title: Cross-cultural adaptation of instruments assessing breastfeeding determinants: a multi-step approach.
abstract: BACKGROUND
  Cross-cultural adaptation is a necessary process to effectively use existing instruments in other cultural and language settings. The process of cross-culturally adapting, including translation, of existing instruments is considered a critical set to establishing a meaningful instrument for use in another setting. Using a multi-step approach is considered best practice in achieving cultural and semantic equivalence of the adapted version. We aimed to ensure the content validity of our instruments in the cultural context of KwaZulu-Natal, South Africa.
  
  
  METHODS
  The Iowa Infant Feeding Attitudes Scale, Breastfeeding Self-Efficacy Scale-Short Form and additional items comprise our consolidated instrument, which was cross-culturally adapted utilizing a multi-step approach during August 2012. Cross-cultural adaptation was achieved through steps to maintain content validity and attain semantic equivalence in the target version. Specifically, Lynn's recommendation to apply an item-level content validity index score was followed. The revised instrument was translated and back-translated. To ensure semantic equivalence, Brislin's back-translation approach was utilized followed by the committee review to address any discrepancies that emerged from translation.
  
  
  RESULTS
  Our consolidated instrument was adapted to be culturally relevant and translated to yield more reliable and valid results for use in our larger research study to measure infant feeding determinants effectively in our target cultural context.
  
  
  CONCLUSIONS
  Undertaking rigorous steps to effectively ensure cross-cultural adaptation increases our confidence that the conclusions we make based on our self-report instrument(s) will be stronger. In this way, our aim to achieve strong cross-cultural adaptation of our consolidated instruments was achieved while also providing a clear framework for other researchers choosing to utilize existing instruments for work in other cultural, geographic and population settings.
authors.affiliation: University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, USA ; Center for Health Intervention and Prevention, University of Connecticut, 2006 Hillside Rd, Unit 1248, Storrs, CT 06269, USA.
authors.forename: Emily L
authors.initials: EL
authors.lastname: Tuthill
authors.affiliation: Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02215, USA ; Department of Pediatrics, Harvard Medical School, Boston, MA 02215, USA.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Butler
authors.affiliation: University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, USA ; Connecticut Children's Medical Center, Institute for Nursing Research and Evidence-Based Practice, 282 Washington St., Hartford, CT 06106, USA.
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: McGrath
authors.affiliation: University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, USA.
authors.forename: Regina M
authors.initials: RM
authors.lastname: Cusson
authors.affiliation: University of KwaZulu-Natal, King Edward Avenue, Scottsville, Pietermaritzburg, South Africa.
authors.forename: Gracia Nokhaya
authors.initials: GN
authors.lastname: Makiwane
authors.affiliation: University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, USA ; Johnson & Wales University, Center for Research and Evaluation, 8 Abbott Park Place, Providence, RI 02903, USA ; College of Arts & Sciences, Johnson & Wales University, 8 Abbott Park Place, Providence, RI 02903, USA.
authors.forename: Robert K
authors.initials: RK
authors.lastname: Gable
authors.affiliation: Center for Health Intervention and Prevention, University of Connecticut, 2006 Hillside Rd, Unit 1248, Storrs, CT 06269, USA.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Fisher
keywords: Breastfeeding; Breastfeeding scales; Content validity; Cross-cultural adaptation; Scale development; Translation