est number of words in the sentence (24 words in English and 19 words in Malay version), which caused trouble during forward and backward translations.

Table 3 shows the details of the finding for each item after going through the different level of translation process and cultural adaptation. Despite having a discrepancy of translation words, the knowledge and the concept of each item were preserved. Most of the items had a direct translation to Malay language except for item 5, 7, 12, 20, and 22. For item 5, parts of the sentence newer homes than in older homes were replaced with houses built before 1978 and houses built after 1978. For item 7, parts of the sentence having lead dust on their hands were removed. For item 12, parts of the sentence the lead a pregnant woman takes into her body were removed. For item 20, the word soap was removed. For item 22, parts of the sentence without too much fatty foods were removed.

A total of eight respondents were recruited during the cognitive (+SD) for each domain; general knowledge, exposure, prevention and nutrition was 1.75 (+ 0.71), 4.50 (+0.93), 1.13 (+ 0.64) and 2.13 (+0.64), respectively. The interquartile range (IQR) was 1 mark for each domain. Only one respondent scored zero for domain prevention (which also scored the lowest for the total knowledge score). The mean (+SD) and IQR for the total knowledge score recorded was 9.50 (+2.45) marks and 5 marks, respectively. The average knowledge level of the respondents during cognitive debriefing was found to be moderate (9 to 16 marks). The lowest total knowledge score was 6 marks and the highest total knowledge score was 13 marks. The time taken to complete the questionnaire was ranging from 8 to 15 minutes. The respondents were able to understand the Malay sentence of each item very well at first attempt.

DISCUSSION

Several studies applied different methods of translation and cultural adaption on the questionnaire (Maneesriwongul & Dixon 2004). However, the more systematic way on translation process and cultural adaptation was adapted in the current study based on the ISPOR standard as the authors believed that the Malay language with different dialect and meaning in Malaysia should be translated with care and detail. As far as can be ascertained, this will be the first study to adopt systematic and standardised methods to translate and adapt the CLKT cross-culturally in Malaysia and other Malay speaking countries like Indonesia, Singapore and Brunei. The process of translating the instrument was stringent, time consuming and involved many people (experts and laymen). Throughout the study, the authors have discussed with the experts and came into agreement in modification of the items, choosing the correct words and sentences, face validity and feasibility of the instrument to avoid unnecessary translation bias. 

The instrument was modified due to difference of exposure in term of socio-demographic background, economy, environment and legal implementation in Malaysia compared to the USA. The modification was performed in the current study in careful manner to preserve the quality of response scale and scoring system of the instrument. The authors decided to remove one item from the original instrument (Statement: Apartment owners are required to tell renters about known lead-containing paint in the apartment when a lease is signed) due to irrelevant implementation in Malaysia. As what has been practiced in the USA, it is a requirement by the federal law for housing built before 1978 that renters must receive all information about lead from the house owner before signing the lease as following; i) the Environmental Protection Agency (EPA) approved information pamphlet on identifying and controlling lead-based paint hazards, ii) any known information concerning the presence of lead-based paint or hazards in the house, and iii) an attachment to the contract that includes a ‘Lead Warning Statement’ (U.S. Environmental Protection Agency 2019). While in Malaysia, the rent control was currently governed by the Control of Rent (Repeal) Act 1997 which replaced the previous Control of Rent Act 1966  (Federal Government Gazette 1997). This act focuses more on fair rent and recovery of possession of controlled premises. Unfortunately, the disclosure about lead health hazards and its prevention through legal rental agreement is neither been mentioned in the law nor widely practiced in Malaysia. 

The authors agreed to revise and modify one item from the original instrument (Statement: Some pottery imported from Mexico or other countries is not safe to use in cooking or for eating, because it contains lead). From the expert’s point of view, the children are more exposed towards toys instead of potteries as they are easily available at home and kindergarten, and because of children’s behaviour of licking or sucking the toys, or in the worst case when they swallow a toy or a piece of a toy (Njati & Maguta 2019). In fact, the toys are always introduced very early to the baby. Previous study found that the toys for toddler had higher lead content compared to the toys for other preschool age (Sun et al. 2018). Most of the toys imported from China contain high lead compared to other countries (Njati & Maguta 2019). In addition, painted toy at the metal, plastic, and wood surfaces were found to have high lead content (Cui et al. 2015; Meyer et al. 2008). Therefore, the statement for this item was modified into “Some kids toys imported from China or other countries are not safe, because it contains lead”. The authors also agreed to add one item into the instrument (Statement: Some stationeries such as colour pencil or crayon is not safe, because it contains lead). Beside toys, children have more contact with the colour pencils and crayon while drawing or colouring. Colour pencil and crayon are the most common type of stationeries which contain high lead (Okonkwo & Maribe 2004; Romieu et al. 1994). Children who tend to bite the pencils and ingest the chips may exposed themselves to this source of lead and may contribute to the total body burden (Okonkwo & Maribe 2004).  Previous studies’ finding showed the relationship between the ingestion of colour pencils and high level of BLL among children (Gorospe & Gerstenberger 2008; López-Carrillo et al. 1996; Olaiz et al. 1996).

The authors referred to an open access online service vocabulary called Malay Literary Reference Centre or Pusat Rujukan Persuratan Melayu (PRPM) for verification of the translated words (from English to Malay and vice versa). This search engine was provided by the Institute of Language and Literature, also known as Dewan Bahasa dan Pustaka (DBP) and enables users to search information holistically across all DBP databases; dictionary, terms, encyclopedias, poetry, cultural language, dialect, proverbs, archive query language, Malay language thesaurus, and content of other websites as determined by DBP (Institute of Language and Literature 2017).

There was no fixed rule to assign the translators. As recommended by ISPOR standard (Wild et al. 2005), the criteria to be well-qualified translator are; i) professional translators, ii) native speakers of the target language and fluent in the source language, usually English, iii) familiar with both cultures, and iv) knowledgeable in the content of the instruments or tools under assessment. In this study, all translators (Dr. A, Dr. B, Dr. C, Dr. D, Dr. E and Dr. F) were eligible to translate the questionnaire. The utilisation of more than one translator in the process gives more perspectives and better outcomes (Epstein et al. 2015). Due to financial constraint, the authors did not assign the certified translator, instead, appointed the translators from doctors and lecturers who are well verse in environmental toxicology. Another reason would be, when the translators were among the subject matter experts, the authors did not have to re-brief or provide additional knowledge.

The translation process was quite challenging because some of the items could not be directly translated. One word might have various meanings in another language and can be considered as being a more complex unit (Harkness et al. 2004). When the authors could not determine a good translation equivalent, a maneuver was done to suit the original meaning as in item 4 and 6. For item 4, the words child’s highest blood lead level were translated into paras plumbum dalam darah kanak-kanak yang paling tinggi. For item 6, the words living in a building were translated into kanak-kanak yang mendiami di dalam bangunan. In special circumstances, the words and the sentence structure should be modified or be improved to suit the thinking process of an average person (Harkness et al. 2004; McKay et al. 1996). For item 5, during cognitive debriefing, the respondents had confusion with the statement of this item. They misinterpreted the newer home as the first-hand house and the older home as the second-hand or used house. The knowledge about the use of indoor lead-based paint in houses built before 1978 was beyond their thinking. They suggested using the benchmark word 1978 to differentiate those kinds of houses. The number of words in Malay sentences are usually more than translated equivalence English sentences. Length of word and sentence, and word frequency will affect the readability and comprehensibility. In other words, the usage of longer words, longer syllables, and longer sentences makes texts more difficult to comprehend (Lenzner 2014). To make the sentences shorter and at the same time preserve the conceptual meaning, the author decided to remove certain words as in item 7, 12, 20 and 22.

A good questionnaire design allows the content to take the front seat. Self-completed questionnaires required a careful construction. The ideal questionnaire design would be in readable font, well organised, sufficient space between items, easy to navigate, clear distinguishable questions from response scale, adequate length and single point of question, unambiguous and clear wording, and use of mechanical devices such as arrows, boxes, asterisks and other symbols (Bee & Murdoch-Eaton 2016).

The achievement of cultural and linguistic equivalence in the newly modified instrument is vital to amplify the points of comparison in results produced in different cultures. A pilot study needed to be carried out after extensive translation and cultural adaptation processes to assess the appropriateness of the Malay-version CLKT to the parents of pre-school children in Kuala Lumpur, Malaysia. The present study was done in a small scale to examine the feasibility of the questionnaire and score pattern among the parents. In future pilot test, the respondents will answer the survey in the planned delivery mode (paper-based format). The data acquired from the pilot test will then be analysed statistically to describe the distribution of response by item and to measure the reliability and validity of the instrument.

CONCLUSION

The original English version CLKT was translated and cross-culturally adapted to Malay language using established international standards. The instrument that was produced is presently being validated by the authors. The authors believed that the cultural and linguistic adaptation of the CLKT for Malaysian population will result in valuable input and supplement work currently being carried out in other places. A robust translation process and cultural adaptation conducted in this study produced a culturally equivalent Malay version of the CLKT when compared with the original English instrument.

ACKNOWLEDGeMENT

The authors would like to thank the Department of Community Health, Faculty of Medicine, UKM for the assistance given for this research. The study was approved by the UKM research and ethics committee: FF-2018-286 and the National Medical Research Register (NMRR) from MOH Malaysia: NMRR-18-3765-45117. This research was funded by UKM research and ethics committee.