Bone Marrow Transplantation (2002) 29, 41–49
 2002 Nature Publishing Group All rights reserved 0268–3369/02 $25.00
www.nature.com/bmt
Quality of life
Translation and validation of the Functional Assessment of Cancer
Therapy–Bone Marrow Transplant (FACT-BMT) Version 4 quality of
life instrument into traditional Chinese
AKL Lau1, CH Chang2,3, JWM Tai5, S Eremenco2,3, R Liang4,5, AKW Lie4,5, DYT Fong6
and CM Lau7
1
Department of Nursing Studies, the University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of
China; 2Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Evanston, IL, USA; 3Institute for Health
Services Research and Policy Studies, Northwestern University, Evanston, IL, USA; 4Department of Medicine, the University of Hong
Kong, Hong Kong Special Administrative Region, People’s Republic of China; 5Bone Marrow Transplant Unit, Queen Mary
Hospital, Hong Kong Special Administrative Region, People’s Republic of China; 6Clinical Trials Centre, the University of Hong
Kong, Hong Kong Special Administrative Region, People’s Republic of China; and 7Centre for Education and Research in Family
Medicine, the University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China
Summary:
The need for a culturally sensitive instrument to assess
quality of life (QOL) of patients in international
oncology clinical trials has been well documented. This
study was designed to evaluate the psychometric
properties of the traditional Chinese translation (TCHI)
of the Functional Assessment of Cancer Therapy–Bone
Marrow Transplant (FACT-BMT) Version 4. The
FACT-BMT consists of the FACT-General and treatment-specific concerns of bone marrow transplantation.
The Chinese translation follows the standard Functional
Assessment of Chronic Illness Therapy (FACIT) translation methodology. Bilingual teams from the United
States and Hong Kong reviewed the translation to
develop a provisional TCHI FACT-BMT, which was
then pre-tested by interviewing 20 native Chinesespeaking BMT patients in Hong Kong. The pre-test
results indicated good content coverage and overall
comprehensibility. A refined translation, taking into
account patient comments, was validated by 134 BMT
patients in Hong Kong. The results indicated the high
internal consistency of the TCHI FACT-BMT scales,
with Cronbach’s alpha coefficients ranging from 0.71
(emotional well-being) to 0.92 (FACT-BMT total). The
FACT-BMT also demonstrated good construct validity
when correlated with SF-36 Health Survey scales. The
QOL of Chinese BMT patients can now be evaluated
using a well-validated international QOL instrument in
their own language.
Bone Marrow Transplantation (2002) 29, 41–49. DOI:
10.1038/sj/bmt/1703313
Correspondence: AKL Lau, Department of Nursing Studies, Faculty of
Medicine, The University of Hong Kong, 21 Sassoon Rd, Pokfulam, Hong
Kong Special Administrative Region, People’s Republic of China
Received 18 April 2001; accepted 18 September 2001
Keywords: cross-cultural translation; quality of life
instrument; bone marrow transplant; psychometric evaluation; FACT-BMT
Bone marrow transplantation (BMT) has become increasingly important in the treatment of various haematological
diseases. Advances in the areas of transplant immunology,
human leukocyte antigen (HLA) testing, pre-BMT conditioning, and post-BMT care have improved the medical
outcomes and survival rates of BMT patients. Attention
must now extend beyond disease and symptom control
(physical indicators) into an evaluation of overall quality
of life (QOL) from the patient’s perspective (psychological
indicators). When the goal of treatment is to improve the
patient’s health status, QOL measurement is essential.
QOL is subjective and multi-dimensional. Cella and
Cherin1 offered a definition of health-related QOL that laid
the groundwork for this measurement. QOL ‘refers to
patients’ appraisal of and satisfaction with their current
level of functioning as compared to what they perceive to
be possible or ideal’. This definition was later modified to
incorporate the multidimensionality of QOL: ‘Healthrelated quality of life refers to the extent to which one’s
usual or expected physical, emotional and social well-being
are affected by a medical condition or treatment’.2 Thus,
QOL measurement should obtain the patient’s perspective
and encompass physical, mental and social well-being.
QOL measures typically consist of several major domains,
including the physical, functional, emotional and social.3,4
The physical domain refers to disease, symptoms and treatment side-effects. The functional domain primarily reflects
one’s capabilities, role limitations and self-care. The
emotional domain includes emotional distress and positive
emotional experiences. The social domain relates to intimacy, sexuality and family relationships, as well as the
extended friendship network and the amount of support and
help that patients obtain from their social networks.
Translation into Chinese of a QOL instrument
AKL Lau et al
42
Several studies have indicated that BMT is associated
with many psychological and physical threats to the QOL
of patients.5,6 Unfortunately, few instruments have been
specifically designed to measure the QOL of Chinese BMT
patients. The few that exist were developed in Englishspeaking countries, and their validity and reliability have
principally been established on Western populations.7,8 The
need for a culturally sensitive instrument to assess the QOL
of patients in international oncology clinical trials has been
well documented.9 To enable clinicians and researchers to
study the QOL of Chinese BMT patients within and across
cultures, a linguistically and culturally equivalent QOL
instrument must be developed.
The Functional Assessment of Cancer Therapy–Bone
Marrow Transplant (FACT-BMT) Version 4 is a selfadministered instrument designed to assess multidimensional aspects of the QOL in BMT patients. It consists of the 27-item FACT-General (FACT-G) and the 23item Bone Marrow Transplantation Subscale (BMTS). The
FACT-G assesses four primary dimensions of QOL, including physical well-being (7 items), social/family well-being
(7 items), emotional well-being (6 items), and functional
well-being (7 items). A five point Likert-type response
scale ranging from 0 to 4 is used (0 = ‘not at all’; 1 = ‘a
little bit’; 2 = ‘somewhat’; 3 = ‘quite a bit’; and 4 = ‘very
much’).
The original FACT-BMT was developed in English
using a standardised approach for item derivation, reduction
and testing,7 and has been used extensively in various clinical trials.10–12 The FACT-BMT was initially translated and
validated in Spanish,13 Dutch, French, German, Italian,
Norwegian and Swedish,14 and subsequently translated into
Japanese, Portuguese and Russian.15 The FACT-G Version
3 was translated into traditional Chinese and tested by Yu
et al16 between 1996 and 1999. This team employed the
double-back translation method, which is less rigorous
compared to the standard FACIT translation methodology
as outlined in Table 1. Their use of focus groups to explore
the cultural equivalence of the Chinese FACT-G translation
was dubious. The success of a focus group depends upon
many important factors, such as the selection of group participants and the handling of group dynamics.17 A dominance
of nasopharyneal carcinoma patients participating in the
two focus groups raises questions about their representativeness. The Hong Kong Chinese Version World Health
Organization QOL measure, abbreviated version
WHOQOL-BREF (HK) was used by Yu’s team16 to perform convergent validity. The subscale correlations
Table 1
between the FACT-G and the WHOQOL-BREF (HK) were
found to be low, and the team eventually had to acknowledge that the evidence concerning convergent validity
was weak.16
The original FACT-G English Version 3 was updated to
Version 4 in 1997 due to the translation and validation of
the FACT-G into more than 20 languages. These changes
involved the de-centering14 of item wording so that the
English source would more closely correspond to the translations both in terms of semantic equivalence and cultural
relevance.18 One noticeable change was that Version 4
excluded the two ‘Relationship with Doctor’ items from the
FACT-G.15 This is particularly suitable in Hong Kong,
where the doctor–patient relationship is different from that
in the US.19 Other changes in Version 4 include item wording, item numbering and scoring.15 Because of these
changes, a new traditional Chinese translation following
well-established FACIT translation methodology was
required; hence, our development of the TCHI FACT BMT
Version 4.
Learning the modern Chinese language has been equated
to a ‘Herculean chore’,20 and translating it is no easy task
either. As Vernon21 has pointed out, ‘Chinese . . . represents
every different word by an ideograph, or pictorial character,
and there are some 3500 of these characters to be learned.
Each character contains two parts: one is the stem . . . the
other is the radical . . . . Some 80 per cent of characters
contain one of 214 radicals.’ To complicate matters, Chinese words are made up of single or, more commonly, double or triple characters. These word-characters must then
be combined in various patterns to depict new concepts.20
The traditional form of Chinese characters is used in
Hong Kong, Taiwan, and other Chinese communities, while
the simplified form is primarily used in mainland China
and Singapore. The simplified form is an attempt, as its
name implies, to simplify those characters required for day
to day reading and writing. The introduction of the simplified form and Putonghua (the official Chinese language)
in mainland China was intended to reduce inter-ethnic and
regional differences.22–24 Another intention was to eliminate
the problem of having dozens of dialects, which can be
mutually unintelligible in different regions. Despite efforts
made since 1956, ‘dialects cannot be abolished by administrative order’,25 for regionality and local roots are traditionally respected by most Chinese, and individuals are highly
reluctant to abandon their dialects.26 Consequently, most
people have become bilingual, and can speak their own
regional dialect and Putonghua.
Translation methodology
Step
Task
1
Forward-translation: English → target
2
3
4
5
6
Reconciliation
Back-translation: Target → English
Independent reviews
Character and grammar verification
Pretesting with patients
Bone Marrow Transplantation
Personnel
Requirements/Purposes
2 native speakers of target language (1 in the US
and 1 in native country)
1 native speaker, familiar with multiple dialects
1 native English speaker
3–4 bilingual experts and coordinating team
Language co-ordinator and bilingual expert
Native speaking patients (15–30) with relevant
diagnosis
Use simple language and capture meaning
Resolve discrepancies
Use simple language
Review steps 1–3 and finalise translations
Proof-read
Assess comprehension and acceptability
Translation into Chinese of a QOL instrument
AKL Lau et al
When one starts to feel confused about ‘the Chinese’ and
their languages, paradoxically one actually gets a better feel
for what researchers have faced during the translation and
validation of any instrument into Chinese. Although simplified Chinese versions of the FACIT scales are also being
developed and tested, this paper alone describes an international collaboration between the US and Hong Kong
teams to translate and validate the FACT-BMT Version 4
into traditional Chinese.
Materials and methods
Marrow Transplant Unit at the Queen Mary Hospital, which
is affiliated with the University of Hong Kong. The
inclusion criteria were: patients must have undergone
BMT; they must have been aged 18 years or older; they
must have been able to read and write Chinese; and they
must have consented to participate in the study. The Chinese version was distributed to these patients during their
follow-up clinic visit. Patients were asked to self-administer
the questionnaire, and most of them were able to complete
it without any assistance. Each patient was then interviewed
and asked to comment on the comprehensiveness and clarity of the items, and the degree of difficulty encountered
when answering the questionnaire.
Development of a provisional traditional Chinese FACTBMT Version 4 for pre-testing
Validation study
The 27-item FACT-G Version 4 was translated into a traditional Chinese character (TCHI) version by employing
the standard FACIT translation methodology14 (see
Table 1), which is a more rigorous version of the doubleback translation method,27 and is ‘superior to single translation and translation by committee’.14
Although only 12 out of 23 bone marrow transplant subscale (BMTS) items are used to derive the BMTS score,7
all 23 items were translated. Firstly, two Chinese-speaking
professional translators performed the forward-translation
from English into traditional Chinese. Secondly, an independent native Chinese speaker reconciled the forwardtranslations by either choosing the best alternative of the
two forward-translations, combining them, or suggesting
another translation when necessary. Thirdly, a native
English-speaking professional translator designated by the
Center on Outcomes, Research and Education (CORE), in
Evanston, IL, US, was asked to translate the reconciled version back into English (back-translation). The CORE translation team then compared the back-translation with the
English source to ensure content and semantic equivalence
and identify potential problems in the reconciled version.
Finally, three independent native Chinese speakers (two
from Hong Kong and one from the US but a native of
Taiwan) reviewed the item history, which included all of
the forward-translations, the reconciliation, and the backtranslation.
The reviewers were asked to work independently and to
consider simple language that would easily be understood
by BMT patients with diverse levels of education. They
either selected the most appropriate translation for each
item from the reconciled and independent forwardtranslations, or provided alternative translations to improve
item content and comprehensibility when necessary. All of
their recommendations were discussed and evaluated extensively by the multi-national translation teams from the US
and Hong Kong. Consequently, a provisional Chinese version was developed. This translation was then submitted to
the language co-ordinator for grammar and character
verification before testing.
To further examine the psychometric properties and clinical
applications of the TCHI FACT-BMT Version 4 after pretesting, a larger study was conducted. Ethical approval was
obtained from the research committee of the chosen hospital. Eligible patients were identified from medical records
and were sent a package containing an invitation to participate, a consent form, a stamped return envelope, the final
TCHI FACT-BMT Version 4, and the Chinese (HK) version of Medical Outcomes Study 36-Item Short Form
Health Survey (SF-36).28–30 The SF-36 is a generic health
status measure, derived from a battery of items included in
the RAND/Medical Outcomes Study. Thirty-five of the
items assess eight dimensions of health including: physical
functioning (10 items), role limitations due to physical
health problems (4 items), bodily pain (2 items), general
health (5 items), mental health (5 items), role limitations
due to emotional problems (3 items), social functioning (2
items) and vitality (4 items). The remaining item asks
respondents about health changes over the past year that
are not currently scored. All BMT patients were included,
with the exception of those for whom transplantation had
occurred less than 1 year previously. The literature has
shown that the latter group was more compromised in terms
of physical functioning and psychological status.31 As
McQuellon et al12 noted, physical well-being and functional
well-being are adversely affected in the short term by bone
marrow transplantation. Scores are known to change
notably for patients assessed initially when they are symptomatic and subsequently when they are free of symptoms.32 Recruiting such patients would have introduced
‘atypical cases’ to our sample. Such an inclusion will be
more useful when we ‘seek to compare extremes of a
phenomenon in order to generate hypotheses about it’.17
The patients in our validation study included those with
chronic myelogenous leukaemia (CML), acute myeloblastic
leukaemia (AML), acute lymphocytic leukaemia (ALL),
non-Hodgkin’s lymphoma (NHL), multiple myeloma, and
miscellaneous conditions. Patients who did not respond
within 3 weeks were telephoned and again asked to
participate.
Pre-testing
Statistical analysis
The provisional version of the TCHI FACT-BMT Version
4 was pre-tested on 20 patients recruited from the Bone
The demographic and clinical characteristics of the validation sample (n = 134) were summarised by descriptive
43
Bone Marrow Transplantation
Translation into Chinese of a QOL instrument
AKL Lau et al
44
statistics. The construct validity of the TCHI FACT-BMT
Version 4 was first studied by examining the internal consistency of the subscales. Specifically, Cronbach’s ␣ coefficients were obtained from the validation sample and were
compared to those from the original English validation
sample. The reliability coefficients of the FACT-G scales
obtained from this translated version were also compared
to those reported by Yu et al.16 Inter-scale correlations
among the TCHI FACT-BMT domains as well as the correlations between these and SF-36 were also obtained and
evaluated by Spearman’s rank correlation coefficients. A
correlation coefficient of at least 0.4 was considered as
practically relevant. Finally, the sensitivity of the TCHI
FACT-BMT was examined by comparing FACT-BMT
scores between patients with and without any pulmonary
diseases who were expected to differ in their QOL scores.
To examine the difference, the two-sample t-test was used
when normal distribution was appropriate, otherwise the
nonparametric Wilcoxon rank sum test was adopted. A 0.05
level of significance was used for all significance tests, and
the Statistical Analysis System (SAS) Version 8.0 was used
for all statistical analyses.
Results
Translation and pre-testing
Among the 23 BMT-specific items, seven required refinement during the translation process, and modifications were
made to improve their comprehensibility (see Table 2).
Overall, patients commented that the TCHI FACT-BMT
Version 4 was easy to complete and the items were relevant. Most patients appeared not to have resumed sexual
activity after BMT, and found it difficult to comment on
this aspect of the questionnaire. Most patients felt uneasy
Table 2
responding to item GE5 (‘I worry about dying’) and item
GE6 (‘I worry that my condition will get worse’). This suggests that a high proportion of patients use avoidance as a
coping mechanism, and it highlights the local belief that
talking about death or any unfavourable outcome is ‘bad
luck’. Reliability coefficients (Cronbach’s ␣) also indicated
acceptable internal consistency, which suggested that these
translated items performed well with the rest of the items
in the same scale.
Validation study
Out of the 201 TCHI FACT-BMT Version 4 questionnaires
that were distributed, 134 (66.6%) were returned. The
demographic and clinical characteristics of the validation
sample are listed in Table 3. The median time since BMT
was 4.0 years, with a range from 1.1 to 9.8 years. Of the
patients, 69.4% were aged between 31 and 50. Of these,
60.5% had been educated to secondary school level, and
21.6% had reached tertiary level or above; 62.7% had no
religious background. The diagnoses in the study sample
were mixed, and included acute leukaemia (n = 52), chronic
leukaemia (n = 47), lymphoma (n = 19), and others
(n = 16).
The internal consistency (Cronbach’s ␣ coefficient) of
the TCHI FACT-BMT Version 4 subscales for the validation sample were summarised and compared with those
of the original English Version 37 and the traditional Chinese Version 316 (see Table 4). The internal consistency of
the TCHI FACT-BMT Version 4 was universally higher
than the English version in all subscales, which indicated
that its structure was generally comparable with the original
English Version 3.
When the item ‘I worry that my condition will get worse’
was added to the emotional well-being subscale in Version
Improvements made to increase comprehensibility of the BMT-specific items during translation
Item No.
Item content
BMT 4
The effects of treatment are worse than I had imagined
BMT5
I am able to get around by myself
BMT8
I have confidence in my nurse(s)
BMT13
I am bothered by a change in the way food tastes
B1
I have been short of breath
BMT16
I have trouble with my bowels
BMT17
My illness is a personal hardship for my close family
members
Bone Marrow Transplantation
Problems and actions taken to improve comprehensibility
With reference to the BMT development and validation, the phrase ‘effects
of treatment’ refers to the side-effects of the treatment. In the original
Chinese translation, the word ‘effects’ can imply results. Therefore, ‘sideeffects’ replaced.
The phrase ‘get around’ has a different meaning in Chinese. It can also
express ‘to move about’. The original English implies that the patient can
move about by himself. Therefore, the final version was rewritten as: ‘I am
able to move around by myself’.
The statement becomes plural by combining the translation and the
reconciled version, as there will be more than one nurse to take care of the
patient. The final amendment reads: ‘I have confidence in the nurse(s) who
take care of me’.
The statement refers to the perception of taste. Therefore, the final version
implies ‘I am bothered by the change of taste’.
The word ‘short of breath’ has a different colloquial interpretation in
Chinese. This word caused some difficulty in the back-translation. The final
version states: ‘When I breathe, I have not enough breath’.
There is different interpretation of the word ‘bowels’. This can imply ‘bowel
movement’ or ‘trouble with stomach and intestinal discomfort’. The final
version reads: ‘I have trouble with stomach and intestinal discomfort’.
In the original item, the illness is the personal hardship of close family
members. The final version reads: ‘My illness causes my close family
personal hardship’.
Translation into Chinese of a QOL instrument
AKL Lau et al
Table 3
Demographic and clinical characteristics of the validation
sample (n = 134)
Demographic
Gender
Male
Female
Age
18–30
31–50
51–65
Education
Primary
Secondary
Tertiary or above
Others
Religion
Buddhism
Catholicism
Chinese idols
Christian
None
Clinical characteristic
Leukaemia type
Acute leukaemic
Chronic leukaemic
Lymphoma
Others
Conditioning regimen
Chemotherapy + radiotherapy
Chemotherapy only
Type of BMT
Allo
Auto
Table 4
n
%
76
58
56.7
43.3
25
93
16
18.7
69.4
11.9
21
81
29
3
15.7
60.5
21.6
2.2
21
11
1
17
84
15.7
8.2
0.8
12.7
62.7
52
47
19
16
38.8
35.1
14.2
11.9
45
89
33.6
66.4
111
23
82.8
17.2
4, the alpha coefficient improved (␣ = 0.78) as compared
to the original five-item scale (␣ = 0.67) in Version 3. The
alpha coefficient (␣ = 0.9) of the total score of the 27-item
Chinese FACT-G Version 4, excluding the two ‘Relationship with Doctor’ items and with the addition of one
emotional well-being item, was comparable to the full 28item English Version 3 (␣ = 0.88). There was no change in
the alpha coefficient (0.92) of the traditional Chinese version when the items ‘I have concerns about my ability to
have children’ and ‘I regret having the bone marrow transplant’ were set aside from the BMTS, but there existed a
slight change, from 0.89 to 0.90, in the English version.
Overall, the alpha coefficients of the TCHI FACT-BMT
Version 4 were universally higher than those of the English
Version 3. As can be seen in Table 4, all alpha coefficients
of the TCHI FACT-G Version 4 are higher than those
reported by Yu et al16 for Version 3.
Construct (concurrent) validity was evaluated by examining the inter-scale correlations of the FACT-BMT itself,
and their correlation with the SF-36. Most FACT-BMT
subscales correlated moderately (r ⬎ 0.40) with the SF-36
scales (see Table 5), which indicated a relatively high
degree of concurrent validity. Criterion-related validity was
also tested by the use of FACT-BMT scores to distinguish
groups known to differ from one another (known-group
comparison). The differences in FACT-BMT scores
between patients with and without pulmonary disease are
summarised in Table 6. Significant differences were found,
except for social/family well-being, functional well-being
and emotional well-being. In general, patients without pulmonary disease scored higher in all subscales of FACTBMT.
45
Descriptive statistics of the traditional Chinese and original English language versions of the FACT-BMT
Version 4
Version 3
Validation
(n = 134)
Mean (s.d.) Alpha coefficients
PWB (7 items)
SFWB (7 items)
RWD (2 items)
EWB (5 items)
EWB (6 items)a,1
FWB (7 items)
FACT-G Total (28 items)
FACT-G Total (27 items)2
BMTS (12 items)
BMTS (10 items)3
TOI (PWB + FWB + 10-item BMTS) (24
items)
FACT-BMT total (12 BMTS) (39 items)
FACT-BMT total (10 BMTS) (37 items)
Englishb
(n = 182)
Mean (s.d.) Alpha coefficients
Chinesec
(n = 1108)
Mean (s.d.)
Alpha coefficients
22.1 (4.8)
20.4 (5.3)
—
15.6 (3.2)
18.3 (4.1)
19.2 (5.3)
—
79.5 (14.3)
28.5 (6.0)
27.3 (5.9)
68.2 (13.7)
0.84
0.83
—
0.71
0.78
0.85
—
0.90
0.64
0.74
0.90
21.6 (5.3)
24.0 (3.8)
7.3 (1.1)
15.2 (3.1)
—
17.7 (5.5)
85.8 (13.6)
—
35.3 (5.6)
27.9 (5.4)
67.2 (13.8)
0.84
0.69
0.62
0.67
—
0.78
0.88
—
0.60
0.63
0.87
21.8
19.3
4.8
13.7
(5.5)
(4.6)
(1.8)
(4.0)
—
13.7 (5.9)
73.4 (14.4)
—
—
—
—
0.75
0.53
0.37
0.65
—
0.75
0.85
—
—
—
—
108.0 (19.8)
106.6 (19.7)
0.92
0.92
121.0 (18.0)
113.7 (17.9)
0.89
0.90
—
—
—
—
PWB = Physical Well-being; SFWB = Social/Family Well-being; RWD = Relationship with Doctor; EWB = Emotional Well-being; FWB = Functional
Well-being; BMTS = Bone Marrow Transplant Subscale; and TOI = Treatment Outcome Index.
a
Consistent with the scoring published in the FACT Version 4 manual, the following clarifications are offered: 1The item ‘I worry that my condition
will get worse’ is added to the Emotional Well-Being scale. 2Six-item Emotional Well-being is used, and two Relationship with Doctor items are excluded.
3
‘I have concerns about my ability to have children’ and ‘I regret having the bone marrow transplant’ have been set aside in the statistical analysis.
b
From McQuellon et al.7
c
From Yu et al16
— = not applicable.
Bone Marrow Transplantation
Translation into Chinese of a QOL instrument
AKL Lau et al
46
Table 5
Construct (concurrent) validity coefficients (n = 134)
FACT-BMT
SF-36
PWB
SFWB
EWB
FWB
FACTG
BMT
TOI
FACTBMT
PF
RP
BP
GH
VT
SF
RE
MH
1
0.37
1
0.50
0.34
1
0.48
0.49
0.49
1
0.75
0.73
0.73
0.78
1
0.66
0.61
0.64
0.65
0.84
1
0.80
0.60
0.65
0.80
0.93
0.93
1
0.75
0.73
0.72
0.77
0.98
0.92
0.97
1
0.52
0.20
0.27
0.47
0.49
0.32
0.51
0.46
0.54
0.19
0.31
0.41
0.45
0.42
0.52
0.46
0.59
0.25
0.30
0.42
0.52
0.47
0.55
0.52
0.56
0.22
0.35
0.34
0.49
0.42
0.52
0.49
0.61
0.42
0.39
0.53
0.61
0.52
0.61
0.60
0.48
0.34
0.37
0.63
0.59
0.57
0.65
0.60
0.45
0.37
0.44
0.57
0.57
0.51
0.59
0.57
0.47
0.47
0.60
0.57
0.65
0.60
0.64
0.66
1
0.53
1
0.55
0.46
1
0.49
0.36
0.41
1
0.43
0.30
0.48
0.50
1
0.46
0.54
0.44
0.37
0.45
1
0.37
0.54
0.30
0.35
0.42
0.57
1
0.19
0.29
0.34
0.27
0.52
0.50
0.56
1
FACT-BMT
PWB
SFWB
EWB
FWB
FACTG
BMT
TOI
FACT-BMT
SF-36
PF
RP
BP
GH
VT
SF
RE
MH
All correlations were significant at the 0.05 level.
PWB = Physical Well-being; SFWB = Social/Family Well-being; RWD = Relationship with Doctor; EWB = Emotional Well-being; FWB = Functional
Well-being; BMTS = Bone Marrow Transplant Subscale; TOI = Treatment Outcome Index; PF = physical functioning; RP = role limitations due to physical health problems; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role limitations due to emotional problems; and
MH = mental health.
a
The item ‘I worry that my condition will get worse’ is added to the Emotional Well-being scale.
b
‘I have concerns about my ability to have children’ and ‘I regret having the bone marrow transplant’ have been set aside in the statistical analysis.
Table 6
FACT-BMT group comparisons
Without pulmonary
disease
(n = 119)
Physical Well-being (7 items)
Social/Family Well-being (7 items)
Emotional Well-being (6 items)a
Functional Well-being (7 items)
FACT-G Total (27 items)3
Bone Marrow Transplant Subscale
(10 items)b
TOI (PWB + FWB + 10-item BMTS)
(24 items)
FACT-BMT Total (10 BMTS)
With pulmonary disease
(n = 15)
P value
Mean
s.d.
Mean
s.d.
22.6
20.6
18.4
19.4
80.7
27.7
4.3
5.2
4.0
5.3
13.8
5.7
17.9
18.5
17.3
17.7
71.3
24.2
6.2
5.8
4.3
4.9
15.7
6.9
0.010
0.194
0.370
0.224
0.017
0.031
69.4
13.1
59.7
15.2
0.010
108.3
18.9
95.5
22.1
0.019
Higher scores reflect better quality of life.
a
The item ‘I worry that my condition will get worse’ is added to the Emotional Well-being scale.
b
‘I have concerns about my ability to have children’ and ‘I regret having the bone marrow transplant’ have
been set aside in the statistical analysis.
Discussion
This paper reports an international collaboration between
multilingual translation teams in the US and Hong Kong
to translate and validate the FACT-BMT Version 4 into
traditional Chinese (TCHI). The translation complied with
the FACIT translation methodology. The backtranslations of some revised modified items were found to
Bone Marrow Transplantation
be satisfactory when compared to the original English version. The results of pre-testing demonstrated the satisfactory reliability of the subscales of the translated version.
The patients were able to complete the questionnaire by
themselves, and commented that the TCHI FACT-BMT
Version 4 was easy to understand and the items were
relevant to measuring health-related QOL.
The results suggest that TCHI FACT-BMT can be
Translation into Chinese of a QOL instrument
AKL Lau et al
applied to measure QOL in patients undergoing BMT in
Hong Kong and other places where traditional Chinese
characters are still in use. There are good reasons to believe
that it can also be applied in mainland China, where simplified Chinese characters are used. As Chen33 has explained
in Modern Chinese History and Sociolinguistics: ‘While it
takes some time for people trained in simplified script to
learn to write in the complicated [or traditional] one, a reading knowledge of the other type of script is very easy to
acquire. In correspondence between people from mainland
China and elsewhere, handwritten characters in different
styles are rarely reported to cause any problems in
comprehension. Difficulties in comprehension due to the
differences between the complicated [or traditional] and the
simplified characters have been exaggerated’ (material in
brackets added). The second reason is that simplified
characters have not completely replaced traditional Chinese
characters. The general public has found it difficult to
accept so many unfamiliar simplified characters within a
limited period of time. As Chen has noted,33 an effective
writing system should strike a balance between ease of production and ease of recognition. While a reduction in the
number of strokes makes characters easier to write, it
makes them less differentiated from each other and thus
less easy to recognise. Simplification makes life easier for
the writer, but more difficult for the reader. However, even
though it will be possible to use the traditional Chinese
version in mainland China, a well-translated simplified Chinese character version is still needed. The development of
such a translation will be discussed elsewhere.
The results from the psychometric evaluation of the
TCHI FACT-BMT Version 4 indicated that its scale structure was generally similar to its original English version.
The alpha coefficients of all subscales obtained from the
validation sample (n = 134) were universally higher than
those from the original English Version 3 sample. It is also
noticeable that all alpha coefficients of the TCHI FACT-G
Version 4 were consistently higher than those reported by
Yu et al,16 which indicates its better psychometric performance. Both concurrent and criterion validity also showed
good construct validity. This study illustrated that the TCHI
FACT-BMT Version 4 is comparable to the original
English version, and better than the traditional Chinese
FACT-G Version 3.
Cross-cultural comparisons are not as simple as one
might expect. The creation of a QOL instrument that can
be translated and validated in different cultures does not
automatically warrant valid and meaningful comparisons
across those cultures. People in different cultures and
societies have different sets of values and are likely to consider different criteria when judging their own QOL. This
cultural relativism points us to the idea that there are alternative paths that can accommodate human needs and
desires.34 In Chinese culture, where the relational and interdependent aspects of the self predominate, self-evaluation
is based to a significant degree on external, social information rather than the private experiences (eg emotion) of,
for instance, an American individual.35 The path to one’s
ideal QOL is thus different in Chinese and American cultures. In American culture it may be the pursuit of happiness. While in Chinese culture, personal happiness occupies
a less salient position. For happiness and unhappiness are
seen to stem from a common ‘root’,36 which is a Confucian
concept. Unhappiness is believed to arrive on the heel of
happiness, and vice versa. An individual’s gain of happiness means the loss of happiness by another individual.
Happiness, therefore, should not be embraced with excessive joy while unhappiness of the moment should be endured
for happiness is just around the corner.35 ‘How am I viewed
by others?’ is a more salient concern in East Asian cultures,37 while in America it is ‘this is what I think’, with
the often overly positive views about the self.38–40 When
an American reports ‘I feel good’ or ‘I lead a good life’,
one may wonder whether this is how the individual wishes
to view himself41 or whether self-deceptive mechanisms
have been involved.42 When similar answers are given by
a Chinese individual, is it because of social desirability
bias, or because of a suspicion that the interviewers are part
of a surveillance system of the Chinese government?17 We
are a long way from claiming any success in making crosscultural comparisons of the QOL of BMT patient, but we
have taken a step closer to such comparisons.43
This is the first study on the QOL of Chinese BMT survivors as measured by the TCHI FACT-BMT Version 4.
One of the study limitations is related to the relatively small
sample, and the unequal sample size in each disease group.
This hindered the possibility of drawing powerful conclusions in terms of cross-group comparisons. A larger
sample size of patients in each subtype of leukaemia would
have facilitated conclusions about how different types of
disease affect patient responses. Another limitation is that
this study has not examined the stability or test–retest
reliability of the instrument due to the unavailability of data
from a second assessment. Longitudinal data collection is
underway, and the TCHI FACT-BMT’s measurement stability will be evaluated. Based on our previous experiences
and reported results of the English version7 we are confident that the test–retest reliability will be high and statistically significant. The results will be reported elsewhere
when data become available. Finally, a prospective longitudinal study is underway to examine the responsiveness
of the TCHI FACT-BMT Version 4 over time.
In conclusion, the international collaboration between the
US and Hong Kong teams has enhanced the development
of a culturally specific Chinese QOL instrument for Chinese BMT survivors. Despite difficulties in translation and
the cultural differences mentioned above, the TCHI FACTBMT Version 4 has high internal consistency and good
overall comprehensibility. It is a well translated and
psychometrically valid tool to assess the QOL of Chinese
BMT patients.
47
Acknowledgements
We wish to thank all of the patients at the Bone Marrow Transplant Unit, Queen Mary Hospital, for their participation. We wish
also to thank the two anonymous referees for their valuable comments and suggestions. This research was supported by a grant
sponsored by the Department of Medicine, the University of Hong
Kong, and the Bone Marrow Transplant Unit, Queen Mary Hospital, Hong Kong SAR, PRC.
Bone Marrow Transplantation
Translation into Chinese of a QOL instrument
AKL Lau et al
48
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