Clinical Outcome Assessments play a vital role in evaluating patient health and treatment efficiency across linguistically and culturally diverse populations. Because of this, COAs need to be translated accurately, while maintaining the conceptual equivalence of items across all languages in the clinical study. However, this is sometimes easier said than done, as COA translation can pose considerable linguistic and semantic challenges. This is frequently due to weaknesses in the source text, as well as deficiencies and oversights in the translation process.

This article looks at linguistic and semantic challenges in COA translation and explores the concept of ‘cultural coating’ that we introduced in earlier articles. We argue that addressing these issues is crucial for making sure that the translations are accurate, culturally appropriate and understandable to the target populations.

Challenges in Linguistic Equivalence: ‘Cultural Coating’

One of the basic tenets of translation theory is that there is no such thing as a perfect translation. This is a fact (and, incidentally, makes the name of a certain translation company seem a little hollow). Even simple concepts such as ‘bag’, ‘house’, ‘dog’ take on a different cultural hue when translating from source to target language. I call this ‘cultural coating’. This is where the translated concept acquires a layer of meaning, nuance, or connotation, a new mantel that a word assumes within a specific cultural context, in a similar way to how an enamel coating adds a distinct finish to a base material. This ‘coating’ can affect how a translated word is perceived and understood in different languages and cultures. Another metaphor could be ‘cultural varnish’ or ‘glaze’.

This cultural coating is a fundamental difficulty in COA translation. Does it mean that the linguistic equivalence of a concept cannot be truly achieved? Can the same concept be translated from source to target languages without distorting meaning? I think there will always be some element of coating. For example, the word ‘depressed’ in English may not have a direct equivalent in certain languages, or it may acquire cultural coating due to taboo and stigma. In some cultures, ‘depression’ is expressed through physical symptoms, rather than emotional ones. This would require contextual modifications to ensure accuracy. In some cultures, there is avoidance of uttering the taboo word, e.g. ‘the Big C’.

In these contexts, people from those cultures would employ strategies to neutralise or mitigate the coating that the word acquires. For example, by circumlocution (indirectly talking around the subject) or euphemism, where ‘cancer’ could be rendered ‘a growth’ or ‘low energy’ for depression. In multilingual societies, one strategy may be to employ a loan word, such as from English. Thus, in a patient consultation in a multilingual setting like Singapore, an oncologist might be holding the encounter in Tamil, Malay or Chinese but switching to English when talking about specific clinical terms, e.g. ‘oesophageal cancer’. These are strategies that are regularly employed in health promotion communication or sometimes in written patient information from a doctor, but never even considered in a COA item. Why not? Perhaps eCOAs could have pop-up information and descriptive clarifications that are tailored to the relevant culture, e.g. ‘You may know this as ‘low energy’.

Semantic Differences, Overlap and Multiple Meanings

Words with more than one meaning can be challenging to translate. In English, ‘tired’ can refer to physical fatigue, emotional exhaustion or even boredom. In another language, ‘tired’ might cover all these nuances. Alternatively, they may have fewer fields of meaning in common with English, or more, and this leads to a loss of meaning. The term in another language may acquire additional cultural coating or it might be stripped down.

It is the same with response choices in COAs, such as ‘mild’, ‘moderate’, ‘somewhat’, ‘severe’. As stated in previous articles, these can overlap in meaning across languages. In some languages, the distinctions between responses may blur to the extent that participants might find it difficult to differentiate between each response choice. On many occasions, we have come across target language versions where ‘mild’, ‘moderate’ and ‘somewhat’ were translated by the same word.

In the COA universe, conceptual equivalence also seems to apply to the look and feel of the COA, including how items are presented, what kind of ‘real estate’ localisers must play with when adapting into another language. How a question appears in the source language must also appear in the same way in languages as diverse as Korean, Hebrew and Quechua. Perhaps, the pop-up function suggested above might be useful to provide additional information, such as descriptions alongside potentially ambiguous terms, e.g. “Moderate pain: some interference with daily activities but manageable.”

Pilot testing in development should focus on potential semantic overlap. This would imply that the validation phases would include cohorts in other countries, languages and cultures, rather than just the source language or location. And when it comes to cognitive debriefing as part of Linguistic Validation, attention needs to be paid to response choices. We have found that this is an area that is becoming increasingly overlooked and receives only limited interrogation. Having stated that, some may argue that such structurally important issues being discussed only at the Linguistic Validation stage is far too late. A parallel is found in readability testing of package leaflets and the seemingly now forgotten debate between formative and summative testing, at least in an EU and UK context.

Making sure that the translations of Clinical Outcome Assessments are accurate and culturally appropriate is more than just a linguistic challenge. It requires acknowledging and navigating cultural coating that concepts acquire when rendered in different languages. Concepts such as depression, pain and illness may not translate directly due to semantic differences, social taboos and varying cultural perceptions. A straightforward word-for-word translation risks distorting the meaning of the word. This can have a negative impact on patient understanding and the reliability of the data elicited from the measure.

COA developers need to go beyond direct translation by incorporating adaptations to local contexts, cultural insights and validation strategies early in the process. Dynamic translation approaches, such as the potential for pop-ups in eCOAs, as well as culturally tailored descriptions, can further aid inclusivity and clarity.

Ensuring linguistic and conceptual equivalence in COAs is like walking a tight rope, balancing faithfulness to the source and adaptability to the target culture. Understanding the concept of cultural coating can create more usable and effective health assessments across diverse populations.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, March 2025