The cross-cultural equivalence of participation instruments: a systematic review Purpose Concepts such as health-related quality of life, disability and participation may differ across cultures. Consequently it is important to test the cultural equivalence of a particular measure. This paper reviews the process of cross-cultural equivalence testing of instruments to measure social participation. Methods An existing cultural equivalence framework was adapted and used to assess the instruments

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... luded 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 therefore five 'extensive' ratings. Articles were included if the instruments focused explicitly on measuring (social) participation and were theoretically grounded in the ICIDH (-2) or ICF. Crossvalidation articles were only included if it concerned an adaptation of an instrument developed in Europe, North America, Australia or New Zealand to an African, Asian or Pacific language version of the instrument 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. Five studies scored no 'extensive' rating at all. Two 'extensive' ratings were assigned to conceptual, item and semantic equivalence, whereas measurement equivalence received no 'extensive' rating at all. The majority of the 'none/minimal' ratings were given for item and measurement equivalence. Conclusion The cross-cultural equivalence testing of participation instruments 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 results. Methods A systematic search was conducted to identify all studies describing the development of, or crosscultural validation of instruments that measure social participation (restriction). Three literature databases were searched: Pubmed (Medline), PsycINFO and Web of Science. A generic syntax was made that consisted of main key words, presented in the title, abstract or main text. The syntax was a variation of the following: AND <(cross-cultur* OR cultur* OR valid* OR equivalence)>. The bibliographies of the articles were scanned to identify other relevant studies. In addition, all the initial developers of the instruments and authors of the cross-validation studies were contacted with the request to inform us if they knew of other possibly relevant studies. The last search was concluded on 10 June 2011. The systematic literature search was performed by the first author. Titles and abstracts of the articles were reviewed and after the exclusion of non-relevant papers, full-text articles were assessed and checked to ascertain whether they met the two-step inclusion round. During the first step, articles were included only if the instruments focused explicitly on the measurement of (social) participation, were theoretically grounded in the International Classification of Impairments, Disabilities and Handicaps (ICIDH or ICIDH-2) or International Classification of Functioning, Disability and Health (ICF), were written in English, freely available or could be obtained from the authors. This resulted in a comprehensive overview of the current state of participations instruments developed. During the second step, the selection was further limited to cross-validation articles describing an adaptation of an instrument developed in Europe, North America, Australia or New Zealand to an African, Asian or Pacific language version of the instrument or vice versa. The process of cultural equivalence testing was assessed by using a modified version of the framework by Herdman (12;13). This framework defines several categories of equivalence (conceptual, item, semantic, operational and measurement) and can be used to assess the extent to which an instrument is suitable for use in a different cultural setting than it was initially developed for (Table 1) . We made several adaptations to this framework, especially regarding measurement equivalence. The benchmarks proposed by Terwee et al. were incorporated in measurement equivalence. Item Response Theory methods (e.g. Rasch analysis) were also added as a subcategory of measurement equivalence, because they provide detailed additional information about the validity of an instrument, relevant in a cross-cultural context. The assessment of the Minimally Important Change (22) van der Zee CH, Priesterbach AR, van der Dussen L, Kap A, Schepers VPM, Visser-Meily JMA et al.