Translation and cultural check of the WAI SR (Working Alliance Inventory Short Revised) in Hebrew using a Delphi consensus procedure

Translation and cultural check of the WAI SR (Working Alliance Inventory Short Revised) in Hebrew using a Delphi consensus procedure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Translation and cultural check of the WAI SR (Working Alliance Inventory Short Revised) in Hebrew using a Delphi consensus procedure Robert D Hoffman, Limor Adler, Naomi Hoffman Cicurel, Yshai Neuman, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8539513/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective: The aim of this study was translating the WAI SR (Working Alliance Inventory Short Revised) into Hebrew and validating cultural correctness to support use of this instrument locally and for comparisons. EGPRN experts chose this instrument for an international research effort regarding therapeutic alliance (TA). Methods: Forward/Backward translation with a Delphi procedure followed by a cultural check. An experts panel evaluated the translation using a Delphi procedure. Then, the Hebrew version was back-translated. This version was compared to the original and adapted within national context. Results: Thirteen experts participated in one Delphi round that reached consensus. To adhere to grammar, the Hebrew version had feminine and masculine versions. After cultural check, the Hebrew version proved true to the original. Conclusion: A Hebrew WAI SR version is now available. It can be used in multinational trials, as WAI SR exists in several languages thanks to the TATA survey. It can also be used locally, in medicine, psychotherapy, training, and in research concerning TA. Practice implications: The Hebrew version can be used regularly in practice in Israel and in academic research, with the goal of improving health outcomes and healthcare provided on both an individual and a national level. Highlights The WAI SR is established and culturally validated as an instrument to study therapeutic alliance. The WAI SR has been translated into Hebrew and is now available to accommodate research in Israel. After cultural and linguistic adjustments the Hebrew WAI SR proved true to the original. Presented is a suggested implementation of a protocol to deploy such research instruments in languages other than the original English. 1. Introduction Efficient patient-therapist relationship appears strongly associated with adherence, satisfaction, and outcome expectations ( 1 ). This relationship is complex, dynamic and specific to each patient and physician. It has been evolving from a paternalistic framework insisting on patient's wellbeing, to a relational framework that empowering patients and focusing on their wishes and rights without neglecting medical needs. This aspect of medical care is known as the physician-patient working alliance ( 2 ) or therapeutic alliance (henceforth, TA). TA in medicine, and specifically in general practice, is at the center of every patient’s care. TA was studied for psychiatric disorders, such as chronic psychotic disorders) ( 3 ), bipolar disorder ( 4 ), substance abuse disorder ( 5 ), depression, etc. Additional research was conducted for somatic diseases, such as cardiac pathologies (hypertension ( 6 , 7 ), diabetes ( 8 ), end-stage renal disease ( 9 ), and rheumatology ( 2 , 10 ). Evaluating TA is important, both as a baseline to compare therapeutic relationships, and as a basis for improvement and quality assessment. As such, it is important for physicians to learn. Many different TA measuring tools exist, but no gold standard or absolute reference. The TATA (Tool Assessment for Therapeutic Alliance) study started in 2013, in the European General Practice Research Network (EGPRN) and was led by the medical university of Brest. It started with a literature review, to find reliable and reproducible tools to evaluate TA ( 11 ). Six tools were found appropriate. Then the most validated scale was chosen using a RAND/UCLA Appropriateness Method (RAM) on a European level utilizing the EGPRN community ( 12 , 13 ). The Working Alliance Inventory Short Revised (WAI SR) is an American questionnaire, originally used in psychology. It was selected as the most reliable assessment tool on a European scale for general practice, education and research. It is one of the most widely used scales for measuring TA. (Annex 1 in supplements) The TATA research group recognized that translations are needed for it be easily used in non-English speaking countries for practice analysis, education and research purposes. In Israel, TA was studied in general practice and other specialties ( 14 – 19 ). This is especially important in the Israeli setting due to the multicultural population and variability of primary care. Due to Israel's location between Africa, Europe and Asia and the flux of peoples of different origins gives Israel an extremely diverse population needing adapted tools to handle that diversity. Waves of immigration have affected Israeli society and healthcare system. Of note were the hundreds of thousands of survivors of the Holocaust, refugees from the surrounding Middle East and north African countries during the 1950s, immigrants from Ethiopia in the 1980s onwards, and immigrants from former Soviet Union in the 1990s onwards ( 20 ). The variance in the population is also manifested in language understanding and literacy. In these situations, misunderstandings arise ( 21 ). Cultural diversity can create conflicts between various sub-groups and groups within the country’s population. This cultural diversity is present in the relationships between patients and doctors. TA is a constant challenge ( 22 ). Consequently, the Israeli WAI SR could allow for doctors and medical students to understand and improve patient-doctor relationships. It may also provide insight into the consistency of scales translated to Hebrew across cultural differences in Israel. This study aims to translate, culturally adapt, and check the consistency of a Hebrew WAI SR compared to the English original. The WAI SR includes two different questionnaires, one for patients and one for therapists, and a scoring sheet to analyze answers. 2. Methods Research group in the EGPRN GP researchers collaborating within the European General Practice Research Network chose the most appropriate tool for evaluating TA using the RAND/UCLA Appropriateness Method (RAM). Decision on the optimal TA measuring tool was reached during semi-annual EGPRN research meetings. Methodology Translation was performed with a Forward/Backward translation using a Delphi procedure, to reach a consensus, with a large panel of experts in a structured and anonymous process ( 23 – 26 ). The Delphi Method is used in both qualitative and quantitative research and requires a multi-stage process ( 30 ). It is a flexible research instrument that is successfully used in many areas of research ( 27 ). A control cultural check was performed to adapt translations to local context. This methodology was standard in all participating countries to ensure homogeneity (for collaborative studies using different translations of WAI SR) ( 28 , 29 ). 2.1 Work team – Forward translation: First, a team had to be formed with two GPs, one linguist and one psychiatrist/psychologist. This team performed the Forward translation of the WAI SR from English to Hebrew. Each member is fluent in both languages and has sufficient cultural knowledge. 2.2 Panel of specialists - Delphi procedure: The Delphi protocol uses a multi-stage self-report questionnaire with individual feedback. Questionnaires were e-mailed to each participant, specialists in primary care and research; participants were personally selected by the head researcher in the team (RH). To avoid peer influences, participants were contacted separately (the Delphi protocol emphasized the need to avoid “mailing list” discussions). Participants signed a consent form and completed a demographic questionnaire (gender, age, career, teaching and research activities, and English proficiency). Participants were presented the translation of WAI SR items (which included WAI SR Patient and WAI SR Therapist sections) with its original version in English and the forward Hebrew version. Participants were asked to rate each translated item using the Likert’s scale, ranging from 1 (total disagreement) to 9 (total agreement). Each score under 7 required an explanation and suggestions were encouraged and considered. Consensus was reached when at least 70% of the scores for each item equaled to or exceeded 7. If an item’s results under 70%, additional Delphi rounds for this item would take place (with a new translation provided using the explanation and suggestions provided by participants), until consensus was reached for every item. In the process, thirteen experts were involved in the first and only round needed. 2.3 Linguists – Backward translation: Two independent translators, unaffiliated with the team, were asked to translate the final Hebrew WAI SR, back into English. Professional linguists were hired for this stage. 2.4 Comparison – cultural check: The backward English version was compared to the original. This was undertaken to ensure that the meaning of each item did not change. If discrepancies were found, it would be discussed and modified by the team. The goal was achieving conceptual and cultural equivalence and not linguistic equivalence ( 21 ). 3. Results 3.1 Characteristics of the tram Table 1 Characteristics of the team The four experts in the team have different backgrounds. The team coordinator was a GP. The two GPs had different practices (group practice and solo practice). All team members came from different environments. In addition, they were all researchers and teachers. Male to female ratio is 1:1. The average age was 47 years old. All are fluent in English. 3.2 Characteristics of the specialists panel Table 2 Characteristics of the experts’ panel - in Supplements Thirteen specialists took part in the Delphi procedure. They were selected to be an exhaustive group of GPs. Male to female ratio was about 1:1. The average age was 55 years old. Type of practice (group or solo practice) and environment (rural or urban) were diverse and evenly distributed. Most participants had teaching activities (91%) but only a few reported research activities (31%). The number of publications was varied; few experts authored many articles, mostly in English. As is standard in Israel, the GPs were all fluent in English. They all signed informed consent forms. 3.3 First Round lead to consensus The team translated both WAI SR questionnaires into Hebrew. To adhere to Hebrew grammar, male and female questionnaire were created. Eventually, we submitted only one gender form (male); it is convention to use a default version in male pronouns in official forms addressing all genders, so this choice was consistent with cultural norms. There were no different words between the gender versions other than the use of the feminine "you" and an additional letter to make verbs the feminine version. Every item of the WAI SR Patient and Therapist was validated after one round. A consensus was then reached. The data collection was achieved between November 2016 and August 2017. The Delphi procedure was then completed and the final Israeli WAI SR issued. Note: The “IMPORTANT” line (item “IMPORTANT”) was translated and rated along with the “INSTRUCTIONS” paragraph (item “INSTRUCTIONS”). The specialists did not evaluate the Scoring sheet, because it was translated later, and the team did not consider it necessary to submit this part to the panel. This was discussed and accepted by the TATA study scientific committee. Table 3 Delphi round N°1, evaluation of the WAI SR Patient Table 4 Delphi round N°1, evaluation of the WAI SR Therapist 3.4 Backward translation and cultural check The whole WAI SR Hebrew translation was relayed to two professional linguists hired to translate the Hebrew WAI SR back to English. They were asked to work together. The backward translation was compared to the original English version. Every item was considered accurate, the meaning was the same, except for the very last item, at the end of the Scoring sheet. Table 5 WAI SR Patient - Cultural check - Comparison of the backward translation and the original version. Table 6 WAI SR Therapist - Cultural check. Table 7 WAI SR Scoring sheet - Cultural check. Modifications as a matter of clarification in the last item. This last item (see above) was made clearer in Hebrew and so the English translation is different. The original version was considered difficult to understand. This was discussed in the team and approved with the other European participants. The Hebrew version was found to be clear and true to the original. 4. Discussion 4.1 Main Results The original English WAI SR was translated into Hebrew. The Hebrew WAI SR has two versions, female and male. The final translation presented in Annex 2: WAI SR Hebrew Version- Patient - Male & Female versions ; Annex 3: WAI SR Hebrew Version- Therapist version, and Annex 4 : WAI SR Scoring sheet Hebrew version (in supplements). 4.2 Strengths and limitations of the study Translation was performed following a Delphi protocol, which is often used in health disciplines ( 23 ). It is a well-structured, academically rigorous process using the judgment of qualified experts, with significant control over bias. It can be used in quantitative or qualitive subjects, as in this study. It was found that it produced accurate and reliable results when the method is applied carefully ( 31 ). We believe there was no information bias. The specialists were contacted by e-mails, separately. They all received the same documents explaining the study and its stages. They answered the survey independently. They had no interactions with one another. This way, there was no dominance effect or peer pressure. It also allowed more creativity in their answers and comments. Anonymity was maintained. The selection process of participants poses the risk of selection bias as it resembles the “snowball” recruiting method. However, as this is a qualitative effort and specific set of skills was required, experts were enlisted from volunteers from the pool of experts. 4.3 Key points It is known that TA is essential in medical care ( 1 , 2 ). The WAI SR was considered as the best tool, measuring TA, to be used in research and in education to broaden knowledge in this subject. To be used in large studies, the tool was to be translated into many languages, on a wide scale. A Hebrew version of the WAI SR was needed, as it is the primary official language in Israel. Israel is historically a multicultural and a plurilingual country, and a large part of the population can be reached with an instrument in Hebrew. This version could be used in multinational future studies, to compare Israel and other countries in teaching and clinical practice. 4.4 Implications for practice, medical training and further research In primary care, an efficient patient-physician relationship is associated with better medication adherence. An emphasis on understanding and facilitating agreement between physician and patient may improve outcomes ( 35 ). The WAI SR questionnaire is a valid tool to evaluate and to analyze this alliance. Scoring sheet may be useful for understanding its strengths and weaknesses in terms of tasks, bonds and goals. In Israel, there are many immigrant physicians, they are a valued resource for the healthcare workforce, and their integration is important. Few studies have explored the education, training needs and ways to facilitate their integration ( 36 ). TA might be a challenge and needs to be studied. According to research, there is a need for curricula fostering patient-centered attitude given the emphasis placed on patient satisfaction and on patient-centered care in the current medical environment ( 37 ). Increasingly, simulations and programs focusing on physician – patient communication are incorporated into physicians’ training ( 36 ). In Israel most medical school programs include medical humanities and communication skills lessons from the first year ( 37 ) as well as simulation training programs. Furthermore, undergraduate medical education in Israel has been shifting towards ambulatory education ( 38 ). The WAI SR could be helpful, as a standard method of evaluation, to improve and maintain a good medical training throughout the training course. And thereby, to improve the quality of the physician – patient relationship. Additionally, there is also a need for future research regarding communication. Indeed, studies brought up the fact that medical students were showing changes of attitude towards patients as they progressed through the clinical curriculum. From a patient- centered attitude to more authoritarianism (39). It could be interesting to compare and to explore these changes of attitudes towards the doctor-patient relationship in different European countries, using the different WAI SR translations, as a standardized and reproducible valuable tool. 5. Conclusion Nowadays, a patient-centered approach appears crucial to treat, comfort and support patients. The quality of TA is key. TA, as a communication skill should be taught, practiced and carried out consistently. The TATA study selected and then approved (on a European level) a tool to assess TA- the WAI SR. The following step was to translate it in additional languages. Here, the original English WAI SR was translated into Hebrew, using a Delphi procedure and a backward translation and was culturally adapted. It includes a patient questionnaire, a therapist questionnaire and a scoring sheet. The Hebrew version is applicable in practice, in training, and in further research. The project can continue on a new level using this tool across Europe, especially comparing results across countries in terms of TA. Declarations Ethics Statements The Ethics Committee of Brest University of Medicine approved the study and the questionnaires in accordance with the Declaration of Helsinki. Informed consent was signed by all participants. Funding Declaration No funding was provided received for this study. Competing Interests Declaration The authors have no competing or conflicts of interest to declare. Data Availability The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author. Consent to Publish declaration Consent to publish declaration: not applicable Acknowledgements We would like to thanks our fellow researchers in the TATA research group under the auspices of the EGPRN (European General Practice Research Network). We would like to thank the Israeli primary care physicians who participated in the Delphi consensus procedure. No funding was received to support this study. Author Contribution RDH, PA and JYLR conceived and designed this study, RDH, NHC, PA, and JYLR developed the methods, RDH, NHC, YN and TS performed the experiments, NHC, MM, and PA performed formal analysis, MM, RDH and NHC wrote the original draft, RDH, NHC, LA, BC and JYLR revised and edited the manuscript, RDH and JYLR administered and supervised this project. 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Supplementary Files Annex1WAISREnglish.docx Annex2WAISRHebrewVersionTherapistversion.docx Annex3WAISRHebrewVersionScoringSheet.docx Annex4WorkingAllianceInventoryShortRevisedWAISRPatientHebrewversion.docx Table1Characteristicsoftheleadinggroup.docx Table2Characteristicsoftheexpertspanel.docx Table3WAISRPATIENTdelphiround1.docx Table4DelphiroundN1evaluationoftheWAISRTherapist.docx Table5WAISRPatientCulturalcheckComparisonofthebackwardtranslationandtheoriginalversion..docx Table6WAISRTherapistCulturalcheck..docx Table7WAISRScoringsheetCulturalcheck.Modificationsasamatterofclarificationinthelastitem..docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 27 Feb, 2026 Reviewers invited by journal 12 Feb, 2026 Editor assigned by journal 10 Feb, 2026 Editor invited by journal 20 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 19 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Le","lastName":"Reste","suffix":""}],"badges":[],"createdAt":"2026-01-07 09:38:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8539513/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8539513/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103051603,"identity":"1cfe1ba8-c8e0-4ffe-840d-78161e110948","added_by":"auto","created_at":"2026-02-20 08:01:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":716316,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/ca347855-9aaf-4d62-9ad6-dad061b0bc54.pdf"},{"id":102964505,"identity":"f58c56e2-8ae9-4e62-bcb6-6956d5cb4f03","added_by":"auto","created_at":"2026-02-19 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15:27:51","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":40342,"visible":true,"origin":"","legend":"","description":"","filename":"Table3WAISRPATIENTdelphiround1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/ae434c2844397888dccf408d.docx"},{"id":102933325,"identity":"974ae651-b0e2-4625-85b5-16f440d3b6d3","added_by":"auto","created_at":"2026-02-18 15:27:52","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":24768,"visible":true,"origin":"","legend":"","description":"","filename":"Table4DelphiroundN1evaluationoftheWAISRTherapist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/fa24cbb0866f23fbcb300334.docx"},{"id":103049563,"identity":"94144d06-be62-482a-b103-759977e708b1","added_by":"auto","created_at":"2026-02-20 07:42:39","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":34724,"visible":true,"origin":"","legend":"","description":"","filename":"Table5WAISRPatientCulturalcheckComparisonofthebackwardtranslationandtheoriginalversion..docx","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/1947dfecf9c44dcf3ce4c31b.docx"},{"id":102933319,"identity":"4f3a7675-1993-4df9-8a12-7abdc499e98b","added_by":"auto","created_at":"2026-02-18 15:27:51","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":35708,"visible":true,"origin":"","legend":"","description":"","filename":"Table6WAISRTherapistCulturalcheck..docx","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/2226a3f7e6e9e74a03d111c2.docx"},{"id":102964082,"identity":"0f60ac33-82e5-43b6-b30d-eff5d95d2634","added_by":"auto","created_at":"2026-02-19 04:21:25","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":24053,"visible":true,"origin":"","legend":"","description":"","filename":"Table7WAISRScoringsheetCulturalcheck.Modificationsasamatterofclarificationinthelastitem..docx","url":"https://assets-eu.researchsquare.com/files/rs-8539513/v1/219e2250e10a6a5a1fa93693.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Translation and cultural check of the WAI SR (Working Alliance Inventory Short Revised) in Hebrew using a Delphi consensus procedure","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eThe WAI SR is established and culturally validated as an instrument to study therapeutic alliance.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe WAI SR has been translated into Hebrew and is now available to accommodate research in Israel.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAfter cultural and linguistic adjustments the Hebrew WAI SR proved true to the original.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePresented is a suggested implementation of a protocol to deploy such research instruments in languages other than the original English.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eEfficient patient-therapist relationship appears strongly associated with adherence, satisfaction, and outcome expectations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis relationship is complex, dynamic and specific to each patient and physician. It has been evolving from a paternalistic framework insisting on patient's wellbeing, to a relational framework that empowering patients and focusing on their wishes and rights without neglecting medical needs. This aspect of medical care is known as the physician-patient working alliance (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) or therapeutic alliance (henceforth, TA). TA in medicine, and specifically in general practice, is at the center of every patient\u0026rsquo;s care.\u003c/p\u003e \u003cp\u003eTA was studied for psychiatric disorders, such as chronic psychotic disorders) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), bipolar disorder (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), substance abuse disorder (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), depression, etc. Additional research was conducted for somatic diseases, such as cardiac pathologies (hypertension (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), diabetes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), end-stage renal disease (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and rheumatology (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvaluating TA is important, both as a baseline to compare therapeutic relationships, and as a basis for improvement and quality assessment. As such, it is important for physicians to learn. Many different TA measuring tools exist, but no gold standard or absolute reference.\u003c/p\u003e \u003cp\u003eThe TATA (Tool Assessment for Therapeutic Alliance) study started in 2013, in the European General Practice Research Network (EGPRN) and was led by the medical university of Brest. It started with a literature review, to find reliable and reproducible tools to evaluate TA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Six tools were found appropriate. Then the most validated scale was chosen using a RAND/UCLA Appropriateness Method (RAM) on a European level utilizing the EGPRN community (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Working Alliance Inventory Short Revised (WAI SR) is an American questionnaire, originally used in psychology. It was selected as the most reliable assessment tool on a European scale for general practice, education and research. It is one of the most widely used scales for measuring TA. (Annex 1 in supplements)\u003c/p\u003e \u003cp\u003eThe TATA research group recognized that translations are needed for it be easily used in non-English speaking countries for practice analysis, education and research purposes.\u003c/p\u003e \u003cp\u003eIn Israel, TA was studied in general practice and other specialties (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This is especially important in the Israeli setting due to the multicultural population and variability of primary care. Due to Israel's location between Africa, Europe and Asia and the flux of peoples of different origins gives Israel an extremely diverse population needing adapted tools to handle that diversity.\u003c/p\u003e \u003cp\u003eWaves of immigration have affected Israeli society and healthcare system. Of note were the hundreds of thousands of survivors of the Holocaust, refugees from the surrounding Middle East and north African countries during the 1950s, immigrants from Ethiopia in the 1980s onwards, and immigrants from former Soviet Union in the 1990s onwards (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe variance in the population is also manifested in language understanding and literacy. In these situations, misunderstandings arise (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Cultural diversity can create conflicts between various sub-groups and groups within the country\u0026rsquo;s population. This cultural diversity is present in the relationships between patients and doctors. TA is a constant challenge (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsequently, the Israeli WAI SR could allow for doctors and medical students to understand and improve patient-doctor relationships. It may also provide insight into the consistency of scales translated to Hebrew across cultural differences in Israel.\u003c/p\u003e \u003cp\u003eThis study aims to translate, culturally adapt, and check the consistency of a Hebrew WAI SR compared to the English original.\u003c/p\u003e \u003cp\u003eThe WAI SR includes two different questionnaires, one for patients and one for therapists, and a scoring sheet to analyze answers.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eResearch group in the EGPRN\u003c/b\u003e \u003c/p\u003e \u003cp\u003eGP researchers collaborating within the European General Practice Research Network chose the most appropriate tool for evaluating TA using the RAND/UCLA Appropriateness Method (RAM). Decision on the optimal TA measuring tool was reached during semi-annual EGPRN research meetings.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethodology\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTranslation was performed with a Forward/Backward translation using a Delphi procedure, to reach a consensus, with a large panel of experts in a structured and anonymous process (\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The Delphi Method is used in both qualitative and quantitative research and requires a multi-stage process (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). It is a flexible research instrument that is successfully used in many areas of research (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). A control cultural check was performed to adapt translations to local context. This methodology was standard in all participating countries to ensure homogeneity (for collaborative studies using different translations of WAI SR) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Work team \u0026ndash; Forward translation:\u003c/h2\u003e \u003cp\u003eFirst, a team had to be formed with two GPs, one linguist and one psychiatrist/psychologist. This team performed the Forward translation of the WAI SR from English to Hebrew.\u003c/p\u003e \u003cp\u003eEach member is fluent in both languages and has sufficient cultural knowledge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Panel of specialists - Delphi procedure:\u003c/h2\u003e \u003cp\u003eThe Delphi protocol uses a multi-stage self-report questionnaire with individual feedback. Questionnaires were e-mailed to each participant, specialists in primary care and research; participants were personally selected by the head researcher in the team (RH). To avoid peer influences, participants were contacted separately (the Delphi protocol emphasized the need to avoid \u0026ldquo;mailing list\u0026rdquo; discussions).\u003c/p\u003e \u003cp\u003e Participants signed a consent form and completed a demographic questionnaire (gender, age, career, teaching and research activities, and English proficiency).\u003c/p\u003e \u003cp\u003eParticipants were presented the translation of WAI SR items (which included WAI SR Patient and WAI SR Therapist sections) with its original version in English and the forward Hebrew version.\u003c/p\u003e \u003cp\u003eParticipants were asked to rate each translated item using the Likert\u0026rsquo;s scale, ranging from 1 (total disagreement) to 9 (total agreement). Each score under 7 required an explanation and suggestions were encouraged and considered.\u003c/p\u003e \u003cp\u003eConsensus was reached when at least 70% of the scores for each item equaled to or exceeded 7.\u003c/p\u003e \u003cp\u003eIf an item\u0026rsquo;s results under 70%, additional Delphi rounds for this item would take place (with a new translation provided using the explanation and suggestions provided by participants), until consensus was reached for every item.\u003c/p\u003e \u003cp\u003eIn the process, thirteen experts were involved in the first and only round needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Linguists \u0026ndash; Backward translation:\u003c/h2\u003e \u003cp\u003eTwo independent translators, unaffiliated with the team, were asked to translate the final Hebrew WAI SR, back into English. Professional linguists were hired for this stage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Comparison \u0026ndash; cultural check:\u003c/h2\u003e \u003cp\u003eThe backward English version was compared to the original. This was undertaken to ensure that the meaning of each item did not change. If discrepancies were found, it would be discussed and modified by the team. The goal was achieving conceptual and cultural equivalence and not linguistic equivalence (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1 Characteristics of the tram\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1 Characteristics of the team\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;four\u0026nbsp;experts in the team\u0026nbsp;have\u0026nbsp;different\u0026nbsp;backgrounds.\u0026nbsp;The\u0026nbsp;team\u0026nbsp;coordinator\u0026nbsp;was\u0026nbsp;a GP. The two GPs had different practices (group practice and solo practice). All team members came from different environments. In addition, they were all researchers and teachers. Male to female ratio is 1:1.\u0026nbsp;The\u0026nbsp;average\u0026nbsp;age\u0026nbsp;was\u0026nbsp;47\u0026nbsp;years\u0026nbsp;old.\u0026nbsp;All are\u0026nbsp;fluent in\u0026nbsp;English.\u003c/p\u003e\n\u003cp\u003e3.2 Characteristics of the specialists\u0026nbsp;panel\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2 \u003cstrong\u003eCharacteristics of the experts\u0026rsquo;\u003c/strong\u003e panel\u0026nbsp;\u003c/em\u003e- in Supplements \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThirteen specialists took part in the Delphi procedure. They were selected to be an exhaustive group of GPs. Male to female ratio was about 1:1. The average age was 55 years old. Type of practice (group or solo practice) and environment (rural or urban) were diverse and evenly distributed. Most participants had teaching activities (91%) but only a few reported research activities (31%). The number of publications was varied; few experts authored many articles, mostly in English. As is standard in Israel, the GPs were all fluent in English. They all signed informed consent forms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.3 First Round lead to consensus\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe team translated both WAI SR questionnaires into Hebrew. To adhere to Hebrew grammar, male and female questionnaire were created.\u003c/p\u003e\n\u003cp\u003eEventually, we submitted only one gender form (male); it is convention to use a default version in male pronouns in official forms addressing all genders, so this choice was consistent with cultural norms. There were no different words between the gender versions other than the use of the feminine \u0026quot;you\u0026quot; and an additional letter to make verbs the feminine version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvery item of the WAI SR Patient and Therapist was validated after one round. A consensus was then reached. The data collection was achieved between November 2016 and August 2017. The Delphi procedure was then completed and the final Israeli WAI SR issued.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNote: The \u0026ldquo;IMPORTANT\u0026rdquo; line (item \u0026ldquo;IMPORTANT\u0026rdquo;) was translated and rated along with the \u0026ldquo;INSTRUCTIONS\u0026rdquo; paragraph (item \u0026ldquo;INSTRUCTIONS\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eThe specialists did not evaluate the Scoring sheet, because it was translated\u0026nbsp;later, and the team did not consider it necessary to submit this part to the panel. This was discussed and accepted by the TATA study scientific\u0026nbsp;committee.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3 Delphi round N\u0026deg;1, evaluation of the WAI SR Patient\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4 Delphi round N\u0026deg;1, evaluation of the WAI SR Therapist\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.4 Backward translation and cultural\u0026nbsp;check\u003c/p\u003e\n\u003cp\u003eThe whole WAI\u0026nbsp;SR Hebrew translation was relayed to two professional linguists hired\u0026nbsp;to\u0026nbsp;translate\u0026nbsp;the\u0026nbsp;Hebrew\u0026nbsp;WAI\u0026nbsp;SR\u0026nbsp;back\u0026nbsp;to\u0026nbsp;English.\u0026nbsp;They\u0026nbsp;were\u0026nbsp;asked to work together.\u003c/p\u003e\n\u003cp\u003eThe backward translation was compared to the original English version. Every item was considered accurate, the meaning was the same, except for the very last item, at the end of the Scoring sheet.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eTable 5 \u003cstrong\u003eWAI SR Patient\u0026nbsp;\u003c/strong\u003e- Cultural check - Comparison of the backward translation and the original version.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 6 \u003cstrong\u003eWAI SR Therapist\u0026nbsp;\u003c/strong\u003e- Cultural check.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 7 \u003cstrong\u003eWAI SR Scoring sheet\u0026nbsp;\u003c/strong\u003e- Cultural check. Modifications as a matter of clarification in the last item.\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis last item (see above) was made clearer in Hebrew and so the English translation is different. The original version was considered difficult to understand. This was discussed in the team and approved with the other European participants.\u003c/p\u003e\n\u003cp\u003eThe Hebrew version was found to be clear and true to the original.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Main Results\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe original English WAI SR was translated into Hebrew. The Hebrew WAI SR has two versions, female and male. The final translation presented in Annex 2: \u003cb\u003eWAI SR Hebrew Version- Patient - Male \u0026amp; Female versions\u003c/b\u003e; Annex 3: \u003cb\u003eWAI SR Hebrew Version- Therapist version, and\u003c/b\u003e \u003cem\u003eAnnex 4\u003c/em\u003e: \u003cb\u003eWAI SR Scoring sheet Hebrew version\u003c/b\u003e (in supplements).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Strengths and limitations of the study\u003c/h2\u003e \u003cp\u003eTranslation was performed following a Delphi protocol, which is often used in health disciplines (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It is a well-structured, academically rigorous process using the judgment of qualified experts, with significant control over bias. It can be used in quantitative or qualitive subjects, as in this study. It was found that it produced accurate and reliable results when the method is applied carefully (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe believe there was no information bias. The specialists were contacted by e-mails, separately. They all received the same documents explaining the study and its stages. They answered the survey independently. They had no interactions with one another. This way, there was no dominance effect or peer pressure. It also allowed more creativity in their answers and comments. Anonymity was maintained.\u003c/p\u003e \u003cp\u003eThe selection process of participants poses the risk of selection bias as it resembles the \u0026ldquo;snowball\u0026rdquo; recruiting method. However, as this is a qualitative effort and specific set of skills was required, experts were enlisted from volunteers from the pool of experts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Key points\u003c/h2\u003e \u003cp\u003eIt is known that TA is essential in medical care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The WAI SR was considered as the best tool, measuring TA, to be used in research and in education to broaden knowledge in this subject. To be used in large studies, the tool was to be translated into many languages, on a wide scale.\u003c/p\u003e \u003cp\u003eA Hebrew version of the WAI SR was needed, as it is the primary official language in Israel. Israel is historically a multicultural and a plurilingual country, and a large part of the population can be reached with an instrument in Hebrew.\u003c/p\u003e \u003cp\u003eThis version could be used in multinational future studies, to compare Israel and other countries in teaching and clinical practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Implications for practice, medical training and further research\u003c/h2\u003e \u003cp\u003eIn primary care, an efficient patient-physician relationship is associated with better medication adherence. An emphasis on understanding and facilitating agreement between physician and patient may improve outcomes (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The WAI SR questionnaire is a valid tool to evaluate and to analyze this alliance. Scoring sheet may be useful for understanding its strengths and weaknesses in terms of tasks, bonds and goals.\u003c/p\u003e \u003cp\u003eIn Israel, there are many immigrant physicians, they are a valued resource for the healthcare workforce, and their integration is important. Few studies have explored the education, training needs and ways to facilitate their integration (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). TA might be a challenge and needs to be studied.\u003c/p\u003e \u003cp\u003eAccording to research, there is a need for curricula fostering patient-centered attitude given the emphasis placed on patient satisfaction and on patient-centered care in the current medical environment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Increasingly, simulations and programs focusing on physician \u0026ndash; patient communication are incorporated into physicians\u0026rsquo; training (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In Israel most medical school programs include medical humanities and communication skills lessons from the first year (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) as well as simulation training programs.\u003c/p\u003e \u003cp\u003eFurthermore, undergraduate medical education in Israel has been shifting towards ambulatory education (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The WAI SR could be helpful, as a standard method of evaluation, to improve and maintain a good medical training throughout the training course. And thereby, to improve the quality of the physician \u0026ndash; patient relationship.\u003c/p\u003e \u003cp\u003eAdditionally, there is also a need for future research regarding communication. Indeed, studies brought up the fact that medical students were showing changes of attitude towards patients as they progressed through the clinical curriculum. From a patient- centered attitude to more authoritarianism (39). It could be interesting to compare and to explore these changes of attitudes towards the doctor-patient relationship in different European countries, using the different WAI SR translations, as a standardized and reproducible valuable tool.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eNowadays,\u0026nbsp;a\u0026nbsp;patient-centered\u0026nbsp;approach\u0026nbsp;appears\u0026nbsp;crucial\u0026nbsp;to\u0026nbsp;treat,\u0026nbsp;comfort\u0026nbsp;and support patients. The quality of TA is key. TA, as a communication skill should be taught, practiced and carried out consistently.\u003c/p\u003e\n\u003cp\u003eThe TATA study selected and then approved (on a European level) a tool to assess TA- the WAI SR. The following step was to translate it in additional languages.\u003c/p\u003e\n\u003cp\u003eHere, the original English WAI SR was translated into Hebrew, using a Delphi procedure and a backward translation and was culturally adapted. It includes a patient questionnaire, a therapist questionnaire and a scoring sheet.\u003c/p\u003e\n\u003cp\u003eThe Hebrew version is applicable in practice, in training, and in further research.\u003c/p\u003e\n\u003cp\u003eThe project can continue on a new level using this tool across Europe, especially comparing results across countries in terms of TA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of Brest University of Medicine approved the study and the questionnaires in accordance with the Declaration of Helsinki. Informed consent was signed by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was provided received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing or conflicts of interest to declare. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish declaration: not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thanks our fellow researchers in the TATA research group under the auspices of the EGPRN (European General Practice Research Network). We would like to thank the Israeli primary care physicians who participated in the Delphi consensus procedure. No funding was received to support this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRDH, PA and JYLR conceived and designed this study, RDH, NHC, PA, and JYLR developed the methods, RDH, NHC, YN and TS performed the experiments, NHC, MM, and PA performed formal analysis, MM, RDH and NHC wrote the original draft, RDH, NHC, LA, BC and JYLR revised and edited the manuscript, RDH and JYLR administered and supervised this project. All the authors discussed the results and provided feedback on the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, et al. The physician-patient working alliance. Patient Educ Couns. 2007;66(1):29\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eFuertes JN, Anand P, Haggerty G, Kestenbaum M, Rosenblum GC. The physician-patient working alliance and patient psychological attachment, adherence, outcome expectations, and satisfaction in a sample of rheumatology patients. Behav Med Wash DC. 2015;41(2):60\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eWeiss KA, Smith TE, Hull JW, Piper AC, Huppert JD. Predictors of risk of nonadherence in outpatients with schizophrenia and other psychotic disorders. Schizophr Bull. 2002;28(2):341\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSylvia LG, Hay A, Ostacher MJ, Miklowitz DJ, Nierenberg AA, Thase ME, et al. Association between therapeutic alliance, care satisfaction, and pharmacological adherence in bipolar disorder. J Clin Psychopharmacol. 2013;33(3):343\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eCook S, Heather N, McCambridge J, United Kingdom Alcohol Treatment Trial Research Team. 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Selectionner un outil de mesure de l\u0026rsquo;alliance th\u0026eacute;rapeutique fiable et reproductible chez l\u0026rsquo;adulte, methode de consensus par RAND/UCLA. These d\u0026rsquo;exercice de medecine. Brest: Facult\u0026eacute; de M\u0026eacute;decine et des Sciences de la Sant\u0026eacute;. 2014.\u003c/li\u003e\n\u003cli\u003eLe Borgne E. Selection of a reproductible and reliable tool assessment for therapeutic alliance in general practice, by a RAND/UCLA consensus method. Th\u0026egrave;se d\u0026rsquo;exercice de m\u0026eacute;decine. Brest: Facult\u0026eacute; de M\u0026eacute;decine et des Sciences de la Sant\u0026eacute;. 2016.\u003c/li\u003e\n\u003cli\u003eSchiff M, Levit S. Correlates of Therapeutic Alliance and Treatment Outcomes Among Israeli Female Methadone Patients. Res on Soc Wo Pract. 2010;20(4):380-390.\u003c/li\u003e\n\u003cli\u003eDahan R, Reis S, Van Raalte R, Hermoni D. Changing the approach for teaching medical students in the primary care setting. 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Reis J Medalie Narratives in Family Medicine: Tales of Transformation, Points of Breakthrough for Family Physicians\u003cstrong\u003e.\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eFam Syst \u0026amp; Health .(2001) 19:2, 121-134.\u003c/li\u003e\n\u003cli\u003eMoran G, Mashiach-Eizenberg M, Roe D, Berman Y, Shalev A, Kaplan Z, Garber Epstein P. Investigating the anatomy of the helping relationship in the context of psychiatric rehabilitation: The relation between working alliance, providers\u0026rsquo; recovery competencies and personal recovery. Psychiatry Research.(2014) 220; 592\u0026ndash;597.\u003c/li\u003e\n\u003cli\u003eClarfield AM, Manor O, Nun GB, Shvarts S, Azzam ZS, Afek A, Basis F, Israeli A. Health and health care in Israel: an introduction. Lancet. 2017 Jun 24;389(10088):2503-2513.\u003c/li\u003e\n\u003cli\u003eWaitzman R. Ethical dilemmas in physician-patient relationship in multi cultural society. Med Law. 2014;33(4):1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eOhana S, Mash R. Physician and patient perceptions of cultural competency and medical compliance. Health Educ Res. 2015;30(6):923\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eManeesriwongul W, Dixon JK. Instrument translation process: a methods review. J Adv Nurs. 2004;48(2):175\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eJones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311(7001):376\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eBourree F, Michel P, Salmi LR. Consensus methods: review of original methods and their main alternatives used in public health. Rev Epidemiol Sante Publique. 2008;56(6):415\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eMcMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eSkulmoski GJ, Hartman FT, Krahn J. The Delphi Method for Graduate Research. J Inf Technol Educ Res. 2007;6:1\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eWHO. Process of translation and adaptation of instruments. WHO. Available from: http://www.who.int/substance_abuse/research_tools/translation/en/ (cited 2018 February 20)\u003c/li\u003e\n\u003cli\u003eSousa 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. J Eval Clin Pract. 201;17(2):268\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eHasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eHallowell M. Techniques to Minimize Bias When Using the Delphi Method to Quantify Construction Safety and Health Risks. In: Building a Sustainable Future - Proceedings of the 2009 Construction Research Congress. 2009. p. 1489\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eKerse N, Buetow S, Mainous AG, Young G, Coster G, Arroll B. Physician-patient relationship and medication compliance: a primary care investigation. Ann Fam Med. 2004;2(5):455\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eCastel OC, Ezra V, Alperin M, Nave R, Porat T, Golan AC, et al. Can outcome- based continuing medical education improve performance of immigrant physicians? J Contin Educ Health Prof. 2011;31(1):34\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eHaidet P, Dains JE, Paterniti DA, Hechtel L, Chang T, Tseng E, et al. Medical student attitudes toward the doctor-patient relationship. Med Educ. 2002;36(6):568\u0026ndash; 74.\u003c/li\u003e\n\u003cli\u003eButollo MA, Holzinger A, Wagner-Menghin M. Doctor-Patient Communication Training in Simulated Situations: Emotions and Perceptions of Simulated Patients during Patient-Centered Conversations. Psychother Psychosom Med Psychol. 2018.\u003c/li\u003e\n\u003cli\u003eReis S, Borkan JM, Weingarten M. The current state of basic medical education in Israel: implications for a new medical school. Med Teach. 2009;31(11):984\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKarkabi K, Castel OC, Reis S, Shvartzman P, Vinker S, Lahad A. A shift to ambulatory medical education in Israel. Clin Teach. 2010;7(2):126\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eTsimtsiou Z, Kerasidou O, Efstathiou N, Papaharitou S, Hatzimouratidis K, Hatzichristou D. Medical students\u0026rsquo; attitudes toward patient-centered care: a longitudinal survey. Med Educ. 2007;41(2):146\u0026ndash;53.\u003cu\u003e \u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8539513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8539513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e The aim of this study was translating the WAI SR (Working Alliance Inventory Short Revised) into Hebrew and validating cultural correctness to support use of this instrument locally and for comparisons. EGPRN experts chose this instrument for an international research effort regarding therapeutic alliance (TA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eForward/Backward translation with a Delphi procedure followed by a cultural check. An experts panel evaluated the translation using a Delphi procedure. Then, the Hebrew version was back-translated. This version was compared to the original and adapted within national context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Thirteen experts participated in one Delphi round that reached consensus. To adhere to grammar, the Hebrew version had feminine and masculine versions. After cultural check, the Hebrew version proved true to the original.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA Hebrew WAI SR version is now available. It can be used in multinational trials, as WAI SR exists in several languages thanks to the TATA survey. It can also be used locally, in medicine, psychotherapy, training, and in research concerning TA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePractice implications:\u003c/strong\u003e The Hebrew version can be used regularly in practice in Israel and in academic research, with the goal of improving health outcomes and healthcare provided on both an individual and a national level.\u003c/p\u003e","manuscriptTitle":"Translation and cultural check of the WAI SR (Working Alliance Inventory Short Revised) in Hebrew using a Delphi consensus procedure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 15:27:43","doi":"10.21203/rs.3.rs-8539513/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"49199495933956674135345506215914949304","date":"2026-02-27T08:51:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T15:22:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T06:42:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T10:38:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T17:32:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-01-19T17:26:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94276aa9-e56a-4c4a-82c2-450d5200ed19","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T15:27:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 15:27:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8539513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8539513","identity":"rs-8539513","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}