Translation Quality Assessment in Health Research: A Functionalist Alternative to Back-Translation

Abstract

As international research studies become more commonplace, the importance of developing multilingual research instruments continues to increase and with it that of translated materials. It is therefore not unexpected that assessing the quality of translated materials (e.g., research instruments, questionnaires, etc.) has become essential to cross-cultural research, given that the reliability and validity of the research findings crucially depend on the translated instruments. In some fields (e.g., public health and medicine), the quality of translated instruments can also impact the effectiveness and success of interventions and public campaigns. Back-translation (BT) is a commonly used quality assessment tool in cross-cultural research. This quality assurance technique consists of (a) translation (target text [TT₁]) of the source text (ST), (b) translation (TT₂) of TT₁ back into the source language, and (c) comparison of TT₂ with ST to make sure there are no discrepancies. The accuracy of the BT with respect to the source is supposed to reflect equivalence/accuracy of the TT. This article shows how the use of BT as a translation quality assessment method can have a detrimental effect on a research study and proposes alternatives to BT. One alternative is illustrated on the basis of the translation and quality assessment methods used in a research study on hearing loss carried out in a border community in the southwest of the United States.

Back-Translation (BT): A Commonly Used Quality Assessment Method

BT as a quality assessment tool in cross-cultural research can be said to have originated with the work of Brislin (1970, 1986). Although in the original 1970 publication, BT was part of a larger and more complex proposal on evaluation, it is the BT aspect of the investigation that has transcended and has been used extensively as the primary method of quality evaluation in some cases and in combination with additional quality control methodologies, such as pretesting, posttesting, and committee consultation, in others. BT is considered “by far the most popular quality assessment tool used in international and cross-cultural social research” (Tyupa, 2011, p. 36). Tyupa (2011, p. 36) reports that in international nursing research, a survey by Maneesriwongul and Dixon (2004, p. 177) showed that of the 47 studies devoted to instrument translation from English into other languages (Chinese, Spanish, Korean, and Finnish), 38 used BT and 13 of these resorted exclusively to BT (no testing). Douglas and Craig (2007, p. 31) point out that in international marketing, 34 of the 45 reviewed international survey reports indicate the use of the BT procedure.

In addition to its presence in social studies, BT figures prominently in health care, specifically in quality-of-life research. An informal PubMed bibliographic search (https://www.ncbi.nlm.nih.gov/pubmed/), carried out by the authors to illustrate the prevalence of BT in the health sciences, returned 38 records (for a period of 5 years), 33 of which used BT in one form or another.¹

Because of the growing interest on the “international” side of health-related quality-of-life (HRQOL) questionnaires and other health-related surveys, researchers are faced with the need to translate existing measures. Although in early studies, BT was the “recommended technique” for quality control (Berkanovic, 1980, p. 1273), in more recent research, translation and cross-cultural adaptation of questionnaires generally include BT as part of the quality control methodology generally motivated by the desire to attain equivalence with existing validated English questionnaires and to make sure differences are due to patient, rather than questionnaire differences (Bonomi et al., 1996; Cella et al., 1998; Eremenco, Cella, & Arnold, 2005; Guillemin, Bombardier, & Beaton, 1993; Herdman, Fox-Rushby, & Badia, 1997). Eremenco, Cella, and Arnold (2005, p. 217), for instance, describe a translation methodology in which two independent translators produce two translations (TT₁ and TT₂) of a source text (ST); TT₁ and TT₂ are reconciled by another translator in a third translation (TT₃). A fourth translator back-translates TT₃ into the source language to highlight discrepancies between the BT and the ST and “to assess equivalence with the source.”

In health fields such as public health and audiology, BT is also a component of translation methodologies and transcultural adaptation of questionnaires, along the lines of HRQOL research (Cardemil et al., 2013; Lichtenstein & Hazuda, 1998). Cardemil et al. (2013, p. 418), for instance, report a transcultural adaptation process in which the Effectiveness of Auditory Rehabilitation Quality-of-Life Evaluation Scale was translated by two bilingual professionals in the areas of otolaryngology and audiology prior to the generation of a consensus version in Spanish. This scale was then back-translated into English by a third bilingual professional and compared to the original version by the author of the original scale. Lichtenstein and Hazuda (1998) describe a process in which the Hearing Handicap Inventory for the Elderly (HHIE) was translated independently by “three individuals fluent in English and the Spanish spoken among Mexican Americans in South Texas.” These were followed by three BTs that were reviewed by an independent reviewer. BT is also a part of the recent adaptation of the HHIE to Arabic (Weinstein, Rasheedy, Taha, & Fatouh, 2015).

In sum, a sample of the literature on the evaluation of cross-cultural instruments demonstrates the prominent role played by BT, used either on its own or in combination with other methods of evaluation (cf. Table 1). Bearing in mind that BT is well established as a quality control mechanism in cross-cultural adaptation of questionnaires and in cross-cultural research in general, it is critical to ascertain its methodological soundness, in particular, by bringing in the interdisciplinary perspective and current knowledge in pertinent fields, such as translation studies. The rest of this article presents the problems faced by BT from a conceptual and theoretical point of view (whether used on its own or in conjunction with committee review or other methods), on the basis of current knowledge in translation studies, and accompanied by illustrative examples (cf. Table 2). It also introduces recent critique and empirical evidence against BT to support the view that BT should be entirely abandoned as a method of translation quality evaluation (cf. Table 2). We propose an alternative functionalist approach based on a case study. Additionally, we argue that any approach to the development of multilingual research instruments will have to consider the specifics of the concrete project and the purpose and audience for which the cross-cultural instruments are adapted/developed. Most instruments will still require separate validation; yet, an approach based on current knowledge on the nature of translation and language mediation has a better chance of obtaining good validation results as well as valid useful findings. The proposed approach is presented also as an initial experience with the method in health-care research and to invite further evaluation and consideration by experts in this field.

Table 1.

Prevalence of Back-Translation in Health-Related Research: Sample Articles.

Study	Steps
Public health and audiology
Lichtenstein and Hazuda (1998; HHIE-Spanish version)	Translation and back-translation
Cardemil et al. (2013)	Translation and back-translation
Weinstein et al. (2015; HHIE-Arabic version)	Translation and back-translation
HRQLR
Guillemin, Bombardier, and Beaton (1993)	Translation, back-translation, committee review, and pretesting
Bonomi et al. (1996)	Two forward translations, reconciled version, back-translation, review, and final translation
Herdman, Fox-Rushby, and Badia (1997)	Translation, back-translation, comparison with source, committee review, and psychometric testing
Cella et al. (1998)	Translation, expert committee, back-translation, pilot testing, and various iterations and drafts
Eremenco, Cella, and Arnold (2005)	Double back-translation method: two forward translations, reconciled version, back-translation, review, finalization, and final translation (updated version of the methodology is given in Bonomi et al. [1996])

Note. HHIE = Hearing Handicap Inventory for the Elderly; HRQLR = health-related quality-of-life research.

Back-translation is bold to make it stand out among the other methods listed and to show that BT is used alone or in combination with other evaluation methods.

Table 2.

Problems of Back-Translation.

Empirical	References
BT implies that perfect equivalence is possible BT introduces an extra layer of transformation that may bring the TT further from the source The more literal the translation, the closer the BT will be to the ST	Brislin (1970)
BT relies on an objectivist view of meaning prevalent in the 1970s, later shown by research in linguistics and psychology to be misguided	Tyupa (2011)
Crucially relies on equivalence Equivalence is a problematic concept in TS Equivalence has been shown to be hard to define even in public health (Herdman Fox-Rushby, and Badia, 1997) Equivalence is word based and concept based (vs. pragmatics, functionality, and textuality) Reflects an outdated view of translation: Scarce reference to any TS literature more recent than Brislin (1970, 1986)	Colina (2015)
Empirical	References
Clear differences found between translations of a medical, quality-of-life questionnaire produced with two approaches: a linguistic, literal approach and one using a functional, and communication orientation Translations produced with the communicative approach were evaluated by users as superior and easier to understand than the linguistic/literal ones, showing that the literal approach which BT favors is often not the most appropriate	Fourie and Feinauer (2005)
Comparing two Swedish versions of the RAQoL questionnaire, results indicate that items translated using the two-panel method are statistically significantly preferred to those based on BT	de Jong et al. (1997) and Whalley et al. (1997)
Testing two versions of the CETSCALE (Shimp & Sharma, 1987)—a literal back-translated one and another one modified to address differences in the construct of consumer ethnocentrism in the Netherlands—it was found that while the BT did not change the meaning of any of the original items, the target-specific version offered questions that were clearer and better adapted to the Dutch concept of consumer ethnocentrism	Douglas and Nijssen (2003)

Note. BT = back-translation; TS = translation studies; TT = target text; RAQoL = rheumatoid arthritis quality-of-life; CETSCALE = Consumer Ethnocentrism Tendencies Scale.

Problems of BT

Despite its commonly accepted use as a standard method of translation quality assessment, BT can present serious challenges of which researchers need to be cognizant. Brislin, in his seminal article about BT in cross-cultural research, warns that a BT may suggest that a translation is equivalent to its ST, since several factors besides good translation can create seeming equivalence between source, target, and back-translated versions (1970, p. 186). Among these are:

1. Translators may have a shared set of rules for translating certain nonequivalent words and phrases (e.g., “amigo” and “friend” are not always equivalent).

2. Some back-translators may be able to make sense out of a poorly written target language version.

3. The bilingual translating from the source language to the target may retain many of the grammatical forms of the source. This version would be easy to back-translate, but worthless for the purpose of asking questions of target-language monolinguals since its grammar is that of the source, not the target (p. 186).

Brislin is referring here to well-known issues in translation studies, such as (i) that equivalence and in particular perfect equivalence is an unattainable goal; (ii) that BT introduces as an additional layer of translation/transformation, which may bring the target closer to or further from the source; (iii) that the more literal the translation, the closer the BT will be to the source. Brislin (1970, 1986, p. 161) warns against the uncritical use of BT and argues for using it in conjunction with other methods.

Note that the “Brislin method” is different from BT and as such has broader value. While BT has its origins in Brislin's proposal, there is much more to this proposal than BT, including the recommendation for a critical use of BT in conjunction with other methods. Generally, what has been adopted from Brislin's work is simply the (uncritical) use of BT (the absence of critical assessment explains in part why BT is still in use). Unfortunately, much of his advice has remained unnoticed, since the justification for the use of BT (if any) generally rests on its status as the standard method of translation quality assessment and the goal to establish linguistic equivalence between the ST and the target text (TT).

Tyupa (2011, p. 36) identifies the linguistic theory behind BT as its major flaw. Brislin (1970), based on Nida (1964), sees equivalence of meaning as the goal of the translation process, more specifically the creation of an equivalent response in the reader. For Tyupa, the problem with that framework is “that meaning was viewed from an objectivist position, the approach adopted in the mainstream linguistics of the day. This contrasts with the view adopted in cognitive linguistics, which treats meaning as inherently dynamic and equates it with conceptualization” (2011, p. 37). In other words, BT is based on the view of meaning prevalent at the time that Brislin published his work. Today, objectivist theories of meaning have been shown by research in linguistics and psychology to be misguided. As Tyupa states “there is no inherent, or objective meaning in the original questionnaires; meanings arise through the process of conceptualization, be it that of the developers, translators, or reviewers” (2011, p. 38).

Outdated View of Translation

In addition to reflecting an objectivist view of meaning, BT relies on an understanding of translation that goes back to the 1970s, not surprisingly, given the influential role of Brislin's proposal from that time. In consonance with the objectivist views of meaning and of structural linguistics, the ultimate purpose of translation was to create a TT that was equivalent to the ST (Catford, 1964; Nida, 1964); therefore, if at some point equivalence was not attained, then BT should be able to identify the errors by highlighting points of difference with the ST. However, research in translation studies, starting at least in the 1980s, has sufficiently shown that this was a restricted and partial notion of translation that focused almost exclusively on the printed text as an object—seen as a sequence of sentences—and on the linguistic structure of these sentences. Essential elements in translation and in text production and reception such as audience, purpose, and social conditions of the text or the translation were rarely, if ever, considered. Guided by the need for a consistent methodology, researchers adapting, translating, and validating instruments for widely different fields and purposes have resorted to a uniform view of translation and translation quality that does not consider the differences involved and that uncritically continues to rely on the view of language dominant in the 1970s and 1980s.

Another important element behind BT is the notion of equivalence. Equivalence is the underlying principle guiding the translation and cultural adaptation of instruments first developed and validated in English, so that they can be used in international contexts without undergoing an entirely new development and validation process. In these fields, BT is one way to make sure that the TT is equivalent to the ST. Much of the literature on cross-cultural research refers simply to equivalence in general, while only a few studies break it down into subtypes. Of these, semantic equivalence is probably the most common, defined generally as equivalence in the meaning of words (Guillemin Bombardier, & Beaton 1993, p. 1423; Lichtenstein & Hazuda 1998); a few studies mention other subtypes such as cultural equivalence (similar meaning and relevance of the constructs examined across cultures) and functional equivalence (the degree to what a concept performs the same way or elicits similar responses; Jones, Lee, Phillips, Zhang Xinwei, & Jaceldo, 2001, p. 300) with very few referring to elements beyond the word or phrase (e.g., Guillemin's experiential equivalence, i.e., the situations evoked should fit the target context). In other words, most notions of equivalence are word based or concept based, as they were at the time in which Brislin published his influential work. Similarly, this view of equivalence does not consider the reader, the context of the translation, or the text as a unit (Colina, 2015, pp. 16–18).

In a review of the definitions of the different types of equivalence discussed in the HRQOL literature, Herdman, Fox-Rushby, and Badia (1997) found that there is a “distinct lack of clarity and a considerable amount of confusion surrounding the way in which various types of equivalence are defined within the HRQOL field” (p. 243). In other words, researchers in this field are coming to the realization of what is a mainstay in translation studies: equivalence is a controversial, vague, and hard to define term. Herdman et al. believe that the confusion around equivalence:

can be at least partially attributed to the approach to cross-cultural aspects of HRQOL adopted by many of those working in the field … much of the research assumes an absolutist stance whereby it is assumed that culture has a negligible influence in the conception and expression of HRQOL. (p. 238)

They suggest that there is:

a pressing need … for a standardization of the terminology used in relation to equivalence, a standardization which should be tied to a clarification of the theoretical framework in which equivalence is discussed. It may well be that other cross-cultural disciplines could provide a guide as to how this should be done. (p. 245)

In sum, BT is highly dependent on equivalence, a clearly ill defined and unstable construct, something that unavoidably affects the validity of BT per se.

The use of BT as a quality control method for translation in cross-cultural research highlights a lay view of translation, based on the notions prevalent in the 1970s, such as meaning as an objective reality and equivalence (at the conceptual or semantic level) as the ultimate measure of translation quality. These notions remain mostly unchallenged in cross-cultural research (with a few exceptions, cf. below) even into the first decade of the 21st century. Among studies in cross-cultural research (e.g., marketing, nursing, quality of life, audiology, etc.), it is difficult to find any references to recent work in translation studies aside from the original work by Brislin and references therein. Even a more recent publication containing a separate section on translation theory only included references to Brislin (1970; e.g., Jones et al., 2001). A notable exception, however, is Fourie and Feinauer (2005) who conducted an updated and comprehensive review of relevant work in translation studies in the context of medicine and health. Similarly, as we mentioned with regard to the concept of equivalence, the HRQOL literature also discusses definitions of equivalence without reference to translation studies. In this context, the statement by Herdman et al. quoted above points to translation studies as one of the disciplines that could serve as a guide to unresolved conceptual issues:

… a pressing need for a standardization of the terminology used in relation to equivalence … which should be tied to a clarification of the theoretical framework in which equivalence is discussed. It may well be that other cross-cultural disciplines could provide a guide as to how this should be done. (1997, p. 247, emphasis added)

While BT can be useful to spot errors in the translation of purely referential meaning and one-to-one meaning correspondences, such as specialized technical terminology in highly specialized objective texts (e.g., translation of chemical compounds in a chemistry paper), it can actually work in the opposite fashion it was intended for other types of text/language. As Brislin noted (see quote above;1970, p. 186, point 3), the more literal the translation, the closer the BT will be to the source. Consequently, BT tends to favor literal translations, identifying them as better translations. A literal translation can, of course, be highly problematic in reader-oriented texts, such as marketing or health promotion, and questionnaires whose main goal is to obtain the requested information from a person. In addition, a highly literal translation can pose severe readability and comprehension problems for a monolingual target language (TL) reader. Fourie and Feinauer (2005, p. 351) mention an example from Afrikaans, in which the term Voortoets Vraelys is a direct, literal translation of “pretest questionnaire.” A BT of Voor-toets Vraelys would result in the original “pretest questionnaire.” However, a more semantically equivalent term is proefvraelys. Thus, BT would, in this case, fail to select the best option and instead identify the translation lacking the additional semantic information as superior.

Although not originally intended to illustrate the problems of BT, Eremenco et al. provide a revealing example of the problems of BT (2005, p. 227). In their study on translation and cross-cultural validation of health status questionnaires, they mention one test item that had poor results in the validation process (i.e., negative item-total correlation with the lung cancer subscale) and also received complaints from two patients in Brazil. The English source item was “my thinking is clear” and the translation with poor results was the very literal o meu pensamento é claro, which was then changed to Consigo pensar claramente (I am able to think clearly). Noticeably, the literal translation did not communicate effectively and naturally with the target population, as it resembled the ST too much, rather than the actual structure of the TL. The literal translation, as expected, was considered of higher quality when BT was used as a measure of translation quality. A quote by the authors is useful in highlighting the misguided assumptions regarding translation:

Although the first Portuguese translation seemed to be a good literal equivalent to the English source, it performed poorly statistically and was problematic for some patients. The revised version, although slightly different in meaning along the lines of “I am able to think clearly,” matched the response choices more closely and performs in a better manner. This item was a threat to the linguistic equivalence of the Portuguese FACT-L and testing was successful in identifying and correcting the problem.” (2005, p. 227, emphasis added)

It is precisely aiming for linguistic equivalence (vs. communicative effectiveness) that created the problem. Linguistic equivalence is an adequate goal for a linguist who wants to understand the linguistic structure of a particular language under study, but not for the translation of a questionnaire item that has to be read and understood by a target reader.

Colina (2015, pp. 91–93) provides another example having to do with pragmatics. In the United States, when a host says to a dinner guest “Why don't you serve yourself more chicken?,” in most cases, she will be inviting the guest to eat an additional serving. However, a literal translation would very likely be understood as a true question in some languages (along the lines of “Are you full or sick? Perhaps you do not like the chicken?”), in particular in languages in which the structure “why don't you” is not the conventional structure used to make a request. This difference is highlighted in English when sometimes, as a joke, an interlocutor will respond according to the literal form of a question, for example, “Would you like to help me?”: “No, but I will help you nonetheless.” In the same way, literal translations could in fact produce a similar response in a serious context. Yet, a BT comparing the literal versus the more customary form of the request would identify the literal one as the higher quality translation.

Languages differ in their wording of requests (and other speech acts) and the level of politeness required for each. When the purpose is that the reader of the translation responds to a request in the same manner as the reader of the source, the structure and form of the translation needs to match pragmatic conventions in the TL, not the source, in order for the request to be successful. As mentioned above, a literal translation risks communicative failure, despite the fact that BT will identify it as the better version of the two.

The above examples highlight the fact that BT as a method of translation quality assessment does not generally work; indeed, it can actually be responsible for the selection of inadequate translations and the subsequent negative effects on research findings.

Recent Critique of BT

A few recent studies have started to recognize the problems of BT in health assessments and measures of patient-reported outcomes (Douglas & Craig, 2007; Fourie & Feinauer, 2005; McKenna & Doward, 2005). As Fourie and Feinauer (2005, p. 351) put it:

back-translation is not necessarily an indication of an accurate translation into the TL … translations which do not communicate appropriately with the TT readers or at a level that the TC [target culture] understands could lead to the collection of incorrect data.

Fourie and Feinauer (2005) review different approaches to translation within translation studies and hypothesize that the approach used will have an effect on the quality of the translation product. To test the hypothesis, they conducted a study in which two sets of translations (one following a linguistic, literal approach and the other, a functional, communication-oriented method) of a medical, quality-of-life questionnaire are compared and evaluated by the target subjects. Fourie and Feinauer found clear differences between the two translations that were implemented. In addition, the questionnaire recipients evaluated the communicative translations produced as superior and as easier to understand than the linguistic/literal ones. Fourie and Feinauer explain that translation is a complex process and recommend that a translator be familiar with the different approaches that can be used. Furthermore, the authors conclude that BT is not necessary as a quality control method and recommend that it should be omitted from the translation process.

McKenna and Doward (2005, p. 89) speculate that BT may have come into existence due to a “requirement for determining the quality of the target version by some sort of ‘scientific’ method.” They add that “despite this need, back-translation has no clear scientific basis and its use casts doubts on the ability of the translators” (p. 89). They refer to a study in progress that compares two Swedish versions of the rheumatoid arthritis quality-of-life questionnaire (de Jong, van der Heijde, McKenna, & Whalley, 1997; Whalley, McKenna, de Jong, & van der Heijde, 1997). Results from the study indicate that items translated using the two-panel method are statistically significantly preferred to those based on BT. They conclude with the strong statement that “it is essential to collect evidence before asserting that back-translation, an untested method—however widely implemented—represents principles of good practice” (p. 90). In addition to objections over the nature of language and translation, these authors point out that BT has never been tested as a method.

Within the marketing context, Douglas and Craig (2007) point out a variety of problems with BT, among them that BT assumes an etic approach to translation, that is, that there is always an equivalent word or construct in the TL. They also highlight that “back-translation is likely to be the most useful when a literal or direct translation is required, but it is less helpful when idioms need to be translated” (p. 33). These authors are also among the few researchers to recognize the difficulties involved in using bilingual translators who are fluent in the relevant languages and who do not use a language the same way monolinguals do. This is an important point in BT, as it is also bilinguals who produce the translations and evaluate the BTs. As the translation studies literature shows (e.g., Jääskeläinen, 1990; Lörscher, 1991, 1992; among many others), bilinguals do not translate the same way a professional translator does; bilinguals often exhibit a literal, word-by-word approach, which would tend to be biased toward a positive outcome of BT.

Douglas and Nijssen (2003) offer evidence of the problems of translating a questionnaire by relying solely on BT. They tested two versions of the Consumer Ethnocentrism Tendencies Scale (CETSCALE; Shimp & Sharma, 1987; initially developed in the United States) in the Netherlands. One was a literal back-translated version of the questionnaire while the other was a modified one that attempted to address differences in the construct of consumer ethnocentrism in the Netherlands. Although the back-translated version of the CETSCALE did not change the meaning of any of the original items, the researchers found that the modified questions were clearer and better adapted to the Dutch concept of consumer ethnocentrism. The analytical portion of the study also favored the modified questionnaire over the back-translated version.

In summary, the above studies highlight the problems of BT and the complexities involved in translating and adapting cross-cultural research instruments (cf. Table 2 for a summary). As Fourie and Feinauer put it, “translators must be able to ascertain the type of translation approach needed, depending on the particular text type and the purpose of the translation” (2005, p. 352). In other words, different translation purposes, fields, texts, and so on, require different translation approaches; consequently, evaluation methods are needed that are capable of considering various approaches. In addition to its problematic nature as a quality evaluation method, BT, as a single evaluation method, cannot serve as the common quality standard for all text types and purposes. The next section considers BT in the context of the methods of translation quality assessment.

BT and Translation Quality Assessment

In addition to the issues analyzed in previous sections, BT faces some difficulties in relation to translation quality assessment. BT reflects an oversimplified and monolithic view of quality, which equates translation quality with perfect equivalence and an objectivist view of the textual content and meaning.

In contrast with this position, a review of current literature on translation quality assessment in translation studies (Colina, 2008, 2009, 2015) reveals a complex and controversial topic even among translation scholars. Colina (2008, 2009, 2015) reviews the main approaches to translation quality (e.g., reader response, textual and pragmatic, and functional), concluding that they reflect different priorities, and a multiplicity of views and assumptions about translation. She also proposes that a quality evaluation system that attempts to be generalizable must be flexible and customizable, adaptable to the purposes for which the translation was created.

Another problem raised by the use of BT as a quality control mechanism is that it casts doubts on the ability of the translation professionals (Fourie & Feinauer, 2005; McKenna & Doward, 2005). If the translators selected are qualified professionals—many studies report the use of bilinguals rather than professional translators—a quality product can be expected. That of course does not mean that quality control and quality checks (e.g., pretesting, committee review) are not necessary, only that there is little to justify the continued use of BT. Additionally, for some types of research instruments, more complex validation processes (independent of the quality of the translation) are necessary to make sure that the translated instrument can produce reliable and valid results.

The present discussion of BT contains evidence and arguments to conclusively argue that, in most cases, if not all, BT should be abandoned as a quality control mechanism in cross-cultural research. However, two questions remain: (i) why did BT become so popular? (ii) What are the alternatives to BT? We address the reasons for the popularity in the following paragraph and the alternatives in the next section.

BT reflects the prevalent views of the 1970s about translation, language, and meaning. Furthermore, the conceptualization of textual content and meaning as an objective, independent reality present in the text, and of translation as complete equivalence and transfer of objectified meaning to another language were appealing to scientific pursuits at the time and have continued to be so up to the present time. This situation was facilitated by extreme specialization and the subsequent siloization of disciplines and experts, which resulted in matters of language and translation being dealt with by researchers with limited understanding and awareness of the complexities of language. Currently, as awareness of the social cognitive aspects of research involving human subjects grows, and interdisciplinarity acquires a privileged spot in academic circles, more current understandings of meaning, language, and translation are starting to inform aspects of scientific research, as seen by some of the articles mentioned here and by this contribution itself.

Alternatives to BT: A Case Study

As we mentioned above, some researchers are starting to take a critical look at the use of BT, whether alone or in combination with other methods, and at alternative ways of assessing the quality of translated or adapted cross-cultural questionnaires and research instruments.

Fourie and Feinauer (2005) recommend omitting BT entirely. Instead, they suggest that translations should be done by professional translators who are familiar with the subject matter followed by a panel review and field testing in the target community. They explain that those who are not professional translators would not be aware of the translation approach they are using. For these authors, it is essential to be able to select the right approach for a specific translation and purpose, as the findings of their study show that there are crucial differences in translations depending on the approach used. Translators must be able to determine, on the basis of the purpose of the translation, how close it should be to the source and how much of an adaptation is required to accomplish the researchers' goals. Fourie and Feinauer also recommend using a functionalist (aka Skopos Theory, cf. Nord, 1997; Reiss & Vermeer, 1984) approach for medical questionnaires like the ones in their study. Finally, these authors highlight the importance of the translation brief that explains to the translators what the researcher requires, for whom the translation is, where it is going to be used, and so on.

Douglas and Craig (2007) argue for a team approach because of the complexity of the translation task, the subjective character of quality assessment, and the multiple skills required (linguistic ability, questionnaire development skills, field expertise, etc.). These authors consider two types of collaborative work, namely, a committee approach (when all participants work together simultaneously) and a team approach (when they work individually). Douglas and Craig recommend replacing BT with five basic iterative stages: translation, review, adjudication, pretesting, and documentation. They refer to an iterative process because there may be parallel translations, which are then adjudicated, followed by revision and possibly additional translations and adjudication, to ensure that the translated instrument is appropriate for the new context.

We will now describe a case study that involves the translation and evaluation of cross-cultural research instruments which eliminate BT and foreground a view of translation and evaluation as a complex process. It is argued that because of the complexity of most research projects and of translation and language mediation per se, translation procedures and strategies established for one specific project cannot be automatically transferred to another without considering project-specific contextual factors and how those impact the translation strategies and approach. The one-size-fits-all approach will not work for the translation of materials and instruments. Translation studies research also demonstrates that translation approaches vary with purpose, audience characteristics, topic, and medium (Nord, 1997). Furthermore, large cross-cultural projects like the one we describe here often necessitate multiple documents and translations that generally consist of different text types and serve different purposes and audiences.

Oyendo Bien is an National Institutes of Health (NIH) funded multiple-year project that aims to develop and test the effectiveness of an innovative community health worker intervention to expand access to hearing health care among older adults facing health disparities. The project involves interdisciplinary faculty with expertise in audiology, public health, and translation studies as well as a community partnership with a federally qualified community health center in Nogales, AZ. Nogales is a border community of 20,837 people with 95% of the population reporting Hispanic or Latino descent and 88.5% reporting that a language other than English is spoken at home (U.S. Census, 2010).

The hypothesis that guides the project is that a community health worker (Promotora) model will be effective and relevant in reducing hearing health disparities via health education, social support, and language mediation. Therefore, an important focus of the work is on the development of culture-specific and language-specific interventions to increase the utilization of hearing health care among the Hispanic/Latino population. The adequacy of language and cultural mediation thus goes beyond mere validity of results, as the success of the project crucially relies on reaching the target population.

Oyendo Bien consisted of (i) a community-needs assessment, including group interviews with community members, one-on-one interviews, and focus groups; (ii) a promotora-facilitated 5-week intervention to improve communication between individuals with hearing loss and a communication partner; and (iii) outcome evaluation as measured by pre/post questionnaires. Consequently, the project required the translation and writing of multiple and varied documents in Spanish in collaboration with team members with different areas and degrees of expertise (public health, audiology, social and health workers, translation studies, and translation practice) and various linguistic profiles (monolinguals, late bilinguals in English and Spanish, heritage speakers, etc.). The documents included multiple text types, from questionnaires to informational notices, consent forms, internal review board documentation, intake forms, scripts (to be read to patients), group questions and interviews (to be delivered out loud), focus group directions and questions, educational materials for presentations, and so on (cf. Table 3 for a sample of the types of documents in the project).

Table 3.

Inventory of Translated Documents in Oyendo Bien.

Documents Intake form Results notification script Research disclosure and IRB documents Photo release Informed consent form Instructions/scripts for hearing test Interviews with a person(s) with hearing loss Prequestionnaire for a person(s) with hearing loss Prequestionnaire for partner Social network partner group questions Community group questions HHIE: Screening version (Weinstein, 1986) Class evaluation

Outcome measures SAC (Schow & Nerbonne, 1982) SESMQ (Jennings, Cheesman, & Laplante-Levesque, 2014) SOAC (Schow & Nerbonne, 1982) SOS-HEAR (Scarinci, Worrall, & Hickson, 2009) IOI-AI (Noble, 2002) IOI-AI-SO (Noble, 2002) NHANES hearing questionnaire (Centers for Disease Control, 2011)

Note. IRB = internal review board; HHIE = Hearing Handicap Inventory for the Elderly; SAC = self-assessment of communication; SESMQ = self-efficacy for situational management questionnaire; SOAC = Significant Other Assessment of Communication; SOS-HEAR = Significant Other Scale for Hearing Disability; IOI-AI = International Outcome Inventory for Alternative Interventions; IOI-AI-SO= International Outcome Inventory for Alternative Interventions—Significant Others; NHANES = National Health and Nutrition Examination Survey.

The overall approach to the translation of these documents is a functionalist approach according to which each document is translated according to the type of text and genre involved and to the purpose that the commissioner (i.e., the research team) wants to attain by means of the translation. The purpose that the translation is intended to achieve will shape the translational approach, that is, the degree of correspondence between the ST and the TT, and many of the translation decisions made by the translation team. In addition, the actual form of the translated text is determined by other contextual factors surrounding the translation, such as the audience (users) and their characteristics, including socioeconomic and geographic considerations, the medium (e.g., Is the translation all in writing or is it to be read to the user by an interviewer?), and the purpose (e.g., to inform readers of a legal requirement, to educate them, to move them to action, etc.). This is in fact not different from what takes place in writing original texts for which authors are well aware of their purpose and their audience. The obvious difference is that in translation, the content is provided as an ST that the translator/translation team is required to follow, as long as the purpose and instructions for the translation allow it. In many cases, the need to achieve a specific goal will determine significant changes to the ST (e.g., advertising, logos, and slogans in public health campaigns) and therefore the approach taken may require a degree of departure from the ST that renders it an adaptation or some other form of language mediation that may no longer qualify as what the source culture considers a “translation.” At times, it may even turn out that translation is not the best option to achieve the intended goal, and bilingual researchers may have to be located to develop original instruments or other materials (in collaboration with research team members) in the relevant language. When the translation and language mediation component are led by a research group that includes members beyond the translators (including a language mediation/translation studies expert), all these issues can be taken into consideration to design a foreign language solution that better addresses research needs.

In accordance with this, the approach used in Oyendo Bien is also a team, collaborative approach to translation and language mediation. As mentioned above, team members involved in the translation process range in areas and types of expertise (public health, audiology, researchers, social and health workers, translation studies, and translation practice) and linguistic profiles (monolingual, late bilinguals in English and Spanish, heritage speakers, etc.). Depending on the issue being discussed, some members will be more active or involved than others. One important difference in this approach with regard to the monitoring and quality of the translation and language mediation discussion is the inclusion of a translation studies expert. This person is a researcher in translation processes and translation competence, who guides the discussion of translation processes and selection; she or he knows what questions to ask and how to make decisions on the basis of the translation goals and the expertise provided by all (content expert, research designers, community experts in touch with the population and their culture language, etc.). She or he is also an expert in the translation studies literature who can educate collaborators and inform them of the best approaches and up-to-date knowledge in translation studies as needed in regard to their goals. In more specific terms, the translation procedure used in Oyendo Bien distinguishes between existing (published) translations and newly created ones. Existing translations (e.g., HHIE-Screening Version, Lichtenstein & Hazuda, 1998) were reviewed and revised by the translation studies expert to ensure that the translation reflected the approach and needs of Oyendo Bien. The revised version was then presented to the group of researchers and community members who worked on content and language using a collaborative team approach (cf. Figure 1).

Figure 1.

Collaborative translation process for Oyendo Bien.

For translations that had to be drafted entirely from an ST, two translations were produced per ST; one was done by a member of the community with some background in the field of expertise and one by a translation studies expert, who was also a professional translator. Community members with expertise in the topic (promotoras) were then asked to select one of the two anonymous Spanish texts and that was the one subsequently used as the point of departure for the group discussion.

The process used in the team meetings was the same regardless of the source of the TTs (a published translation or a new translation selected between two options). In the meetings, language and content were discussed in similar terms, guided by the purpose and target audience for the project. In some instances, the language of the translation had to be changed, as the translation may have been a bit formal or not adequate for the target speakers or for the form of delivery (in interviews); in others, it was the content, which was considered unnecessarily long, repetitive, and/or irrelevant for the population under study, or it was deemed unable to gather the information needed by the researchers. In order to make decisions about omitting or modifying content, and to make sure that the intended content was present, original research team members (bilingual and monolingual) were also part of the team meetings on the Spanish text.

As content, language, and cultural experts were present in the same meetings, all these aspects could be considered simultaneously allowing those involved to take into account the interaction of all factors in regard to the research purpose. The translation expert participated by monitoring and guiding translation decisions and the bilingual processes in accordance with the translation approach selected and the contextual factors impacting it. The translated texts produced by the team were used in the pilot version of the study. During the pilot sessions (interviews, focus groups, and interventions), the researchers observed responses to the translation questions and sought feedback from the users. This was delivered to the team meetings for revision before adopting the final form.

Examples 1 and 2 illustrate how the approach and the process described here were put into practice. They contain the published translation of selected questions of the HHIE (Lichtenstein & Hazuda, 1998; reproduced as printed and identified by LH in the examples) and the translation used for Oyendo Bien (OB in the examples). Given that the objective of the translation in Oyendo Bien is to obtain answers/information from patients, there is no need to replicate the linguistic structure of the source. Patients should be able to understand the questions easily. In the case of Oyendo Bien, the patient population consists of older adults, of lower socioeconomic and educational level, and who are mostly monolingual Spanish speakers living in the small border town of Nogales, AZ. Therefore, the Spanish text of the HHIE used for the Oyendo Bien project should reflect the semiinformal variety of Spanish spoken in Nogales, and the questions on the form should be formulated in such a way that they will most likely to be understood and answered with ease by the patients.

Consider, for instance, Example 1: LH retains the word order of the source English text, that is, subject (hearing problem) + verb (cause to feel frustrated). For Oyendo Bien, a more natural (i.e., commonly occurring) structure was selected, one in which the patient is literally asked about feelings of frustration or confusion caused by the hearing problem. The rationale for this is that there is nothing in the Oyendo Bien version that would necessitate the preservation of English word order over a more frequently used one in Spanish (one in which the patient is literally asked about feelings of embarrassment caused by the hearing problem). Patients found the question easy to understand and they answered without hesitation. In general, LH reveals a fairly literal approach to the translation of the HHIE that reflects the structure of the ST (this is not unexpected since, according to Lichtenstein & Hazuda, 1998, the translation was done by bilinguals tending to follow a structural/literal/sign-oriented approach to translation; cf. Colina, 2008, p. 111, and references therein). In another example (not included here), researchers found a potential comprehension difficulty in the LH because of a dictionary equivalent was chosen for “handicapped,” in reference to a physical disability (i.e., desventaja física). A contextually relevant form that only refers to a disadvantage (i.e., desventaja) made more sense for the patients in Oyendo Bien. Additional changes were also made as a result of the pilot testing (e.g., Example 2). One research team member with knowledge of Spanish administered the pilot and took notes on comprehension and other issues. These were shared with the larger group (including the translation studies expert) who worked on revising the documents with the objective of obtaining the measures and/or asking the questions that were more appropriate for the project goals. For instance, the question in Example 2 had to be changed after the pilot because the idea of not attending church due to hearing problems was confusing for the target population. In this case, it was the content of the English question (rather than the translation) that created confusion.

Example 1

Does a hearing problem cause you to feel frustrated when talking to members of your family?

NO _______ YES _______ SOMETIMES _______

LH: ¿El problema auditivo de no oir bien le causa que se sienta frustrado/frustrada o confundido cuando esta [sic] hablando con miembros de su familia?

OB: Se siente frustrado/a o confundido cuando habla con miembros de su familia porque no oye bien.

Sí _______ No _______ A veces _______

Example 2

Does a hearing problem cause you to attend religious services less often than you would like?

NO _______ YES _______ SOMETIMES _______

LH: ¿El problema auditivo de no oir bien le ocasiona que no puede asistir tan seguido como quisiera a servicios religiosos?

OB: No asiste a servicios religiosos tanto como quisiera porque no oye bien

Sí _______ No _______ A veces _______

While many changes affected linguistic structure exclusively (which was unnecessarily similar to the English text), most required knowledge of language, culture, and the research project itself in ways that could not be easily separated, thus requiring the presence of all research team members.

Limitations and Future Directions

It is important to note that materials translated for Oyendo Bien are substantially different from quality-of-life questionnaires and other general surveys produced for multiple countries and reviewed earlier in this article.² These questionnaires are administered to large number of patients and also require psychometric and other types of sophisticated validity tests. Oyendo Bien is a research project that targets a small border community on the Arizona–Mexico border (with multiple documents, mediums and tasks, and an education component); therefore, the use of translations that rely on BT and that are validated on large clinical populations with different linguistic, cultural, and socioeconomic backgrounds is not an appropriate methodological decision. As a result, instruments were customized for the patients, including existing materials with similar goals in mind. The point that needs to be stressed—and that constitutes the core of a customizable, functionalist approach—is that it is precisely the differences between research projects—purposes, population characteristics, and so on—that guide the translation process and that these should be assessed before making a decision on how to carry out the language mediation component. The functionalist approach, however, does not obviate validity studies, so that results can be generalizable to as broad a community as possible. A validity study on a larger population is planned for the future in order to establish psychometrics on the translations used.

It should be pointed out that a functionalist approach requires more time and expert involvement than BT. Cost can also be a consideration for some studies. While projects that involve a large research team, like the one described here, may be able to involve additional collaborators (often across fields in large universities) for minimal cost, others, such as quality-of-life questionnaires, that require translation into a large number of languages may call for creative solutions (e.g., foreign partnership, etc.) to save time and money. Despite these potential limitations, the research team using a functionalist, team approach also has more control over the translation/language mediation process, which becomes a more integral part of the project under this model, as it recognizes the nature of language and culture as essential to global health research. In short, the benefits of research findings that are better aligned with the needs of global populations and with less of a source culture bias outweigh the limitations of the functionalist approach. Future research should be conducted that systematically reviews translation quality methods in health research from the point of view of the translation approach employed and the specific needs of the research project.

Conclusion

This article examines BT as a method of translation quality assessment in health research. It reviews the existing literature, the extent of the use of BT, and the problems presented by the method, including recent criticisms; this article discusses how BT became established as the standard for translation quality assessment in cross-cultural research. Finally, we present an innovative approach to translation in health research as an alternative to BT. This approach is based on a functional, customized, collaborative view of language mediation, and it is illustrated by a case study in audiology and public health, accompanied by textual examples.

In terms of quality evaluation, this article offers a view of quality dependent upon the requirements and the function of the specific translation (rather than on BT alone or in combination with other methods) as determined by the commissioner(s), in this case the research team leaders. The team also includes a translation studies specialist who decides the translation approach to be used and the criteria for translation evaluation. Quality evaluation criteria should be guided by the needs of the project. While the translated materials developed can still be subjected to psychometric evaluation and translation quality evaluation methods (e.g., Colina, 2008, 2009; House, 2001), a process like the one presented here has a higher chance of producing quality materials than BT, given that it is based on current knowledge about translation and translation quality in translation studies.