Danish translation, adaptation and initial validation of the clinical assessment of modes questionnaires

Abstract Background The Clinical Assessment of Modes questionnaires (CAMQs) determine clients' preferential modes for therapy (CAM-C1), clients’ perception of modes used by the occupational therapist (OTs) during therapy (CAM-C2), or modes the OTs believed to have used (CAM-T). Access to valid CAMQs for Danish OTs and clients required a rigorous translation and cultural adaptation process. Objectives To translate and culturally adapt the CAMQs into Danish, examining face validity in a Danish context. Material and methods A 10-step guideline for the process of translating and culturally adapting questionnaires was followed. Steps 1–6 included translation into Danish, steps 7–8 involved cognitive debriefing interviews and validation based on the Content Validity Index (CVI) analyzed using Kappa statistics. Steps 9–10 finalized the process. Results CAMQs were translated into Danish. Based on cognitive debriefing interviews and CVIs involving 15 clients and 7 OTs, modifications regarding titles, layouts, instructions, wording and response categories were performed in all Danish CAMQs. The Item CVI and the modified kappa revealed that most participants had a high level of agreement on the cultural relevance. Conclusions and significance Translated versions of the CAMQs have been culturally adapted into Danish. The current Danish versions seem culturally relevant and useable in Danish occupational therapy.

Introduction contributions to therapy. The empathizing mode focuses on utilizing gentle inquiry, mirroring, and summary statements to explicitly demonstrate one's ongoing efforts to understand the clients' perspective. When the encouraging mode is utilized, the OTs attempt to instil and reinforce the clients' hope and courage for engagement in occupation. The instructing mode consists of an educational and teaching style in the interaction with the client. Finally, by utilizing the problem-solving mode, OTs rely on pragmatic thinking and consider alternative perspectives, asking strategic, agenda-based questions that allow clients to see a broader range of solutions, options, consequences, or dimensions of an issue [7].
A study by Taylor et al. [8] investigated the use of therapeutic modes in a sample of practicing OTs in the United States. The encouraging mode was found to be the most frequently used, whereas the empathizing mode was the least used. This pattern of mode use was similar across clients and circumstances. To determine the use of modes, the Self-Assessment of Modes Questionnaire (SAMQ) was employed [8]. The SAMQ is based on the IRM and designed to assist OTs in identifying their preferred mode of use during therapy sessions.
Still, there might be a disproportion between the modes employed by the OT and what the client needs and requests. One way to determine any discrepancies is to evaluate the communication styles used between the client and therapist [1]. Accordingly, another three instruments, the Clinical Assessment of Modes questionnaires (CAMQs), have been created by Dr. Taylor based on the six modes. The 'CAM-Client Time 1' (CAM-C1) is administered to a client prior to therapy to determine the client's preferential modes for the upcoming therapy sessions, whereas the 'CAM-Client Time 2' (CAM-C2) is administered to a client after therapy to assess the client's perception of what modes the OT used during therapy. The 'CAM-Therapist' (CAM-T) is administered to the OT after therapy has concluded to assess the OT's perception of what modes the OT believed he or she used with that client. The CAM-C1, CAM-C2, and CAM-T assessments are self-report questionnaires with between 30 and 33 items, using a five-point Likert scale. These assessments are currently undergoing research for psychometric properties and clinical utility [9].
There are several indications of the relevance of the IRM and its applications in a Danish context. First, the IRM and related instruments are already presented in the curriculum in several of the Bachelor's programs of Occupational Therapy in Denmark, and the first step to translate parts of the IRM textbook into Danish has been taken [10]. Second, the various interpersonal skills used by OTs and the corresponding responses by the clients, are known to play a vital role to strengthen the clienttherapist relationship. However, OTs tend to use a limited number of interpersonal skills and this may not correspond to the behaviour that the clients prefer to be used by the OTs. While the SAMQ provides the OTs insights into their own therapeutic style, the CAMQs represent tools to evaluate the client-therapist relationship. The use of these questionnaires in clinical practice, therefore, offers so far unseen opportunities to strengthen the therapeutic relationship.
The SAMQ has previously been formally translated and culturally adapted into Danish (D-SAMQ) [11]. Consequently, it is important to conduct a rigorous translation, including cultural adaptation and validation of the CAM-C1, CAM-C2, and CAM-T into Danish [12,13]. This should then be followed by additional psychometric testing [13,14]. This study describes the process of translating and culturally adapting the CAM-C1, CAM-C2, and CAM-T questionnaires into Danish and examining the face validity of the questionnaires in terms of relevance and comprehensiveness in a Danish context.

Instrumentation
All three CAMQs include similar parts with a few differences; all items are rated on five-point Likert scales, except from item 32 in CAM-C2, and item 38 in CAM-T. In these items, several response options are presented to the client and the therapists regarding things that they would have done differently. The client resp. the OTs are asked to tick off their top priority [15]. For further, the Clearinghouse website can be visited: Intentional Relationship Model Clearinghouse. ahslabs.uic.edu The CAM-C1 consists of a title, an initial instruction, a section with demographic questions, items 1-8 (called 'About You'), followed by items 9-38 all related to the communication style between client and OT. In the end, there is a qualitative question for the clients to make further comments if needed.
The CAM-C2 consists of a title, followed by items 1-30 related to the clients' perception of the therapists' ability to communicate. Items 31-32 concern the clients' satisfaction with the occupational therapy service, whereas items 33-40 include the demographic section 'About you'. Here too, a qualitative question is placed in the end for further comments.
The CAM-T consists of a title, an initial instruction, and begins with the demographic section, including items 1-5. This is followed by items 6-35 related to the communication with clients, and items 36-38 concerning how satisfied the OT perceives the client to be with the service. Here too, a qualitative question is placed in the end for further comments.
The CAM-C1 is used before the therapy process is initiated to assess the client's communication preferences. For example, the first item is: 'I want my therapist to help me get access to resources or people in the community in which I live'. Items are rated from 'Not at all important' to 'Extremely important'. The CAM-C2 is used after the therapy process is concluded to assess the client's perception of what modes the therapist used e.g.: 'My therapist helped me get access to resources or people in the community in which I live'. Here, items are rated from 'Never' to 'Very frequently'.
After the therapy process is concluded, the CAM-T is used to assess the OT's perception of his/her communication with a specific client during therapy. The OT rates to which extent he/she has done what is stated in items representing plausible therapeutic actions (modes). For example, the first item is: 'I helped this client to get access to resources or people in the community in which he/she lives'. Ratings are ranging from 'Never' to 'Very frequently'.
The CAM-C2 and the CAM-T both include a section related to perceived satisfaction, including two overall questions.

Design and procedures
The translation of CAM-C1, CAM-C2 and CAM-T was planned and conducted using a guideline for translation and cultural adaptation of patient-reported outcome measures recommended by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force [13]. In 1999, the ISPOR Task Force group -Translation and Cultural Adaptation (TCA) was formed to address the lack of consistency in terminology and methodology related to translation and cultural adaptation of outcome measures. Based on a review of the literature and existing guidelines, the task force group developed a consensus-based guideline for translation and cultural adaptation of patient-reported outcomes measures, representing principles of good practice [13]. This guideline was also used when translating the SAMQ into Danish.
The 10-step process is presented in a flow chart ( Figure 1). Further details about each of the steps are provided below.
Translation (steps 1-6) 1. Preparation: First, the developer of the original questionnaires, Dr. Taylor, granted permission to translate, culturally adapt and initially validate the CAMQs into Danish versions of the instruments (D-CAM-c1, D-CAM-c2 and D-CAM-T).
2. Forward translation: Next, two of the authors (KTN and MSP) individually forward-translated the CAM-C1 and CAM-C2 while another two authors translated the CAM-T (AEL and KTN) into Danish. All authors (but Dr. Taylor) are native Danish and experienced in speaking and writing in English. This, to find equivalent terms and expressions while retaining the meaning of the original questionnaires. During this process, both translators had access to the theoretical framework of the CAMQs, i.e. the IRM [1] to retain the conceptual meaning, while also translating into colloquial language.
3. Reconciliation: Based on the two forward translations, four of the authors (AEL, KTN, MSP and EEW) went through the translated versions, sentence by sentence, and resolved any discrepancies to developed consensus versions. Any differences between versions were discussed and a logbook was used to document decisions. Issues related to translational incongruence in terms of choice of words, comprehension, and cultural issues, were described in the logbook and were to be addressed at the cognitive debriefing interviews in step 7.
4. Back translation: Back translations were performed by the translation bureau 'Easy Translate' [16]. Excel files containing only the Danish consensus versions of the translated instruments were forwarded to Easy Translate and professional translators then performed a literal back translation into English.

5.
Back-translation review: To ensure conceptual equivalence Dr. Taylor reviewed the English back translations of the three instruments [15]. 6. Harmonization: Identified disparities from the back-translation review were discussed and dealt with by the authors. The authors needed to reach a consensus with regards to the new Danish versions. Unsolved issues were to be discussed in the cognitive debriefing interviews.

Cultural adaptation (step 7)
7. Cognitive debriefing evaluating comprehensibility, equivalences and cultural relevance: Cognitive debriefing interviews were planned separately for clients and OTs to a) assess the level of comprehensibility and cognitive equivalence (i.e. conceptual, item, semantic and operational equivalence) of the preliminary Danish translations of the CAMQs (D-CAMQs), b) to discuss unsolved translation issues and obtain consensus on alternative phrasings [13,17] and c) evaluate the cultural relevance of the items included in the questionnaires [13,17].
To evaluate the cultural relevance of each item, the Content Validity Index (CVI) was applied [17] by asking participants to rate the cultural relevance of each item on a four-point Likert scale: 'Not relevant', 'Somewhat relevant', 'Relevant' and 'Very relevant'. The included therapists performed the rating using Survey Xact [18] and the clients performed the rating based on a paper questionnaire.
Individual cognitive debriefings with clients (D-CAM-C1 and D-CAM-C2) Due to the COVID-19 pandemic, the planned groupbased cognitive debriefing interviews with clients were changed into individual, virtual cognitive debriefing interviews. Thus, from Marts to April 2020, participants for the D-CAM-C1 and D-CAM-C2 cognitive debriefing interviews were recruited through various occupational therapy settings, i.e. mental health and physical rehabilitation within regional and community-based settings to ensure a heterogenic sample representing the diversity in occupational therapy practice. Furthermore, diversity in terms of gender and age was also considered [13].
Before the cognitive debriefing interviews, an interview guide for the clients was developed. The interview guide was pilot tested on the first author (AEL),  leading to a few changes before use. Based on the interview guide, demographic data (age, gender, and diagnosis) was collected, and all included items were discussed one by one. Further, potentially non-clarified issues from the reconciliation and harmonization phases were brought up. With very few changes, the same interview guide was used for the cognitive debriefing interview with the OTs, for instance, the demographic data was collected in a survey.
The majority of the D-CAM-C1 and D-CAM-C2 cognitive debriefing interviews were performed using Skype, to enable visual contact between the participant and the interviewers. Two interviews, however, were conducted using telephone-based on participant preferences. The 30 items were discussed one by one with focus given to the non-clarified issues to obtain client perspectives and solutions on translation matters. The interviews were conducted by bachelor students and tape-recorded to preserve the client's wording in the subsequent analysis.
Following the cognitive debriefing interviews, participants rated the CVI on the cultural relevance of each item in D-CAM-C1 and D-CAM-C2 using a paper questionnaire. Due to a data collection error, the collection of CVI data needed to be repeated. As the clients participating in the cognitive debriefing interviews could not be reached because of discharge/ cessation of therapy, CVI data was collected among a second study sample recruited using the same strategy as described above.
Online group-based cognitive debriefing with occupational therapists (D-CAM-T) Participants representing potential users of the D-CAM-T (Danish OTs working as clinicians and occupational therapy educators) were recruited during April and May 2020, following recommendations by the ISPOR Task Force [13]. Aiming for a representative sample in terms of gender, age, and vocational experience (i.e. years since graduation and field of work), OTs across Denmark were invited to participate. Potential participants received an email with information related to study aim and procedures and an invitation to an online group-based cognitive debriefing interview.
One week before the online cognitive debriefing interviews, participants received an e-mail with the preliminary version of the D-CAM-T and a Survey Xact link to an online questionnaire on demographics (gender, age, education besides occupational therapy education, years since graduation as OT, field of work and knowledge about the CAM-T) and rating of the cultural relevance of the items included in D-CAM-T based on CVI. In preparation for the online cognitive debriefing interviews, participants were instructed to fill in the D-CAM-T questionnaire with a selected client in mind. In addition, the participants were asked to make notes if experiencing difficulties related to comprehension, ambiguities and/or lack of clarity. The participants were asked to bring their notes to the online cognitive debriefing interviews.
Two of the authors (KTN and EEW) conducted the online group-based cognitive debriefing interview, guided by an interview guide. Based on the interview guide the 30 items were discussed one by one and potential non-clarified issues from the reconciliation and harmonization phases were brought up to obtain participant perspectives and solutions. One author served as moderator and the other as co-interviewer taking notes and interacting when needed. Furthermore, the co-interviewer was keeping track of time.

Data analyses (steps 8)
Descriptive statistics on demographic data were performed using Microsoft Excel [19]. Age (OTs and clients) and years since graduation (OTs) were presented using median and range due to lack of normal distribution. The distribution of gender, the field of work (OTs), employment setting (OTs), and prior knowledge of the CAM-T (OTs) were presented in numbers and percentages. Types of diagnosis (clients) and settings were described in frequencies [19].

Review of cognitive debriefing results and finalization
Comprehensiveness. D-CAM-C1 and D-CAM-C2: Data based on the individual cognitive debriefing interviews were analysed using a qualitative description approach inspired by content analysis procedures but without following the process rigorously [20]. Looking at notes and consulting the recordings from the interviews, an initial inductive/data-driven analysis based on the empirical data was performed. During this process, data was discussed, condensed, structured and coded. Mismatches or uncertainties in the wording of the questionnaires were identified according to the themes in the interview guide, and a matrix of D-CAM-C1 and D-CAM-C2 was developed. In these matrixes, all notes and comments were inserted together with a proposed solution, and the interview notes were re-consulted to clarify and secure that all translational or equivalence issues were identified.
D-CAM-T: Based on the interview notes, the consensus results from the cognitive debriefing interview with the OTs were inserted in a matrix. Thus, issues related to the D-CAM-T were inserted followed by information from the interview notes, including what the problem was concerned, and a description of the solutions suggested by the participants.
Finally, all matrices were reviewed to demine if some of the solutions were to be implemented across all three instruments.
Cultural relevance -CVI and kappa statistics The following procedures were applied for data on all three instruments. First, CVI for each item (item-CVI, I-CVI) [17] was calculated by dividing the number of participants who rated the item to be 'relevant' or 'very relevant' with the total number of participants. Thus, revealing the proportion of agreement (x); The closer to 1.0 the higher level of agreement. Next, a consensus index of inter-rater agreement adjusted for a chance [17] was calculated using Kappa statistics. More specifically, the probability of a chance occurrence (p c ) was first computed using the formula for a binominal random variable, with one specific outcome: 5N (N¼number of participants and A ¼ number of participants agreeing on good relevance.) Next, modified kappa (k Ã ) was computed to designate the agreement among participants on the relevance of the specific items: k Ã ¼ (I-CVI_p c )/(1_pc). The guidelines described by McHugh [21] were used as evaluation criteria for the modified kappa: None ¼ k 0.20; Minimal ¼ k of 0.21 to 0.39; Weak ¼ k of 0.40 to 0.59; Moderate ¼ k of 0.60-0.79; Strong ¼ k of 0.80 to 0.90 Almost perfect ¼k > 0.90.

Proofreading
After having incorporated the suggestions from the participants into new versions of D-CAM-C1, D-CAM-C2 and D-CAM-T, the next step was proofreading. In this process, we unified the changes across the three instruments to ensure that the same wording is used for the same aspect.

Final report
This publication serves as the final report related to the process of translating and culturally adapting the CAMQs into a Danish context.

Ethical considerations
The study was conducted in accordance with standard ethical guidelines for research [22]. Formal approval from the National Committee on Health Research Ethics was not needed given the nature of the study and the type of data collected [23]. The therapists participating in step 7 provided consent to participate in the online Survey Xact questionnaire and clients participating in step 7 signed a statement of consent. All participants were informed of their right to withdraw at any time without any consequences and further, they were guaranteed confidentiality.

Results
The results will be presented chronologically, following the steps outlined in the methods section.
The translation phase (steps 2-6) As described the translation was performed in five steps. First, authors in pairs translated the CAM-C1/ C2 and the CAM-T questionnaires, respectively. This was followed by a process of consensus-based harmonizing between all four Danish authors in which consequential corrections were made across the questionnaires. A wording close to the original American version was sought while simultaneously maintaining fluent Danish. The consensus versions were back-translated to American English, presented to Dr. Taylor, who commented on specific wordings that varied from the original version. For instance, in CAM-C1, Q19 specifying the differences in the word 'confident' (from the original questionnaire) denoting high levels of self-efficacy became 'competent' in the back-translated version denoting baseline functionality. Similarly, in Q30, attention was made to the word 'conviction' denoting confidence as opposed to' convincing' denoting persuasion. This process led to few changes in the Danish versions, and clarification of issues highlighted to be followed up in the cognitive debriefing interviews.

The cognitive debriefing (step 7)
Participants Twelve OTs and 24 clients, 12 for cognitive debriefing interviews and 12 for CVI scoring respectively, were invited to participate in the study. A total of seven OTs accepted the invitation, whereas seven clients accepted to participate in the cognitive debriefing interviews, and eight clients filled in the paper-based CVI questionnaires. Not responding to the invitation, lack of time (OTs) and challenges related to online participation (clients) were reasons for not participating. In Table 1 demographic data on all participants are presented.

D-CAM-C1 and D-CAM-C2
Based on individual cognitive debriefing interviews with seven clients, modifications were suggested in relation to layout, wording and formulation of questions. More detailed information about suggested changes is presented in Supplemental Appendix A.
In the section named About You, the clients reported that the instructions were comprehensible, however several clients pointed out that the layout of the questionnaire was disturbing. For instance, the use of Roman numerals when listing response possibilities was perceived as disturbing, and the clients suggested replacing Roman numerals with bullets or Arabic numbers or simply removing these. Similarly, the font type and size were considered too monotonous without variation, resulting in clients missing out on several questions. Furthermore, the clients found the order of questions illogical and suggested re-arranging the questions into interrelated topics.
Your therapist's ability to communicate: D-CAM-C1 section II (Q9-38)/D-CAM-C2 section I (Q1- 30) In the section named Your Therapist's Ability to Communicate, the clients expressed concerns related to wording, including cultural divergence in the wordings, and sentence constructions.  OTs further education a n (%) 2 c (28.6) OTs prior knowledge about CAM-T 0 (0) a E.g. diploma, master, b students (participant teaching at an OT Bachelor's program), c one participant was at the time enrolled in a master's program.
No comments were given on the D-CAM-C2, Section II: Satisfaction, Q31-32.

D-CAM-T
Based on the group cognitive debriefing interview with seven OTs, modifications were suggested in relation to title, instructions, demographic questions, and questions and response categories in relation to the communication style. See Supplemental Appendix B for detailed information about suggested changes.

Title and instructions
The participants all agreed on presenting the original title of the questionnaire below the heading; 'Communicating with your Client in Therapy (CAM-T)'. Moreover, the participants recommended providing more information about the purpose and content of the questionnaire for clinical use in the initial instructions.
About you: Section I (Q1-5) In relation to Q4, the participants agreed on adding an additional educational degree reflecting the Danish educational system, if D-CAM-T should be used for research purposes.

Cultural relevance -CVI
The participant ratings indicated that all three instruments included culturally relevant items. Raw ratings and I-CVIs for CAM-C1, CAM -C2 and CAM-T are presented in Tables 2-4.

CAM-T
In relation to the CAM-T items, the OTs also had a high level of agreement on cultural relevance. The Items CVI (I-CVI) and the modified kappa (k Ã ) revealed that the participants had a high level of agreement (almost perfect) on the cultural relevance in relation to n ¼ 19 (58%) items. No agreement was found in relation to one item (3%) (Q14). Finally, 7 items (21%) ( Table 4) were rated not relevant by 1-2 participants (14-28%).

Discussion
The present study is part of a larger research project with the overall aim of providing Danish OTs with valid and reliable Danish versions of the SAMQ and the CAMQs. Our rationale for conducting the larger project is our notion that a therapeutic relationship in which the client is awarded a more active role in the occupational therapy process, is a central mechanism to promote occupational engagement. Thus, this study is the second of the entire project and aimed to perform and describe the process of translating and culturally adapting the CAM-C1, CAM-C2, and CAM-T questionnaires into Danish and examining the face validity of the questionnaires in terms of relevance and comprehensiveness in a Danish context. A tenstep process as recommended by the ISPOR Task Force was used [13]. This process led to translated versions of the questionnaires, where adaptations were made related to the title, layout, instructions, wording and response categories. Overall, clients and OTs reported that the questionnaires included culturally relevant items, and given the changes made, we believe the current Danish versions are culturally equivalent to the original American versions. This translation and adaptation process, including initial validation, is the first step towards making the CAMQs useable in a Danish occupational therapy context. While the CAMQs has been translated into Norwegian [24], Spanish, Mandarin and Persian [15], this is the first paper to present the results of the translation process, as recommended by the ISPOR Task Force. It is therefore not possible to compare and discuss our results against previous findings. Instead, as the main reason for following a stringent process when translating and culturally adapting any instrument is to ensure cultural equivalence between the original and translated versions, we will discuss how different types of equivalences have been addressed, including conceptual, semantic, operational and item equivalence [25][26][27].
In this study, the forward and back-translation process, including a back-translation review, was conducted to avoid any mistranslations or omissions and to ensure conceptual equivalence, i.e. that the meaning of any concepts employed was the same. Through this process, some mistranslations were identified which led to a few changes in the Danish versions. The conceptual equivalence was further examined in the cognitive debriefing process, including 'experts' that is the users (i.e. OTs and their clients) of the questionnaires, which resembles the universalist approach [12,27]. The participants identified concepts like 'reward' and 'tell/told' as understandable, but in this context culturally inappropriate to use. Hence, the meaning of these concepts was not the same in a Danish context and therefore re-formulated. Another issue raised by both the clients and the OTs was the word 'control'. Particularly the clients reported not understanding the meaning of the word and its use in the questionnaires. Dr. Taylor was therefore consulted to clarify this. Consequently, questions mentioning 'control' were reformulated.
Semantic equivalence is concerned with sentence structure, use of colloquialism or idioms and whether the level of language used is appropriate to the end users [25][26][27]. Here, the client participants identified several examples of language use probably representing professional language, rather than ordinary Danish language. This included examples such as 'consider many different ways of doing', 'help me deal with my challenges', 'resources' and 'improve my performance or behavior' that needed reformulation.
As for operational equivalence, which refers to a similarity of format, instructions and administration [25][26][27], both clients and OTs brought up issues. While the original format was kept during translation, clients suggested changes to the final layout to improve the readability and avoid overlooking questions. In addition, the OTs suggested more information about the purpose of the questionnaires for clinical use to increase clinical utility. Even though all three versions of the CAMQs were developed to be used in the clinic to enhance the client-therapist relationship, the instructions introduce that the purpose of having clients and OTs fill in the questionnaires is research. Moreover, the questionnaires include demographic questions, applied for research purposes. Poor attention to such matters may compromise the overall functional equivalence, meaning that the instruments do not do what they are supposed to do equally well between cultures. Therefore, the need for an introduction, presenting the purposes for clinical use was discussed among the authors, including the developer of the questionnaires, Dr. Taylor. It was decided to develop new introductions to D-CAM-C1, D-CAM-C2 and D-CAM-T and to omit the demographic questions in all three instruments.
To determine the item equivalence i.e. the relevance of the questionnaire items [25][26][27], the participants were asked to rate the cultural relevance of each item using the CVI approach [17]. In the CAM-C1 and CAM-C2, several items were rated as not relevant by up to four of the clients. When examining these items in more detail, two types of items considered not relevant appeared. The first group of items concerned issues related to information about: resources and people in the community, including resources and people not a part of the hospital or clinic; people with similar experience or disability; and legal rights for people with disabilities. A similar pattern was seen in three of the items in the CAM-T rated as not relevant by a few of the OTs. These results might reflect a cultural difference in the way the health and social welfare systems are organized between the USA and Denmark, affecting what is expected to be addressed during occupational therapy interventions. The second group of items not considered relevant by some of the clients contained concepts that were identified as either inappropriate (e.g. reward) or hard to conceive (e.g. control), which might explain why some of the clients found the items irrelevant. The Danish participant's reactions to these two groups of wording can be explained as a cultural difference between the societies of Denmark and the USA. In Denmark, basic equality includes a flat hierarchy [28] and freedom of speech [29]. Democracy is highly valued in Danish society, and according to the Democracy Barometer, which rests on the three principles of freedom, control, and equality, Denmark has held the highest score on the Democracy Quality Scale since 1995 [30,31]. Denmark's strong civil rights are reflected in the Danish Health Act, which ensures respect for individual integrity and provides equal access to healthcare [32]. Therefore, Danish clients and OTs might be more alert to a language which implies differences in equality than those in other countries.
A similar pattern was not seen in the CAM-T ratings. Instead, there were differences of opinion across a few items, e.g. as to whether the therapist should reveal something about their personal experiences so that this client should not feel alone. Still, variation among therapists is to be expected, related to their preferred therapeutic modes [8].

Methodological considerations/limitations
Which method to use to translate questionnaires is debated [12,13,26,27]. In the present study, the 'Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes' developed by the ISPOR Task Force group -Translation and Cultural Adaptation group [13 ] was employed. These guidelines were based on a review of evidence from current practice, a review of the literature and existing guidelines. Each approach to translation and cultural adaptation was considered systematically in terms of rationale, components, key actors, and the potential benefits and risks associated with each approach and step. The results of this review were subjected to discussion and challenge within the TCA group, as well as consultation with the outcomes research community at large. Through this review, a consensus emerged on a broad approach, along with a detailed critique of the strengths and weaknesses of the differing methodologies. Hence, we consider this approach highly valid for the process of translation.
Due to the COVID-19 pandemic, the planned group-based face-to-face Cognitive debriefing interviews with the clients and the OTs were transformed into online cognitive debriefing interviews using Skype. This is not necessarily a limitation as some research suggests that online interviews offer more flexibility in terms of time and place and may therefore also make it possible to reach a broader group of participants [33]. Moreover, as some of the clients were not comfortable with using Skype, the Cognitive debriefing interviews with the clients were transformed into individual interviews conducted by phone. This may present a problem since the purpose of the cognitive debriefing interviews was to reach a consensus among the participants [13]. On the other hand, by adapting to these clients' needs, it was possible to enhance their perceived anonymity, offer flexibility regarding time and place, resulting in comfortable and secure participation. Moreover, similar issues in terms of the wording were brought up by several clients and some of the clients' issues were the same as those pointed out by the OTs. Therefore, many of OT's consensus suggestions could be used to revise across questionnaires.
Another potential limitation is that it was not the same clients who participated in the cognitive debriefing interviews who also filled out the CVI. A data collection error occurred, and we were therefore forced to repeat the collection of the client CVI data. As some of the clients in the meantime had ended their therapy, they could no longer be reached. A second study sample was recruited using the same strategy as the one used with the clients involved in the cognitive debriefing interviews. Although the same strategy was applied, there were some variations between the two samples; the clients in the CVI sample presented with a more equal gender distribution, were younger, primarily had a psychiatric diagnosis and nearly all were recruited from a regional setting (See Table 1). While two client samples can be considered a potential weakness, it can also be viewed as a strength as it may provide a broader perspective on the cultural relevance of the items from different types of clients. The fact that most women participated in the study raises concern regarding the representativeness of the study sample, as women might be concerned with other issues than men. However, given that the majority of Danish OTs are female, and neither the questionnaires nor the interview guides used in the cognitive debriefing interviews were gender-specific, we trust that gender issues do not affect the representativeness of the results.

Future research
In an earlier paper, we reported on how the SAMQ was translated and adapted using a similar process as described in the present study [11]. The next steps will involve studies of the psychometric properties of the Danish versions of both SAMQ and CAMQs, the clinical utility of the instruments as well as the potential benefit of applying the questionnaire to support a client-centered practice. This will allow developing recommendations for how the questionnaires can be used and strong arguments for the implementation of the instruments in occupational therapy practice. Based on the next phase of the project we expect that the D-SAMQ and the D-CAMQs will be ready for use among Danish OTs and occupational therapy students, and hopefully improve occupational therapy practice by establishing a fruitful therapeutic relationship and supporting a client-centered approach.

Conclusion
In this study, the CAM-C1, CAM-C2, and CAM-T questionnaires were translated and culturally adapted into Danish in a ten-step process as recommended by the ISPOR Task Force including evaluating the Content Validity Index (CVI) and inter-rater agreement adjusted for chance using Kappa statistics. This led to translated versions of the questionnaires, where adaptations were made related to the title, layout, instructions, wording, and response categories. Overall, clients and OTs reported that the questionnaires included culturally relevant items, and given the changes made, we believe the current Danish versions are culturally equivalent to the original American versions. This study is the first step towards making the CAMQs useable in Danish occupational therapy.