When patients who primarily read non-Latin, non-left-to-right (LTR) scripts engage with clinical questionnaires, they experience a multi-dimensional cognitive burden. This arises not only from the content of the questionnaire but from how it is visually structured, linguistically framed and culturally designed.

This article covers common scripts and how they affect cognitive processing of clinical questionnaire content.

Directionality Difference (LTR versus RTL)

Readers from Right-to-Left (RTL) scripts like Arabic, Urdu, Hebrew and Farsi face a fundamental visual-spatial dissonance when confronted with questionnaires formatted in a Western LTR style.

• Eye Movement and Visual Path: Native RTL readers habitually scan from right to left, meaning their eyes are “trained” to seek key information on the top-right of a page. Western questionnaires, however, position instructions, stems and titles in the top-left, creating a mismatch because this is often carried over in translation and in the constraints set by eCOA providers.

• Cognitive reorientation: every time RTL readers must “flip” their directional bias to process an LTR layout, they expend extraneous cognitive effort just to navigate the questionnaire.

• Form-field alignment issues: Many Western-style forms align tick boxes or response fields to the left, which feels counterintuitive to RTL readers who expect anchors to be on the right.

This leads to visual-cognitive friction, slowing down task completion and sometimes increasing the risk of missing instructions or items altogether.

Script-Type Complexity

Different scripts involve varying visual processing loads:

• Logographic Systems, such as Chinese, Japanese Kanji: Each character encodes meaning and sound simultaneously. Readers are used to dense, high-information symbols but are less familiar with the alphabetic letter-by-letter decoding required in Roman scripts.

• Syllabic Systems, such as Japanese Kana, Korean Hangul: These emphasise sound units and often feature blocky, modular characters, which visually contrast with the linear stringing of Western alphabets.

When confronted with Western-origin questionnaire, these readers experience:

• Decoding fatigue from processing unfamiliar letter-based units.

• Increased sub-vocalisation (mentally sounding out words), which heightens intrinsic cognitive load, especially for technical or medical terms.

For example, reading “neuropathic pain” in Roman script may require a Mandarin speaker to mentally convert the Romanised word into pinyin or Chinese phonetic chucks, increasing working memory strain.

3.           Western Survey Logic versus Non-Western Norms

Western clinical questionnaires often rely on a linear, modular logic:

• Use of Likert scales, such as 1-5 “Strong Disagree” to “Strongly Agree”.

• Preference for direct self-assessment of internal scales, such as “How would you rate your level of anxiety?”

For readers from non-Western cultural-linguistic contexts this may clash with communication expectations:

• High-context cultures, e.g. East Asian, Middle Eastern, expect more indirect or relational framing of questions.

• Some cultures express narratively or relationally, e.g. “I cannot work as well” instead of “I feel fatigued”.

When the questionnaire format does not match these norms, patients face:

• Conceptual ambiguity, wondering if their interpretations “fit” what the questionnaire is asking.

• Increased decision-making load, especially when selecting between gradient responses, such as choosing between “somewhat agree” and “agree”,

4.           Semantic and Structural Ambiguity

When questionnaires are translated directly without cultural adaptation:

• The translated text may lose idiomatic clarity, increasing intrinsic cognitive load. For instance, Western phrases like “feeling down” or “trouble concentrating” may not map neatly onto equivalent terms in languages like Japanese or Arabic.

• Grammatical mismatches emerge. In languages like Japanese or Korean, passive or honorific constructions are often expected when addressing patients, while English favours active voice and directness.

• In polysynthetic languages, such as some Arctic languages like Inuktitut, a single word might encode what takes an entire sentence in English. Translating into or from such structures can disrupt flow and coherence, requiring extra mental reconstruction.

5.   Layout and Typography Load

Visual complexity also plays a major role:

• Small fonts in Roman script can be harder to process for readers used to larger, visually distinct characters, such as Chinese hanzi or Arabic script with prominent diacritics.

• Condensed Western layouts, with dense blocks of text or tightly packed instructions, may clash with the expectations of cultures accustomed to more white space or vertical reading formats, e.g. Japanese traditional layouts.

• Visual anchors, such as bullet points, numbered lists may not follow culturally familiar patterns. For example, Western-style indented text blocks can confuse readers used to right-justified or centre-aligned reading habits.

6.   Emotional and Cultural Self-Expression Barriers

Readers from non-Western script backgrounds may also experience emotional-cognitive load when Western questionnaires push for direct self-disclosure about sensitive health topics.

Cultures that emphasise collectivism, modesty or privacy may find it cognitively taxing to:

• Express distress openly.

• Quantify symptoms numerically.

• Discuss mental health in the same way physical health is discussed.

The misalignment between Western-style surveys and cultural expectations can lead to:

• Response bias, such as gravitating towards neutral, middle-of-the-scale responses.

• Social desirability bias, i.e. selecting answers perceived as more “acceptable” in the clinical context.

This results in lower-quality data and adds to emotional strain, as patients may feel discomfort or even shame while completing questionnaires.

     7.      Working Memory Overload

Script reorientation, translation gaps, culturally unfamiliar logic and visual dissonance each are elements that place a heavy burden on working memory. This is especially problematic in clinical settings, where patients may already be:

• Anxious about their condition.

• Fatigued or in pain.

• Pressed for time due to appointment constraints.

These external factors, combined with script-based challenges, can push working memory beyond its limit, resulting in errors, incomplete answers or survey abandonment.

Summary

When clinical questionnaires are not adapted to accommodate diversity in script and culture, they unintentionally increase total cognitive load across several domains:

Thank you for reading,

Mark Gibson, Leeds, United Kingdom

Nur Ferrante Morales, Ávila, Spain

August 2025