Translation and Cross-Cultural Adaptation of Expressed Emotion Measure

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Translation and Cross-Cultural Adaptation of Expressed Emotion Measure

Tetiana Pastryk

Volyn Medical Institute, Ukraine

Mykhailo Kots

Lesya Ukrainka Volyn National University, Ukraine

Abstract

Large gaps of data still exist within the Ukrainian context utilizing Expresses Emotion as a warm, hostile, critical or emotional over-involving behaviour towards individual with a mental or physical condition. The aim of the current article was to suggest translation and cross-cultural adaptation of level of expressed emotion (LEE) as it is perceived by service users. This study applies the LEE which includes four factors: perceived lack of emotional support (pLES: 19 items), perceived intrusiveness (pIN: seven items), perceived irritation (pIR: seven items), and perceived criticism (pC: five items). All items are rated according to frequency and intensity on a four-point Likert scale 1 to 4 (1: untrue; 2: somewhat untrue; 3: somewhat true; 4: true). The total score of the 38 items is entitled perceived expressed emotion (pEE). LEE has strong psychometric properties in adolescents and adults. The translation LEE followed WHO guidelines (2020) and comprises some stages, namely a forward translation from English to Ukrainian, a back translation, expert panel validation, pretesting and cognitive face-to-face interviews with 10 clinical psychologists. The Ukrainian translation version of LEE meets requirements of LEE original version. However, some items were transformed according to semantic, grammatical or stylistic norms of the Ukrainian language. The Ukrainian version of LEE is the first psychometric tool to assess expressed emotion in a Ukrainian healthcare setting.

Keywords: level of expressed emotion, service users, Ukrainian translation, cultural adaptation

Анотація

Пастрик Тетяна, Коць Михайло. Переклад та крос-культурна адаптація опитувальника «Рівень емоційної експресивності»

Незважаючи на поширеність терміна емоційної експресивності (ЕЕ), досі не існує надійного психометричного інструменту для діагностики ЕЕ як теплої, або навпаки ворожої, з елементами критики та гіперопіки поведінки стосовно осіб, які мають проблеми з фізичним чи психічним здоров'ям. Метою цієї праці є переклад та культурна адаптація опитувальника «Рівень емоційної експресивності» (РЕЕ), як він сприймається користувачами психологічних чи медичних послуг. Наше дослідження використовує опитувальник РЕЕ, який місить чотири фактори: сприйняття нестачі емоційної підтримки, сприйнята гіперопіка, сприйняте роздратування та сприйнята критика. Усі пункти опитувальника оцінюються за шкалою від 1 до 4 за мірою інтенсивності чи частотності (1: не згоден, 2: дещо не згоден, 3: частково згоден, 4: повністю згоден). Сумарний показник сприйнятого РЕЕ становить 38 і тлумачиться як рівень сприйнятої ЕЕ. Переклад опитувальника виконувався згідно з рекомендаціями ВООЗ (2020) і містив такі етапи: прямий переклад, зворотний переклад, валідизація опитувальника експертами, претестування та когнітивні інтерв'ю з 10 клінічними психологами. Українська версія РЕЕ відповідає повною мірою оригінальній версії опитувальника. Водночас, деякі пункти змінювалися чи вилучалися відповідно до семантичних, граматичних та стилістичних норм української мови. Українська версія опитувальника РЕЕ - перший психометричний інструмент для визначення ЕЕ в українському контексті охорони здоров'я.

Ключові слова: рівень емоційної експресивності, користувачі психологічних чи медичних послуг, український переклад, культурна адаптація.

Introduction

The family environment is fast becoming a key instrument in health psychology. Family relationship is a robust predictor of the quality of life of a person with a mental or physical condition. Recent studies indicate that vulnerability to illness, the process of treatment, adaptation to illness and recovery are determined by several psychological, social and family factors. A growing body of literature recognizes the importance of family relationships on the quality of life of a person with a condition (Cole & Reiss, 1993). The existing body of research on health-related quality of life suggests that the biopsychosocial model proposed by Engel (1979) is the most applicable. This model focuses on clinical and personal aspects of recovery, including full integration of three components: medical (clinical symptoms and physiological pathology), psychological (cognitions, emotions, behavioural patterns, in particular psychological distress, fear, strategies of avoidance and protective behaviour) and social (family relationships, socio-economic factors, place of work) (Engel, 1979). This model considers that psychophysiological reactions, such as chronic pain and other diseases, often cannot be explained by only one physiological factor but require a complex approach.

Expressed emotion (EE) is a construct that represents specific behaviour toward a person with a condition. This behaviour could be expressed in warmth, critical comments, hostilities or emotional over-involvement. Evidence consistently suggests that EE is a key concept in family members' attitudes toward a person with a condition. Brown and Rutter (1966) introduced this concept by examining individuals with schizophrenia with a high risk of relapse. Their study proved that the risk of relapse increases if relatives demonstrate critical comments and emotional over¬involvement towards individuals with a condition.

Recent findings indicate that EE is a reliable psychosocial predictor of relapses in mental and physical health (Wearden et al., 2000). Wearden et al. (2000) point out that the concept of EE covers three aspects: the behaviour of relatives, the quality of relationships and the home environment. The conceptualization of EE focuses on assessing family relationships, represented by five types of behaviour: critical remarks, hostility, positive remarks, warmth, and emotional over-involvement. At the current stage, Hooley and Parker (2006) evaluate EE exclusively based on criticism, hostility, and emotional over-involvement since these types of EE are closely related to chronic diseases of mental and physical etiology.

Evidence consistently suggests that there are poor effects of EE on different physical conditions, namely diabetes, asthma, rheumatoid arthritis, heart surgery, and obesity (Wearden et al., 2000). It is still unknown whether EE effects differ for health-related quality of life in individuals with mental or physical conditions. The research results showed no comprehensive studies of EE in the literature regarding patients with a medical diagnosis compared to persons with mental illnesses (Zasiekina, 2018). Recent studies indicate that individuals with type 1 diabetes have 17% relatives with extremely high EE, compared with 41.4% high EE for individuals with schizophrenia and 28% high EE for individuals with dementia (Wearden et al., 2020). There is also no solid data confirming an association between EE and rheumatoid arthritis, heart surgery, and obesity. However, the recent results indicate an association between the critical comments and the frequency of asthmatic and epileptic attacks (Bressi et al., 2007).

Studies of EE show the importance of family environment and characteristics of relatives. However, recent studies consider EE as a measure of the service-users¬relatives relationship. In addition, there are studies introducing EE as a tool for assessing other environments of an individual with a condition, namely healthcare staff (Tanaka et al., 2015). The results of recent studies indicate that there is reciprocal negativity within the relationship. Namely, there is an association between high levels of EE in relatives, healthcare staff and service users (Cook et al., 1991). Foster et al. (2003) developed the perceived EE in staff. They considered it a convenient measure that may have utility for both research and clinical purposes.

Much uncertainty still exists about the tools with solid psychometric properties for assessing EE. However, the Camberwell Family Interview (CFI), which was first applied to examine the family environment of individuals with schizophrenia, and the Five-Minute Speech Sample (FMSS) are considered reliable tools for determining EE.

CFI is usually conducted three months before a person is admitted to the hospital and a few days after admission. The survey is a three-hour semi-structured interview with relatives of an individual with a condition and requires special training to conduct, code and interpret the data. Therefore, instead of the CFI, many studies apply the express FMSS analysis method, which is more convenient to use. In a five- minute interview, relatives are asked to talk continuously for 5 minutes about a family member with a condition. The idea of using FMSS was proposed by Gottschalk and Gleser (1979). According to them, speech discloses intra-personal qualities and relatives' responses to the individual with a condition, which are frequently hidden during structural or semi-structural interviews. Relatives' speech is not interrupted but is recorded, transcribed, coded and later analyzed. Coding corresponds to the following subscales: anxiety (description of events or threats of death, shame, guilt, separation); hostility (description of hostile-aggressive behaviour); hope (expression of optimism about the health-related quality of life). Hooley and Parker (2006) point out that although the measure takes less time to administer compared with CFI, it also requires the relative's participation, and trained coders must still be used.

The alternative tool is the Level of expressed emotion questionnaire (LEE) (Cole & Kazarian, 1988). LEE comprises 60 items, which assess the family environment of the individual with a condition. The LEE assesses the family environment according to the four subscales Intrusiveness, Emotional Response, Attitude Toward Illness, and Tolerance and Expectations. Hooley and Parker (2006) point out that a thorough evaluation of the LEE scale is complicated because not all investigators use the LEE in its standard (60-item) form. Recently 60-item questionnaire has transformed into a 38-item questionnaire (Hale et al., 2007). The main advantage is that it is more easily administered and could be applied to adolescents and adults.

38-item LEE consists of four factors: perceived lack of emotional support (pLES: 19 items), perceived intrusiveness (pIN: seven items), perceived irritation (pIR: seven items), and perceived criticism (pC: five items). Each item is scored on a scale from 1 to 4 (1: untrue; 2: somewhat untrue; 3: somewhat true; 4: true). The total score of the 38 items is perceived expressed emotion (pEE) (Gerlsma & Hale, 1997). LEE had solid psychometric properties. Cronbach's alphas for the individual scales were: pLES = 0.88 (in subsamples ranging from 0.87 to 0.89), pIN = 0.83 (range 0.78-0.85), pIR = 0.82 (range 0.81-0.83) and pC = 0.73 (range 0.70-0.77). Cronbach's alpha for the total score, pEE, was 0.93 (Gerlsma & Hale, 1997).

Only a limited number of EE have been identified in the Ukrainian context. In addition, there is no psychometric tool for assessing EE in the Ukrainian population. Therefore, the current study aims to translate and make a cultural adaption of the LEE to the Ukrainian context.

Method

Following WHO recommendations for the translation of psychometric tools (2000), we used a four-step procedure, including direct translation (3 translators who are familiar with health psychology terminology); a group of experts for backtranslation (2 people) and expert panel scrutiny; pretesting and cognitive interview; the final version.

In the first stage, we compared three versions of the translated text. We reached a consensus on the final text of the questionnaire translation. The choice of words and grammatical structures in each case was discussed. This stage aims to find the conceptual equivalent of a word or phrase instead of word-for-word translation. All translators were instructed to translate the original term in the most appropriate way considering its content.

Next, two translators (for one of them, English is the mother tongue, and Ukrainian is the second language, and for the other, vice versa) did back translation. The translators worked independently and were unaware of the original version of the questionnaire. The back-translation at this stage aims to focus on conceptual and cultural equivalence instead of linguistic equivalence. In the cases of discrepancies, an expert panel, including forwarding and back translators, searched for a satisfactory version of the translated text.

We returned to the Ukrainian version when different lexical units conveyed the same meaning. We tried to find more accurate lexical equivalents of the proposed meaning. Researchers in the General and Clinical Psychology Department at Lesya Ukrainka Volyn National University, Ukraine, (n=5) discussed each item for content validation of the back-translated version. Every item was discussed concerning sentence structure, comprehensibility, definition clarity, relevance and sensitivity. Therefore, clarity of statement/wording, relevance (matching the context), emotionality (ability to cause certain emotions), and suggestions for alternative wording were the main steps in validating LEE.

At the stage of the pretesting and cognitive interview, we determined the content validity of the questionnaire and the overall satisfaction with each item of the questionnaire. For this purpose, we gathered a group of clinical psychologists (n=10) in the Department of General and Clinical Psychology at Lesya Ukrainka Volyn National University who have not less than five years' experience of work with adolescents and adults with the mental or physical condition. Pre-test respondents in the current research included individuals' representative of those who will be administered the questionnaire in future. Considering the specific behaviours of significant others towards adolescents and adults with a physical or mental condition, pre-test respondents included clinical psychologists with the experience of work at schools and hospitals.

After obtaining consent from participants, the conversation was recorded and later transcribed. The group of experts received the questionnaire in advance, read all the statements, recorded their concerns regarding each item, and, if necessary, suggested alternative lexical items. The same criteria as the previous stage were used to evaluate the statements. This stage resulted in obtaining the final version of the Ukrainian version of LEE. The relevance of the context involves the correspondence of the self-reporting statements of significant others' attitudes and behaviours. The comprehensibility of the statement / the clarity indicates the correct wording. If it was necessary to repeat the statement or clarify what was meant, such a statement was reviewed again.

Results

Evidence consistently suggests that the LEE questionnaire met most requirements for relevance and comprehension. However, the interviewees reflected on statements according to their professional experience and suggested the variants for cultural adaptation.

Relevance of LEE Questionnaire

Table 1 indicates statements which form the examples of cultural adaption.

The clinical psychologist working with anxiety disorders in adolescents and adults suggested making changes to item # 3:

I think it would be better to change the grammatical construction "when I am ill" in Ukrainian from “коли я хворий" на "коли я хворію”. It helps to avoid complications with grammatical constructions denoting gender in the Ukrainian language.

The clinical psychologist working with adolescents with ADHD considers some wordings in item # 3 inappropriate

Table 1

Examples of statements which form the basis of the cultural adaption according to relevance

In my opinion, the word “уважний” does not fit the context since it means cognitive process. It is often associated with disorders aligned with attention deficit. Therefore, the most appropriate word in the Ukrainian context is “дбайливий”.

The clinical psychologist working with mental disorders in adolescents suggested making changes to item # 4

The item implies not just seeing or even understanding or comprehension; it is about compassion and empathy for significant others when the individual has a physical or mental condition. Therefore, considering the lexical norms of the Ukrainian language, we suggested the correct version is “поділяти точку зору”.

The clinical psychologist with experience at the hospital suggests some changes to item 6 since it looks too complicated for an individual with a mental condition.

Individuals with mental conditions frequently do not comprehend complex sentences. Therefore, it is better to use the noun “помилки” instead of the subordinate clause. My experience indicates that the best comprehension relates to the most straightforward language forms and constructions.

The clinical psychologist with experience at the hospital with adolescents suggests some changes to item 8, pointing out the relevance of the LLE questionnaire to health-related quality of life.

It is unclear what limitations are meant. Considering the context of specific attitudes and behaviours towards a person with a physical or mental condition, we should clarify the type of limitations. Therefore, it's better to use disease limitations. translation cross cultural expressed measure

The clinical psychologist with experience of work with adolescents with a mental condition at school suggests an alternative wording to item # 13

I think it is better to change “почуватися хворим” to “почуватися погано”. It is connected with stigma, especially in adolescents, and it is a barrier for them to recognize that they are unhealthy. The phase “почуватися погано” is more neutral.

The clinical psychologist with experience of work with adolescents was concerned about # 16, pointing out its low relevance to the context.

The word combination “вимагати інформацію” seems not to be relevant to the context of health issues in the relations between relatives and family service users. Especially it sounds too complicated for adolescents. So, I think this item means knowing more about conditions to be supportive and helpful to their family member.

The clinical psychologist with previous experience at the hospital suggested making changes to item # 25.

The item is about thinking straight, but not logically. It is not about abstract or logical thinking; it is about understanding the family member's condition. Therefore, it is more appropriate to use “думати чітко” instead of “мислити логічно”.

In the translation and cultural adaptation of the LEE questionnaire, we tried to convey the wording and content of the original text as accurately as possible. In addition, some questionnaire items were clarified, shortened or supplemented based on the results of discussions at all stages, considering the context of Ukraine and the functioning of individuals with mental or physical conditions.

Comprehensibility/Clarity

The comprehensibility of the statement / the clarity indicates the correct wording. During the cognitive interview, some statements need clarification. In this case, these statements were reviewed again.

# 7 “Make me feel relaxed when they are around" being initially translated into “Дають мені розслабитися, коли вони поруч"". Following the guideline WHO that translator should always aim at the conceptual equivalent of a word or phrase, not a word-for-word translation, we transform the final version of translation into “їх присутність мене стишує”.

# 15 “Will not help me when I'm upset" was initially translated into “Не допомагають мені, коли я засмучений"". After the cognitive interview and pretesting, the respondents pointed out that it is impossible to help when the person is upset and suggested the word combination “Байжужі до мене, коли я засмучений”.

#19 “Expect the same level of effort from me, even if I don't feel well" after the back translation was “очікують від мене такого ж рівня зусиль"" which worsens the clarity of the item. After pretesting and cognitive interview, some translational changes were suggested from “такого ж рівня зусиль"" to “oчікують від мене високої активності"".

# 27 “Are always nosing into my business"" was considered according to the WHO guideline to avoid the use of any jargon, technical terms that cannot be understood clearly; and colloquialism, idioms or vernacular terms that cannot be understood by common people in everyday life (WHO, 2020). However, considering the original text and target audience, the final translated version was “Завжди пхають ніс у мої справи"".

Discussion

The article aimed to translate and make a cultural adaption of the LEE to the Ukrainian context. In contrast to other EE questionnaires, the LEE questionnaire assesses perceived EE. It possesses a four-factor structure for adolescents and adults. Additionally, evidence consistently suggests that the four-factor LEE model fits both younger and older adolescents and boy and girl adolescents. Therefore, the LEE is a valuable tool for assessing EE and has solid psychometric properties. As Epstein et al. (2019) point out, any techniques for cultural adaptation will be helpful if they contribute to conveying the exact content of statements. Therefore, the study applied the step-by-step instructions for translation and cultural adaptation of psychodiagnostic tools proposed by WHO. Given the solid psychometric properties of the original LEE questionnaire, we tried to follow the content of the statements as closely as possible. At the same time, because the target population could be adolescents and adults with physical or mental conditions, some wordings of the questionnaire were transformed to meet the requirements of relevance and comprehensibility/clarity. The study results indicate that the Ukrainian version of LEE may be an essential psychometric tool for assessing EE in adolescents and adults.

Conclusions

The findings of this research provide insights for the importance of step-by-step process to obtain different language versions of the English instrument that are conceptually equivalent in each of the target coantries/caltares. This study has raised important questions about, firstly, the complexity of the process of translation and cultural adaptation of psychological tools, and secondly, the lack of psychometric measures for assessing EE in the Ukrainian population. Limited to translation and cultural adaptation, this study lacks the demonstration of the psychometric properties of the Ukrainian version of LEE. Revealing the psychometric properties of the LEE would be a fruitful area for further work. In addition, the LEE could be a tool for assessing other environments of the individual with a condition, namely healthcare staff (Tanaka et al., 2015). In the case of adolescents and young adults with a condition, the LEE could also indicate reciprocal negativity within the relationship between adolescents with a condition and teachers. Applying the LEE in a new environmental context may have important practical implications for research and clinical purposes.

References

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Appendix

Оцініть кожне із наведених тверджень, яке стосується Ваших рідних (медичного персоналу чи вчителив ), за шкалою 1-4, де 1 - не згоден, 2 дещо не згоден, 3 дещо згоден, 4 - повністю згоден

1. Намагаються заспокоїти мене, коли я почуваюся погано.

2. Співчувають мені, коли я хворію або засмучений.

3. Дбають про мене, коли я хворію.

4. Поділяють мою точку зору.

5.Часто звинувачують мене в тому, що я вигадую, коли почуваюсь погано.

6. Ставляться з розумінням до моїх помилок.

7. Їхня присутність мене стишує.

8. З розумінням ставляться до моїх обмежень через хворобу.

9. Стараються полегшити мій стан, коли я хворію.

10. Вислуховують мене.

11. Терпляче ставляться до мене, навіть коли я не відповідаю їхнім очікуванням.

12. Дають відчути, що мене цінують як особистість.

13. Звинувачують мене в перебільшенні, коли я кажу, що я нездоровий.

14. Заспокоюють мене, коли я засмучений.

15. Байдужі до мене, коли я засмучений.

16. Хочуть більше дізнатися, щоб зрозуміти мій стан, коли я почуваюся погано.

17. Реагують спокійно на мене, навіть якщо все йде не так як слід.

18. Не знають, як впоратися з моїми емоціями, коли мені погано.

19. Очікують від мене високої активності, навіть якщо я почуваюся погано.

20. Сердяться, коли я щось роблю не так.

21. Дратуються, коли все йде не так.

22. Ще більше ускладнюють ситуацію, коли все йде погано.

23. Засмучуються, коли я не узгоджую усе з ними.

24. Можуть впоратися зі стресом.

25. Не можуть мислити чітко, коли щось пішло не так.

26. Вміють усе тримати під контролем у стресових ситуаціях.

27. Завжди пхають ніс у мої справи.

28. Хочуть знати усе про мене.

29. Завжди втручаються.

30. Порушують мою приватність.

31. Увесь час перевіряють, чим я займаюсь.

32. Наполягають на тому, щоб я звітував, куди я збираюся.

33. Не контролюють моє життя.

34. Висловлюють критичні зауваження у мій бік.

35. Дратуються, якщо я у них щось прошу.

36. Показують, що люблять мне.

37. Намагаються мене змінити.

38. Зазвичай погоджуються зі мною.

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