Translation and Cross-Cultural
Equivalence of Health Measures
Context
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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
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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
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Concepts can be:
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Abstract and general
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Concrete and specific
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Number of hospital beds per capita
More abstract concepts
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Applicable to different cultures, but
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Happiness, Ability
More imprecise
Specific concepts
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Less cross-culturally applicable
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More context dependent
Types of Cross-Cultural
Equivalence
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Is it operationalized in same way? (Same general
measurement procedures)
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Item equivalence: Items should mean the same
thing to people in one culture as in another
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Scalar equivalence (E.g., is the distance between
“moderately severe” and “severe” the same in both
cultures?)
Requirements for cross-cultural
equivalence
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Conceptual/functional
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Equivalence in construct operationalization
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Item equivalence
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Scalar equivalence
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Hierarchical: must have first before second
Conceptual/Functional
Equivalence
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Is there a universal situation?
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Does construct mean the same thing in both
cultures?
Can goal of behaviour be identified?
Are same antecedent-consequent relations
demonstrable across cultures?
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Does same situation result in same behaviour
across cultures?
Equivalence in operationalization
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Is it operationalized in same way?
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Same procedure
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E.g. measuring disability with
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Questions on self-care
Measuring visual impairment with
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Snellen chart
Item equivalence
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Measured by same instrument
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Items should mean the same thing to people
in one culture as in another
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E.g. on FAS test, items with identical meaning in
French are not FAS, but T, N and P
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“No ifs, ands, or buts”
Scalar Equivalence
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Measured on the same metric
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Numerical value on scale has same degree of
intensity or magnitude of the construct
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E.g. is the distance between 6 (moderately severe)
and 7 (severe) the same in both cultures?
Developing cross-cultural measures
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Sequential approach
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Simultaneous approach
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Translate an instrument into another language
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 crosscultural equivalence
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Direct translation and comparison
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Better translation techniques
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Multi-trait, multimethod
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Item response theory methods
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Differential item functioning
Strategies: continued
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Response pattern method
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Factor analysis
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Multidimensional scaling
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Combined etic-emic approach
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Multi-strategy approach
Methods for assessing
equivalence
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Factor analysis
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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
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Simultaneous factor analysis in different populations
Factor structure should be the same
Test whether data are similar to be called equal
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Same factor pattern-loadings
Same goodness of fit
Differential item functioning
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Related to IRT theory
Needed because tests can have matching
factor structures and still be biased
DIF analyses
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Compare reference and focal groups
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In translation from English to French, English
reference and French focal
Differential Item Functioning
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DIF = a different in item score between two
groups who are equal in ability.
First step: match on ability (total score)
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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
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Uniform
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Difference in difficulty between reference
and focal group
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Item may be more difficult for one group
Non-uniform
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Difference in discrimination between
reference and focal group
When you find DIF or nonfactorial equivalence
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Study reasons why
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Content experts
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Review item wording, translation, cultural
meaning.
Translation
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Simply translate instrument and administer
it
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Simple tests of difference: assumes scalar
equivalence
Translation-back translation
Issues to Consider
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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
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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
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Quality of life is subjective & valuespecific
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?
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“…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
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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
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“Does poor health prevent you from seeing
your friends?”
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Meaning of “friend” differs in UK, US, and
Australian English
Even more differences between Ami(e),
Amigo and Freund
Suggestions
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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