Table 1.

Procedure of translation and validation of the BMQ in the Maltese language

Steps	Critical components
Preparation	Permission was obtained from Prof Robert Horne (the developer) for use of the instrument. He clarified ambiguities and provided a document on how to use and analyse the BMQ. This form of consultation was essential for better translation equivalence.
Forward translation	One independent forward translation was carried out using Maltese fonts by the principal investigator. Harmonisation of this initial translation was carried out with the Department of Translation at the University of Malta, where items were discussed within the context to be measured, in an attempt to avoid literal translations which can mislead the purpose of the study. At the same time, free translation was also avoided as it could wander too far from the meaning of the original. The translation was based on the SkoposTheory.34
Reconciliation	The forward translation was discussed and revised for better harmonisation of concepts in the instrument, with the intention of capturing the conceptual meaning of the items. This was done through an expert panel in order to resolve discrepancies and allow for agreement between speech habits and preferences in the translated language. This functional approach in the translation was considered to respect the target patients and their situation and cultural background.
Back translation	The Maltese version was back translated to English by a certified translator who had no access to the original version of the BMQ, since reversibility is crucial to equivalence.
Back translation review	The back translation was reviewed against the English version so as to ensure conceptual equivalence of the translation carried out, avoiding mistranslations and translation losses which would render an incomplete replication of the source questionnaire in the target one.
Cognitive debriefing results and finalisation	Finalisation of the translation allowed for any necessary modifications or rewording of the items. Satisfactory review of comparison of both English versions (back translation and original) resulted in the finalisation of the Maltese language version of the BMQ. This editing process was needed to create a Maltese text which is maximally suitable for the intended patients. Improvements were considered necessary to fix problems which may hinder the mental processing of the questions, and to tailor these questions to the intended patients.
Proofreading	The draft in the Maltese language was checked for minor errors that might have been disregarded during the translation process by the principal investigator and a colleague. Conforming to the rules governing Maltese writing is important since it respects the general feeling of the people – errors in Maltese are often regarded as denigrating the language in the Maltese Islands
Final report (translation and validation)	The explanation of the process undertaken to effectively translate the BMQ into the Maltese language is presented in the results and discussion section under the section BMQ.

Procedure as per Wild et al., 2005 - Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures.34