Print this page Email this page Users Online: 919 | Click here to view old website
Home About us Editorial Board Search Current Issue Archives Submit Article Author Instructions Contact Us Login 

 Table of Contents  
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 169-171

Cross-cultural adaptation of Jefferson scale of empathy-health professions students version: An experience with developing the Tamil translation

1 Department of Community Medicine, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
2 Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Union South-East Asia Office, New Delhi (Past); Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh (Current), India
3 Department of Physiology, Saveetha Medical College, Chennai, Tamil Nadu, India

Date of Web Publication19-Sep-2017

Correspondence Address:
Kathiresan Jeyashree
Department of Community Medicine, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_312_16


Background: Empathy is a key cognitive attribute among healthcare professionals that fosters better patient– healthcare provider relationships. The Jefferson scale of empathy (JSE) measures self-rated empathy among various groups of healthcare professionals–health professionals, medical students and health professions students (HPS). The authors present the experience in translating the JSE-HPS version into an Indian regional language with insights into the issues faced in every step. Methods: With official permission from the Thomas Jefferson University, the authors embarked on the translation proceeding through forward translation (three rounds of modification), back translation (two independent translates), and synthesis of a final translated version. While targeting literary accuracy, the simplicity and comprehensibility of the instrument by the study population were also ensured. Variations in regional dialects and accents across the population were considered. Results: The back-translated version was evaluated for semantic, content, cultural, and technical equivalence. It was then pretested on ten students followed by a group discussion with them to ensure the comprehensibility of the tool and the differences between written and spoken language were addressed through necessary modifications. Discussion: The Tamil translation of the HPS version of JSE is now approved by and officially available with the Thomas Jefferson University.

Keywords: Empathy, health professions students, Jefferson Scale, nursing, Tamil, translation

How to cite this article:
Jeyashree K, Kathirvel S, Prathibha MK. Cross-cultural adaptation of Jefferson scale of empathy-health professions students version: An experience with developing the Tamil translation. Educ Health 2017;30:169-71

How to cite this URL:
Jeyashree K, Kathirvel S, Prathibha MK. Cross-cultural adaptation of Jefferson scale of empathy-health professions students version: An experience with developing the Tamil translation. Educ Health [serial online] 2017 [cited 2022 Jan 28];30:169-71. Available from:

  Background Top

Empathy is the physician's ability to understand the patients' concerns by placing himself/herself in the patient's position.[1] It is an essential skill to build good healthcare provider–patient relationships and reap better clinical outcomes.[2] Hojat et al. define empathy as as a cognitive attribute that involves an ability to understand the patient's inner experiences and perspective and a capability to communicate this understanding.[3]

The Jefferson scale of empathy (JSE) is the widely used instrument for objective measurement of self-rated empathy among physicians, medical students, and other healthcare professionals – health professions students.[4],[5] Initially called the JSPE, it is now widely termed as JSE to include scales to measure empathy among various populations, namely, JSE physicians, medical JSE students, and other JSE healthcare professionals, and JSE health professions students (JSE-HPS). The HPS version has replaced the earlier JSE nursing students' version which was applicable only to nursing students.[6] The current JSE-HPS version has 20 items rated on a scale of 1–7 ranging from strongly disagree to strongly agree.

Tamil is an Indian regional language predominantly spoken by people in the state of Tamil Nadu in India and the Union territory of Puducherry. It is the official language of two countries, namely, Sri Lanka and Singapore. Besides these countries, it is also widely used in Malaysia, (where it is one of the languages of education), Tamil diaspora in the USA, UK, Canada, and few Asian countries.

Every year, in Tamil Nadu, India, over 10,000 students enter Bachelors/Diploma courses in nursing and allied health sciences after completing their higher secondary education. There are private and government colleges of nursing (around 170 in total) and other allied health sciences. Although the medium of instruction in these courses is English, the students are mostly from vernacular (Tamil) medium schools where English is taught as a second language. The widely spoken language by patients being Tamil, the healthcare providers' medium of interaction with the patients is also Tamil. Given that the English comprehension is limited among this population and the need for conceptual understanding of empathy to respond appropriately to the JSE, the authors embarked on a Tamil translation of the HPS version of JSE.

  Methods Top

Forward translation

The official permission to translate the JSE-HPS to Tamil was obtained from the Thomas Jefferson University. The guidelines and references on translation and back translation provided by the Thomas Jefferson University were adhered to besides those proposed by Guillemin et al.[7] The three authors who were proficient in Tamil and English language performed the Tamil translation. Following three rounds of modification, the forward translated version was developed.

Back translation

The back translation was done by three other healthcare professionals who were proficient in both English and Tamil and unaware of the original English version of the instrument. One back translated version was synthesized by discussion among the three authors and compared with the original English version for semantic, content, cultural, and technical equivalence.

  Pretesting Top

The instrument (Tamil and English version) was administered to ten HPS who were proficient in English and Tamil. Group discussion with the ten participants for pretesting was moderated by the author. Suggestions and experiences regarding the questionnaire's understandability, ambiguity of terms, and time taken were noted.

  Discussion Top

Translation of instruments to other languages is vital to promote cross cultural applicability of tools and their widespread application for research.[8],[9] The process of translation is neither straightforward nor easy.[10] Besides the challenges posed by technical terms, for example, health- or illness-related terms that abound in health measurement scales, the use of idioms, figures of speech, examples, and cultural context of the questions that cannot be literally and directly translated are also to be dealt with care.[11] While they have to be relevant in the new form, the construct that is being measured needs to remain unaltered. While translating JSE-HPS to Tamil, the authors have adhered to commonly recommended standards for translating health measurement scales.[10],[12]

One of the foremost challenges faced by the authors was the difference between the spoken Tamil and the written form. The written form of Tamil has retained its original form since many centuries. Diglossia has led to the divergence between the spoken and written form over the years.[13] The literary Tamil or the written form is rarely used in informal oral communication between people in day to day life.[14] A compounding issue was the liberal mix of the English language with Tamil in its spoken form. The mix is so commonly used to make the Tamil words for certain terms sound alien to the common human, for example, history and patient.

While targeting literary accuracy, the simplicity and readability of the instrument by the study population should not be compromised. Hence, the authors were careful to strike a balance between retaining the meaning of the items and their understandability by the respondents. It is preferable that the translators translate into their mother tongue, which was the case with our authors. Besides the authors felt that the translation should be done by those who understood the construct of empathy and the purpose of the instrument.[7] The involvement of more than one person in the forward translation process led to critical evaluation of the translated version and it was revised thrice before the final version was arrived at.

Although two direct equivalents of the word “empathy” are available in Tamil, they are sparsely used in day to day life. There was also a risk of the term being misinterpreted as sympathy. Hence, the authors circumvented the problem by providing both the terms and the word “empathy” within brackets. The authors also included the translation of the definition of empathy used by Hojat et al. while developing JSE.[5]

Literal word-to-word translation was avoided while the overall content and meaning of the items were retained carefully, for example, phrases like “stand in their patients' shoes.” Colloquial terms were used with caution keeping in mind the variations in regional dialects and accents of Tamil across different districts of the state and across various socioeconomic strata and literacy levels.

The patient–healthcare provider relationship and healthcare delivery systems and scenarios vary across the world. The JSE-HPS does not refer specific scenarios or examples of patient–healthcare provider interactions. Thus, retaining the cultural/local relevance of the tool was not a major challenge while translating it. The authors ensured that the meaning of each of the translated items was same in the cultural context as in the original English version.

Although JSE-HPS does not use too much of technical jargon, it was a challenge finding simple equivalents of few words and phrases into Tamil, for example, “history,” “therapeutic in its own right.”

The method of administration was to be retained as self-administration of printed questionnaires. The Tamil translation of the HPS version of JSE is now approved by and officially available with the Jefferson University. The translated instrument can be used after testing for psychometric properties.

  Conclusion Top

The authors have translated the JSE-HPS version to Tamil language. A pragmatic approach to translation requires an understanding of the source and target language and cultures to effectively translate the instrument. One has to be cognizant of the differences between written and spoken language and aim to keep the instrument understandable by the target population. The cultural milieu has to be understood and the translation should be appropriate and relevant in the areas where the translated version will be applied. At every step of translation, the goal should be to retain equivalence between the original and translated versions which ultimately captures the construct.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Halpern J. What is clinical empathy? Journal of General Internal Medicine 2003;18:670-74.  Back to cited text no. 1
Kim SS, Kaplowitz S, Johnston M V. The Effects of Physician Empathy on Patient Satisfaction and Compliance. Evaluation & the Health Professions 2004;27:237-51.  Back to cited text no. 2
Hojat M, Gonnella JS, Nasca TJ, et al. The Jefferson Scale of Physician Empathy: Further psychometric data and differences by gender and specialty at item level. Academic medicine: Journal of the Association of American Medical Colleges 2002;77:S58-S60.  Back to cited text no. 3
Hojat M, Mangione S, Nasca TJ, et al. The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data. Educational and Psychological Measurement 2001;61:349-65.  Back to cited text no. 4
Hojat M, Gonnella JS, Nasca TJ, et al. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry 2002;159:1563-69.  Back to cited text no. 5
Thomas Jefferson University. Jefferson Scale of Empathy. Available from: [Last Accessed on 2016 Nov 07].  Back to cited text no. 6
Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: Literature review and proposed guidelines. Journal of Clinical Epidemiology 1993;46:1417-32.  Back to cited text no. 7
Streiner DL, Norman GR, Cairney J. Translation. In: Health measurement scales: A practical guide to their development and use. UK: Oxford University Press, 2015, pp. 30-8.  Back to cited text no. 8
Di Lillo M, Cicchetti A, Scalzo A Lo, et al. The Jefferson Scale of Physician Empathy: Preliminary Psychometrics and Group Comparisons in Italian Physicians. Academic Medicine 2009;84:1198-202.  Back to cited text no. 9
Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice 2011;17:268-74.  Back to cited text no. 10
Sartorius N, Kuyken W. Translation of Health Status Instruments. In: Quality of Life Assessment: International Perspectives. Berlin, Heidelberg: Springer Berlin Heidelberg, 1994, pp. 3-18.  Back to cited text no. 11
Sperber AD. Translation and validation of study instruments for cross-cultural research. Gastroenterology 2004;126:S124-8.  Back to cited text no. 12
Ferguson CA. Diglossia. WORD 1959;15:325-40.  Back to cited text no. 13
Schiffman H. Standardization or restandardization: The case for 'Standard' Spoken Tamil. Language in Society 1998;27:359-85.  Back to cited text no. 14

This article has been cited by
1 Cultural adaptation and psychometric properties of the Jefferson empathy scale health professions students’ version in SpanishOccupational therapy students
Sergio Serrada-Tejeda,Patricia Sánchez-Herrera-Baeza,Mª. Pilar Rodríguez-Pérez,Nuria Máximo-Bocanegra,Rosa Mª. Martínez-Piédrola,Nuria Trugeda-Pedrajo,Elisabet Huertas-Hoyas,Marta Pérez-de-Heredia-Torres
BMC Medical Education. 2021; 21(1)
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article

 Article Access Statistics
    PDF Downloaded343    
    Comments [Add]    
    Cited by others 1    

Recommend this journal