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. 2025 Feb 6;43(12):e01240. doi: 10.1097/CIN.0000000000001240

Issues in Using Four Languages in a Culturally Tailored Technology-Based Intervention Study

Asian American Breast Cancer Survivors With Depressive Symptoms

Eun-Ok Im 1, Dongmi Kim 1, Jianing Quan 1, Wonshik Chee 1
PMCID: PMC12704666  PMID: 39912738

Abstract

To provide culturally competent care for racial/ethnic minorities, it is important to provide information and coaching/support in the languages that users can understand. However, issues in using multiple languages, especially in culturally tailored technology-based intervention research among racial/ethnic minority cancer survivors, have rarely been discussed. The purpose of this article is to discuss the issues in using four different languages among Asian American breast cancer survivors with depressive symptoms in a culturally tailored technology-based intervention study for cancer pain management and make suggestions for future technology-based intervention research using multiple languages. Research diaries written by the research team members, the recordings of biweekly research team meetings, and postings on Microsoft Teams were analyzed using content analysis. The issues included: (1) difficulties in recruiting eligible translators for multiple languages; (2) differences in selecting words by translators’ traits; (3) difficulties in ensuring conceptual equivalence in measurements; (4) necessary contextual translation based on cultural understanding; (5) avoiding words with stigma; and (6) required multiple repeated steps. These methodological and conceptual issues need to be considered in future culturally tailored technology-based intervention research among racial/ethnic minorities, especially Asian American breast cancer survivors.

KEY WORDS: Culture, Cultural tailoring, Technology-based intervention, Computers, Mobile devices, Asian, breast cancer, Depression

With increasing usages of computer and mobile technologies among racial/ethnic minorities,1,2 technology-based interventions are viewed as a future direction for more equitable delivery of information and care. For instance, in 2021, about 69% of African American adults and 67% of Hispanic adults reportedly owned a desktop or laptop computer.2 In 2024, 84% of Asians, 75% Hispanics, and 68% African Americans reportedly subscribed to home broadband.2 Furthermore, the COVID-19 pandemic has provided unique opportunities for remote care through technology-based intervention modalities.3 Computer and mobile technologies are now being used for health monitoring of chronic conditions, infectious disease reporting, and dissemination of information.4 The use of technologies in health research is ubiquitous among racial/ethnic minorities in these days. A number of researchers are using computer and mobile technologies to assess healthcare needs of specific populations and/or provide information and education to the specific populations.5–7

With the increasing usages of computer and mobile technologies, multiple languages are frequently used in intervention studies among racial/ethnic minorities to provide culturally tailored care.8–10 Culturally tailored care considers languages, cultures, and contexts in the way that aligns with the client’s cultural norms, meanings, and values.11 One of the adopted ways is a language match.12 Indeed, multiple languages are helpful in providing information and education to racial/ethnic minorities by improving their understanding of information and/or education, consequently changing their health behaviors and improving their health outcomes.8–10 Machine translation systems, such as Google Translate and Microsoft Translator, have become widely used tools, offering quick and accessible translations across numerous languages.13,14 Although these technologies are useful for basic communication, they often struggle with accurately translating cultural nuances and context-specific meanings, which are crucial in healthcare research.15 Therefore, the necessity for skilled human translators still remains, particularly for complex tasks where cultural sensitivity and domain expertise are essential.16 Yet, it could also cause some biases because of multiple contextual factors.8 For instance, the unique traits of translators (eg, immigration generation, expertise) could affect the translation process, which subsequently cause some systematic misunderstanding of specific words.8–10 However, little discussion has been done about practical issues in using multiple languages in culturally tailored technology-based intervention research.

The purpose of this article is to discuss the issues in using four different languages among Asian American breast cancer survivors with depressive symptoms in a culturally tailored technology-based intervention study for cancer pain management and make suggestions for future technology-based intervention research using multiple languages. Here, “issue” is defined as “a subject or problem that people are thinking and talking about an important subject or topic” (by Britannica Dictionary).17 First, the parent study for this article is concisely presented. The approach used to support the discussion points on the issues is described. Then, the identified issues are discussed with supporting evidence. Finally, based on the issues, some suggestions are made for future culturally tailored technology-based intervention research using multiple languages.

THE PARENT STUDY

The purpose of the parent study was to develop and determine the efficacy of a culturally tailored technology-based cancer pain management program for Asian American breast cancer survivors with depressive symptoms. Using Bandura’s theory18 as the theoretical basis, the technology-based program was developed with individual and group coaching/support from interventionists and peers. The program also included the information and coaching/support components related to breast cancer survivorship, cancer pain management, and depressive symptom management; these components aimed to make changes in the women’s attitudes, self-efficacy, perceived barriers, and social influences related to cancer pain management. The program included five major components: (1) sub-ethnic specific social media sites, (2) sub-ethnic specific educational modules, (3) sub-ethnic specific online resources, (4) chat functionality, and (5) individualization functionality using a machine learning method. The program targeted Chinese, Korean, and Japanese women in the United States as the first sub-ethnic groups for the intervention development. Chinese were selected because they were the major sub-ethnic group within Asian Americans.19 Koreans were selected because they were the fastest-growing sub-ethnic group within Asian Americans.19 Japanese were the sub-ethnic group with the highest prevalence rate of breast cancer within Asian Americans.20,21 About 77% of Asian Americans speak their native languages rather than English at home, and almost 31% of Asian Americans have limited English proficiency.22 Thus, four different languages (English, simplified and traditional Chinese, Korean, and Japanese) that were primary languages (most commonly spoken languages) of the sub-ethnic groups were selected for the program development. The development phase included the actual development of the program, an expert review, and a usability test. For this discussion paper, only the issues from the development phase are included; the clinical trial phase testing the full efficacy of the program is ongoing.

For the program development, educational modules, online resources, and questionnaires were translated using the Translation, Review, Adjudication, Pretesting, and Documentation method.23 As the principles of translation, several rules were set at the beginning of the study. First, all the questionnaires were translated using the standard back-translation process. Yet, educational modules and online resources were translated by a bilingual researcher first. Then, the accuracy of the translation was checked by a different bilingual researcher. The questionnaires had a specific known feasible number of items, whereas the educational modules and online resources included a large volume of content that could not be manageable using the standard back-translation process. According to Cha et al,24 the combination of multiple techniques without a back-translation method could be as effective as a standard back-translation method depending on the research environment where the study was conducted (ie, limited availability and accessibility of bilingual professional translators). The principles were kept throughout the research process, and the consistent method was used for all the translation process. All the translators were required to have at least a bachelor degree in a health-related area, and all of them were in an Master of Public Health program or PhD program in a health-related discipline. Before hiring them, intense interviews in the languages of origin (eg, Mandarin Chinese, Korean) were conducted, and their proficiencies in writing/speaking skills were confirmed. Also, the translation protocol/guideline related to health-related terms including depressive symptoms was provided to them.

APPROACH FOR THIS DISCUSSION PAPER

During the first program development phase, the minutes of research team meetings were recorded by the project coordinator, and research diaries on issues in the use of multiple languages were written by individual team members. All the research records were saved in Microsoft Teams and analyzed using a simple content analysis.25 Individual words in the records were the unit of analysis, and line-by-line coding was done by all authors of this article. All the codes from the coding process were categorized, and idea categories of the issues were identified while reviewing and comparing the codes and categories. Themes reflecting the issues in the use of four languages were extracted and discussed among the research team members. The extracted and agreed themes were used to support the following discussion points.

THE ISSUES

The identified issues are: (1) difficulties in recruiting eligible translators for multiple languages; (2) differences in selecting words by translators’ traits; (3) difficulties in ensuring conceptual equivalence in measurements; (4) necessary contextual translation based on cultural understanding; (5) avoiding words with stigma; and (6) required multiple repeated steps. The issues and their related implications are summarized in Table 1.

Table 1.

Issues in Using Multiple Languages and Their Implications

Issues Implications
Difficulties in recruiting/retaining eligible translators for multiple languages Develop plans for recruitment, retention, and training of bilingual research team membersUtilize various recruitment channels, including university online job boards and professional networksGet referrals from current translators through their networks
Differences in selecting words by translators’ traits Train bilingual translators to have consistencies in translationShare research objectives and goals with translators (eg, through regular interactions between researchers and translators)Have flexibility in making decisions related to translations because there would exist unexpected cases related to the translation processDiscuss cultural nuances with translators because some word choices can be different even among qualified bilingual translatorsConsider target populations, contexts, social norms, customs, and values to ensure cultural appropriatenessEstablish a review process involving at least two bilingual researchersPrioritize conceptual equivalence when translating measurements by focusing on underlying meanings rather than literal translationsPilot test or have feedback sessions with the target group
Keeping conceptual equivalence in measurements
Necessary contextual translation based on cultural understanding
Avoiding words with stigma
Required multiple repeated steps Make efforts to reduce the burden of repeated administrative stepsGet familiar with institutions’ policies related to the use of multiple languages (eg, IRB policies, information technology policies related to language software, etc) at an early stage of researchEstablish a centralized electronic repository for all translation-related documents, such as informed consent, recruitment flyers, and previous translations
 Establish clear communication channels among research team members including translators
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Difficulties in Recruiting Eligible Translators for Multiple Languages

The translation of the study materials was mainly done by bilingual graduate research assistants in public health because the translators needed to know and understand the medical terms as well as the specific languages. The study materials were extensive to translate because (1) four languages were included, and (2) the materials included questionnaires, flyers, study announcements, emails, educational modules, online resources, and the guidelines for the use of Fitbits. One of the first challenges that the research team had was difficulties in recruiting and retaining graduate research assistants who could translate the materials in four different languages. The research team posted the translator jobs on online and offline job bulletin boards in the university where the study was conducted, and referrals from students and professors in the university were sought.

Mainly because the study was conducted in a private university in a southeastern area of the United States, the pool of available bilingual translators was extremely limited; even identifying bilingual research assistants was challenging. A total of two PhD students were available for potential bilingual translators at the school of nursing. Furthermore, PhD students who were fully supported by the university (with full tuition and monthly salary) were not easily attracted to research assistant positions. Their interests in working as a research assistant totally depended on their willingness to get involved in a research project and their research interests. Master’s degree students in nursing were mostly part-time students with full-time jobs as well. Eventually, six bilingual graduate students were recruited from the school of public health, where a number of international students were enrolled; only six were eligible, and all of them were hired. It took more than 6 months to recruit all necessary bilingual research team members who could translate for the study. Then, three of six translators resigned from the position within a year because of their graduation. Furthermore, the research team met unexpected institutional situations (eg, resignation of many research administrative staff members after the COVID-19) and personal situations such as international summer travels and graduations.

Differences in Selecting Words by Translators’ Traits

The second issue was differences in selecting words for translation depending on translators’ traits (eg, age, year of entry in the United States, geographical area). A total of 10 translators were involved (4 Koreans, 2 Japanese, and 4 Chinese) during the translation process: the mean age was 27.1 (SD = 11.8) years, and the mean year of entry in the United States was 6.44 (SD = 5.68) years. Interestingly, there were generational differences (by age) in word choices. Indeed, in South Korea, younger generations tend to use more loanwords directly, particularly from English, compared with older generations.26 Partially under the influences of this recent tendency, among Korean translators, older ones tended to use Korean words in the original Korean language, and younger ones tended to use direct phonetic translations of English words. For instance, the English word of “survivor” was translated into “생존자” by an older translator, but into “서바이버” by a younger translator. “생존자” is the exact Korean word that is comparable to “survivor” in English, whereas “서바이버” is a phonetic dictation of “survivor” in Korean. The same phenomenon was prominent in all other language translations. As noted in the research team’s earlier study,27 many words or phrases in English were translated phonetically among Japanese Americans. Especially younger Japanese translators used katakana, one of the written languages in Japanese, to translate phonetically some English words, whereas older Japanese translators used the original Japanese words.

Depending on the year when a translator moved to the United States, the translated words of the same English words were different as well. The translators who moved to the United States in recent years were using more recent words from their original countries than those who moved to the United States 10 or 20 years ago. In recent years, in South Korea, younger and older generations exhibit distinct differences in their use of honorific words,28 which actually influenced the Korean translation in this study. For instance, to call a participant politely, a translator who moved to the United States from South Korea 20 years ago used “Ssi” (씨 meaning Mrs or Miss), whereas a translator who moved to the United States in recent years used “Sunsangnym” (선생님 meaning teacher/master). Similarly, the translated words in Mandarin Chinese were different depending on where the translators originally came. When Chinese translators called a participant politely, a translator from Mainland China used “lady” in simplified Chinese, whereas a translator from Taiwan used “Miss” in traditional Chinese.

Difficulties in Ensuring Conceptual Equivalence in Measurements

Ensuring conceptual equivalence in translating the informed consent or study announcement materials was not a big concern; the differences in the wordings could be easily detected and managed between translators. However, ensuring conceptual equivalence in translating questionnaires (especially measurement scales) was difficult because of multiple reasons. First, the translators needed to consider that Asian Americans had tendencies to select a midpoint value rather than an extreme one on a scale because of their cultural tendencies.29 Also, there existed no exact words in Chinese and Korean languages differentiating some degrees of pain and symptoms. For instance, “a little bit” and “somewhat” on a 5-point Likert scale (0 = not at all, 1 = a little bit, 2 = somewhat, 3 = quite a bit, and 4 = very much) had the same meaning in Chinese and Korean; there was no conceptual difference between the two words.30,31 In Chinese, “a little bit” could be translated to “有一点” and “somewhat” could be translated to “有一些”. Yet, these two words are basically the same in Chinese. Also, “quite a bit” and “very much” have the same conceptual meanings in Korean. Thus, the translators needed to work on differentiating these words on the scale by explaining individual words in detail.

Necessary Contextual Translation Based on Cultural Understanding

A word in English could be translated into multiple different words with vague differences in meanings in some languages. Thus, the research team needed to differentiate the words intentionally by setting some principles based on their cultural understanding of the words. For instance, “depression” could mean the same to “depressive symptoms” or “depressive feeling” in Korean. Thus, the translators tried to differentiate these words by using different words with different degrees of symptoms. For instance, “depression” was translated into a word indicating a medical diagnosis with severe symptoms (우울증); “depressive symptom” was translated into a word indicating a symptom (우울증상), and “depressive feeling” was translated in a word indicating an emotion (우울감). Asians including Chinese, Korean, and Japanese tend to stigmatize mental illness, including depression. Thus, rather than using depression (a disease), using a symptom (depressive symptom) would save their face. “Saving face” in Asian culture is very important to maintain dignity, honor, and social standing of a person or a family. 32 “Saving face” plays a significant role in human interactions in Asian cultures, where avoiding public embarrassment and preserving own reputation is crucial.33 Admitting vulnerability by agreeing to participate in a study among people with a stigmatized condition (in this study, depression and cancer) may be viewed as a failure.32 Thus, directly using the term with stigma (depression) would not work for this population.

In addition, the contexts of some words needed to be specified because a particular word could have various meanings depending on the contexts. For example, among Korean Americans, age could mean differently depending on the explanation. There existed two different ages among Korean Americans: the official age (the same to age in the United States) and the traditional age including 1 year in the womb. Thus, further explanations were provided when age was asked, and we also asked the date of birth to ensure the accuracy of the data.

Cultural differences between the United States and their countries of origin often resulted in difficulties in finding an exact Korean word that fitted with an English word. For example, “anxious,” “nervous,” and “restless” have slightly different nuances in English. However, in a Korean dictionary, it would be “불안한” or “긴장한”. The case was the same in Chinese language; it could be translated as “不安焦虑” or “担心”. Thus, the translators needed to review the entire paragraph carefully and provided an appropriate definition or adding a contextual explanation to the words. Also, in Korean language, “never married” could be simply translated into “미혼”. However, “미혼” could mean “married and divorced” or “never married.” Thus, the translators needed to provide an explanation of “미혼” as “never married” to clarify the meaning. “Intersex” could be another example. This word could be translated to “간성” in Korean, but people could not easily understand because this word was rarely used among laypeople. Therefore, Chinese characters of “間性” (with a clear meaning) were placed in parentheses to clarify the meaning of the word in Korean; Koreans often use Chinese characters to clarify the meanings of Korean words.

Avoiding Words With Stigma

Most Asian cultures have cultural stigma attached to cancer and depression. Thus, it was important to avoid the words that might increase the perception of stigma. For instance, the English word of “dysthymia (persistent depressive disorders)” could be translated into either “心境恶劣” or “精神抑郁症” in Chinese, depending on the contexts. However, the term “心境恶劣” could reinforce stigma associated with mental disorders and could imply negative personality traits. On the other hand, 精神抑郁症 a phonetic translation, could be perceived as less stigmatizing. Thus, the latter was used to translate dysthymia. Another example was “survivor.” As mentioned above, the English word of “survivor” could be translated into “생존자” or “서바이버” in Korean depending on the translators’ age. Although “생존자” is the exact Korean word comparable to “survivor” in English, this Korean word could strengthen the stigma attached to cancer (easily linked to death). Yet, the Korean word of “서바이버” (direct phonetic translation) was perceived as less stigmatized.

As described above, the word “depression” could be translated into a few different Korean words: a medical diagnosis (우울증), a symptom (우울증상), or an emotion (우울감). When the word indicating a medical diagnosis (우울증) was used, the perceived stigma was the highest among the three words. Actually, during the participant recruitment process in the later phase, a few potential participants first agreed to participate in the study and then later declined to participate while mentioning that they did not know that the study was about depression (a medical diagnosis). Subsequently, the research team needed to make changes in the wordings in study flyers while trying to avoid the word indicating a medical diagnosis.

Required Multiple Repeated Steps

Repeated multiple steps were necessary due to frequent changes in translators and translations. For instance, two major factors prompted institutional review board (IRB) modifications in this study: (1) changes in the translators and (2) updates in the content of study materials. As discussed above, due to difficulties in hiring bilingual research staff members, we hired international students and visiting scholars for translation. Because international students and visiting scholars tended to stay in the United States for a short period, the research team experienced multiple turnovers of translators during the study period. Furthermore, whenever we made changes in the content of the informed consent, Web site, program, and/or questionnaire, we needed to go through repeated translation process and subsequent IRB modification submissions. The institution where the study was conducted required all language versions for an IRB approval. Therefore, multiple IRB modifications needed to be made whenever we had updates in any content of the study materials. For instance, the project Web site was ready for data collection with multiple language versions. Then, a consultant reviewed the Web site and provided feedback on one specific area. Then, the change due to the feedback required subsequent translations of the change into multiple languages and additional IRB modifications. Furthermore, repeated computer programming was necessary for the repeated changes of study materials in multiple languages.

DISCUSSION

This article presented six issues that were identified in a culturally tailored technology-based intervention study using four different languages among three sub-ethnic groups of Asian American breast cancer survivors with depressive symptoms. Most of these issues have been reported in traditional multilingual research. Yet, the literature has rarely reported these issues in adopting multiple languages in technology-based intervention research. Rather, the literature has focused on the fact that computer and mobile technologies could provide better media for communication and presentation of study materials.34–36

The issue related to difficulties in recruiting eligible translators for multiple languages might be mainly due to the geographical location where the study was conducted. The quality of translation could depend on the qualifications of translators (eg, skills, knowledge, and experience).37 Especially in healthcare fields, even highly qualified and trained translators could have difficulties in translating the materials accurately and adequately.37–39 Thus, in the parent study, it was essential that the translators knew and understood medical terms. As discussed above, originally, we tried to recruit registered nurses who were bilingual rather than professional translators. However, due to difficulties in recruiting eligible translators, mainly international students or visiting scholars were hired from public health and other health-related disciplines. Subsequently, we had high turnover rates; most of the research team members could be involved in the study only during the period when they were pursuing their degrees (mostly, one or two semesters).

Second, the issues related to ensuring conceptual equivalence in measurements have been reported in traditional research.8,40 Ensuring conceptual equivalence is very important in quantitative research because the quantitative measurements depend on similar latent constructs on metrics.8 Yet, at the same time, the infeasibility of ensuring conceptual equivalence in translation has been reported in traditional research because sociocultural contexts are different across different languages.8,40

Third, the issue related to necessary contextual translation based on cultural understanding has been reported in both traditional research and technology-based research.8,40 Difficulties in understanding the translated phrases/sentences due to language differences in grammar or word meanings have been reported,8,40 which supports the necessity of contextual translation. Indeed, cultural meanings related to specific words in the target languages need to be carefully considered when multiple similar words are available in the target languages. The cultural nuances linked to specific words in the target languages might be very important to solicit the participants’ participation in a study. As described above, in the parent study, the use of a specific word referring to a medical diagnosis of depression certainly discouraged the research participation. Yet, contextual translation needs to be carefully done because of a validity issue: semantic translations (not word-for-word translations) could result in differences in the meanings of the original and back-translated phrases/sentences.

Third, the issue related to differences in selecting words by translators’ traits has been indirectly reported in traditional research.37,41,42 Bilingual translators usually do not have equivalent language skills and/or cultural beliefs and beliefs in both languages; they could have difficulties in understanding colloquial phrases, terms, slangs, and/or jargons.37,41,42 Also, translators could put some words from the second language unconsciously and/or from their own personal understanding and interpretation derived from their former experience.43

Finally, the literature indicates that multilingual studies (even traditional research studies) have administrative issues that are usually more important than methodological issues,41 which is consistent with the final issue (required multiple repeated steps) reported in this article. As described above, in this study, multiple administrative steps for IRB modification submissions needed to be repeated whenever there were changes in the study materials. Yet, compared with traditional research, additional repeated administrative steps (Web site revisions and subsequent computer programming) were needed.

There exist a few limitations in this discussion paper. Most of all, the discussion points made in this article need a careful interpretation and generalization because only Chinese, Korean, and Japanese Americans were included. Also, the issues would be applicable only for the development phase of the technology-based intervention using computers and mobile devices as a medium for communication and presentation of study materials. Moreover, there were limitations due to the geographical area where the study was conducted (a southeastern area of the United States).

SUGGESTIONS FOR FUTURE TECHNOLOGY-BASED INTERVENTION RESEARCH

The following implications are proposed based on the issues discussed in this article. First, future researchers need to develop plans for recruitment, retention, and training of bilingual research team members when they are developing multilingual technology-based interventions in geographical areas where not many bilingual translators are available. In addition to traditional recruitment strategies (eg, university online job boards, professional networks), getting referrals from current translators through their networks could facilitate the recruitment of translators.

Second, training translators is crucial to have consistencies in translation for technology-based interventions. Sharing research objectives and goals of the interventions with translators (eg, through regular interactions between researchers and translators) can enhance the translators’ understanding of the interventions and facilitate appropriate, credible, and consistent translations of intervention materials.

Third, future researchers need to have flexibility in making decisions related to translations because there would exist unexpected cases (eg, stigmatized words, same words with different meanings in different contexts). The research team needs to discuss cultural nuances with translators because some word choices can be different even among qualified bilingual translators. Target populations, cultural contexts, social norms, customs, and values need to be considered to ensure cultural appropriateness. Establishing a review process involving at least two bilingual researchers is crucial to assess the contextual clarity and cultural suitability of translations especially by giving particular attention to specialized terms and potential stigma associated with certain words.

Fourth, it is important to prioritize conceptual equivalence when translating measurement scales by focusing on underlying meanings rather than literal translations. Pilot testing or having feedback sessions with a target group could provide an opportunity for researchers to assess the conceptual equivalence of translated terms in measurement scales.

Finally, researchers need to make efforts to reduce the burden of repeated administrative steps due to changes in translated materials. They need to make themselves familiar with their institutions’ policies related to the use of multiple languages (eg, IRB policies, information technology policies related to language software, etc) at an early stage of their research. Establishing a centralized electronic repository for all translated documents, such as informed consent, recruitment flyers, and questionnaires, could reduce the need for redundant administrative tasks. Surely, clear communication channels among research team members including translators are essential to reduce repetitive IRB procedures and technical modifications due to changes in translated materials.

CONCLUSIONS

In this article, issues in adopting and using multiple languages in a culturally tailored technology-based intervention study were discussed. As in traditional research, the use of multiple languages in technology-based research could bring about multiple conceptual and methodological issues. These issues need to be considered in future culturally tailored technology-based intervention studies among racial/ethnic minorities, especially Asian American breast cancer survivors. Addressing the unique challenges reported in this article is crucial for future culturally tailored technology-based interventions for Asian American breast cancer survivors with pain and/or depressive symptoms. The use of multiple languages in technology-based intervention studies definitely requires a careful study design and a flexible implementation plan with creative strategies to deal with unexpected issues.

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Acknowledgments

The authors appreciate the efforts made by the research team including a dozen research assistants who have been involved in the study.

Footnotes

This study was funded by the National Institute of Health/National Cancer Institute (NIH/NCI; R61CA280979/R33CA280979).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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