COSMIN database

The cross-cultural equivalence of participation instruments: a systematic review

Stevelink, S. A. and van Brakel, W. H.
PURPOSE: Concepts such as health-related quality of life, disability and participation may differ across cultures. Consequently, when assessing such a concept using a measure developed elsewhere, it is important to test its cultural equivalence. Previous research suggested a lack of cultural equivalence testing in several areas of measurement. This paper reviews the process of cross-cultural equivalence testing of instruments to measure participation in society.

METHODS: An existing cultural equivalence framework was adapted and used to assess participation instruments on five categories of equivalence: conceptual, item, semantic, measurement and operational equivalence. For each category, several aspects were rated, resulting in an overall category rating of 'minimal/none', 'partial' or 'extensive'. The best possible overall study rating was five 'extensive' ratings. Articles were included if the instruments focussed explicitly on measuring 'participation' and were theoretically grounded in the ICIDH(-2) or ICF. Cross-validation articles were only included if it concerned an adaptation of an instrument developed in a high or middle-income country to a low-income country or vice versa.

RESULTS: Eight cross-cultural validation studies were included in which five participation instruments were tested (Impact on Participation and Autonomy, London Handicap Scale, Perceived Impact and Problem Profile, Craig Handicap Assessment Reporting Technique, Participation Scale). Of these eight studies, only three received at least two 'extensive' ratings for the different categories of equivalence. The majority of the cultural equivalence ratings given were 'partial' and 'minimal/none'. The majority of the 'none/minimal' ratings were given for item and measurement equivalence.

CONCLUSION: The cross-cultural equivalence testing of the participation instruments included leaves much to be desired. A detailed checklist is proposed for designing a cross-validation study. Once a study has been conducted, the checklist can be used to ensure comprehensive reporting of the validation (equivalence) testing process and its results.

IMPLICATIONS FOR REHABILITATION: * Participation instruments are often used in a different cultural setting than initial developed for. * The conceptualization of participation may vary across cultures. Therefore, cultural equivalence - the extent to which an instrument is equally suitable for use in two or more cultures - is an important concept to address. * This review showed that the process of cultural equivalence testing of the included participation instruments was often addressed insufficiently. * Clinicians should be aware that application of participations instruments in a different culture than initially developed for needs prior testing of cultural validity in the next context.
Disabil Rehabil
1464-5165 (Electronic)
Publication year:
Functional status:
Cognitive/mental functioning
Physical functioning
Role functioning
Social functioning
Adults (18-65)
Seniors (65+)
Certain conditions originating in the perinatal period and related symptoms
Certain infections and parasitic diseases and related symptoms
Codes for special purposes
Congenital malformations, deformations and chromosomal abnormalities and related symptoms
Diseases of and symptoms related to the blood and blood-forming organs and certain disorders involving the immune mechanism
Diseases of and symptoms related to the circulatory system
Diseases of and symptoms related to the digestive system
Diseases of and symptoms related to the ear and mastoid process
Diseases of and symptoms related to the eye and adnexa
Diseases of and symptoms related to the genitourinary system
Diseases of and symptoms related to the musculoskeletal system and connective tissue
Diseases of and symptoms related to the nervous system
Diseases of and symptoms related to the respiratory system
Diseases of and symptoms related to the skin and subcutaneous tissue
Endocrine, nutritional and metabolic diseases and related symptoms
External causes of morbidity and mortality
Injury, poisoning and certain other consequences of external causes
Mental and behavioural disorders and related symptoms
Neoplasms and related symptoms
Pregnancy, childbirth and puerperium and related symptom
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
PRO / non-PRO:
Patient Reported Outcome
Type of measurement instrument:
2 - Interviews
CHART - Craig Handicap Assessment and Reporting Technique   
IPA - Impact on Participation and Autonomy   
LHS - London Handicap Scale   
PIPP - Perceived Impact of Problem Profile
P-Scale - Participation Scale