J Clin Epidemiol Vol. 51, No. 11, pp. 925–932, 1998 Copyright © 1998 Elsevier Science Inc. All rights reserved. 0895-4356/98 $–see front matter PII S0895-4356(98)00083-3 Cross-Cultural Comparisons of the Content of SF-36 Translations across 10 Countries: Results from the IQOLA Project Anita K. Wagner, 1 * Barbara Gandek, 1 Neil K. Aaronson, 2 Catherine Acquadro, 3 Jordi Alonso, 4 Giovanni Apolone, 5 Monika Bullinger, 6 Jakob Bjorner, 7 Shunichi Fukuhara, 8 Stein Kaasa, 9 Alain Leplège, 10 Marianne Sullivan, 11 Sharon Wood-Dauphinee, 12 and John E. Ware, Jr. 1 1 Health Assessment Lab at the Health Institute, New England Medical Center, Boston, Massachusetts; 2 Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; 3 Mapi Research Institute, Lyon, France; 4 Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM), Barcelona, Spain; 5 Dipartimento di Oncologia, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy; 6 Abteilung Für Medizinische Psychologie, Universitätskrankenhaus Eppendorf, Hamburg, Germany; 7 institute of Public Health, University of Copenhagen, Copenhagen, Denmark; 8 Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; 9 Unit for Applied Clinical Research, The Norwegian University for Science and Technology, Trondheim, Norway; 10 Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 292, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France; 11 The Health Care Research Unit, Institute of Internal Medicine, Sahlgrenska University Hospital and Göteborg University, Göteborg, Sweden; and 12 School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, Canada ABSTRACT. Increasingly, translated and culturally adapted health-related quality of life measures are being used in cross-cultural research. To assess comparability of results, researchers need to know the comparability of the content of the questionnaires used in different countries. Based on an item-by-item discussion among International Quality of Life Assessment (IQOLA) investigators of the content of the translated versions of the SF-36 in 10 countries, we discuss the difficulties that arose in translating the SF-36. We also review the solutions identified by IQOLA investigators to translate items and response choices so that they are appropriate within each country as well as comparable across countries. We relate problems and solutions to ratings of difficulty and conceptual equivalence for each item. The most difficult items to translate were physical functioning items that refer to activities not common outside the United States and items that use colloquial expressions in the source version. Identifying the origin of the source items, their meaning to American English-speaking respondents and American English synonyms, in response to country-specific translation issues, greatly helped the translation process. This comparison of the content of translated SF-36 items suggests that the translations are culturally appropriate and comparable in their content. J CLIN EPIDEMIOL 51;11:925–932, 1998. © 1998 Elsevier Science Inc. KEY WORDS. Health status, health-related quality of life, translations, SF-36 Health Survey, cross-cultural comparisons, IQOLA INTRODUCTION Measuring health status is an important component of national and international health services research and of increasing interest in clinical practice. A number of health- status measures have been developed, mostly for use in En- glish-speaking countries [1]. For use in the growing number of large multicenter, multicountry trials, as well as to assess the health status of different cultural groups within a coun- try, the need for non–English language measures has in- creased. One approach to meet this need is to translate and adapt measures originally developed in English for use in a different cultural context. However, health status measures developed for use in one country cannot just be translated into another language; rather, for a questionnaire to be rel- evant and appropriate in a different setting, cultural adapta- tion is needed, which may lead to differences between translated versions and the source questionnaire. Similari- ties and differences in the content of adapted question- naires determine the interpretation of results of cross-cul- tural health status assessments. As previously described [2–4], the International Quality of Life Assessment (IQOLA) translation and adaptation procedure focused on translation of the SF-36 such that conceptual equivalence with the source version was main- *Address for correspondence: Anita K. Wagner, Pharm. D., M.P.H., Health Assessment Lab, NEMC #345, 750 Washington Street, Boston, MA 02111. Accepted for publication on 7 July 1998.