Background for Culturally Appropriate Measures

Lack 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 interventions^1-3.  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 population⁷.  If 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 interventions.

What is a culturally appropriate measure⁸?

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.

Cultural Adaptation

General Concepts

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 meanings^{9, 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 METs^{9, 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.

Back-Translation:  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 equivalence. 

 

Recommended Steps for Translation¹⁶

1. 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.

2. Translation into the second language should occur with at least two independent translators to improve the quality of the instrument

3. 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.

4. 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.

5. For 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.

6. 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:

1. Assess comprehension
   • Did you understand all of the words?

2. 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

3. 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.

4. 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?

5. 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:

1. Did any of the questions make you feel uncomfortable?
   • Indicate whether the question is upsetting

2. Were there activities that we missed?

3. Would you prefer to have answers to pick from or do you prefer open answers?

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.

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Published Review:

Martinez, SM, Ainsworth, BE, Elder, JP. A Review of Physical Activity Measures Used Among US Latinos: Guidelines for Developing Culturally Appropriate Measures (pdf). Annals of Behavioral Medicine.

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