Background for Culturally Appropriate Measures
of physical activity is a major risk factor for chronic disease resulting in
the need for research on the measurement of physical activity in the general
U.S. population. In the Latino
population there is a disproportionately high prevalence of chronic disease
which makes this ethnic minority group a target for physical activity
assessment and interventions1-3. Most
physical activity questionnaires are valid and reliable for measuring physical
activity in the mainstream English speaking population and contain content that
is relevant to conventional American behaviors. Questionnaires presented in Spanish have often been translated
from English to Spanish without the use of culturally appropriate guidelines
for adaptation for Latino populations4. Physical
activity levels in Latinos may be underreported due to an inability to assess
physical activity in a culturally sensitive manner that identifies with
different norms 5.
Consequently, the Latino population in the U.S. has been identified as
the least physically active racial and ethnic minority group which may be a
possible misrepresentation 6.
It is important to develop assessment materials that are
culturally appropriate, with reliability and validity established in the target
questionnaires and intervention materials are to be translated from English
into Spanish for use in Latino populations, cultural relevance, validity, and
reliability of the materials also should be established in the target population. Using culturally appropriate tools to
measure physical activity in Latino populations will provide data on true
physical activity levels needed to facilitate the promotion of physical
activity among Latinos and improve evaluation of physical activity
What is a culturally appropriate
A culturally appropriate
measure seeks to be culturally equivalent across subgroups and populations by
taking into account the following:
- Shared norms: socially desirable behaviors (e.g. “the do’s and don’ts”)
- Shared beliefs: ideas or assumptions about the world
- Shared values and expectations: moral standards perceived as desirable and esteemed
In creating culturally
appropriate measures, it is also essential to consider linguistic
appropriateness or the target population’s reading and comprehension
levels. Bilingual review, assessing
readability, and pilot testing are several methods for reviewing the quality of
translation for validating a culturally appropriate measure.
Conceptual equivalence: Do people
attach the same meanings to terms and concepts? This is critical, because the concepts of physical activity types
(e.g., household chores, walking, gardening) and intensity (e.g., moderate vs.
vigorous) must be understood and measured in similar ways 5. For
measurement items, it is recommended that terms be explained to assure
similarity between measures.
Cultural equivalence: Are the
cultural norms, beliefs, values and expectations the same for different
populations? This type of equivalence
can be determined after back-translating the items and pilot testing with
members of the target population, and then comparing their opinions with the
intent of the measurement items.
Linguistic equivalence: Do the words
and grammar have similar meanings across different cultures and languages? It is much more important to translate the
meaning of the survey, rather than the words.
Translation procedures must establish that the items of the original and
new surveys have similar meanings9, 10.
Metric equivalence: Do the numbers mean the same
thing? This is not a major
consideration for most items that ask about frequency in times per week or
duration in hours or minutes per session.
However, intensity levels must be consistent for activities given as
examples, with moderate intensity being activities of 3-6 METs and vigorous
intensity being activities of > 6 METs9, 10.
Ideally, measures should not be applicable to a single culture or language. Instead, the items should be translated and
culturally appropriate so that the new version sounds natural and smooth, and
have the same interpretation across cultures.
There are a wide variety of
physical activities undertaken by people throughout the world. In developing countries, occupational
activities and transportation may involve more activity than in more developed
countries 11, 12. In specific
countries or regions, occupational and leisure time physical activity may be
more prevalent among rural residents than urban residents13. In
presenting the questions to the participants, an introductory commentary is
recommended in order to identify culturally relevant activities. A guide for cultural adaptation and
translation of the International Physical Activity Questionnaire (IPAQ) is
available at: www.ipaq.ki.se.
Types of Translation
One important reason why
emphasis is placed on developing and creating measures with high levels of
cultural equivalence (e.g., “responsibility" vs. "burden”) is that it
allows investigators to compare measures and results between cultures. When
comparing surveys, investigators should consider the following types of translation14:
Forward Translation: Also known
as “translation”, should be performed by one translator qualified to understand
the objectives, concepts and terminology being covered by the instrument 5, 15. The
translator’s primary language should be native to the target population and
he/she should be proficient in English.
Translators should target
conceptual equivalence of a word or phrase and not literal translation. The definition of the original term should
be translated while maintaining cultural relevance.
This consists of using the
same approach as forward translation; however the material is translated back
to English by an independent translator, who is predominantly English speaking
and who has no previous exposure to the original measurement items.
During this process,
emphasis should be on conceptual and cultural equivalence and not linguistic
Recommended Steps for Translation16
- Translate all materials from the original English version. In this process, it is recommended that investigators consider
changing the words to get across the same meanings (i.e. conceptual and
linguistic equivalence). Some words may
need to be changed to match words with a similar concept in the second language
(e.g., “vigorous” may not be familiar in a given culture, but the term, “very
hard” may be understood). For all
items, make sure the underlying concept is retained in translations. When examples of physical activities are
given, it is recommended that the activities presented in the survey are
culturally appropriate for the population considered, but also meet the
requirements for appropriate classification. For example, if using METs, check the MET intensities from the
Compendium of Physical Activities (http://prevention.sph.sc.edu) to make sure
that vigorous intensity activities are > 6 METs and moderate intensity
activities are 3-6 METs.
- Translation into the second language should occur with at least two
independent translators to improve the quality of the instrument
- Ask the
translators to make the concepts understandable by people in the target
population. In countries where there
are multiple dialects of the same language, it may be necessary to have
translators who speak the different dialects translate the survey and agree on
the best translation for use in the study.
- Review the
translated measure by a group of bilingual people who are similar with the
target population. Ask the group to
ensure that the translation will be acceptable to monolingual people.
conceptual and cultural equivalence, it is recommended that two different
translators translate the new version back into English (back translation)
In the case
that there is more than one translation created, there should be a backward
translator for each translation. The
translators should reach a consensus for the different translations and then
consider revising after pilot testing.
- It is recommended that a group of bilingual
people meet again to review the back-translation and decide on the final
version. It is most important that the
meanings of the two versions are comparable; the back-translation does not need
to reflect the original wording.
Recommended Steps for Pilot Testing
Many used physical activity
instruments developed in English (e.g., Behavioral Risk Factor Surveillance
System, National Health and Nutrition Examination Survey) have undergone
psychometric evaluation in the English-speaking population. Since the validity and reliability of
available PA measures have not been examined in other cultures, their
applicability to communities like Latinos are in question. Some basic preliminary steps are recommended
prior to the implementation of the measures.
Cognitive Interviews 17, 18. It is
recommended that the translated version be pilot tested using a cognitive
interview approach involving ten participants from the targeted community. Different dialects of the same language used
within that community, including low and middle education levels or social
class should be represented.
Think-aloud or cognitive interviews with structured probes can identify
items where responses might be affected by racial or cultural experience. The responses participants provide will help
researchers identify whether the population is interpreting the survey
questions in the same way as the researcher.
For each item:
- Assess comprehension
- Did you understand all
of the words?
- Ask them to explain how they would answer the question
- Talk out loud as you answer the question
- Describe what you were
thinking as you answer the question
- Assess clarity of question
- What do you think is being asked?
- What does this question mean to you?
- Tell in your own words what you thought the question was asking.
- Determine whether they need
additional help in answering the questions such as definitions, examples, etc.
- What types of examples
might help other people understand this question?
- Ask them to describe how they would have asked
this question to a sister or a friend
- If you were asking this
question to a friend or family member, how would you ask it?
At the end of the survey, ask more general questions such as these:
Based on the information
collected in the pilot testing, consider if other changes to the instrument are
necessary. Make only changes that do
not change the meaning of the instrument.
- Did any of the questions make you feel
- Indicate whether the question is upsetting
- Were there activities that we missed?
- Would you prefer to have answers to pick from
or do you prefer open answers?
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