Translation and cross-cultural adaptation of English-based tools are essential to ensure validity, cultural relevance, and appropriateness for the target population. Peña (2007) identifies key forms of equivalence to consider: linguistic, functional, cultural, and metric. Herdman et al. (1998) propose a complementary framework encompassing conceptual, item, semantic, operational, and measurement equivalences. Recent studies applying these frameworks emphasise participatory approaches and pretesting with children and young people to enhance cultural relevance and comprehension (Cruchinho et al., 2024; Fekar Gharamaleki and Fathipour-Azar, 2025; Verde-Avalos et al., 2025). These models guide the adaptation processes in child development (Peña, 2007) and quality-of-life research (Herdman et al., 1998), making them relevant to this study.

Conceptual equivalence refers to the extent to which the constructs have the same meaning and relevance across cultures and should be examined prior to translation, as cultural differences may influence how constructs are understood (Herdman et al., 1998). Linguistic or semantic equivalence involves accurate translation, typically through forward and back translation and expert consultation to resolve discrepancies (Cruchinho et al., 2024; Herdman et al., 1998; Peña, 2007).

Functional equivalence ensures that the tool measures the same construct in the new culture, while cultural equivalence concerns how items and responses are interpreted (Herdman et al., 1998; Peña, 2007). Operational equivalence addresses administration procedures, instructions, and formats (Herdman et al., 1998). Measurement equivalence refers to psychometric properties such as reliability and validity.

Metric equivalence (Peña, 2007), referring to similarity in item difficulty across cultures, is less relevant here because the selected tools assess experiences rather than performance (Herdman et al., 1998). Similarly, establishing full psychometric equivalence is most critical when cross-cultural comparisons are intended (Peña, 2007). In the present study, the tools are used to inform individual schools about risk and protective factors affecting the psychosocial experiences of children and young people, rather than cross-national comparisons. Nonetheless, formal psychometric evaluation of the Slovak versions may be considered in future research.

Guidelines for translation and cultural adaptation vary. The World Health Organisation (WHO) recommends forward translation, expert review, back-translation, and pretesting with the target population (Snider and Schafer, 2018). Cruchinho et al. (2024) propose an eight-step process including translation, harmonisation, and field testing. Sousa and Rojjanasrirat (2011) outline a seven-step process, the first five steps focusing on wording and cultural adaptation. In a systematic review of adaptations of the Cognitive Emotion Regulation Questionnaire, Fekar Gharamaleki and Fathipour-Azar (2025) demonstrated the importance of transparent translation and cultural adaptation procedures; however, three of the 13 destination countries reviewed did not report sufficient methodological details.

Translation, cultural adaptation, and validation are time- and resource-intensive processes requiring rigorous methodology and involvement of experts and the target population (e.g., Cruchinho et al., 2024; Snider and Schafer, 2018; Sousa and Rojjanasrirat; 2011). As a result, researchers often build on existing translations and focus primarily on psychometric validation (e.g., Ronzón-Tirado et al., 2019; Verde-Avalos et al., 2025). The present study concentrates on the earlier stages of translation and cultural adaption, given resource constraints and the primary goal of informing individual schools.

Levels of cross-cultural validation depend on the relationship between the original and target populations, ranging from “no change in culture” and “immigrants in the original country” to “different country but same language” to “different country and language” (Cruchinho et al., 2024; Guillemin et al., 1993). Potential sources of bias include conceptual differences, item relevance, and administration methods (Cruchinho et al., 2024).

Contemporary studies continue to highlight context-sensitive adaptations of English-based instruments. Granat et al. (2022) examined item clarity and comprehensibility in a Swedish healthcare adaptation of a self-efficacy in palliative care scale. Mao et al. (2021, p. 99) identified conceptual differences between Chinese and Western quality-of-life measures, noting the inclusion of traditional Chinese medicine concepts such as “weather adaption” and “spirit,” which are absent in Western instruments. These examples illustrate that although, foundational guidelines such as Guillemin et al. (1993) remain highly relevant, participatory and context-sensitive approaches are increasingly emphasised. Similarly considerations apply in Slovakia, where school-based mental health initiatives remain relatively recent and inconsistently implemented.

Drawing on the shared goal of improving education and mental health in Slovak schools, this study emerged from a research-practice partnership between university researchers and the Slovak national mental health charity, Liga za dusevne zdravie. Such partnerships aim to bridge the gap between research and practice and are recognised for their potential to foster both target interventions and systemic change (McGeown and Sjölund, 2025). Our work adds to examples from European countries including Sweden, Norway, Germany, England, and Scotland, highlighted by McGeown and Sjölund (2025).

Building on previous collaborations (e. g., Janik Blaskova and Winter, 2025, this partnership was a natural progression. Liga za dusevne zdravie [the League for Mental Health] launched Koalicia skol za dusevne zdravie [the Coalition of Schools for Mental Health] to work directly with schools to promote wellbeing and prevent mental health difficulties among pupils, students, and staff. For a small annual fee, member schools gain access to mental health activities, a regional coordinator, and detailed consultation on their Pohodomer results. To date, the League has gathered data from approximately 15,000 pupils and students and 1,500 teaching staff. In some schools, longitudinal data have been collected over multiple years, enabling monitoring of longer-term trends.

Prior informal feedback and observations from practice have indicated strong face validity of the Pohodomer. Schools report that it captures relevant issues and clarifies areas of concern. The data help schools identify mental health challenges and guide the development of psychologically safe environments.

Despite its widespread use, Pohodomer has not yet undergone formal cultural validation. Given increasing national interest in school-based mental health screening, the Ministry of Education, Research, Development and Youth and affiliated organisations such as the Research Institute of Child Psychology and Pathopsychology (VUDPaP), the National Institute for Education and Youth (NIVAM), and the State School Inspection have expressed interest in identifying or developing similar tools. This has further motivated Liga za dusevne zdravie to strengthen the methodological rigour and psychometric quality of the instrument. Table 1 summarises selected tools and their current use within Pohodomer.

The research-practice partnership team shared a commitment to including children and young people in the cultural adaptation process. Accordingly, we extended the participatory approach of research-practice model to the stakeholder groups targeted by Pohodomer. Participatory approaches have gained prominence over the past four decades (Duea et al., 2022), and consultation with target populations is recognised as a core principle [International Collaboration for Participatory Health Research (ICPHR), 2013].

This study examines existing Slovak translations of selected tools used to screen mental health experiences of children and young people in schools. Feedback from administrators highlighted limitations in item wording, prompting a systematic review of the translations. The aim was to revise the wording and enhance linguistic and cultural relevance in order to improve data quality. Following adaptation, the tools may also be relevant to organisations such as the Slovak Ministry of Education, VUDPaP, NIVAM, and the State School Inspection.

The study adopts a qualitative approach, actively involving children and young people from schools outside the Koalicia skol za dusevne zdravie to explore how they interpret and relate to the questionnaire items. This approach is consistent with qualitative methods recommended in instrument adaptation research (Guillemin et al., 1993; Peña, 2007; Sousa and Rojjanasrirat, 2011). Focus group discussions were conducted to identify potentially problematic items, instructions, and response options, and to generate alternative wording that is clearer and more meaningful.

The present study has three key objectives:

By achieving these objectives, we aim to better align the tools with Slovakia’s linguistic and cultural context and support school-based mental health initiatives through improved data quality.

This study employed a qualitative approach to achieve its objectives. It followed established guidelines from the WHO and other researchers (e.g., Cruchinho et al., 2024; Zhao et al., 2024), while adjusting the sequence of steps as the tools had already been translated into Slovak and were in use by Koalicia skol za dusevne zdravie in Slovakia.

Building on the revised Brislin's (1970) translation model, we engaged in group discussions with bilingual experts in the field of psychology and education (Jones et al., 2001). We adopted a symmetrical translation approach, which prioritises conveying culturally relevant meaning rather than literal equivalence (Cruchinho et al., 2024; Sousa and Rojjanasrirat, 2011). This approach was applied when the original meaning of items did not fully align with their literal translations or when direct translation was not feasible due to cultural differences. The symmetrical approach was consistent with the study’s participatory methodology, as children and young people were consulted to develop a version of the instrument that was meaningful for them. Their suggestions were incorporated into the revised Slovak versions prior to back-translation.

In line with the participatory approach, this study sought representatives from the target groups of the selected tools. A convenience sampling strategy was used to recruit participating schools, beginning with schools where the research team had established contacts with teachers acting as gatekeepers. Schools were selected based on prior collaboration and willingness to participate. Participants were recruited specifically for this qualitative study; the questionnaires were not administered at the whole school level.

Efforts were made to include a range of age groups across school levels and to capture variation at the upper secondary level. Participants were recruited from a gymnasium, which provides a broad academic education aimed at university entry, and a secondary industrial school of engineering, which focuses on technical and vocational training. A key inclusion criterion was that participants had no prior experience with the screening tools.

Teachers informed children and young people about the study, emphasising voluntary participation,. and distributed information sheets to carers. Informed consent was obtained from carers and from young people over 16 years of age, while informed assent was obtained from younger participants.

Participants were recruited from two locations in Slovakia. Site 1 is a small urban city in the south of the country, while Site 2 is a mid-sized urban city in the northwest. Locations outside the capital, Bratislava, were intentionally selected, as mental health and wellbeing activities, including screening and research activities, are more established there than in other regions. This approach aimed to include participants who may better reflect the broader Slovak population. The names of the participating cities have been anonymised to protect confidentiality.

Table 2 presents the sociodemographic characteristics of the sample, including location, school level, and the screening tools completed and discussed.

This study drew on a multiple qualitative data sources across three phases to inform the translation and cultural adaptation of existing Slovak versions of selected mental health questionnaires. Table 3 provides an overview of each phase, including input data, parties involved, and key outputs.

Qualitative data, including the original and translated versions of questionnaires, researcher notes, focus group transcripts, were analysed using complementary methods to ensure a comprehensive understanding of the translation and cultural adaptation process.

First, an item-by-item comparative review of the original and translated questionnaires was conducted in collaboration with the translator and the research-practice partnership team. This process assessed linguistic accuracy, conceptual consistency, clarity, and cultural relevance.

Second, focus group transcripts were analysed using a descriptive qualitative approach to capture participants’ interpretations, understanding, and emotional responses to specific questionnaire items (Peña, 2007; Schoua-Glusberg and Villar, 2014; Snider and Schafer, 2018). Transcripts were reviewed iteratively, and participant feedback was organised around key domains: interpretation, cultural relevance, and linguistic clarity (Guillemin et al., 1993; Sousa and Rojjanasrirat, 2011). These domains proposed item modifications.

Together, the item-level comparative review and qualitative analysis of focus groups enhanced linguistic precision and strenghtened the cultural validity of the adapted tools.

The cultural adaptation process typically begins with forward translation into the target language (e.g., Cruchinho et al., 2024; Snider and Schafer, 2018; Zhao et al., 2024). However, as Slovak versions of the selected tools were already in use, the study worked with the existing translations.

The primary aim was to refine these versions to ensure linguistic clarity and cultural validity. Although substantial data had already been collected using existing versions, the research-practice partnership team remained open to revisions informed by empirical findings from the qualitative phase.

The process began in February 2025, when the research-practice partnership team identified items for qualitative exploration based on practitioner feedback from meetings of the Koalicia skol za dusevne zdravie. In parallel, the first author reviewed the Slovak translations against the original versions and consulted practitioners regarding previous translation decisions. Items requiring further exploration were prioritised, while remaining open to new issues and suggestions raised by the participating children and young people during revised questionnaire administration and focus group discussions.

In March and April 2025, two consecutive teaching sessions (90 min in total), were allocated per group. Six groups completed the questionnaires and then participated in focus group discussions. Focus groups were audio-recorded using an offline voice recorder and documented in researcher notes. Based on participant feedback, the first author revised selected items, and the updated version was shared with the research-practice partnership team before back-translation.

In May 2025, back-translation into English was conducted by an independent translator with no prior involvement. The first author and translator reviewed discrepancies and agreed on final revisions to the Slovak versions.

In June 2025, version 2.0 of the selected tools was finalised and issued. The specific changes are outlined in the Result section.

Ethical approval was obtained from the Ethics committee, Faculty of Social and Economic Studies, Comenius University in Bratislava, Slovakia. The study was conducted in accordance with the Declaration of Helsinki, GDPR regulations under the Act No. 18/2018, and the ethical guidelines of the University.

Given that participants were under 18 years of age, informed consent was obtained from parents or guardians and head teachers. Young people aged 16 and over also provided consent, while younger participants provided assent. Age appropriate information sheets and consent forms were distributed.

Participants were informed verbally and in writing about the study’s purpose, voluntary participation, and their right to withdraw. They were also provided with information about available mental health support services.

At the end each session, participants were invited to share reflections on the process and to provide any feedback.

We systematically documented challenges observed during administration and identified issues related to (a) administration and technical feasibility, (b) item clarity and comprehension, and (c) completion time and response processing. Prior to administration, participants were informed that responses were anonymous and that there were no right or wrong answers. They were invited to raise their hand if they had questions. Only a small number did so. Overall, participants were willing to engage with the questionnaires and actively discuss their content during the subsequent focus groups.

To identify questionnaire items for group discussions, we drew on the research-partnership team’s prepared item list, researcher notes on questions raised during administration, and open-ended questions to participants about any words that seemed “strange or funny.” Findings are organised into three analytic areas: abstract concepts, linguistic and semantic equivalence, and cultural a.

This study was shaped by a research-practice partnership that combined everyday school experiences with research rigor. This collaboration guided decisions and ensured that cultural adaptations were systematically documented and reflected upon, creating a stronger foundation for transparency and future development. As highlighted by recent literature (McGeown and Sjölund, 2025), partnerships of this kind are essential for developing tools that are both methodologically sound and relevant for real-world contexts. Shared expertise between researchers and practitioners enhanced alignment with practical needs in schools and laid the groundwork future cross-cultural validation, field testing, and full psychometric validation of the tools (Cruchinho et al., 2024). These reflections highlight how sustained collaboration between research and practice can strengthen the development and implementation of school-based mental health screening tools, contributing to meaningful educational change.

Our experience administering the selected tools, along with follow-up discussions, revealed several practical considerations for administrators and practitioners. A key issue is that not all schools, children, and young people in Slovakia have consistent access to the internet or digital devices such as mobile phones and tablets. This reflects broader infrastructural challenges, including regulations restricting mobile phones use in primary and lower secondary schools (Ministry of Education, Research, Development and Youth of the Slovak Republic and Research Institute of Child Psychology and Pathopsychology, 2024), as well as inconsistent internet connectivity, even in urban areas. These findings highlight structural limitations in digital access within the Slovak education system, which may similarly affect other countries implementing school-based mental health screening tools.

One output of this study was the development of revised recommendations for the Pohodomer Administrator Manual to support the standardisation of administration procedures and enhance the psychometric robustness of the tool. The manual is designed to ensure consistent administration and to provide all children and young people with the same information, particularly regarding anonymity and the absence of right or wrong answers. The Slovak education system places strong emphasis on knowledge-based assessment, which may encourage children to seek the ‘correct’ response or attempt to please teachers. This tendency may be particularly pronounced given that many pupils are unfamiliar with self-report questionnaires.

We found it essential to emphasise the importance of supporting comprehension of abstract concepts, especially among young participants, those from non-Slovak-speaking backgrounds, and children and young people with reading difficulties or special educational needs. This need is increasingly relevant in the Slovak context, given the recent arrival of children and young people from Ukraine and other regions affected by conflict. While teachers, who typically act as administrators, are generally familiar with their pupils’ individual needs, external administrators such as school psychologists or newly appointed teachers, may require additional guidance. Key recommendations are outlined in Appendix A. These practical considerations underline the importance of contextual feasibility when implementing school-based mental health screening tools, particularly in education systems with strong assessment cultures and variable digital infrastructure.

A distinctive aspect of this study is the sequence in which translation and cultural validation were conducted. Typically, these precede implementation; however, in this case, the tools were already in use when the need for a more systematic, research-based approach became evident. Although this post-hoc validation is not methodologically ideal, Pohodomer version 1.0 had demonstrated practical value. Ongoing discussions between Koalicia skol za dusevne zdravie and member schools supported teachers and school psychologists in interpreting results withing their specific contexts and identifying areas requiring additional mental health and wellbeing support.

A key strengths of this study is the close collaboration between researchers and practitioners working directly with schools. This partnership grounded the adaptation process in real-world educational settings, enhancing practical relevance and usability. Another strength is the involvement of children and young people from diverse school types and regions across Slovakia, increasing contextual sensitivity and applicability.

Despite these strengths, several limitations should be acknowledged. The post-hoc nature of validation means that further psychometric testing is required, particularly for broader or longitudinal use. Although children and young people were actively involved, their participation was constrained by time, resources, and school-based practicalities. Future studies should include larger and more diverse samples and, where possible, conduct validation earlier in the adaptation process.

Another limitation relates to focus group discussions. While some items were prioritised based on earlier review phases, participants were invited to raise additional unclear terms, and clarification requests were documented during administration (e.g., difficulties with the term “lonely”). However, due to time constraints and the length of the questionnaires, a full item-by-item review was not feasible. Consequently, some potentially confusing elements may not have been identified or verbalised. Future studies could allocate more time or incorporate a systematic one-by-one exploration of all items to further strengthen participant-led input.