Translation and Cross-Cultural Equivalence of Health Measures

Context Multinational companies & international

drug trials Cross-cultural research within Canada International health studies General sense of globalization – but does

this downplay differences?

Relevance of Culture Culture shapes the way we conceive of health and

illness Influences customary behaviours, relationships

with others Influences relative values of symptoms Reactions to pain, etc. Expectations & definitions of feeling good, etc. ‘Questionnaire sophistication’ of the group

Level of abstraction Concepts can be:

Abstract and general Happiness, Ability

Concrete and specific Number of hospital beds per capita

More abstract concepts Applicable to different cultures, but

More imprecise

Specific concepts Less cross-culturally applicable

More context dependent

Types of Cross-Cultural Equivalence

Is it operationalized in same way? (Same general measurement procedures)

Item equivalence: Items should mean the same thing to people in one culture as in another

Scalar equivalence (E.g., is the distance between “moderately severe” and “severe” the same in both cultures?)

Requirements for cross-cultural equivalence Conceptual/functional

Equivalence in construct operationalization

Item equivalence

Scalar equivalence

Hierarchical: must have first before second

Conceptual/FunctionalEquivalence

Is there a universal situation? Does construct mean the same thing in both

cultures?

Can goal of behaviour be identified? Are same antecedent-consequent relations

demonstrable across cultures? Does same situation result in same behaviour

across cultures?

Equivalence in operationalization Is it operationalized in same way?

Same procedure

E.g. measuring disability with

Questions on self-care

Measuring visual impairment with

Snellen chart

Item equivalence Measured by same instrument

Items should mean the same thing to people in one culture as in another

E.g. on FAS test, items with identical meaning in French are not FAS, but T, N and P

“No ifs, ands, or buts”

Scalar Equivalence Measured on the same metric

Numerical value on scale has same degree of intensity or magnitude of the construct

E.g. is the distance between 6 (moderately severe) and 7 (severe) the same in both cultures?

Developing cross-cultural measures Sequential approach

Translate an instrument into another language Simultaneous approach

Conceptualize & develop measure in each culture Set of equivalent items that reflect the same

construct in different cultures Core instrument plus culture-specific

additional components

Strategies for ensuring cross-cultural equivalence Direct translation and comparison

Better translation techniques

Multi-trait, multimethod

Item response theory methods

Differential item functioning

Strategies: continued Response pattern method

Factor analysis

Multidimensional scaling

Combined etic-emic approach

Multi-strategy approach

Methods for assessing equivalence Factor analysis

Empirical analysis of how items relate to one another Shows how many concepts scale measures and which

items measure that scale Confirmatory: must have theory about how items go

together Simultaneous factor analysis in different populations Factor structure should be the same Test whether data are similar to be called equal

Same factor pattern-loadings Same goodness of fit

Differential item functioning Related to IRT theory Needed because tests can have matching

factor structures and still be biased DIF analyses

Compare reference and focal groups In translation from English to French, English

reference and French focal

Differential Item Functioning DIF = a different in item score between

two groups who are equal in ability. First step: match on ability (total score)

Internal test of item bias 2nd step: for each score group, compares

performance of reference and focal group on each item

Two types of DIF Uniform

Difference in difficulty between reference and focal group Item may be more difficult for one group

Non-uniform Difference in discrimination between

reference and focal group

When you find DIF or non-factorial equivalence Study reasons why

Content experts

Review item wording, translation, cultural meaning.

Translation Simply translate instrument and administer

it Simple tests of difference: assumes scalar

equivalence Translation-back translation

Issues to Consider Goal: to adapt measure for a new country, or to

make comparisons across countries? Translation or adaptation? Back-translation gives

identity rather than equivalence In most countries the ‘official’ language differs

from the vernacular. Which do we use? We still know little about effect of linguistic

variations within countries

Issues - continued Why was this instrument chosen? Are

these features relevant in another culture? At least some of the content of most scales

will be culture-specific (e.g., some of NHP seen as blasphemous in Arabic countries)

Was the scale developed on a particular cultural group?

Quality of Life Quality of life is subjective & value-

specific Invented in the USA; ¿not universal? Definition will at least vary across cultures

(naïve enthusiasm for QoL) Handicap reflects impairment +

environment, so measures may perform differently in different environments

Translation, or Domination?

“…with refinements and changes introduced here and there in order to convey the meaning of the English questions as accurately as possible…” (A. Leighton)

Words & Concepts An etic approach (phonetic) describes the

physical properties of the word, without referring to its functional meaning: language

The emic approach takes account of the context, meaning and purpose of the word: concepts

Translation Example “Does poor health prevent you from seeing

your friends?”

Meaning of “friend” differs in UK, US, and Australian English

Even more differences between Ami(e), Amigo and Freund

Suggestions Plan cross-cultural applications from the outset Consider relevance of quality of life carefully: omit? Avoid questionnaires! Use ‘DIF’ analyses Run within-country analyses Develop measures within each country Seek core set of universal items (WHO QoL) Make sure the values are explicit