As of 2011, 25.3 million people in the United States had limited English proficiency (LEP). This number includes people born outside and inside the United States (Zong and Batalova, 2015). Spanish is the most spoken language in the United States after English, with increases in other nonEnglish languages occurring as the United States continues to diversify (Gonzalez-Barrera and Lopez, 2013). This population shift has major implications for health equity and health literacy.
One important strategy to address health equity and patient-centered care is the translation of health materials used by health providers. Translations of health-related materials are not as straightforward as you might think. In this commentary the authors provide their perspective on how to proceed to ensure equity in translated health materials.
Let us say that we have some health material in English that is in plain language and is at a sixth grade reading level. It addresses health literacy because we have ensured that the intended audience can access the information, understand it, and act on it to improve health. It could be a written document for the Internet or print, a video script, or a radio announcement.
Now that we have this quality product, let us say we want to reach speakers of other languages, for example, Spanish speakers, with this information. We have it translated into Spanish by an expert. According to Standard 8 of the National CLAS (Culturally and Linguistically Appropriate Services) Standards, we have “provided easy-to-understand print and multimedia materials . . . in the languages commonly used by the populations in the service area” (OMH, 2013).
Or have we?
We cannot assume that the translated version will be in the plain language and at the sixth-grade reading level of the original English language document or source document. Nor can we assume that it addresses health literacy for speakers of the language to which we have translated the material. There is currently limited research or guidance about adapting translated health materials for people in the United States who are speakers of languages other than English or speakers who have LEP.
In the Toolkit for Making Written Material Clear and Effective, the Centers for Medicare and Medicaid Services states that “part of the translator’s task is to identify . . . implicit meanings and decide how to convey them to readers of a different language that has different taken-for-granted cultural and linguistic complexities” (CMS, 2010). The World Health Organization states that the goal of translating and adapting is to “achieve different language versions of the English instrument that are conceptually equivalent in each of the target countries/cultures. That is, the instrument should be equally natural and acceptable and should practically perform in the same way. The focus is on cross-cultural and conceptual, rather than on linguistic/literal equivalence” (WHO, nd). In A Guide to Choosing and Adapting Culturally and Linguistically Competent Health Promotion Materials, the
National Center for Cultural Competence states, “Messages in health promotion materials should reflect the health beliefs and practices of the intended audience” (Bronheim and Sockalingam, 2003).
In the 20-plus years of translating and adapting health materials from English, the authors have consistently seen that there is an immediate disparity between the source document and the Spanish language translation. In most cases, the translated document has a higher level of complexity and an increased reading grade level. The increased reading grade level can range on average from one to three grade levels higher than the source document. This disparity is even more dramatic considering that people with LEP are predominantly immigrants (Pandya et al., 2011). And immigrants have a significantly lower level of literacy than the general population in the United States (Sum et al., 2004).
Another significant disparity that can result from a material translated from English is a cultural one. We cannot assume that a document translated from English to Spanish or any other language will reach and speak to the intended audience in the same or intended way. Cultural adaptations need to be considered and addressed as appropriate so that key messages are conveyed in culturally meaningful and respectful ways.
Here are the new standards the authors recommend to ensure equity in translated health materials:
1. Comprehensive translation:
- Translation by a trained professional. This professional should be certified, have significant experience and strong references, and be able to show the client published work samples.
- Translation quality assurance by another trained professional. This second professional reviews the original translation.
- Final translation adaptation. If there is a discrepancy, the two translators discuss and come to consensus on final translation.
2. Plain language adaptation. This type of adaptation means adjusting for comprehension, reading grade level, consistency in terms, and natural flow in the translated language.
3. Cultural adaptation. This type of adaptation means adjusting for cultural appropriateness, appeal, and motivators. It includes adjusting not only text but images and graphics.
4. Back translation to English for clients with brief justifications of plain language and cultural adaptations.
5. Field test with intended audience.
6. Modify and finalize material on the basis of feedback from the intended audience.
7. Include the intended audience in the distribution and application of materials.
CLAS Standard 8 is valuable, and it is important to achieve. But translation is subject to unintended bias. Therefore, to address disparities in translated health materials, the authors urge taking the standard even further with the new standards recommended above. These new standards promote health equity in health materials for speakers and readers of languages other than English. They also help minimize health disparities by improving health literacy, which is a key component to ensuring we have an informed, healthy population.
- Bronheim, S., and S. Sockalingam. 2003. A guide to choosing and adapting culturally and linguistically competent health promotion materials. http://nccc.georgetown.edu/documents/Materials_Guide .pdf (accessed January 2015).
- Centers for Medicare &Medicaid Services. 2010. Toolkit for making written material clear and effective. Section 5: Detailed guidelines for translation, 35. https://www.cms.gov/Outreach-andEducation/Outreach/WrittenMaterialsToolkit/downloads/ToolkitPart11.pdf (accessed January 2015).
- Gonzalez-Barrera, A., and M. H. Lopez. 2013. Spanish is the most spoken non-English language in U.S. homes, even among non-Hispanics. Pew Research Center. http://www.pewresearch.org/facttank/2013/08/13/spanish-is-the-most-spoken-nonenglish-language-in-u-s-homes-even-among-nonhispanics/ (accessed August 13, 2013).
- Office of Minority Health. 2013. Think culture health: National CLAS standards, standard 8. https://www.thinkculturalhealth.hhs.gov/content/clas.asp (accessed January 2015).
- Pandya, C., M. McHugh, and J. Batalova. 2011. Limited English proficient individuals in the United States: Number, share, growth and linguistic diversity. Migration Policy Institute. http://www.migrationpolicy.org/research/limitedenglish-proficient-individuals-united-states-numbershare-growth-and-linguistic (accessed January 2015).
- Sum, A., I. Kirsch, and K. Yamamoto. 2004. A human capital concern: The literacy proficiency of U.S. immigrants. Princeton, NJ: Educational Testing Service, Center for Global Assessment, Policy Information Center, Research and Development. World Health Organization. nd. Management of substance abuse: Process of translation and adaptation of instruments. http://www.who.int/substance_abuse/research_tools/translation/en/ (accessed January 2015).
- Zong, J., and J. Batalova. 2015. The limited English proficient population in the United States. Migration Policy Institute. http://www.migrationpolicy.org/article/limited-englishproficient-population-united-states/ (accessed July 8, 2015).