These instruments were specifically developed so they could be adapted for use in local settings throughout the world. HPRT is in the process of writing a major toolkit that provides an extensive guide to the development and use of the HSCL-25/HTQ in culturally diverse populations traumatized by mass violence and natural disaster. The following brief discussion reviews the issues that need to be considered in the adaptation of the HSCL-25 and HTQ.
Screening instruments cannot simply be translated from English into the language of the local community, population, or patients. The following issues need to be addressed for the successful cultural adaptation of these instruments.
All available ethnographic and clinical experience must be reviewed and evaluated before adapting the instruments. All cultures have different worldviews, and different ways of describing and labeling emotional distress and human suffering. Local categories of emotional distress (CEDs) help place the instruments within their proper cultural context. Local symptoms of CEDs may or may not overlap with Western DSM-IV psychiatric criteria.
The translation process for these instruments has three steps:
This is a fascinating process that is not only essential in constructing a culturally valid instrument, but also teaches the users of the instrument the cultural nuances, i.e., the richness and texture associated with all responses.
It must always be remembered that an excellent item-by-item symptom translation may not result as a whole in a valid diagnosis in the culture in which the instruments are being used.
The manner and method in which human beings injure and hurt others varies from society to society. Torture and trauma experiences in one society may differ radically from another society. This is partially due to the variation in meaning given to different types of trauma events in different cultures. The HTQ trauma list and its torture subsection, however, are not relativistic because they strive to choose only those events that are clearly considered violent and harmful by the majority of local citizens. The adapter of the HTQ, therefore, must conduct background field work as well as review available human rights reports and clinical experience in order to construct a culturally valid trauma/torture list.
Through its research, HPRT has found that trauma events can be placed in eight general categories:
Under each of these categories, individual types of events unique to the survivor’s situation can be clarified and included in the HTQ’s trauma event list.
The HSCL-25 and HTQ can generate symptom scores. For Indochinese populations 1.75 and 2.50 have been scientifically identified as suitable cut-off scores for the presence of psychiatric illnesses on the HSCL-25 and HTQ, respectively. In theory, however, each newly adapted screening instrument must have its cut-off point determined by comparing the scores on the instruments to a clinical diagnosis. The future toolkit will go into considerable detail on the establishment of cut-off points, their interpretation and usefulness. Fortunately, patterns of symptom response make these instruments extremely valuable to the clinician in evaluation and the monitoring of treatment.
All 25 items of the HSCL-25 are of clinical importance. The 16 items for depression are often used alone for scientific assessments that are primarily interested in determining the presence or absence of depressive illness. Depending on the purpose of the screen, the entire HSCL-25 or its subsections can be used separately.
A number of modifications have been made by HPRT that can be seen in the latter versions of the instrument (e.g., compare original Vietnamese version of HTQ to current Vietnamese version). These modifications, while not changing the basic construct of the HTQ, have improved its measurement accuracy.
The original HTQ included the following yes/no responses to its list of trauma events: experienced, witnessed, heard about, no experience. Empirical evidence revealed the primary importance of assessing experience alone, although witnessing can also be an important trauma event. Factor analysis on a number of large-scale studies using the HTQ revealed the 8 generic categories of trauma. Each of these 8 categories will help guide the comprehensive elucidation of culturally relevant trauma events. Precision of language (e.g., questions on torture) in describing specific torture/trauma events was also improved.
Improvement in clarifying symptoms associated with head injuries.
The first 16 items for PTSD based upon DSM-IIIR/DSM-IV remain unchanged. The second set of items for cultural/refugee specific symptoms have been expanded to 24 to include all possible culture-specific symptoms related to functioning and social disability. Additional research is necessary to demonstrate the validity of these items in the refugee setting.