review stages ([<reflink idref="bib21" id="ref28">21</reflink>]); the unavailability of native English back translators ([<reflink idref="bib21" id="ref29">21</reflink>]) and difficulties in adapting measures in such a way that both the uniqueness of the culture is preserved as well as the characteristics and intent of the items ([<reflink idref="bib10" id="ref30">10</reflink>]). While there are alternatives available for the same concept, finding a deliberate choice of words so as to ensure all types of equivalence can be an additional major challenge, requiring additional culturally relevant examples to be added for better comprehension and understanding ([<reflink idref="bib8" id="ref31">8</reflink>]).</p> <p>As compared to measures for adults, fewer measures were found to have been systematically adapted for children ([<reflink idref="bib13" id="ref32">13</reflink>]). Scales have been adapted into various Indian languages such as the adaptation of the Kaufman Assessment Battery for Children, Second Edition (KABC-II) for 6 to 10 year-old Kannada-speaking children of low socioeconomic status in Bangalore, India ([<reflink idref="bib9" id="ref33">9</reflink>]) and the Child-Behavior Checklist to Malayalam ([<reflink idref="bib25" id="ref34">25</reflink>]). Autism specific measures used for diagnosis including the Autism Diagnostic Observation Schedule (ADOS) and the Childhood Autism Rating Scale (CARS) have been translated to Brazilian Portuguese ([<reflink idref="bib11" id="ref35">11</reflink>]; [<reflink idref="bib12" id="ref36">12</reflink>]). The ADOS, Social Communication Disorder Checklist (SCDC), Autism Spectrum Quotient-Child version (AQ-C) and Social Communication Questionnaire (SCQ) have also been translated and validated in Hindi and Bengali for use with South Asian populations ([<reflink idref="bib14" id="ref37">14</reflink>]). Adaptation of quality of life measures for use in Chile, Germany, Spain and South Africa ([<reflink idref="bib26" id="ref38">26</reflink>]; [<reflink idref="bib29" id="ref39">29</reflink>]) have also been carried out, including the translation and adaptation of the Child Health Utility- 9D (CHU-9D) to Canadian French ([<reflink idref="bib13" id="ref40">13</reflink>]), without any major difficulties. There has been a single study conducted on the adaptation of Vineland to Bahasa Indonesian which resulted in eliminating several specific behaviors from the original adaptive behavior subdomains which were inappropriate to a non-urban Indonesian context, and adding in their place behaviors more appropriate in the Indonesian context ([<reflink idref="bib22" id="ref41">22</reflink>]).</p> <p>This article describes the framework of cross-cultural adaptation of measures followed in the Communication-centered Parent-mediated treatment for Autism Spectrum disorder (ASD) in South Asia (COMPASS) trial ([<reflink idref="bib7" id="ref42">7</reflink>].). Ethical approval for work conducted in COMPASS was obtained from the Sangath Institutional Review Board (IRB), the Indian Council of Medical Research (ICMR) and from the University of Manchester Research Ethics Committee. COMPASS is a parallel-group randomized controlled trial commenced in Delhi, India, in December 2019 which aims to evaluate the clinical- and cost-effectiveness of the Parent-mediated intervention for ASD in South Asia-Plus (PASS Plus) intervention ([<reflink idref="bib3" id="ref43">3</reflink>]) in addition to Treatment as Usual (TAU) compared to TAU alone. The study aims to evaluate 240 children ages 2 to 9 years with ASD recruited from clinics in two tertiary government hospitals in Delhi. In this trial, a suite of measures evaluating different aspects of childhood functioning were scheduled for administration at pre-randomization and at 9 and 15-month follow-up. Since the study is in a geography where most families speak Hindi, the evaluation measures needed to be administered in this language. While some measures used in COMPASS have published Hindi versions, three widely used and well-validated measures of child development and wellbeing did not have published Hindi versions. These measures are (a) Vineland Adaptive Behavior Scales-Third Edition (Vineland-3) ([<reflink idref="bib17" id="ref44">17</reflink>]); (b) Communication and Symbolic Behavior Scales-Developmental Profile (CSBS-DP) Caregiver Questionnaire ([<reflink idref="bib24" id="ref45">24</reflink>]); and (c) CHU-9D ([<reflink idref="bib19" id="ref46">19</reflink>]). Moreover, given that these measures were developed in a high income, Western country context, the items of the measure were not always relevant in terms of the experiences of the local population, due to, for example, cultural differences in normative age expectations and differences in leisure and domiciliary activities.</p> <p>The primary objective of this study is to describe the process of cultural adaptation undertaken, of measures of childhood functioning in a low- and middle-income country (LMIC), specifically, Northern India. The process of adaptation described in this article builds upon previously reported procedures and entails a careful selection of the procedural steps that were contextually most appropriate and the addition of steps to fill the gaps encountered in previous procedures. The adaptation aimed to establish semantic, idiomatic, conceptual, experiential, and technical equivalence between the original and adapted Hindi versions of the measures. The understanding of these various types of equivalence was primarily obtained from one of the most cited works in the area ([<reflink idref="bib5" id="ref47">5</reflink>]). The concept of technical equivalence was borrowed from another adaptation framework ([<reflink idref="bib10" id="ref48">10</reflink>]), as the adapted Hindi versions of measures were developed with an outlook of achieving a measure that was homogenous with the English version in terms of the "layout and technical conventions of the instruments, such as the presence of boxes, underlined or bold words, punctuation and syntax, and the numbering and coding system" ([<reflink idref="bib10" id="ref49">10</reflink>], p. 297).</p> <hd id="AN0189133594-2">Method</hd> <p></p> <hd id="AN0189133594-3">Measures</hd> <p>Three measures culturally adapted in COMPASS were:</p> <p></p> <ulist> <item> Vineland-3 which is a measure of adaptive functioning used to assess individuals with intellectual, developmental, and other disabilities. The Interview Form of the measure asks about the child's adaptive functioning from a parent or caregiver using a semi-structured interview technique. It has 502 items across five domains viz., communication, daily living skills, socialization, motor skills, and maladaptive behavior of which two are optional. In COMPASS, first four domains of the scale were adapted and used for trial evaluations. The Likert response options (0, 1, 2) include never, sometimes and usually. Some items use different response options (0, 2) which indicate no or yes. Domain-wise as well as overall scale score are used to interpret an individual's level of functioning.</item> <p></p> <item> CSBS-DP is a 41-item scale that assesses seven language predictors viz., emotion and eye gaze, communication, gestures, sounds, words, understanding, and object use. The responses were scored either on a 3-point Likert scale which indicated not yet, sometimes, often; rarely, sometimes, often; or rarely, sometimes, usually. Some items on the scale were in the form of checklists.</item> <p></p> <item> CHU-9D is measure of pediatric health-related quality of life which can be used in health economic analysis. It contains nine questions with five response-levels per question.</item> </ulist> <p>A stepwise process was followed for the translation and adaptation of measures. The various steps of the cultural adaptation process were carried out in rural Haryana in the district of Rewari and in the urban setting of the National Capital Territory (NCT) of Delhi in Northern India. Most of the residents of these locations understood and spoke the Hindi language. The number of participants at each stage is detailed in Table 1. The demographic description of these participants has been provided while describing the steps of adaptation. A detailed description of each step of the process is as follows:</p> <p></p> <ulist> <item> <bold> Step 1. Permissions: </bold> Prior to the process of cultural adaptation of the three measures Vineland-3, CSBS-DP and CHU-9D, permissions to adapt them were obtained from their respective publishers viz., Pearson, Brookes Publishing, and University of Sheffield.</item> <p></p> <item> <bold> Step 2. Orientation: </bold> The team of researchers (MKA, SJ, GL, SP) with a minimum of Masters' level education in Psychology were involved in the cultural adaptation process. The researchers were native speakers of Hindi and were fluent in English as well because they were educated in institutions where medium of instruction was English. They were oriented on the measures prior to starting the cultural adaptation process by the Senior Research Coordinator (DK) who had training and previous experience with administration of these measures. A scoping review of literature was conducted around the various methodological frameworks of adaptation. Following this, and after extensive discussions within the team a methodology which represented an amalgamation of approaches from the most cited frameworks which were contextually appropriate were adopted.</item> <p></p> <item> <bold> Step 3. Forward translation: </bold> The English language measures were translated into Hindi. The measures were divided into sections and each of these sections were independently translated by a team member mentioned in Step 2. Several rounds of discussions were then held amongst the team members to identify and resolve inaccuracies. Discrepancies if any, were resolved by following the majority opinion. The translations were aimed to be clear, simple, and concise.</item> <p></p> <item> <bold> Step 4. Cognitive interviewing: </bold> A convenience sample of participants, who were field workers of a school health program being conducted within the same organization as the present study in NCT of Delhi, were selected for discussions to check for accuracy, comprehension and relevance of language used in the measures. These field workers had experience of working in the local context with children and families. A different set of field workers were part of each cognitive interview with separate discussion for each tool. During each interview, one researcher led the interview while the other primarily acted as a note taker. These interviews were conducted in the form of feedback sessions in which field workers would review the measures and provide expert feedback on how they believed families would interpret and respond to the measure. Their feedback was incorporated in the translations after seeking consensus amongst all researchers. The broad focus areas of these interviews ([<reflink idref="bib20" id="ref50">20</reflink>]) was:</item> <p></p> <item> To test more than one choice words or translated phrases that have not been agreed upon by the translators.</item> <p></p> <item> To identify items that may be unclear or that may confuse the target population.</item> <p></p> <item> To reframe statements by adding or deleting word or modifying instructions in a way that will make the items clearer, their application in the field easier.</item> <p></p> <item> To compare these findings with the original version and address discrepancies.</item> <p></p> <item> <bold> Step 5. Pre-testing and piloting: </bold> This step involved checking whether the adapted measures continued to hold their meaning in a real-life setting. These adapted measures were administered to caregivers of typically developing children and families of children with ASD (see Table 1) after obtaining their written consent. Families of children with ASD were referred from two tertiary care hospitals based in NCT of Delhi: All India Institute of Medical Sciences (AIIMS) and Maulana Azad Medical College—Lok Nayak Hospital (MAMC-LNH). Families of typically developing children were recruited with the help of local field workers in rural Rewari who were working in a project for the organization. Any items where families did not understand the language or the underlying construct, were discussed and changes suggested by them were recorded. Each measure was pre-tested and piloted by all researchers in the team working in pairs with one researcher focusing on administration of the measure and the other making notes of suggestions. Consensus meetings were held amongst all researchers to arrive at the final items in the measures.</item> <p></p> <item> <bold> Step 6. Back translation: </bold> The field-tested versions were back-translated by an external consultant who was fluent in English and Hindi. They were blind to the original versions of the measures. The team of researchers compared the original and the back-translated versions of the measures. Discrepancies observed upon comparison of the two versions were discussed with the consultant to produce a final version of each tool.</item> <p></p> <item> <bold> Step 7. Publisher approval: </bold> The adapted versions of the measures were shared with publishers for their approval.</item> </ulist> <p>Table 1. Number of Participants for Cognitive Interviews, Pretesting, and Piloting of Measures.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Measures</th><th align="center" colspan="2">Number of participants</th></tr><tr><th align="center">Cognitive interviews</th><th align="center">Pretesting and piloting</th></tr></thead><tbody><tr><td>Vineland-3</td><td>6</td><td>38</td></tr><tr><td>CSBS-DP</td><td>6</td><td>20</td></tr><tr><td>CHU-9D</td><td>6</td><td>20</td></tr><tr><td>Total</td><td>18</td><td>78</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note</emph>. Vineland-3 = Vineland Adaptive Behavior Scales–Third Edition; CSBS-DP = Communication and Symbolic Behavior Scales–Developmental Profile; CHU-9D = Child Health Utility–9D.</p> <p>Throughout these processes, matrices of changes in translations and comments and suggestions by participants were maintained to record changes at each step. Table 2 provides a sample of the information recorded in the matrix. The original matrix has the forward translated and final versions of the tool written in the original Hindi (Devanagari) script. These have, however, been written in the Romanic script for ease of understanding for readers. In the given template, question 16 of the CSBS-DP questionnaire is described. Differences at each step of the adaption are highlighted (in bold and italics). Table 3 provides meaning of each of the headings in the matrices.</p> <p>Table 2. Sample of Matrix Developed to Trace Findings of Each Step of Adaptation Process of the Measure.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Item no.</th><th align="center">Original item</th><th align="center">Forward translation-I</th><th align="center">Forward translation-II</th><th align="center">Back translation</th><th align="center">Final version</th></tr></thead><tbody><tr><td>16 (From CSBS-DP)</td><td>Does your child try to get you to notice interesting objects, not to get you to do anything with them, but just to get you to look at them (for example, show you an object or point to a picture in a book)?</td><td><italic>Kya (bacche ka naam) aapko dilchasp cheezein dikhaane ki koshish karte hain, isliye nahin ki vo aapse kuch karvana chahte hain, par bas aapko unn cheezon ko sirf dikhaane ke liye, (udaahran ke liye, aapko koi cheez dikhaana ya kitaab mein kisi tasveer ki taraf ishara karenge)?</italic></td><td><italic>Kya (</italic><bold><italic>aapka bacha</italic></bold><italic>) aapko dilchasp cheezein dikhaane ki koshish</italic><bold><italic>karta/karti</italic></bold><italic>hai, isliye nahin ki vo aapse kuch karvana chahte hain, par</italic><bold><italic>sirf isliye taaki aap unn cheezon ko dekhein</italic></bold>. <italic>(udaahran ke liye, aapko koi cheez dikhana ya kitaab mein kisi tasveer ki</italic><bold><italic>or</italic></bold><italic>ishaara</italic><bold><italic>karega/karegi</italic></bold><italic>)?</italic></td><td>Does [your child] try to –<bold><italic>show</italic></bold> interesting <bold><italic>things</italic></bold> to you, not <bold>because they want</bold> you to do anything—but <bold>just want</bold> you to look at them (for example, shows you <bold><italic>something</italic></bold> or point<bold><italic>s</italic></bold> to <bold>any</bold> picture in <bold><italic>the</italic></bold> book)?</td><td><italic>Kya (</italic><bold><italic>aapka bacha</italic></bold><italic>) aapko dilchasp cheezein dikhaane ki koshish</italic><bold><italic>karta/karti</italic></bold><italic>hai, isliye nahin ki vo aapse kuch karvana chahte hain, par</italic><bold><italic>sirf isliye taaki aap unn cheezon ko dekhein</italic></bold> (<italic>udaahran ke liye, aapko koi cheez dikhana ya kitaab mein kisi tasveer ki</italic><bold><italic>or</italic></bold><italic>ishaara</italic><bold><italic>karega/karegi</italic></bold><italic>)?</italic></td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Note</emph>. CSBS-DP = Communication and Symbolic Behavior Scales–Developmental Profile.</p> <p>Table 3. Description of Headings in the Matrix.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th align="left">Original item</th><th align="center">Item in the original measure in English</th></tr></thead><tbody><tr><td>Forward translation-I</td><td>Items translated from English to Hindi</td></tr><tr><td>Forward translation-II</td><td>Revised items in Hindi after cognitive interviews, pretesting and piloting</td></tr><tr><td>Back translation</td><td>Items translated back to English</td></tr><tr><td>Final version</td><td>Items finalized in Hindi</td></tr></tbody></table> </ephtml> </p> <p>Equivalences were established during each stage of the adaptation process to ensure that the three measures were suitable for use in Hindi, in the Northern Indian context. They were operationally defined in this study as follows:</p> <p></p> <ulist> <item> Semantic: The researchers attempted to adapt items in Hindi which gave an exact meaning of English expression. Words that were a direct translation of the English expression were not used if they were not easily understood by the respondents because the words used in Hindi were not in common usage. Instead, if required a phrase in Hindi was used to describe single-word English expressions.</item> <p></p> <item> Idiomatic: The researchers aimed to understand the underlying concept of English idioms or phrases and then attempted at achieving translations of those idioms or phrases which were not literal word-to-word translations but were their appropriate versions in Hindi and were more acceptable and commonly used by the target population.</item> <p></p> <item> Experiential: The researchers adapted items in such a way that they were relevant to the culture and population in which they would be administered.</item> <p></p> <item> Conceptual: The researchers ensured that the underlying construct in the original and adapted item was same.</item> <p></p> <item> Technical: The researchers maintained the grammar, punctuation, sentence structure, instructions, layout and format, and mode of administration of adapted measures as they were for the original measures.</item> </ulist> <hd id="AN0189133594-4">Results</hd> <p>The steps described in Figure 1 were used to achieve cross-cultural equivalence for the three measures to yield their best representative versions for the study. The final versions of the three measures ensured their equivalence in five forms viz., semantic, idiomatic, experiential, conceptual, and technical. This section describes how each of these were attained with examples from these three measures.</p> <p>Graph: Figure 1. Process of Adaptation of Measures</p> <hd id="AN0189133594-5">Semantic Equivalence</hd> <p>Semantic equivalence pertains to the meaning of individual words present within each item. Operationalizing this type of equivalence was a two-step process. The first step was to find a Hindi word or phrase with equivalent meaning for each English word or phrase in every item of the original measure. The second step was to carefully check the grammar of each item.</p> <p>For example, in Vineland-3, item no.27 "Safely climbs up and down high objects (for example, jungle gym, ladder, tree)," was adapted to <emph>"uunchi cheezon par saavdhani se chadhte aur utarte hain (udaharan ke liye, bacchon ke khelne ka jhula jis par wo chadh, baith, latak, koodh sakein, seedhi, pedh)"</emph> and back-translated as <emph>"</emph>Safely climbs up and down the high objects (for example, a children's play swing on which they can climb, sit, hang, jump, ladder, tree)." In this example where the item aimed to measure gross motor skills in "climbing" activities, the focus was on achieving a semantic equivalent for the word "jungle gym" in Hindi. As there was no culturally relevant word for it, the terms were expanded to provide a description of the structural and functional attributes of a jungle gym, roughly translated as "a swing for kids which on which they can climb, sit, hang or jump."</p> <p>Similarly, in item 26 from the Expressive subdomain of Vineland-3, "Uses possessives in phrases or sentences; grammar need not be correct (for example, "This is mine," "Your book," "This is Carol's desk")," was adapted to "<emph>aise shabdon ka chote ya bade vakyon mein istemal karte hain jinse pata chalta hai ki kaun si cheez kiski kai; vyakran ka sahi hona zaruri nahi (udaharan ke liye, "aapki kitab," "yeh sonu ki mez hai)"</emph> and back-translated as "Use such words in phrases or sentences, which shows which thing belongs to whom; grammar does not have to be correct (for example, "This is mine," "Your book," "This is Sonu's table")." In this example, two words "possessives" and "phrases" were translated and elaborated using more than one word, specifically "<emph>shabd jinse pata chalta hai ki kaun si cheez kiski kai"</emph> (words that convey what things belongs to whom) and <emph>"chote vakya"</emph> (small sentences), respectively.</p> <p>Item 17 from CSBS-DP, "Does your child try to draw your attention to exciting or unexpected things, such as a pop-up toy or something falling down?" was adapted to "kya (aapka baccha) aapka dhyaan romanchak ya apratyashit (aisi cheezein jo achanak hui ho aur jinke baare mein pehle se na socha ho) cheezon ki or aakarshit karne ki koshish karta/karti hai, jaise ki pop-up toy ya kuch girti hui cheez?" and back-translated as "Does (your child) try to draw your attention to exciting or unpredictable things (things that have happened suddenly and that you have not thought of before), such as pop-up toy or something falling?." Here, "exciting or unexpected things" was adapted as <emph>"aisi cheezen jo achanak hui hon aur jinke baare mein pehle se na socha ho"</emph> (things that have happened suddenly and that you have not thought of before). Although there are literal translations for the words in Hindi (<emph>romanchak ya aprayashit)</emph>, both these words were difficult to understand and not used in normal conversation by the target population and thus, they were replaced with descriptions instead.</p> <hd id="AN0189133594-6">Idiomatic Equivalence</hd> <p>Idiomatic equivalence was particularly challenging to obtain as the idioms and expressions are deeply connected to the culture of origin and it is often difficult to find an equivalent in the culture under study.</p> <p>During the process of adaptation, only one such expression was identified which was "figuring-out." There were multiple items in which this expression was used but during the adaptation process, each of the items had described the same expression in a different manner. For instance, the coping skills subdomain of Vineland-3, item 12 "How often does he/she ask for help when he/she can't figure out how to do something?" was changed to, "<emph>jab vo samajh nahi paata/paati ki koi cheez kaise karni hai, tab vo aksar kitni baar madad maangta/maangti hai?"</emph> which back-translated as "When he/she cannot understand how to do something, how often does he/she ask for help?"; making the description more granular by elaboration.</p> <p>Similarly, item 50 from the community subdomain of Vineland-3, "What does he/she do to figure out how to get somewhere?," was adapted to <emph>"ye pata lagaane ke liye ki kahin par kaise pahuchna hai, wo kya karta/karti hai?"</emph> and back-translated to "What does he/she do to find out how to find a place?" Here, <emph>"pata lagaane ke liye"</emph> (to find out) was used to express the same term in English "to figure out." Hence, even though the expression in the original version was the same, two different sets of descriptions were used to explain the same idiom, keeping in mind what the item was trying to elucidate.</p> <hd id="AN0189133594-7">Experiential Equivalence</hd> <p>For achieving experiential equivalence, the researchers made culturally specific translations, wherever necessary, in order to evoke the sameness of response in the culture of study such that the object or experience in the original version fit the cultural context of the current study.</p> <p>One of the examples to illustrate these modifications is item 18 from the domestic subdomain of Vineland-3, "Is careful when operating household appliances or equipment (for example, vacuum cleaner, lawnmower, iron, power tools)" when adapted in Hindi, became "<emph>gharelu upkarno ya mashino ka istemal karte samay saawdhaan rehte hain (udaharan ke liye, paani garam karne wali rod, press,vashing mashin, heater ya bijli se chalne wali cheezen)</emph>," back-translated as, "Is careful when operating household appliances or equipment (for example, immersion rod used for heating water, iron, washing machine, electric room heater or things that use electricity)." The examples from the original items were replaced with culture-specific examples which were present in children's homes.</p> <p>Similarly, item 24 from Play & Leisure subdomain of Vineland-3, "Plays with others at simple card or board games based only on chance (for example, "Candyland," the card game "War")," was adapted as "<emph>doosron ke saath aasaan kard ya board game khelte hain jo keval kismet par aadharit hota hai (udaharan ke liye, patton ka koi khel jaise taash,uno, business game, ludo, saanp-seedhi)</emph>," which back translates with culturally relevant examples as "Plays with others at simple card or board games based only on chance (for example, any card game like playing cards, Uno, business game, Ludo, Snakes and Ladders)." Some other examples to illustrate the change are use of words like "<emph>khelne wali mitti/chikni mitti"</emph> (playing clay/wet clay) for Play-Doh, representing common materials available with the same consistency and physical attributes of Play-Doh. Similarly, using "<emph>gol roti ya cheela ya roll</emph>" (round chapatti or pancake or roll)" for "hot dogs or pancakes," were seen to have similarities in their preparation styles to the original items.</p> <hd id="AN0189133594-8">Conceptual Equivalence</hd> <p>Conceptual equivalence was achieved successfully for all three measures. In Vineland-3, a set of interview topics were provided in the original measure which were based on the construct that each item measured. These topics which provided the necessary benchmark in order to make the comparisons between the original and adapted items.</p> <p>For example, item 10 of the domestic subdomain of Vineland-3 measures "Food Preparation Basics." This item, "Prepares a simple snack or meal" was adapted to "<emph>Aasaan halki-fulki khaane ki chiz ya khana bana lete hain</emph> which back-translates as "Prepares easy food items." Similarly, item 12 of the community subdomain measures the concept of money. This item, "Says the value of a penny (1 cent), nickel (5 cents), dime (10 cents) and quarter (25 cents) when asked," when adapted became, "<emph>jab pucha jaaye, tab 1 rupaye, 5 rupaye, 10 rupaye, 25 rupaye ki keemat batate hain,"</emph> back-translated as "When asked, says the value of 1 rupee, 5 rupees, 10 rupees, 25 rupees." Here, penny was replaced with rupees, which is the currency in the study setting.</p> <hd id="AN0189133594-9">Technical Equivalence</hd> <p>In order to ensure technical equivalence, uniformity was obtained in response options, interview topics, numbering of items and division into age bands, gender-neutrality or specific mention of gender among items and formatting. The layout of the measures, administration, and scoring were kept consistent with the original measure.</p> <hd id="AN0189133594-10">Discussion</hd> <p>The primary goal of this article was to present a process of cultural adaptation of measures of childhood functioning in a LMIC. The objective was to illustrate a systematic manner in which to adapt outcome measures such that they were culturally—as well as linguistically—equivalent. This implied that the adapted versions were best representative of the culture under study while retaining the required characteristics and the intent of the items of the original version. In order to produce culturally appropriate assessments for the COMPASS trial, a seven-stage process of adaptation of measures of childhood functioning was used. Several iterations were employed until all the measures were optimally equivalent to the original version.</p> <p>The process undertaken to adapt these measures had several strengths. Having two researchers involved during each step ensured greater accuracy. The researchers' characteristics were well suited for undertaking the adaptation process in terms of their understanding of measures, familiarity with geographical setting of the study and competency in English and Hindi languages. In addition, the different steps of the adaptation involved representatives from communities in which the measure were to be administered. This allowed for stimulating interactions and exchange of ideas, thereby helping in developing optimal translations ([<reflink idref="bib21" id="ref51">21</reflink>]). Finally, careful consideration was given not just to linguistic translation but to the different kinds of equivalence between the original and translated versions of the instrument. All of these factors make them generalizable to be used for assessment of childhood functioning and not limited for use with target population of COMPASS.</p> <p>Various challenges were encountered while these measures were being adapted. The adaptation process was carried out in NCT of Delhi (Northern India), a melting pot of various cultures, where people use different dialects of Hindi language. So, incorporating the best-suited and widely used Hindi words or expressions was difficult. Having at least two translators and community representatives helped taking into account the dialectical variation. When ideas differed between different researchers, a consensus was obtained on the basis of opinions of the majority in the team ([<reflink idref="bib21" id="ref52">21</reflink>]). Suggestions were additionally tested out during cognitive interviews and pretesting to ensure the appropriateness of the consensus reached. In terms of step-wise process, since expert review committee could not be constituted due to resource constrains, back translation was used despite it being considered an optional step ([<reflink idref="bib4" id="ref53">4</reflink>]; [<reflink idref="bib16" id="ref54">16</reflink>]). The other major issue came about while understanding the types of equivalence as they have been defined differently by various authors and experts ([<reflink idref="bib1" id="ref55">1</reflink>]; [<reflink idref="bib5" id="ref56">5</reflink>]; [<reflink idref="bib6" id="ref57">6</reflink>]; [<reflink idref="bib8" id="ref58">8</reflink>]; [<reflink idref="bib10" id="ref59">10</reflink>]; [<reflink idref="bib25" id="ref60">25</reflink>]). Following the most cited and contextually appropriate definitions was found to be an acceptable solution. Another key challenge was around Vineland-3 being a long, extensive measure with 458 items. Obtaining homogeneity amongst words or phrases and reaching a consensus was very time-consuming and resource-intensive. Finally, due to different levels of permissions obtained from publishers, it took careful consideration for researchers to achieve a balance between making items culturally equivalent in accordance with the extent to which adaptations were permitted.</p> <p>The foremost limitation of the adaptation process undertaken by researchers was that it was qualitative in nature. The quantitative component in terms of evaluation of psychometric properties of the measures could add to the utility and validity of the adapted versions of these measures ([<reflink idref="bib1" id="ref61">1</reflink>]; [<reflink idref="bib8" id="ref62">8</reflink>]; [<reflink idref="bib12" id="ref63">12</reflink>]; [<reflink idref="bib21" id="ref64">21</reflink>]; [<reflink idref="bib28" id="ref65">28</reflink>]; [<reflink idref="bib29" id="ref66">29</reflink>]). Finally, the participants of cognitive interview, some of whom were parents as well, had extensive experience of working with the local population. However, sampling representatives from the target population for conducting cognitive interviews, in this case, caregivers of children with autism, to ensure the relevance of each item would have made the process more robust ([<reflink idref="bib27" id="ref67">27</reflink>].; [<reflink idref="bib28" id="ref68">28</reflink>]).</p> <p>As increasing numbers of studies are being conducted within LMICs with non-English speaking communities, the systematic process of adaptation presented here could act as a guiding framework to those who are new to this process. Following this framework will ensure that an adapted measure is more relatable to the target population. This will imply that more quality responses can be generated using these adapted measures and the construct under study is also investigated more accurately.</p> <hd id="AN0189133594-11">Conclusion</hd> <p>This article describes the systematic process of cultural adaptation of three measures of childhood functioning viz., Vineland-3, CSBS-DP and CHU-9D which do not have published Hindi versions. The process followed for adaptation had multiple steps and an iterative flow. The Hindi versions of the measures reflect not just literal but culturally relevant translations which maintain equivalence with the original measures in English language. The process described can help in translation of other psychological measures in LMICs. However, more published research dedicated to understanding facilitators and barriers to this process in the future will add to the knowledge base such that teams can build incrementally on the experience described here. Building on limitations of this work, researchers can add quantitative components to adaptation of measures in order to establish an empirical understanding of the outcome of this process. Having greater autonomy from publishers can further reduce the complexities in achieving equivalence. Given that development of standardized measures which can be used in their original form in all cultures may not be practically possible, having a structured adaptation process is suggested, which will enable use of these measures in various contexts.</p> <p>The authors thank all the participants for their time and cooperation. They would also like to acknowledge research associates on the COMPASS study for their contributions to the translation of the instruments in this study. They are grateful to Dr. Deepali Verma for her time toward back translation of measures.</p> <ref id="AN0189133594-12"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref7" type="bt">1</bibl> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref3" type="bt">2</bibl> <bibtext> The authors acknowledge funding from the U.K. Medical Research Council/Wellcome/DfID Joint Global Health Trials Award, grant no. 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  Data: Cross-Cultural Adaptation of Measures of Childhood Functioning for Low- and Middle-Income Countries: A Process Description in a Northern Indian Context
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  Label: Authors
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  Data: <searchLink fieldCode="AR" term="%22Minal+Abhilashi%22">Minal Abhilashi</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0000-5068-7822">0009-0000-5068-7822</externalLink>)<br /><searchLink fieldCode="AR" term="%22Sanchita+Johri%22">Sanchita Johri</searchLink><br /><searchLink fieldCode="AR" term="%22Gitanjali+Lall%22">Gitanjali Lall</searchLink><br /><searchLink fieldCode="AR" term="%22Sonakshi+Pandey%22">Sonakshi Pandey</searchLink><br /><searchLink fieldCode="AR" term="%22Reetabrata+Roy%22">Reetabrata Roy</searchLink><br /><searchLink fieldCode="AR" term="%22Divya+Kumar%22">Divya Kumar</searchLink><br /><searchLink fieldCode="AR" term="%22Saani+Shakeel%22">Saani Shakeel</searchLink><br /><searchLink fieldCode="AR" term="%22Sheffali+Gulati%22">Sheffali Gulati</searchLink><br /><searchLink fieldCode="AR" term="%22Monica+Juneja%22">Monica Juneja</searchLink><br /><searchLink fieldCode="AR" term="%22Jonathan+Green%22">Jonathan Green</searchLink><br /><searchLink fieldCode="AR" term="%22Gauri+Divan%22">Gauri Divan</searchLink><br /><searchLink fieldCode="AR" term="%22Kathy+Leadbitter%22">Kathy Leadbitter</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Focus+on+Autism+and+Other+Developmental+Disabilities%22"><i>Focus on Autism and Other Developmental Disabilities</i></searchLink>. 2025 40(4):220-229.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications and Hammill Institute on Disabilities. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Adjustment+%28to+Environment%29%22">Adjustment (to Environment)</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Rating+Scales%22">Behavior Rating Scales</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Media+Adaptation%22">Media Adaptation</searchLink><br /><searchLink fieldCode="DE" term="%22Semantics%22">Semantics</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Patterns%22">Language Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Punctuation%22">Punctuation</searchLink><br /><searchLink fieldCode="DE" term="%22Sentence+Structure%22">Sentence Structure</searchLink><br /><searchLink fieldCode="DE" term="%22Instruction%22">Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Layout+%28Publications%29%22">Layout (Publications)</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22India%22">India</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Vineland+Adaptive+Behavior+Scales%22">Vineland Adaptive Behavior Scales</searchLink><br /><searchLink fieldCode="SU" term="%22Communication+and+Symbolic+Behavior+Scales%22">Communication and Symbolic Behavior Scales</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10883576251349216
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1088-3576<br />1538-4829
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Measures assessing childhood functioning are often developed in high-income countries and need to be adapted for use in low and middle-income countries where the constructs they measure may not be relevant in their original form. This study describes the framework of cross-cultural adaptation of three measures, viz. Vineland Adaptive Behavior Scales--Third Edition; Communication and Symbolic Behavior Scales--Developmental Profile Caregiver Questionnaire and Child Health Utility-9D, followed in the Communication-centered Parent-mediated treatment for Autism Spectrum disorder in South Asia trial. The primary objective was to adapt these measures using a stepwise process while establishing semantic, idiomatic, conceptual, experiential, and technical equivalence between the original and adapted versions. Resulting items of each measure conveyed the same meaning and intent in both the original and adapted versions. The adapted versions had grammar, punctuation, sentence structure, instructions, layout and format, and mode of administration as they were in the original measures.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1490896
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1490896
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/10883576251349216
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 220
    Subjects:
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Adjustment (to Environment)
        Type: general
      – SubjectFull: Behavior Rating Scales
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Media Adaptation
        Type: general
      – SubjectFull: Semantics
        Type: general
      – SubjectFull: Language Patterns
        Type: general
      – SubjectFull: Punctuation
        Type: general
      – SubjectFull: Sentence Structure
        Type: general
      – SubjectFull: Instruction
        Type: general
      – SubjectFull: Layout (Publications)
        Type: general
      – SubjectFull: India
        Type: general
      – SubjectFull: Vineland Adaptive Behavior Scales
        Type: general
      – SubjectFull: Communication and Symbolic Behavior Scales
        Type: general
    Titles:
      – TitleFull: Cross-Cultural Adaptation of Measures of Childhood Functioning for Low- and Middle-Income Countries: A Process Description in a Northern Indian Context
        Type: main
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            – D: 01
              M: 12
              Type: published
              Y: 2025
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            – Type: issn-print
              Value: 1088-3576
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              Value: 40
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              Value: 4
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            – TitleFull: Focus on Autism and Other Developmental Disabilities
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