Language Translation Methods for Instruments in Research for Limited English Proficiency (LEP) Participants: A Literature Review
As the globalization phenomenon grows, the interaction between multicultural societies and these cultures emerge leading to diversity in cultural heritage and social aptitudes. (1) Therefore, healthcare providers should be aware of disparities in the healthcare setting due to race and ethnicity. (1) The lack of translated instruments in a research study affects the low levels of recruitment and retention of participation in of minority populations. (2) The 1993 National Institute of Health (NIH) Revitalization Act mandated that minorities should be included in randomized clinical trials, identifying underrepresented minorities as American Indians, African Americans, and Latinos. (2) Research is multifaceted and scientifically driven towards the need for increased ethnic minority participation in public health. (2) Enhancing the ability to make precise scientific implications will provide an increase towards the skills that are necessary to achieve the goal of determining public health problems. (2) As a result, innovative thinking by a pool of multidisciplinary investigators that are ethnically and culturally diverse will inform the scientific effort necessary to create meaningful and substantial improvements in the public’s health, including eliminating health disparities. (2)
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The Migration Policy Institute reports that twenty-two percent (66.5 million) people ages 5 and older reported speaking a language other than English at home. (3) Among the top languages that are spoken at home is Spanish (62%), Chinese (5%), Tagalog (3%), Vietnamese, Arabic, French (including Cajun), and Korean (about 2 % each). (3) The prevalence of Spanish speakers is mainly from this being the official language in twenty-one countries. The diversity in English use and speaking ability amongst the foreign born is likely affected by their education level in comparison to those who possess a bachelor’s degree or higher than those who have a high school diploma. (4) Furthermore, many foreign-born individuals’ live long periods in the United States with Limited English Proficiency (LEP). Nevertheless, some have limited English-speaking ability or may not speak English at all, even after many years residing in the United States. (4) Despite legal protection provided under Executive Order 13166 which improves access to services for persons with Limited English Proficiency (LEP) (5), obtaining language-congruent health information may be very difficult for non-English speaking groups in the United States. (6)
Language barriers can impact on major health disparities regardless of an individual’s socioeconomic status. (6) This may lead to seeking care later, reduced quality of care, and failing to seek certain kinds of care, such as mental health, pre-natal care, and chronic care. (6) Cross-cultural research often involves a team of health care providers including physicians and nurses for translating questionnaires in an appropriate method to clinicians and health care practitioners who are mindful that unless these potential problems are addressed, their research results may be unclear. (7) There are local health departments that serve LEP groups, but restricted funding prevents these facilities from translating their elaborated health promotion materials into different languages. (6) Ina cross-cultural research setting translating questionnaires for use can present potential problems that can compromise validity and quality if questionnaires are not prepared properly. More importantly, these results can be uncertain due to improper understanding by an LEP population. (7) The specific method used for translation isn’t important moreover than the acknowledgement that the process must be appropriate and the validation process rigorous. (7)
There are various translation methods that have been used to increase the level of understanding of an LEP population regarding to what is being stated in a medical setting. The important factors to be accounted for are: 1)time, 2)cost and 3)quality. (6) Machine translation (MT) has been one of the methods implemented as a tool that uses translation models that has been trained from a great quantity of text data in the relevant languages (6); these methods reduce translation costs, but are not error-free (6). Since the process of language translation can be slow and expensive, various forms of MT have been developed. Nevertheless automatic MT systems process text translation rather fast and inexpensively, but the quality is far from a skilled translator. (8) Some studies have shown that even though there is reduced translation time with MT, the product is of lower quality, and even if speed does increase, translators often don’t like working with MT output. (8) The comparability of the results from MT translation and human translation (HT) can also lead to erroneous research conclusions due to the lack of cultural and ethnic relevant dialect so this adaptation can be challenging, thus validity can be threatened. (7) A high quality language translation can be costly, so in order to lower this cost MT has been developed as assistance so humans can work with machines in concert. (8)
Evidence has indicated that MT combined with human post editing with translators who are fluent in both the original text and target language, from the subsequent MT output produces a better quality product at less cost (6; 8). Unfortunately, translators are not always an expert in specific subject areas of the instrument like specialized medical subjects, for example, which are – difficult content areas. (7) With this in mind, a potential solution to focus on economic limitations, and guaranteeing access to health information for the public, would be for public health departments to initially translate materials using MT software followed by HT by native speakers, preferably with a public health background, and then post-editing the documents for clarity and accuracy. (6) Another method of translation consists of back-translation in which the original text is translated into the target language by one translator and subsequently translated back into the source language by an independent translator who is blinded to the original text. (7) The back-translation is preferred although it can be time consuming and expensive. (7) The validation of the translation and the psychometric analysis of the instrument are evaluated by teams of experts, bilingual individuals, or focus groups of potential research participants. (7) If this option is used, no cross-language instrument should be handled without the assurance of language equivalence offered by the blind back-translation technique. (9) Regardless of the chosen method of translation, the most important are steps are recognizing the proper translation process and conducting a rigorous validation procedure. (7)
Cross cultural adaptation is supported by a mixture of guidelines for psychometrics can produce an acceptable end result for research comparable to the original version. (10) In order for that to occur, there would be a process proceeded by adapted steps from published recommendations to ensure equivalence between the original and the target language. (10) The psychometric properties are evaluated through analysis of internal consistency, factor analysis and other evidences of validity. (11) The existence of a common, brief, and valid instrument to assess health behaviors would be useful to understand the possible role of countries socio-cultural factors (11) unfortunately, that isn’t always the case. Perhaps, a cultural competence concept will increase acceptance and approval of cultural differences between groups. (11)
The research team should measure the translated instruments for use in several health system scenarios, for not only the technical and semantic equivalence of the survey questions, but also the inclusion of cultural relevance content in the instruments before even starting the data collection (8; 9). Furthermore, without having this evaluation done prior to start obtaining data, factor analyses post-data collection could be inconsistent and less rigorous (9). As a result of multi-disciplinary approach in research, there are five levels of cross-cultural equivalence: content, semantic, technical, criterion, and conceptual. (13; 14)
There are a few concerns when translating an instrument revolving scientific and ethical issues that can pose threats to internal validity, also known as “instrumentation”. (12; 14) Instrumentation can pose a major threat if different respondents receive a different version of the measure, making it invalid to infer that differences in the versions of the instrument are a viable alternative explanation. (12) For instance, a questionnaire was given to a Hispanic population where they were given the choice to choose between an English or Spanish version of the instrument. (9) The instrument was not back-translated due to willingness or limited capability. As a result, the data obtained suggested that Hispanics that were interviewed in Spanish responded differently to some items than the Hispanics that were interviewed in English therefore the differences can affect the conclusions of the study in regards of the level of correlation between two or more variables. (9)
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3. The United States Department of Justice. Executive Order 13166. The United States Department of Justice. [Online] March 19, 2019. [Cited: June 20, 2019.] https://www.justice.gov/crt/executive-order-13166.
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11. Quantitative methods for verifying semantic equivalence of translated research instruments: A Chinese version of the experiences in close relationships scale. Mallinckrodt B, Wang C. 3, s.l. : Journal of Counseling Psychology, 2004, Vol. 51.
12. Cross-cultural adaptation and psychometric properties’ evaluation of the modern standard Arabic version of Cumberland Ankle Instability Tool (CAIT) in professional athletes. Korakakis, V Abassi, M Kotsifak, A Manai, H AbuEsba, A 6, San Antonio, Texas : PLoS ONE, 2019, Vol. 14.
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13. Spanish Version of the Family Health Behavior Scale: Adaptation and Validation. Lanzarote-Fernandez, M Lozano-Oyola, J Gomez-de-Terrenos-Guardiola, M Vaviles-Carvajal, I Martinez-Cervantes, R Palcic Moreno, J. 5, s.l. : Int J Environ Res Public Health, 2019, Vol. 16.
14. The Spanish version of the Cultural Competence Assessment (CCA-S): Trancultural validation study and proposed refinement. Raigal-Aran, L Ferre-Grau, C Belzunegui-Eraso, A. Tarragona, Spain : Nurse Education Today, 2018, Vol. 72.
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17. Lee, J Pérez-Stable, E Gregorich, S Crawford, M Green, A Livaudais-Toman, J Karliner, L Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. Journal of General Internal Medicine. [Online] February 9, 2017. [Cited: July 1, 2019.] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515780/.
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