Health Promoting Universities (HPUs) have proven to be effective settings for improving the health of the university communities—students, faculty, staff and the wider public over the last three decades (1–3). The HPU initiative has evolved into a global movement with regional, national and international networks established. These networks foster collaboration between HPUs across countries, regions and globally, providing valuable resources: strategic documents, action frameworks, practical application experience, good examples, case studies and assessment tools (2, 4–6).

To achieve designation as an HPU, the application of a “whole university approach” to health is a key prerequisite (1, 7, 8). This involves integrating health in all aspects of the institution’s life, making it a core value of the university culture, and implementing processes and policies aimed at improving the health of the entire university community through activities at all possible levels (8).

The scientific literature reveals various methods by which HPUs evaluate their efforts and the effectiveness of their activities while striving to achieve “whole university” involvement. Typically HPUs use self-designed questionnaires, focusing on specific health issues such as students’ risky health behaviors or health awareness. Additionally, interviews assessing health promotion (HP) activities are conducted with staff or representatives of the HPU initiative coordinators (3, 9, 10). These approaches measure the effectiveness of isolated actions among specific university groups under the HP label.

Given that the “whole university approach” is fundamental to the initiative, comprehensive assessment is necessary (11). In this process, the university should be viewed as a unified entity, and the assessment should encompass the health and behavior of people, the conditions of the university environment, and the built-in organizational structures. The involvement of all people of the institution in the planning and implementation of initiatives improving health and wellbeing is one of the main principles of HPU, and evaluating the participation of the entire university community aims to hear the voice of students, lecturers and staff (11, 12). A number of HPUs have conducted such complex assessments, while those that have not cite the absence of a suitable instrument as a barrier (10).

The UK (13) and the Chilean (14) networks provide questionnaires for comprehensive assessment of the HPUs. The German (15) and North American (16) networks have their own good practice standards. One of the tools that is freely available and therefore used by universities around the world is the UK Healthy Universities Network Self-Review Tool (13). It has been developed for use in all stages of institutional self-assessment.

The HPUs initiative is new to Bulgaria, and the potential of the Bulgarian higher education institutions as health promoting settings has not been studied. However international experience has proved that successful and sustainable implementation of the HPU initiatives depends on their adaptation to local needs, traditions and cultures of the respective countries (3, 9, 17). Earlier studies of HP initiatives and policies’ transfer in Bulgaria reveal that international HP programs and documents, created in western environments, in English language may be more effective if culturally adapted to the specific Bulgarian context and language, which applies to all HP documents and instruments (18).

The aim of the present work is to present the process of cultural adaptation of the HPUs’ Self-Review Tool into Bulgarian.

Тhis paper describes the systematic cultural adaptation process of a specific instrument designed for self—assessment of a health-promoting higher educational institution (university, campus, college etc.) referred to as the SRT. Our aim was to develop a conceptually relevant Bulgarian version of the instrument suitable for a culture different from the original western European context in which the tool was initially developed and applied (13). While the SRT had been applied in institutions outside the UK, it had not been culturally adapted for non-English speaking cultures until this study.

The cultural adaptation of the HPU Self-Assessment Tool in Bulgarian was justified and initiated based on previous research indicating the applicability and effectiveness of international documents in the field of HP, including in Bulgaria (18, 23).

It was recognized that such cultural adaptation is not only important, but also essential, as even translations edited by experts, as in the expert Delphi panel in this study, could not ensure full understanding of HP-related texts by the wider university community.

Despite following an internationally recognized methodology for cultural adaptation, the process did not progress quickly and smoothly. This could be primarily attributed to the lack of familiarity with HP concepts in Bulgaria such as the “healthy settings initiative” and with the role of educational environments in promoting health, particularly the HPU. Additionally, there was a scarcity of strategic HP documents in Bulgarian and recognizable real-life examples, as, e.g., the HP schools, which could have served as a foundation for the HPU initiative (24).

According to leading HP experts in our country, the adoption of the philosophy of HP in Bulgaria is accompanied by a number of difficulties. One of them is related to specificities of the political culture across all social domains, characterized by a high degree of centralization of management and high-power distance between top and lower levels in institutions, including educational ones (18). On the other hand, there are barriers related to the interpretation of the concept of HP itself.

Created in countries with Western European culture, the terminology is difficult to adapt to the Bulgarian language and culture (18). Even today the HP concepts are defined as insufficiently theoretically developed and practically applied in Bulgaria (25).

Pinto et al. (26) note that HP instruments developed on the basis of generally accepted HP principles need to be adapted to the specific cultural characteristics before their application in diverse national contexts.

In our case the entire cultural adaptation process of the SRT took approximately 10 months. A similar duration was reported for the adaptation of a smoking prevention questionnaire to the Bulgarian language (18) which is comparable to reports by other authors (27).

Some studies validating foreign instruments, report no major discrepancies between the first-stage translations and the original document (28). Others like ours find poor comparability between the translations and the original texts, attributing this to the translators’ focus on wording rather than meaning (29).

All stages of the methodology applied by us proved to be important for achieving the intercultural adaptation. The work of the Delphi Expert panel and the pilot-test stage with the participation of representatives from the entire university community were particularly useful. Our experience is supported by other researchers. Oliveira and Bandeira (30) identified these two phases as significant for the successful adaptation of a psychological instrument assessing personality structure and organization to Brazilian culture and traditions.

Expert input was essential for the adaptation of HP terminology but insufficient. It was found that even after the decisions of the Delphi panel, difficulties in understanding some terms and concepts, especially among students persisted. This might be attributed, on one hand, to the professional bilingual competence of the experts. Such hypothesis was proposed by Norwegian researchers working on the cultural adaptation of an English language instrument (29). Experts fluent in English more easily understand the concepts in their language, which does not automatically apply to a monolingual target population (29). On the other hand, while experts use HP terms freely and routinely, these terms are rarely present in daily Bulgarian speech, explaining the differential understanding between experts and the wider audience.

Thus, testing among representatives of the university community proved to be a particularly useful procedure. The active participation, comments and suggestions of the participants greatly aided the cultural adaptation in our research. This was also confirmed by Oliveira and Bandeira (30), according to whom this stage led to the clarification of confusing and misinterpreted elements. Squires et al. (31) described the cultural adaptation of an instrument in 12 European countries, in 11 languages. For the purpose of their study, the adaptation methodology included translations of the original instrument into the target languages and expert panels were held three times. It was found that in one of the countries, Poland, the process of cultural adaptation was impossible without pilot testing, which turned out to be the key success factor.

The apparent difficulties with testing the instrument among some respondents led to the conclusion that not all statements are equally applicable to all participants. According to Chengelova (32), survey questions should correspond to the competence and level of awareness of the social group to which respondents belong. The creators of the original SRT recommended that it should be completed not individually but by a team of representatives from the entire university community (11). Thus, various statements would receive answers from respondents who are competent to provide an opinion on behalf of their target group.

The cultural adaptation of the SRT in our study resulted in a change in 61 of the total 68 statements. Similar results were reported by Lopatina et al. (33), discussing the adaptation of a WHO health literacy assessment tool for Russian-speaking populations in Germany, Israel, Russia, Kazakhstan, and the United States. The linguistically and culturally adapted instrument in Russian was obtained after changing 95% of the questions.

An interesting, but also sought after and expected effect of our research was the popularization of the HPU initiative among the study participants. They shared their positive attitude because their opinion was sought and valued. Respondents showed interest and paid attention to health promotion activities at the university that they had not noticed before.

One possible limitation of our study is the convenience sampling of respondents in the Delphi expert panel. However, the choice of participants could not affect the content of the questionnaire, as the discussion focused on achieving the best possible Bulgarian wording for all the questions from the international instrument, rather than determining which questions to include. A second limitation is that the study was conducted within a specific higher education institution predominantly offering teaching in health and medical specialties and disciplines. However, this does not limit the opportunities for the proposed instrument to be tested in other organizations. On the positive side, we can highlight that this is the first systematic cultural adaptation of a self-assessment tool for the HPU in Bulgarian language.

The presented cultural adaptation process of the HPU self-assessment tool confirms earlier experience that the cross-cultural adaptation of theoretical HP documents to the Bulgarian language and culture is a difficult but an essential process. It creates prerequisites for the ideas, concepts and practical experiences of established HPU to be adopted and developed in Bulgarian higher education institutions. Such a process should always be considered in situations aimed at the application of public health or health promotion policies, strategic documents or instruments in societies with cultures different from the Western Europe and languages other than English.

What follows from now on? We hope that the “HPU Self-Assessment Tool” in Bulgarian will be implemented in other Bulgarian universities to assess their potential to become part of the HPU initiative.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Комисия по етика на научните изследвания (КЕНИ) на МУ Варна/Committee on ethics of scientific research of the Medical University of Varna. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

PB: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing. KD: Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing.