Cross‐cultural adaptation of the empowerment scale of pregnant women in China context: An integrative method of translation and linguistic validation

Abstract

Aim

To translate the Empowerment Scale for Pregnant Women (ESPW) into Chinese and to assess its linguistic validity.

Methods

The integrative method of the translation process, the Delphi technique, and cognitive interviews were used to implement cross‐cultural adaptation and enhance comprehensibility and linguistic validation. This study recruited 14 experts in the expert review and cognitively reviewed 15 pregnant women.

Results

The two‐round Delphi method created agreement on cultural applicability. The results of content validity achieved good levels: The item‐level content validity index (CVI) ranged from 0.78 to 1.00, and the scale‐level content validity index, calculated using two different formulas, were 0.97 and 0.81, respectively. Kappa values ranged from 0.74 to 1.00. Pregnant women could understand most of the items and response options in the cognitive interview. The revisions to the wording were made based on suggestions from experts and pregnant women.

Conclusion

The prefinal simplified Chinese ESPW was semantically and conceptually equivalent to the English version, which was well prepared for further psychometric tests in the next stage of cross‐cultural adaptation.

Patient or Public Contribution

This comprehensive method successfully developed a Chinese tool to measure the empowerment of pregnant women, indicating the international applicability of this tool and the methodological scientific nature. The simplified Chinese ESPW has the potential to support the identification of empowerment levels of pregnant women and the evaluation of the effectiveness of health education and promotion programmes.

INTRODUCTION

According to the sustainable development goals for maternal health published by World Health Organization (2021), the strategic significance of empowering pregnant women is to safeguard maternal and fetal health and well-being. Involvement in the antenatal care process could contribute to increasing the perception of empowerment for pregnant women (Hermawati, 2019). Nevertheless, the lack of empowering pregnant women may be detrimental to their involvement in antenatal care and the quality of healthcare they achieve (Merrell & Blackstone, 2020). Moreover, the inadequate utilization of antenatal care is a major social factor in high-risk pregnancy (Abedin & Arunachalam, 2020). It is not uncommon for women to be threatened by a high-risk pregnancy. There are more than 20 million of them worldwide, mostly from developing countries (Alkema et al., 2016). It is reported that high-risk pregnancies may occur in nearly 22% of pregnant women, which is intensively related to their well-being and strongly calls for appropriate antenatal care (James & Steer, 2018; Mirzakhani et al., 2020). Therefore, it is warranted for health professionals and policymakers to strengthen pregnant women's empowerment.

From the perspective of midwives, empowerment is defined as the capability to make strategic life decisions (Nieuwenhuijze & Leahy-Warren, 2019). Yet, empowerment can serve as a meaningful indicator of health education (Speakman et al., 2014). As highlighted in the previous studies, empowering pregnant women could influence the health of themselves, their infants and their quality of life during pregnancy (Nieuwenhuijze & Leahy-Warren, 2019; Yeh et al., 2018). As an important component of health providers in antenatal care, nurses are available to pregnant women. The core roles of empowering pregnant women entail providing support and health education, and promoting self-determination and healthy lifestyles (Bahri Khomami et al., 2021; Nieuwenhuijze & Leahy-Warren, 2019).

As patient empowerment is valued by policymakers and professionals, measuring empowerment plays a prerequisite role in sustainable health development (Wallerstein, 2006). The assessment of empowerment may help them better understand the levels of empowerment and the effect of pregnancy-centred interventions (Small et al., 2013). Several instruments were identified for measuring the empowerment of pregnant women in two previous systematic reviews (Campbell et al., 2021; Pekonen et al., 2020). The most popular ones used in related studies are the Empowerment Scale for Pregnant Women (ESPW) and the Pregnancy-related Empowerment Scale developed by Klima et al. (Campbell et al., 2021; Klima et al. (2015); Pekonen et al., 2020). Based on the findings of these two reviews, the most popular ones used in related studies are the ESPW developed by Kameda and Shimada in 2008 and the Pregnancy-related Empowerment Scale developed by Klima et al. in 2015. Nevertheless, compared to the existing instruments measuring pregnant women's empowerment, ESPW could be a more applicable one with comprehensive considerations (Liu et al., 2024).

When choosing an international instrument, inconsistent cultural backgrounds can influence the successful cross-cultural validation of the instruments (Pekonen et al., 2020). Moreover, the similarity of the source culture is a crucial issue in conceptual equivalence (Zaragoza-Salcedo et al., 2023). The ESPW is a self-reported instrument developed in Japan and has tested the measurement properties in Japanese pregnant women (Kameda & Shimada, 2008). China and Japan share some similar fertility cultures due to their geographical proximity. Therefore, from the perspective of cultural background, the ESPW seems to be a more appropriate choice in the Chinese context. Regarding application, the ESPW was originally used to evaluate the effect of health education (Kameda & Shimada, 2008). Furthermore, with the ease of responding, it works well in different types of clinical studies (Aliabadi et al., 2022; Tavananezhad et al., 2022), indicating that it has usually been applied in clinical research with an international scope.

The ESPW has been successfully translated from the English version to the Farsi version (Silva, 2014) and the Farsi version (Hajipour et al., 2016). As far as we know, there are no studies that have been related to the ESPW in the Chinese context, and especially none that have reported on the cross-cultural adaptation of this instrument. To count on the utilization of the ESPW in the new country and new cultural context, this study was designed to translate the English version of the ESPW into simplified Chinese, thereby performing linguistic validation by considering the semantic, idiomatic and conceptual equivalence in Chinese pregnant women and evaluating the content validity.

METHODS

This study was conducted using the integrative method of the translation process, the Delphi technique and cognitive interviews. As for methods consideration, the method of linguistic validation employed the standard procedure proposed by Beaton et al. (2000). However, the various methods of the translation and validation process have been proposed in the literature (Buck et al., 2022; Maneesriwongul & Dixon, 2004; Zaragoza-Salcedo et al., 2023), and a translation and cross-cultural guideline has recommended that suitability should be the priority option when considering a method (Epstein et al., 2015). Furthermore, it is well-documented in the literature that the comprehensive method not only collects suggestions from each step but also considers the perceptions of potential users, which could strengthen the adaptability and validity (Buck et al., 2022). Hence, this study finally adopted an available 7-step method which added the Delphi method and cognitive interview based on the recommendation (PROMIS, 2016) and previous studies (Alelayan et al., 2022; Buck et al., 2022).

Preparation of the translation and cultural adaption of the ESPW

Permission was obtained from Professor Kameda, the developer of the ESPW. The ESPW consists of 27 items divided into five subgroups, namely self-efficacy, future image, self-esteem, support and assurance from others, and joy of an addition to the family, as outlined in the work by Kameda and Shimada (2008). Respondents used a 4-Likert scale with options ranging from ‘strongly disagree = 1’ to ‘strongly agree = 4’. For the translation and cultural adaptation of the ESPW, we engaged bilingual translators and experts. The experts were required to meet specific inclusion criteria: (1) they should have majored in one of the following fields: nursing, obstetrics, psychology or statistics; and (2) they should have a minimum of 10 years of professional experience in their respective domains.

Process of translation and cultural adaption of the ESPW

Step 1: Initial translation

Two bilingual translators with Chinese as their native language undertook this translation process from the English version to the simplified Chinese version. One individual was a clinical nurse specializing in the obstetrics department, while the other was a professional translator with a background in English studies. They had a Ph.D. degree and worked for more than 5 years. The final versions of this step were named T1 and T2.

Step 2: Synthesis of the simplified Chinese translation

The synthesis process was finished by a consensus online meeting on 1 March 2023. The two translators of the original translation and two researchers (a midwife who had worked for more than 7 years and a bilingual nursing professor) took part in the discussion. All people put forward their opinions on each item and thoroughly discussed the inconsistency of understanding. The formulation of the synthesis version was corrected based on the necessary reassignment and marked as T12.

Step 3: Back translation

T12 was back-translated from the simplified Chinese version to the English version by two new bilingual translators who had been also unfamiliar with health care and the content of the instruments but had English as their native language. The first back-translator was a psychologist and the second was an educator. Without discussion and any revision, the final versions of this step were called BT1 and BT2.

Step 4: Synthesis of the English translation

The consensus online meeting was performed on 10 March 2023. The two back-translators and the two researchers discussed the misunderstanding or confusing words. The synthesis version was completed after minor corrections.

Step 5: Expert panel review

The experts from different professions were invited to the expert panel through snowball sampling. Sixteen experts (six midwives, four senior nurse researchers, four obstetric doctors, one psychologist and one statistician) met the criteria very well and were invited to participate in the expert panel. A Delphi method with two rounds was adopted in this study. Informed consent was obtained through messages from all the experts before review. The written guides including purposes and method of the review and deadline were present in the front of the forms in each round. In the first round, experts could put forward any comments on linguistic understanding of the simplified Chinese version. Two of the authors and xx) synthesized the discrepancies and prepared the written guides for the second round. The first author (xx) had email consultations with the developer about the items that were not integrative or were ambiguous at the synthesis stage. In the second round, the comments of the experts focused on balancing the discrepancies. All of them submitted the feedback within 1 week by sending the forms and the total process was completed within 3 weeks.

Step 6: Cognitive interviews

To strengthen the linguistic validity in the target population, this study employed the cognitive interview according to the recommendation from the PROMIS guideline (PROMIS, 2016). The individual interviews were performed with a convenience sample of pregnant women in a tertiary hospital in Hubei province, China. The inclusion criteria for pregnant women were (1) age over 18 years old; and (2) being able to read and write during the interview. All pregnant women signed the written informed consent before cognitive interviews. Fifteen pregnant women were recruited, which met the recommended sample size for this stage of the study (Wild et al., 2005). The all-author research team developed the interview guide by prioritizing comprehensibility and comprehensiveness, in alignment with the criteria outlined in COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) as described by Terwee et al. (2018). The main questions encompassed an evaluation of the overall assessment, all the items and response options, as summarized in Table 1.

TABLE 1 Cognitive interviewing questions.

Evaluation dimension	General assessment and cognitive debriefing
Comprehensibility	1. What do you think about this survey? 2. Can you understand all the questions in the survey? Which ones do you not understand? Please explain the reasons in your own words. 3. Which one is causing you confusion or postponement of the answer? Why?
Comprehensiveness and relevance	4. Do you think these questions are important to reflect your empowerment? Why? 5. Did you have any questions about the response options? Are they easy to understand? 6. Would you like to make some suggestions to change or revise the inappropriate expressions of this instrument?

The process of the cognitive interview started on the 2nd of April and ended on the 5th of April. Following an explanation of the study's purpose and procedure, the pregnant women completed the ESPW questionnaire. Subsequently, the first author (Yanjia Liu) conducted face-to-face interviews with the pregnant women. During these interviews, the pregnant women provided verbal feedback regarding any words or items they found incomprehensible, assessing their clarity and phrasing. They were also encouraged to suggest more appropriate phrases in everyday language to replace any expressions they deemed inappropriate. These cognitive interviews took place in a conversation room within the obstetrics clinic. As pregnant women were a vulnerable group that needed careful attention in the study and usually underwent many medical examinations during antenatal visits, data collection was conducted in simplified Chinese without the use of video or audio recording to save time. All information was documented through written field notes, and the senior researcher (Mei Chan Chong) ensured the completeness of these records and interview reports. Finally, the first author (Yanjia Liu) transcribed and extracted the data.

Step 7: Discussion and finalization

Each member of the research team was engaged in the review process, contributing to the resolution of any discrepancies. The final simplified Chinese version was then meticulously formatted following the unanimous decisions made by all the authors.

Content validity

To align with the recommended range of experts, which typically falls between 6 and 10 experts as suggested by Yusoff in 2019 (Yusoff, 2019), this study invited nine experts with over 15 years of experience from the expert panel to contribute to the assessment of content validity. The relevance scale utilized a 4-point Likert scoring system, with 1 indicating ‘not relevant’, 2 indicating ‘weak relevance’, 3 indicating ‘moderate relevance’ and 4 indicating ‘high relevance’. Content scoring 3 or higher was considered an agreed item and recorded as 1, while those scoring less than 3 were considered invalid in terms of relevance and recorded as 0, in line with the criteria established by Wynd et al. in 2003 (Wynd et al., 2003). The content validity indices (CVI) were measured by the feedback of the experts, encompassing item-level content validity index (I-CVI) and scale-level content validity index (S-CVI) (DeVon et al., 2007). I-CVI and S-CVI were calculated by the formulas: I-CVI = (agreed items)/(number of experts); S-CVI/Ave = (sum of proportion relevance rating)/(number of experts) or S-CVI/Ave = (sum of I-CVI scores)/(number of items); S-CVI/UA = (sum of universal agreement scores)/(number of items), respectively (Yusoff, 2019). The acceptable score of I-CVI is 0.78 at least while the satisfied scores of S-CVI/Ave and S-CVI/UA were over 0.90 and 0.80 (Wynd et al., 2003). The kappa statistic (k) was used to evaluate the inter-rater agreement and computed by the formula k = I-CVI-pc/1−pc and pc = (N!/A! (N−A)!) × 0.5 N (Polit et al., 2007). The N represents the number of experts while the A refers to the number of experts in agreement. A kappa value over 0.60 and 0.74 was considered good and excellent respectively (Polit et al., 2007). The analysis of the data was calculated in Excel 2003.

RESULTS

Linguistic validation of the CV-ESPW

The overall linguistic validation was the result of synthesizing the forward-backward translations, the expert review and the cognitive interview. The translation process was conducted successfully and provided valuable content for the following expert review. The results of the expert review and cognitive interview reached an agreement on the different expressions. The synthesis results created the final CV-ESPW.

Most words were prone to be directly translated to the target language during the forward-backward translations. However, as many words can explain the same concept or highly similar signification in the Chinese language, the synthesis was full of changes. For example, the sentence ‘I imagine how my pregnancy will be’ was translated in two different ways in the forward translation. Two sentences were correct in terms of comprehensibility, but the second one was rejected because it was too formal. All the multi-expressions such as ‘can probably’ ‘key person’ and ‘medical professionals’ were discussed and finally reached a consensus in the online meeting. Regarding back-translation, there were no grammatical issues whereas some words were translated into synonyms. For example, ‘deal with’ was forward-translated to ‘处理’ and back-translated to ‘handle’. No obvious differences or inaccuracies in the translations were found at the stage of the synthesis.

Expert panel review

Two experts dropped out in the second round without giving feedback. In final, 14 experts, consisting of 6 midwives, 3 senior nurse researchers, 3 obstetric doctors, 1 psychologist and 1 statistician, finished the two-round review. The characteristics of the experts are presented in Table 2. As the sentences of the original version are simple, a total of 18 comments for the items in the first round and 10 items in the second round were proposed. We revised the expressions based on the experts' comments and sent the email to the developer for help. The examples of comments and changes were summarized and described in the table (Table 3). The final translation version was improved by the consensus on semantic and idiomatic equivalence.

TABLE 2 Characteristics of experts and pregnant women.

	Expert (n = 14)	Pregnant women (n = 15)
Age, mean (SD)	41.93 (5.99)	29.53 (5.38)
Work, mean (SD)	19.35 (7.55)	NA
Female, n (%)	13 (92.86)	15 (100%)
Professional title, n (%)		NA
Senior-grade	2 (14.29)
Associate senior-grade	8 (57.14)
Medium-grade	4 (28.57)
Education, n (%)
Doctorate degree	3 (21.43)	0 (0.00)
Master's degree	8 (57.14)	0 (0.00)
Bachelor's degree	3 (21.43)	7 (46.66)
High school	0 (0.00)	4 (26.67)
Middle school	0 (0.00)	4 (26.67)
Parity	NA
1		7 (46.67)
2		8 (53.33)

TABLE 3 Results from two-round Delphi methods, examples of comments and changes.

Delphi method
Dimension in the first round	Examples of comments	Examples of changes
Linguistic improvements	Item 15: I can probably deal with what I am worried about. Three experts were a little confused by the expressions ‘can probably’ and ‘what I am worried about’	We researched the consensus on the expression ‘can probably’ after consulting the developer. ‘what I am worried about’ retains the direct translation
Item 4: I can probably take care of what I need to do during the pregnancy. One expert suggested using ‘孕期 (during the pregnancy)’ instead of ‘怀孕期间 (during the pregnancy)’ for the sake of being more concise	Changing the expression
Item 14: I would like to enjoy my pregnancy. One expert suggested ‘享受我的孕期 (enjoy my pregnancy)’ should be translated as ‘享受孕期的喜悦(enjoy the joy of pregnancy)’	Keep the original intention of the author
General comments	It is necessary to have a clear definition of the words in some items	No changes were made. The psychometric test will be conducted in the next stage
Some items may not be appropriate for the current domains, revisions should be considered based on the psychometric test
The instrument is expected to be used in hospitals
Confirmatory feedback	Good to understandable	No changes were made
	Most items are relevant to empowerment, but some need to be re-examined
Dimension in the second round	Examples of comments	Examples of changes
Linguistic improvements	Item 22: I have confidence about managing the pregnancy and that I can somehow make do. The understandability of ‘managing the pregnancy’ and ‘I can somehow make do’ should be improved. They are defined in completely different ways, so they can't share the ‘and’	The ‘that’ has been paid attention to, there are two parts to the sentence and the sentence represents a causal relationship. The revision has been made
Misspelling of Chinese words such as ‘形象 (future image)’ and ‘形像 (objective image)’	Correction of the misspelling
General comments	Since Item 1, Item 3 and Item 24 do not have any obvious distinction of the similar concept, it is necessary to clarify them in the next step	Clarify them based on the results of the psychometric test
Semantic meanings in some sentences remain under further discussion	Minor changes have been made after consultation with the developer
Confirmatory feedback	Satisfaction with the good expressions in the revision items	No changes were made
Most of the items are clear without any confusing words

Content validity of the CV-ESPW

Nine experts who have worked for more than 15 years in hospitals. All of them took part in the survey and they agreed with the acceptability of the item content with a satisfied percentage (79%–100%). The range of I-CVIs was from 0.78 to 1.00 (Table 4), indicating that most items were considered relevant. The S-CVI/Ave (both methods) and S-CVI/UA were 0.97 and 0.81, respectively, demonstrating both methods revealed good content validity. The kappa value ranged from 0.74 to 1.00, being considered good to excellent agreement and supporting the correct random agreement of relevance.

TABLE 4 Content validity of the ESPW.

Item	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	Proportion relevance
Expert 1	4	4	3	3	3	4	4	4	3	3	4	3	3	4	4	3	3	4	4	4	4	4	4	3	3	3	4	1.00
Expert 2	4	4	4	3	4	3	3	4	4	3	4	4	3	4	4	4	3	4	3	4	4	4	4	4	4	4	4	1.00
Expert 3	4	3	3	4	4	4	4	4	3	3	3	3	3	4	4	3	3	3	4	4	3	4	4	3	3	4	4	1.00
Expert 4	3	3	4	4	3	4	2	3	3	3	2	3	2	3	3	4	3	3	3	3	3	4	4	3	3	4	3	0.89
Expert 5	4	4	4	3	3	4	4	4	3	3	3	2	3	4	3	4	3	3	3	4	3	3	4	4	3	4	3	0.96
Expert 6	3	4	4	3	4	4	3	3	3	3	3	3	3	4	4	4	3	4	4	3	4	4	4	3	4	3	3	1.00
Expert 7	3	3	4	4	4	4	4	4	3	3	4	3	3	3	4	4	4	3	4	4	4	4	4	4	4	4	4	1.00
Expert 8	4	4	4	4	4	4	2	4	4	4	1	4	1	4	1	4	4	3	4	4	4	4	4	4	4	4	4	0.85
Expert 9	3	4	4	4	4	4	3	4	4	4	4	4	4	3	4	4	4	4	4	3	4	4	4	4	4	3	4	1.00
Agreement (n)	9	8	9	9	9	9	6	9	9	9	7	7	7	9	8	9	8	9	9	9	9	9	9	9	9	9	9
I-CVI1	1.00	1.00	1.00	1.00	1.00	1.00	0.78	1.00	1.00	1.00	0.78	0.89	0.78	1.00	0.89	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
S-CVI/Ave2																												0.97
S-CVI/Ave3																												0.97
S-CVI/UA 4																												0.81
Pc	0.002	0.002	0.002	0.002	0.002	0.002	0.164	0.002	0.002	0.002	0.164	0.070	0.164	0.002	0.070	0.002	0.002	0.002	0.002	0.002	0.002	0.002	0.002	0.002	0.002	0.002	0.002
Kappa value	1	1	1	1	1	1	0.74	1	1	1	0.74	0.88	0.88	1	0.88	1	1	1	1	1	1	1	1	1	1	1	1

Cognitive interviews of the CV-ESPW

All participants had no refusals to complete the questionnaires and no dropouts in the middle of the interview. The pretest version of the ESPW was administered to pregnant women in a quiet consulting room where no one else was present. The average time for completion of the questionnaire was 15 min. The predesigned questionnaires were answered sequentially and without hesitation in the cognitive interviews. Pregnant women reported that most of the items were understandable and accurate. The interview identified some comprehension difficulties that confused the pregnant women (Table 5). For example, Item 2 had comprehension difficulties due to being too abstract for a primipara, which was revised using specific scenarios. Pregnant women also expressed that the response options were easy to understand and the instructions helped them answer the questionnaires. Some pregnant women have postponement and revision of the answers in Item 2 and Item 19. The main reason for this phenomenon was that the items were reversed questions and the pregnant women neglected the instructions or were confused by ‘myself raising children’. Therefore, the highlights were marked to attract their attention to the instructions. Most of the participants suggested a few minor changes to the words to make them simpler and easier to understand (Table 5).

TABLE 5 Modified items of the CV-ESPW after cognitive interview.

Item	Reasons for revision
2. I cannot imagine myself raising children	Pregnant women said ‘自己/myself’ is not specific. Because family support in raising children is common. We replaced it with ‘独自/on my own’
12. I imagine how my pregnancy will be	Some pregnant women said ‘将会是怎样/how my pregnancy will be’ seemed like an unknown process and may be full of risks during pregnancy. Thus, we replaced it with ‘怀孕的样子/What pregnancy looks like’
18. My family and friends acknowledge my way	One pregnant woman indicated that ‘我的方式/my way’ is too abstract. We revised it with ‘我的生活方式/my lifestyle’ after consulting with the developer
19. I think my strength for delivery is weaker than other people's	Some pregnant women said they don't know other people's strengths and why they compare themselves to others. Their suggestion was the removal of the words ‘than other people's’

DISCUSSION

To the best of our knowledge, this study presents the inaugural introduction and translation of the ESPW into simplified Chinese. Linguistic validation and cultural adaptation were meticulously executed to guarantee the semantic and conceptual alignment between the original version and the simplified Chinese rendition. The outcome of this study yielded a simplified Chinese version that demonstrated commendable content validity and practical applicability. Therefore, this Chinese version could be a well-prepared instrument for further psychometric tests in the next stage of cross-cultural adaptation. Additionally, the utilization of this tool holds significant potential for aiding healthcare professionals and policymakers in evaluating empowerment in the context of health education and promotion efforts.

The process of forward and backward translations effectively achieved its intended purpose with a streamlined approach. Despite the challenge of maintaining conciseness in conceptual formation, which may complicate the translation process (Zeffiro et al., 2021), the success of our efforts can be attributed to the simplicity of sentences, user-friendly response options and effective introductions. The inherent diversity of the Chinese language and culture necessitated minor revisions during the synthesis stage, as English words could have multiple Chinese translations (Madi & Badr, 2019). The reconciliation process of these different translations also offered valuable methodological insights for future research.

Combining various methods can enhance linguistic validation and cultural adaptation (Buck et al., 2022). The Delphi method played a crucial role in the expert panel review, facilitating consensus in the translation and evaluation of the instrument. Both rounds of review resulted in minor linguistic improvements in the first round, with confirmatory comments from experts in the second round. The content validity of the CV-ESPW was deemed acceptable, affirming its relevance in assessing empowerment among pregnant women.

To ensure comprehensibility and usability, it was advisable to conduct cognitive interviews after the translation, gathering input from potential users (Graneheim, 2004; PROMIS, 2016; Wild et al., 2005). In this study, we employed the respondent debriefing method for pregnant women, consistent with prior research (Alelayan et al., 2022). Results indicated that the CV-ESPW items were well-received in terms of relevance and ease of understanding. Notably, the educational level is a positive predictor of pregnant women's empowerment (Borghei et al., 2016). In this study, more than half of the pregnant women had educational levels below a bachelor's degree, which might potentially influence their perceptions of empowerment. Their positive feedback attested to the instrument's comprehensibility, making it a suitable choice for measuring empowerment among pregnant women. Additionally, the cognitive interview aspect of our study provided a valuable advantage, as it offered insights into pregnant women's perspectives that were not as thoroughly documented in other versions such as the Portuguese (Silva, 2014) and Farsi version (Hajipour et al., 2016), which focused more on psychometric tests.

LIMITATIONS

The study exhibits certain limitations. First, the data collection and analysis methods we employed may have influenced the depth of information gathered regarding pregnant women's experiences with the instrument. Second, since most English expressions in the CV-ESPW were concise and colloquial, we encountered relatively few instances of cultural conflicts. Consequently, our translation process and cognitive interviews may offer limited insights for future studies. Lastly, due to the utilization of convenience sampling, the participants lacked individuals with higher levels of education, such as master's or doctoral degrees, thereby limiting the representativeness of pregnant women in our study. Therefore, further research would be imperative to validate this instrument in a larger and more diverse population.

CONCLUSION

Recognizing the imperative to evaluate the empowerment of pregnant women, we introduced the English version of the ESPW in China through a process that encompassed linguistic validation and cultural adaptation. This comprehensive approach, which included translation, the Delphi method and cognitive interviews, adhered to rigorous guidelines and was informed by previous research endeavours. Consequently, we successfully developed a simplified Chinese version of a pertinent tool for measuring the empowerment of pregnant women, which could provide a good basis for further psychometric tests.

IMPLICATIONS FOR NURSING PRACTICE

In terms of clinical implications, this comprehensive method successfully developed a Chinese tool to measure the empowerment of pregnant women, indicating the international applicability of this tool and the methodological scientific nature. The ESPW was designed using professional terminology but was easily understood by pregnant women. Thus, it could be an ideal tool to capture pregnant women's perceptions of empowerment in clinical practice and thereby support their antenatal care. On the other hand, this valuable tool empowers health professionals and clinical researchers to effectively gauge the level of empowerment among pregnant women. It holds significant potential for supporting the monitoring of the effectiveness of health education and promotion programmes, and enhancing the management of antenatal care in the field of nursing.

AUTHOR CONTRIBUTIONS

Mei Chan Chong: supervision, writing—reviewing and editing; Yanjia Liu: writing—original draft preparation, data collection; Chong Chin Che: writing—reviewing and editing; Mukhrib Hamdan: supervision, writing—reviewing and editing.

ACKNOWLEDGEMENTS

None to report.

FUNDING INFORMATION

None to report.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest. All authors were responsible for reviewing and the final editing and approval of the manuscript.

DATA AVAILABILITY STATEMENT

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

ETHICS STATEMENT

Research Ethics Committee approval for the study was secured from Gong'an County People's Hospital, the institution from which the participants originated, on 1 April 2023. Informed consent was duly obtained from both experts and pregnant women before the commencement of the study. The cognitive interviews were conducted anonymously.

References

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