Hindi translation and cross-cultural adaptation of the Liverpool University Neuroleptic Side-effect Rating Scale (LUNSERS): A cognitive debriefing study

ABSTRACT

Background:

The Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) is a comprehensive self-report tool for assessing subjective adverse events during antipsychotic treatment.

Aim:

We aimed to translate LUNSERS into Hindi for its application in the Indian population.

Methods:

We followed the translation methodology provided by the World Health Organization (WHO) and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2005 task force (English to Hindi). We completed the forward (n = 2) and back translation (n = 2), reconciliation by an expert panel (n = 5), and cognitive debriefing (20 participants). After suggested culturally relevant changes, the final version was drafted.

Results:

Participants included Hindi-speaking adult male participants on second-generation antipsychotics. Reported side effects included sedation, tiredness, tension, restlessness, difficulty concentrating, and memory problems. A total of eight items were revised following cognitive debriefing. The influence of “Hinglish” was a factor influencing a change in interpretation.

Conclusion:

The Hindi-translated self-report tool (LUNSERS) can help screen antipsychotic-related side effects in a busy Indian clinical setting.

INTRODUCTION

The use of antipsychotics has encountered a shift in recent decades.[1] Among other factors, side effects due to the use of antipsychotics guide the choice of the agent for treatment. Numerous tools exist to record antipsychotic side effects, which can help guide drug selection and dosing. Self-report tools can be easily filled out by patients while waiting for their consultation, saving crucial time during busy clinics.[2] The Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) is one such comprehensive self-report instrument for assessing and quantifying the subjective adverse events during antipsychotic treatment.[3] When required, it can also be administered by mental health workers if the client is unable to complete it. It is available in English, German, and Romanian.[3]

Hindi is a common language in the northern part of India.[4] There is limited availability of self-reported measures for antipsychotic side-effect rating in the Hindi language. The Glasgow Antipsychotic Side-Effect Scale (GASS) is available but limited to assessment of antipsychotic side-effects related to second-generation antipsychotics. Its official translated version is not readily available in the database.[5] LUNSERS provides a more comprehensive assessment, including side-effect domains related to first-generation antipsychotics as well. Additionally, it has “red-herring” items to monitor for overreporting during the assessment.[3] Translation of a patient-reported outcome measure into an Indian language has its own set of challenges, including low health and questionnaire literacy, cultural mediation of health expressions, response style biases, and requires a systematic approach.[6,7] To date, no validated or adapted Hindi version of LUNSERS exists, limiting its use in routine clinical practice in Northern India. Therefore, we planned this study with the aim of translating the LUNSERS scale into Hindi using standard translation methodology.

METHODS

The validity and reliability of LUNSERS are established.[3,8,9] It consists of 51 items, with each item scored on a five-point Likert rating scale of 0–4. For the purpose of cross-cultural adaptation of the LUNSERS, we adopted the methodology provided in the translation guidelines of the World Health Organization (WHO) and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2005 task force.[10,11] The guidelines comprise several steps for adopting a translation of patient-reported measures. These include obtaining permission from the developers of the scale, constituting a bilingual expert panel, two forward translations into the target language (e.g., English to Hindi), two backward translations into the original language, and cognitive debriefing. The cognitive debriefing was conducted with a selected number of participants (e.g., 10) to check for cultural and linguistic acceptability. The final draft was compiled after reconciliation of inputs from cognitive debriefing and shared with the developers. The translation process was completed at a tertiary center in North India. The ethics approval for the study was obtained from the Institute Ethics Committee (IEC-409/02.07.21). The authors adopted the following steps for translation [Supplementary Figure 1 ^{(711.6KB, tif)} ]:

Phase 1: Forward and back translations of the LUNSERS

The authors of the original LUNSERS were contacted, and permission was obtained for the Hindi translation. A panel of five bilingual (proficiency in reading and writing both English and Hindi) experts working in the field of mental health was formed. Forward translations (English to Hindi) by two bilingual individuals were later compiled into a single draft (LUNSERS Hindi V1). This draft was given to two other bilingual people who had not seen the original scale before, and they back-translated it (Hindi to English). This was reviewed by the expert panel, and the final draft was made by consensus of all the experts (LUNSERS Hindi V2).

Phase 2: Cognitive Debriefing of the LUNSERS Hindi V2 draft

After the developers’ review and approval, the cognitive debriefing was conducted with the LUNSERS Hindi V2 draft. The questionnaire for the cognitive debriefing interview was developed to pre-test the instrument on the target population (10–15 participants) using in-depth personal interviews.[10]

For cognitive debriefing, 20 participants aged 18 to 60 years, of either sex, and currently on daily antipsychotic medications for greater than 2 weeks were recruited from the psychiatry outpatient clinic. Interviews for cognitive debriefing were conducted by a single interviewer who was fluent in both languages and was a psychiatrist familiar with the application of LUNSERS. We included participants having a history of any affective or non-affective psychotic illness as per ICD-10 criteria. Those with severe psychiatric or medical illness hindering the interview or unwilling to participate were excluded. Written informed consent was obtained from the patient or their family members. Participant data were collected cross-sectionally from December 2024 to February 2025.

The participants were interviewed systematically, using the cognitive debriefing questionnaire, which had questions for each item of the scale. The questions asked about their understanding of the item, rephrasing in their own words, their choice of answer, understanding of all words, any unacceptable or offensive words, and any alternative expressions. The responses were audio-recorded after taking consent. Written notes were also taken during the interview.

After the interviews, there was a cognitive debriefing review by the expert panel. The audio records were referred to where required. The questions for cognitive debriefing were organized into domains of understandability (yes/no), unacceptable words or phrases (yes/no), and suggested alternatives for expression. The data on specific domains were categorized based on the number of participants. The expert panel reviewed the responses and suggested alternatives, with the compilation of a final draft (LUNSERS Hindi V3) after discussion. Descriptive analysis was used to summarize the participant data.

RESULTS

The LUNSERS Hindi V2 was compiled after forward and backward translation and expert discussion regarding several items, as provided in Table 1 and Supplementary Tables S1 and S2. The participants for cognitive debriefing included adult males (median 30 years) (n = 14) belonging to middle socio-economic status (n = 13). Common diagnoses in the participants included bipolar disorder (n = 11) and schizophrenia (n = 7). All participants were receiving second-generation antipsychotics for a median of 6 months [Supplementary Table S3].

Table 1.

Item revision during reconciliation (only conflict items displayed)

Ref	LUNSERS Original Questionnaire	Issues Encountered and Resolved During the Review
1, 3, 4	LUNSERS QUESTIONNAIRE Assessment No.: Assessment Date:	“प्रश्नावली” is a more acceptable spelling. “क्रमांक” is better understood and more accurately back-translated. “दिनांक” is better understood and more accurately back-translated.
5	Please indicate how much you have experienced each of the following symptoms, in the last month, by ticking the appropriate boxes.	• “पिछले महीनें” back translates to “last month” hence chosen over “पिछले ३० दिनों “ • महसूस is more commonly used in spoken Hindi • “उपयुक्त बॉक्स में टिक करके बताएं।“ is more accurately back-translated.
9 Q3, 10 Q4	Runny nose Increased dreaming	“नाक बहना” was accurately back-translated “आना” is literally translated to coming whereas “देखना“ is seeing. In review, “आना” was found to be more appropriate
13 Q7	Swollen or tender chest	“Tender chest” here means pain in the chest on palpation and not soft, thus “छाती में सूजन या दर्द” was selected in review.
14 Q8	Chilblains	No literal translation was found for “chilblains,” so translated as per meaning, and translation 1 was selected for review.
15 Q9	Difficulty in concentrating	“एकाग्रता में कठिनाई” was more accurately backtranslated.
18 Q12, 19 Q13	Urine darker than usual Period problems	“गहरा” is accurately backtranslated to „darker“ “माहवारी” is more commonly used than “महीने/पीरियड” and is also more accepted. Discussed in review and finalised.
22 Q16	Feeling sick	“उल्टी जैसा लगना” was accurately backtranslated.
23 Q17, 52 Q46	Increased sex drive Reduced sex drive	Although translation 2 was better backtranslated, translation 1 was selected as it was found to be more culturally appropriate in review. “शारीरिक सम्बन्ध बनाने” is accurately backtranslated. It also sounds culturally more appropriate in the final review.
25 Q19, 40 Q34	Muscle stiffness Muscle spasms	“मांसपेशियों में जकड़न” more accurately back-translated “मांसपेशियां अकड़ जाना” is more accurately backtranslated
26 Q20	Palpitations	“दिल की धड़कन बढ़ना” accurately backtranslated, no Hindi word for palpitation, so it was translated as per meaning, selected in review.
27 Q21	Difficulty remembering things	“चीजों को याद रखने में कठिनाई” was more accurately backtranslated.
29 Q23, 32 Q26	Lack of emotions Depression	“भावनाओं की कमी” is back-translated to “lack of emotions” more accurately “भावनाएं कम व्यक्त करना” was back-translated to “inability to express emotions”, whereas here it refers to both difficulty experiencing and expressing emotions. “उदासी” is more commonly used in spoken language than “विषाद”
30 Q24	Difficulty achieving climax	The word “कामोन्माद” is too literary and will not be understood by common people. It is also culturally less acceptable than “शारीरिक सम्बन्ध में सुख”. Although “शारीरिक सम्बन्ध में सुख” literally back-translates to “pleasure in sexual relations”. This question was difficult to translate as no literal translation for climax is available, which is commonly used in day-to-day language.
35 Q29	Slowing of movements	“धीरापन” is more commonly used for slowness than “धीमापन”.
36 Q30	Greasy skin	“चिकनी त्वचा” backtranslated as oily skin
38 Q32, 57 Q51	Difficulty passing water Passing a lot of water	“दिक्कत” is more commonly used than “कठिनाई”. Although both can be used interchangeably and both are commonly used. “ज़्यादा पेशाब आना” backtranslated to “increased urination” which is accurate as per concept elaboration.
41 Q35	Sensitivity to sun	“धूप के कारण जलन या दाने” is used as there is no word for photosensitivity in Hindi.
43 Q37	Over-wet drooling mouth	“लार गिरना” is better understood for excessive or hypersalivation, although it literally backtranslates to “drooling of saliva”
48 Q42	Neck muscles aching	“गर्दन की मांसपेशियों में दर्द” is more accurately backtranslated.
49 Q43, 54 Q48	Shakiness Parts of body moving of own accord (For example foot moving up and down)	“कम्पन महसूस करना” is more accurately backtranslated. “शरीर के अंग” translates to body parts.
50 Q44	Pins and needles	“हाथों पैरों में झनझनाहट लगना या सुई चुभना” is more accurately backtranslated
53 Q47, 55 Q49	New or unusual skin marks Itchy skin	“त्वचा में कोई बदलाव” is more near in meaning to the concept elaboration. “खुजली होना” used commonly in spoken Hindi.

Supplementary Table S1.

Forward Translations of the Scale

Ref	LUNSERS Original Questionnaire Wording	Hindi translation 1	Hindi Translation 2
1	LUNSERS QUESTIONNAIRE	लूनसर्स प्रश्नावली	लूनसर्स प्रश्नावली
2	Name:	नाम	नाम
3	Assessment No.:	क्रमांक	मूल्यांकन संख्या:
4	Assessment Date:	दिनांक	मूल्यांकन संख्या:
5	Please indicate how much you have experienced each of the following symptoms, in the last month, by ticking the appropriate boxes.	पिछले ३० दिनों में आपने ये लक्षण कितने ज़्यादा महसूस किये है , टिक कर के चिन्हित करे.	आपने पिछले महीनें में निम्नलिखित लक्षणों में से प्रत्येक का कितना अनुभव किया है? कृपया नीचे दिए गए उपयुक्त बॉक्स में टिक करके बताएं
6 R1-51	Not at all Very little A little Quite a lot Very much	बिलकुल भी नहीं बहुत कम कम अधिक बहुत अधिक	बिलकुल भी नहीं बहुत कम थोड़ा सा काफी बहुत ज्यादा
7 Q1	Rash	चक्कते या दाने	लाल चकत्ते
8 Q2	Difficulty staying awake during the day	दिन के समय जगे रहने में दिक्कत	दिन के दौरान जगे रहने में कठिनाई
9 Q3	Runny nose	नाक से पानी बहना	नाक बहना
10 Q4	Increased dreaming	ज़्यादा सपने आना	ज्यादा सपने देखना
11 Q5	Headaches	सरदर्द	सिर दर्द
12 Q6	Dry mouth	मुँह सूखना	मुँह सुखना
13 Q7	Swollen or tender chest	छाती/स्तन में सूजन या दर्द	सूजी हुयी या नरम छाती
14 Q8	Chilblains	बिवाई /ठण्ड में उँगलियों में सूजन	बिवाई
15 Q9	Difficulty in concentrating	एकाग्रता में कठिनाई	ध्यान केंद्रित करने में कठिनाई
16 Q10	Constipation	कब्ज़	कब्ज
17 Q11	Hair loss	बाल झड़ना	बाल झड़ना
18 Q12	Urine darker than usual	पेशाब का रंग गाढ़ा होना	मूत्र का रंग सामान्य से अधिक गहरा होना
19 Q13	Period problems	महीने/पीरियड में दिक्कत	माहवारी की समस्याएं
20 Q14	Tension	तनाव महसूस करना	तनाव
21 Q15	Dizziness	चक्कर आना	चक्कर आना
22 Q16	Feeling sick	उलटी जैसा लगना	बीमार महसूस करना
23 Q17	Increased sex drive	ज़्यादा शारीरिक सम्बन्ध बनाने का मन करना	यौन-रूचि में वृद्धि
24 Q18	Tiredness	थकान महसूस करना	थकान
25 Q19	Muscle stiffness	मांसपेशिओं में खिंचाव	मांसपेशियों में जकड़न
26 Q20	Palpitations	दिल की धड़कन बढ़ना	तेज और अनियमित दिल की धड़कन
27 Q21	Difficulty remembering things	याद्दाश्त में दिक्कत	चीजों को याद रखने में कठिनाई
28 Q22	Losing weight	वज़न कम होना	वजन कम होना
29 Q23	Lack of emotions	भावनाएं कम व्यक्त करना	भावनाओं की कमी
30 Q24	Difficulty achieving climax	शारीरिक सम्बन्ध में सुख ना महसूस होना.	कामोन्माद पर पहुँचने में कठिनाई
31 Q25	Weak fingernails	कमज़ोर नाखून	कमजोर नाखून
32 Q26	Depression	उदास रहना	डिप्रेशन/ विषाद
33 Q27	Increased sweating	ज़्यादा पसीना आना	अधिक पसीना आना
34 Q28	Mouth ulcers	मुँह के छाले	मुंह में छालें आना
35 Q29	Slowing of movements	हाथ-पैर चलाने में धीरापन	गति का धीमा होना
36 Q30	Greasy skin	चेहरे पे चिकनाई आना	चिकनी त्वचा
37 Q31	Sleeping too much	ज़्यादा सोना	बहुत ज्यादा सोना
38 Q32	Difficulty passing water	पेशाब करने में दिक्कत	पेशाब करने में कठिनाई
39 Q33	Flushing of face	चेहरा लाल हो जाना	चेहरा लाल होना
40 Q34	Muscle spasms	मांसपेशियां अकड़ जाना	मांसपेशियों में ऐंठन
41 Q35	Sensitivity to sun	धूप के कारण जलन या दाने	सूर्य के प्रति संवेदनशीलता
42 Q36	Diarrhoea	दस्त	दस्त
43 Q37	Over-wet drooling mouth	ज़्यादा थूक आना	मुँह अधिक गीला गीला रहना
44 Q38	Blurred vision	धुंधला दिखाई देना	धुंधली दृष्टि
45 Q39	Putting on weight	वज़न बढ़ना	वजन बढाना
46 Q40	Restlessness	बेचैनी	बेचैनी
47 Q41	Difficulty getting to sleep	नींद आने में दिक्कत	सोने में कठिनाई होना
48 Q42	Neck muscles aching	गर्दन में दर्द	गर्दन की मांसपेशियों में दर्द
49 Q43	Shakiness	कम्पन महसूस करना.	कम्पन
50 Q44	Pins and needles	हाथों पैरों में झनझनाहट लगना / सुई चुभना	चुभता हुआ दर्द
51 Q45	Painful joints	जोड़ों में दर्द	जोड़ों में दर्द
52 Q46	Reduced sex drive	शारीरिक सम्बन्ध बनाने का मन ना करना	यौन-रूचि में कमी
53 Q47	New or unusual skin marks	त्वचा में कोई बदलाव	त्वचा पर नये या असामान्य निशान
54 Q48	Parts of body moving of own accord (For example foot moving up and down)	हाथ-पैर खुद ही हिलना	शरीर के अंगों का अपने हिसाब से चलना (उदाहरण के लिए- पैर का ऊपर-नीचे होना )
55 Q49	Itchy skin	खुजली होना	त्वचा में खुजली
56 Q50	Periods less frequent	महीने /पीरियड ना आना	माहवारी में कमी
57 Q51	Passing a lot of water	ज़्यादा पेशाब आना	बहुत ज्यादा पेशाब होना
58	Please check that you have given your answer to all the statements.	एक बार देख ले की आपने सारे सवालों के जवाब टिक कर दिए है	कृपया जांच लें कि आपने सभी कथनों के लिए अपने उत्तर दिये है।
59	Thank you for your time in completing this questionnaire.	धन्यवाद	इस प्रश्नावली को पूरा करने में समय देने के लिए आपको धन्यवाद।

Supplementary Table S2.

LUNSERS Hindi V1 and Backward Translations of The Scale

Ref	LUNSERS Hindi V1	English back translation 1	English back translation 2
1	लूनसर्स प्रश्नावली	LUNSERS Questionnaire	Lunsers questionnaire
2	नाम	Name	Name
3	क्रमांक	Valuation Number	Number
4	दिनांक	ValuationNumber	Date
5	पिछले ३० दिनों में आपने ये लक्षण कितने ज़्यादा महसूस किये है , टिक कर के चिन्हित करे.	How much symptoms of the below mentioned points did you experience during the last month. Please tick the appropriate box given below	Tick and mark the symptoms based on their severity in the last thirty days
6	बिलकुल भी नहीं बहुत कम कम अधिक बहुत अधिक	Not at all Very Less Nominal Sufficient Very high	Absolutely not Very less Less Quite much Very much
7	चक्कते या दाने	Red spots	Spots or dots
8	दिन के समय जगे रहने में दिक्कत	Difficulty being awake during the day	Difficulty in staying awake during daytime.
9	नाक से पानी बहना	Running nose	Watery secretions from nose
10	ज़्यादा सपने आना	Having a lot of dreams	Excessive dreaming
11	सरदर्द	Headache	Headache
12	मुँह सूखना	Dry mouth	Dry mouth
13	छाती/स्तन में सूजन या दर्द	Swelled or soft chest	Pain or discomfort in chest/breast
14	बिवाई /ठण्ड में उँगलियों में सूजन	Heel cracks	Swelling in fingers during winters
15	एकाग्रता में कठिनाई	Difficulty in foussing attention	Difficulty in concentration
16	कब्ज़	Constipation	Constipation
17	बाल झड़ना	Hairfall	Hair fall
18	पेशाब का रंग गाढ़ा होना	Urine darker than normal	Dark coloured urine
19	महीने/पीरियड में दिक्कत	Menstruation problems	Menstrual difficulties
20	तनाव महसूस करना	Stress	Feeling tensed
21	चक्कर आना	Dizziness	Dizziness
22	उलटी जैसा लगना	Feeling sick	Urge to vomit
23	ज़्यादा शारीरिक सम्बन्ध बनाने का मन करना	Increased sexual desire	Experiencing increased desire for sexual relations
24	थकान महसूस करना	Tiredness	Feeling tired
25	मांसपेशिओं में खिंचाव	Muscle stiffness	Muscle pulls
26	दिल की धड़कन बढ़ना	Fast or irregular heart beat	Increased heart rate
27	याद्दाश्त में दिक्कत	Difficulty in remembering things	Difficulty in recollection
28	वज़न कम होना	Weight loss	Weight loss
29	भावनाएं कम व्यक्त करना	Less emotions or feelings	Inability to express emotions
30	शारीरिक सम्बन्ध में सुख ना महसूस होना.	Difficulty in achieving climax	Dissatisfaction in sexual relations
31	कमज़ोर नाखून	Weak nails	Brittle nails
32	उदास रहना	Depression	Feeling sad
33	ज़्यादा पसीना आना	Excessive sweating	Increased sweating
34	मुँह के छाले	Mouth ulcers	Ulcers in mouth
35	हाथ-पैर चलाने में धीरापन	Slowing down	Slowing of hand or limb movements
36	चेहरे पे चिकनाई आना	Smooth skin	Oily face
37	ज़्यादा सोना	Sleeping a lot	Increased sleep
38	पेशाब करने में दिक्कत	Difficulty urinating	Difficulty in urination
39	चेहरा लाल हो जाना	Red face	Redness over face
40	मांसपेशियां अकड़ जाना	Muscle cramps	Tightness in muscles
41	धूप के कारण जलन या दाने	Sensitivity to the sun	Burning or dots experienced in sunlight
42	दस्त	Diarrhea	Diarrhoea
43	ज़्यादा थूक आना	Mouth remians very wet	Increased salivation
44	धुंधला दिखाई देना	Blurred vision	Blurring of vision
45	वज़न बढ़ना	Weight gain	Weight gain
46	बेचैनी	Restlessness	Restlessness
47	नींद आने में दिक्कत	Difficulty sleeping	Difficulty in falling asleep
48	गर्दन में दर्द	Neck muscle pain	Neck pain
49	कम्पन महसूस करना.	Shivering	Experiencing tremors
50	हाथों पैरों में झनझनाहट लगना / सुई चुभना	Stinging pain	Pin prick or lightening sensation in hands and feel
51	जोड़ों में दर्द	Joint pain	Pain in joints
52	शारीरिक सम्बन्ध बनाने का मन ना करना	Decreased sexual interest	Loss of desire for sexual relations
53	त्वचा में कोई बदलाव	New or unusual scars on the skin	Any changes in skin
54	हाथ-पैर खुद ही हिलना	Body parts working on their own (For example, foot going up and down)	Involuntary movements of hands and feet
55	खुजली होना	Itchy skin	Itching
56	महीने /पीरियड ना आना	Menstrual reduction	Absence of menstrual cycles
57	ज़्यादा पेशाब आना	Excessive urination	Increased urination
58	एक बार देख ले की आपने सारे सवालों के जवाब टिक कर दिए है	Please check that you have provided your answers to all the statements.	Recheck that all questions have been answered
59	धन्यवाद	Thank you for taking the time to complete this questionnaire.	Thank you

Supplementary Table S3.

Sociodemographic and Clinical Characteristics of the Participants (n=20)

Variable	Frequency (percentage)	Median (IQR)
Age (years)		30 (35-26)
Sex
Male	14 (70)
Female	6 (30)
Marital Status
Married	5 (25)
Unmarried	15 (75)
Occupation
Student	4 (20)
Homemaker	3 (15)
Skilled worker	1 (5)
Unemployed	12 (60)
Socio-economic status
Upper	3 (15)
Middle	13 (65)
Lower	4 (20)
Primary diagnosis
Schizophrenia	7 (35)
Psychosis unspecified	1 (5)
Bipolar type 1 – Mania with Psychotic symptoms	3 (15)
Bipolar type 1 – Depression with Psychotic symptoms	3 (15)
Bipolar type 1 – Mixed episode with Psychotic symptoms	5 (25)
Depression with psychotic symptoms	1 (5)
Duration on current antipsychotics (months)		6 (10.5–2.25)
Current antipsychotic drug
First-generation antipsychotic	0
Second-generation antipsychotic	16 (80)
Clozapine	4 (20)
Other Psychotropics
SSRI	6 (30)
SNRI	3 (15)
Other antidepressants	1 (5)
Lithium	4 (20)
Valproate	1 (5)

The recorded self-reported side effects by most of the patients on the LUNSERS Hindi V2 draft commonly included constipation, palpitations, sleeping too much, restlessness, difficulty in concentrating, tension, tiredness, difficulty remembering things, and depression, as detailed in Supplementary Table S4.

Supplementary Table S4.

LUNSERS Hindi V3 Draft Self-Report Scores

Hindi-translated LUNSERS item number	Frequency of participants with Likert rating of “A little” or higher (out of 20)
No items	None
Item 1, 3, 7, 8, 13, 17, 24, 25, 28, 32, 33, 35, 36, 46, 47, 49, 50	1-5 participants
Item 2, 4, 5, 6, 11, 12, 15, 16, 19, 22, 23, 27, 29, 30, 34, 37, 38, 39, 41, 42, 43, 44, 45, 48, 51	6-10 participants
Item 10, 20, 31, 40 (constipation, palpitations, sleeping too much, restlessness)	11-15 participants
Item 9, 14, 18, 21, 26 (difficulty in concentrating, tension, tiredness, difficulty remembering things, depression)	16-20 participants

More than 25% of the participants had difficulty understanding a total of eight items (15.69%). This included item numbers 15, 19, 29, 30, 31, 36, 39, and 56, which were difficulty in concentrating (n = 10), period problems (n = 8), lack of emotions (n = 8), difficulty achieving climax (n = 7), weak fingernails (n = 6), greasy skin (n = 14), flushing of face (n = 7), and periods less frequent (n = 8), respectively. Item 36 (greasy skin) was misunderstood by most participants (70%), followed by item 15 (difficulty in concentrating). No participants reported any unacceptable or offensive words or phrases in the scale. For some items, the participants were more familiar with certain English terms than the classical Hindi translated versions. Supplementary Tables S5–S7, along with Figure 1, provide a more detailed account of this.

Supplementary Table S5.

Cognitive Debriefing - Understandability: Participant Frequency

Cognitive debriefing item number	Frequency of participants with difficulty in understanding (out of 20)
Item 1, 3, 4, 5, 6, 9, 11, 12, 17, 21, 24, 28, 32, 33, 34, 37, 38, 44, 45, 46, 47, 51, 53, 57, 58, 59	No difficulty in understanding
Item 2, 7, 8, 10, 13, 14, 16, 18, 20, 22, 23, 25, 26, 27, 35, 40, 41, 42, 43, 48, 49, 50, 52, 54, 55	1-5 participants had difficulty
Item 15, 19, 29, 30, 31, 39, 56	6-10 participants had difficulty
Item 36	11-15 participants had difficulty
No items	16-20 participants had difficulty

Supplementary Table S7.

Summary table for changes made

Cognitive debriefing item number*	Item description	Number of participants reporting the issue	Suggested alternative modes of expression by the participants (verbatim)	Changes made after discussion with the expert panel
15 Q9	एकाग्रता में कठिनाई	10	“focus” “ध्यान देने में कठिनाई” “किसी चीज़ में focus करने में दिक्कत” “ध्यान लगाने में दिक्कत”	ध्यान देने में कठिनाई
19 Q13	माहवारी में दिक्कत	8	“Periods” “महीने” “Date/Periods” “Periods/महीने”	पीरियड्स में दिक्कत
29 Q23	भावनाओं की कमी	8	“ख़ुशी की बात से खुश नहीं होना या दुःख की बात से दुखी” “Happiness से Happy feel नहीं करना” “ख़ुशी गम का अहसास पहले जितना नहीं होना”	भावनाओं की कमी
30 Q24	शारीरिक सम्बन्ध में सुख न महसूस होना.	7	“Sex life अच्छी है या बुरी” “Sex के time मज़ा”	शारीरिक सम्बन्ध में सुख न महसूस होना
31 Q25	कमज़ोर नाखून	6	“नाखून टूट तो नहीं रहे” “नाखून टूट जाना” “नाखून टूट तो नहीं जाते”	नाखून कमज़ोर हो जाना
36 Q30	चिकनी त्वचा	14	“Oily skin” “Oily/त्वचा चिप चिप होना” “चिप चिप होना” “त्वचा Oily होना” “Oily त्वचा” “त्वचा पर तेल जैसा लगना”	चिपचिपी तवचा
39 Q33	चेहरा लाल हो जाना	7	“चेहरे में लालपन” Misinterpreting as a proverb – “गुस्सा करना”	चेहरे में लालपन हो जाना
56 Q50	माहवारी में कमी	8	“Periods” “महीने” “Date/Periods” “Periods/महीने”	“पीरियड्स में कमी”

*Only items with frequent understandability issues among participants are displayed

Figure 1.

Cognitive debriefing–understandability matrix representation. ^@ Rows represent cognitive debriefing test item numbers, and columns represent participants. * Green represents “yes”, and red represents “no” for understandability

Supplementary Table S6.

Cognitive Debriefing—Final Changes After Discussion

Ref	LUNSERS Items	Issues in Review
1	LUNSERS QUESTIONNAIRE	“प्रश्नावली” is a more acceptable spelling.
2	Name:	Same in both translations.
3	Assessment No.:	“क्रमांक” is better understood and more accurately backtranslated.
4	Assessment Date:	“दिनांक” is better understood and more accurately backtranslated.
5	Please indicate how much you have experienced each of the following symptoms, in the last month, by ticking the appropriate boxes.	• “पिछले महीनें” backtranslates to “last month” hence chosen over “पिछले ३० दिनों” • महसूस is more commonly used in spoken Hindi • “उपयुक्त बॉक्स में टिक करके बताएं।“ is more accurately backtranslated.
6 R1-51	Not at all Very little A little Quite a lot Very much	Final version accepted after review, so that it is framed like a Likert scale.
7 Q1	Rash	Same in both translations.
8 Q2	Difficulty staying awake during the day	Same in both translations.
9 Q3	Runny nose	“नाक बहना” was accurately backtranslated
10 Q4	Increased dreaming	“आना” is literally translated to coming whereas “देखना” is seeing in review, आना was found to be more appropriate.
11 Q5	Headaches	Same in both
12 Q6	Dry mouth	Same in both
13 Q7	Swollen or tender chest	“Tender chest” here means pain in the chest on palpation and not soft, thus “छाती में सूजन या दर्द” was selected in review.
14 Q8	Chilblains	No literal translation was found for “chilblains,” so translated as per meaning, and translation 1 was selected for review.
15 Q9	Difficulty in concentrating	“एकाग्रता में कठिनाई” was more accurately backtranslated.
16 Q10	Constipation	Same in both
17 Q11	Hair loss	Same in both
18 Q12	Urine darker than usual	“गहरा” is accurately backtranslated to “darker”
19 Q13	Period problems	“माहवारी” is more commonly used than “महीने/पीरियड” and also more accepted. Discussed in review and finalised.
20 Q14	Tension	Same in both
21 Q15	Dizziness	Same in both
22 Q16	Feeling sick	“उल्टी जैसा लगना” was accurately backtranslated.
23 Q17	Increased sex drive	Although translation 2 was better backtranslated, translation 1 was selected as it was found to be more culturally appropriate in review.
24 Q18	Tiredness	Same in both
25 Q19	Muscle stiffness	“मांसपेशियों में जकड़न“ more accurately back-translated
26 Q20	Palpitations	“दिल की धड़कन बढ़ना” accurately backtranslated, no Hindi word for palpitation so it was translated as per meaning , selected in review.
27 Q21	Difficulty remembering things	“चीजों को याद रखने में कठिनाई“ was more accurately backtranslated.
28 Q22	Losing weight	Same in both
29 Q23	Lack of emotions	“भावनाओं की कमी” is backtranslated to “lack of emotions” more accurately “भावनाएं कम व्यक्त करना” was backtranslated to „inability to express emotions“, whereas here it refers to both difficulty experiencing and expressing emotions.
30 Q24	Difficulty achieving climax	The words “कामोन्माद“ is too literary and will not be understood by common people. It is also culturally less acceptable than “शारीरिक सम्बन्ध में सुख”. Although “शारीरिक सम्बन्ध में सुख” literally backtranslates to “pleasure in sexual relations”. This question was difficult to translate as no literal translation for climax is available, which is commonly used in day-to-day language.
31 Q25	Weak fingernails	Same in both
32 Q26	Depression	“उदासी” is more commonly used in spoken language than “विषाद”
33 Q27	Increased sweating	Same in both translations
34 Q28	Mouth ulcers	Same in both translations
35 Q29	Slowing of movements	“धीरापन” is more commonly used for slowness than “धीमापन”.
36 Q30	Greasy skin	“चिकनी त्वचा“ backtranslated as oily skin
37 Q31	Sleeping too much	Same in both
38 Q32	Difficulty passing water	“दिक्कत” is more commonly used than “कठिनाई”. Although both can be used interchangeably and both are commonly used.
39 Q33	Flushing of face	Same in both
40 Q34	Muscle spasms	“मांसपेशियां अकड़ जाना” is more accurately backtranslated
41 Q35	Sensitivity to sun	“धूप के कारण जलन या दाने” is used as there is no word for photosensitivity in Hindi .
42 Q36	Diarrhoea	Same in both
43 Q37	Over-wet drooling mouth	“लार गिरना” is better understood for excessive or hypersalivation, although it literally backtranslates to “drooling of saliva”
44 Q38	Blurred vision	Same in both
45 Q39	Putting on weight	Same in both
46 Q40	Restlessness	Same in both
47 Q41	Difficulty getting to sleep	Same in both
48 Q42	Neck muscles aching	“गर्दन की मांसपेशियों में दर्द” is more accurately backtranslated.
49 Q43	Shakiness	“कम्पन महसूस करना” is more accurately backtranslated.
50 Q44	Pins and needles	“हाथों पैरों में झनझनाहट लगना या सुई चुभना” is more accurately backtranslated
51 Q45	Painful joints	Same in both
52 Q46	Reduced sex drive	“शारीरिक सम्बन्ध बनाने” is accurately backtranslated. It also sounds culturally more appropriate in final review.
53 Q47	New or unusual skin marks	त्वचा में कोई बदलाव is more near in meaning to the concept elaboration.
54 Q48	Parts of body moving of own accord (For example, foot moving up and down)	शरीर के अंग translates to body parts.
55 Q49	Itchy skin	“खुजली होना” used commonly in spoken Hindi.
56 Q50	Periods less frequent	“माहवारी” more culturally appropriate as per reviewer.
57 Q51	Passing a lot of water	“ज़्यादा पेशाब आना” backtranslated to “increased urination” which is accurate as per concept elaboration.
58	Please check that you have given your answer to all the statements.	“कृपया जांच लें कि आपने सारे प्रशनों के उत्तर दे दिये है।“ is accurately back translated
59	Thank you for your time in completing this questionnaire.	Same in both

DISCUSSION

We translated the LUNSERS into Hindi. During our cognitive debriefing, we found that several participants had difficulty understanding the translated terms used to describe “periods” and “difficulty achieving climax.” This could be related to the hesitancy surrounding the discussion of topics related to sexual health.[12] The language or “slang” used to describe various sexual terms differs from the classical Hindi terminologies.[12]

Another important highlight was the suggestion of English language terms by the participants for better expression of certain translated terms in the LUNSERS Hindi V2 draft. An example is the term “concentrating,” where several participants suggested the use of the term “focus” in place of the Hindi-translated word “ekagrata”. This could possibly be due to the uncommon use of the more formal and complex Hindi language terminologies and integration of adopted words from English literature into the Hindi language.[13] It also reflects the integration of English literature with the Hindi language in day-to-day communication for the general population. Recent literature supports this notion, highlighting the rise of “Hinglish” speaking individuals.[13]

The strength of our study is that we followed the WHO and ISPOR 2005 task force guidelines and frequently requested inputs from the developers. The study limitations include having no psychometric validation, with a small, single-center sample, and difficulties in generalizability to all Hindi-speaking individuals. This translated version requires further validation research.

This study provides a perspective on the translation of a self-reported instrument. We selected LUNSERS for translation into Hindi after considering its comprehensive nature, clinical relevance, reliability, validity, and relevance of the translated language to the population of our region. This translated self-report tool can help screen antipsychotic-related side effects in a busy clinic and inform clinicians about the side effects experienced by individuals at a glance. Future work on this translated version could elaborate further on other psychometric properties and improve the validity of the Hindi translated version of LUNSERS.

Declaration regarding the use of generative AI

The author(s) attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures, or other informational content of this manuscript.

Supplementary material

This article has supplementary material and can be accessed at this link. Supplementary Material at https://links.lww.com/IPSY/A23.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure 1

Stepwise summary of the translation process

Funding Statement

Nil.