It’s all in the translation

1. It’s all in the translation Sarah A. Felknor, DrPH Associate Professor and Director Southwest Center for Occupational and Environmental Health The University of Texas School of Public Health HHDRC Summer Institute El Paso, Texas May 23, 2011

2. Take Away Messages • The old gold standard of forward/back translation alone is not sufficient to tap into salient cultural realities and can be a source of random or systematic error • Translation of items should follow principles of questionnaire design to reduce error and ensure accuracy and consistency • Methods and lessons learned from three case studies in Latin America

4. Lecture Outline • Definitions • Steps in Designing and Conducting Surveys • Principles of Questionnaire Design • Three Case Studies • Survey of Safety Climate in Public Hospitals in Costa Rica and its Association with Safety Practices and Work Injuries • Cultural and Psychosocial Influences on Disability in Latin America • Survey of Working Conditions and Health in Central America

5. Definitions Translation 1: an act, process, or instance of translating: as a : a rendering from one language into another; also : the product of such a rendering First Known Use of TRANSLATION 14th century Synonyms: rephrasing, restatement, restating, rewording, translating, paraphrase Antonyms: quotation, quote Source: m-w.com.

6. Steps in Designing and Conducting Surveys

7. Cultural Aspects of Survey Design

9. Cultural Aspects of Principles of Questionnaire Design • Researchers should start with a culturally clear idea of the concept they want to measure • Know your study population and the context in which you will conduct your survey • The phrasing of questions operationalizes the concept of interest and should reflect the level of measurement • These concepts need to be culturally appropriate and accurate

10. Cultural Aspects of Principles of Questionnaire Design • Consider format, order and cultural context in which questions are asked • Multiple statistical tests are available to evaluate internal consistency and reliability of translations • Web questionnaires require special consideration • Different modes of data gathering present different cues to respondent and can affect how respondent proceeds with questionnaire

11. Cultural Aspects of Principles of Questionnaire Design • Four main stages for Respondent (R) • Comprehension of question • Retrieval of information • Judgment of appropriateness/concern for R • Response stage • Framework for identifying various stages • Provides basis for design and evaluation of Qs to minimize errors • Translation must take into account the cultural norms that define the study concepts and provide context for R to respond

12. Framework for Evaluating Stages of Questionnaire Response

13. Three Case Studies • Survey of Safety Climate in Public Hospitals in Costa Rica and its Association with Safety Practices and Work Injuries • Cultural and Psychosocial Influences on Disability in Latin America • Survey of Working Conditions and Health in Central America

14. Survey of Safety Climate in Public Hospitals in Costa Rica Study Objectives • Identify factors associated with safety climate for future training program • Assess relationship between safety climate and • Work Practices (Universal Precautions) • Workplace Injuries

15. Survey of Safety Climate in Public Hospitals in Costa Rica Methods • Cross sectional survey of hospital HCWs • Previous validated scales • Pre-testing • Translation and back translation • Focus groups and cognitive testing • Pilot (N=100) • Internal validity of Spanish translation • Survey Administration

16. Survey of Safety Climate in Public Hospitals in Costa Rica Lessons Learned • Initial focus groups were critical at design stage to understanding cultural context in which key study constructs were operationalized at a group level • Cognitive interviews helped with refine response categories and appropriate translation of key variables • Pilot test identified need to reverse-score certain items • Pilot tested different modes of administration – implications for final study

17. Questions?

18. Cultural and Psychosocial Influences on Disability in Latin America Study Objectives • International prospective multi-centre study of Cultural and Psychosocial Influences on Disability (CUPID) • To determine the prevalence of and risk factors for MSDs • To explore risk factors for the persistence of symptoms and associated disability, and influence of personal beliefs on the chronicity of pain and extent of associated disability; • To determine whether the outcomes within each cultural group are influenced by individual tendency to somatise, and/or by the individual differences in health beliefs;

19. Cultural and Psychosocial Influences on Disability in Latin America Methods • Spanish version questionnaire translated from original English to Catalan and then to Spanish by researchers in Barcelona • Focus groups conducted in each country by local study teams to assess language usage and comprehension

20. Cultural and Psychosocial Influences on Disability in Latin America Methods • Interviewer-based survey in Nicaragua • Self-administered in Costa Rica • Web-based in Colombia

21. Cultural and Psychosocial Influences on Disability in Latin America Lessons Learned • Focus groups resulted in changes in translation of certain words in all countries • Cultural adaptations made for certain response categories • Race changed to nationality • Number of floors walked per day

22. Questions?

23. Survey of Working Conditions and Health in Central America Study Objectives • Cross sectional multinational study to evaluate conditions of employment, work and health among the economically active population in the formal and informal sectors in six countries in Central America: Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica and Panama

24. Survey of Working Conditions and Health in Central America Methods • Cross sectional survey based on European Union Survey of Working Conditions and Health • Study team of UT-UPF-SALTRA designed questionnaire • Professional survey firm contracted to translate and pilot test feasibility • Interviewer-based survey in all countries

25. Survey of Working Conditions and Health in Central America Lessons Learned • Spanish language was modified in each country • Response categories were not universally understood • Feasibility of identifying formal and informal sector was tested • Accessibility and best approach of subjects was tested in each country

26. Survey of Working Conditions and Health in Central America LessonsLearned (cont.) • Duration of interview variedby country • Guatemala: 26 minutos • El Salvador: 27 minutos • Honduras: 27 minutos • Nicaragua: 26 minutos • Costa Rica: 35 minutos • Panamá: 37.5 minutos

27. Survey of Working Conditions and Health in Central America Lessons Learned (cont.) • El Salvador – suggested using a card for items that had multiple response options • Nicaragua and Panama – some respondents did not understand response categories that compared frequency to being more to less than ‘usual’ or ‘normal’ and suggested changes to “Often”, “Sometimes”, “Seldom” or “Never” • Nicaragua – many people work on Sundays and concepts of regular work shifts need to be adjusted accordingly

28. Questions?

29. !Gracias!