When a questionnaire is designed in one language and script, such as English with Latin script and is then translated into another language, e.g. Arabic, Chinese or Japanese. It may retain the original layout, typography and formatting conventions that are intuitive to speakers of the source language but foreign to readers of the target language.

For example:

·       Western documents typically favour a left-to-right (LTR) reading flow, while Arabic is right-to-left (RTL).

·       Western questionnaire may rely heavily on bold fonts, bullet points or checkbox styles that are less familiar or carry different connotations in other cultures.

·       Line spacing, question ordering and visual grouping of items may follow Western conventions but may not align with the reading comfort or expectations of other scripts.

This mismatch can create a cognitive friction where the reader must expend mental energy in understanding the content and navigating an unfamiliar visual and structural format.

An Increased Cognitive Load

Cognitive Load refers to the mental effort required to process and understand information. When readers encounter a questionnaire that “feels foreign” visually:

·       Mental processing slows down: The reader must mentally re-map the structure. This means adapting left-to-right layouts mentally into and right-to-left context.

·       Distraction from content: instead of focusing solely on the clinical questions, respondents split their attention between the meaning and the navigation.

·       Fatigue and errors: higher effort leads to greater fatigue and potential for misunderstanding or answering incorrectly due to skipped lines, misread instructions or misinterpreted clinical scales.

An Undermining of Measurement Validity

COAs are designed to measure subjective concepts like pain, anxiety or quality of life. If the design itself feels foreign or awkward:

·       Respondent engagement drops, which can cause less thoughtful or hurried responses

·       Measurement equivalence is threatened because the experience of taking the questionnaire differs across cultures, leading to variability unrelated to the construct being measured, such as stress from the layout itself.

·       Bias risk increases, potentially compromising the integrity of cross-cultural clinical trials or health studies.

Lack of Cultural and Linguistic Adaptation

Linguistic adaptation should not stop at accuracy in translation and conceptual equivalence. It should also adapt the “look and feel”. If not, then:

·       The translated tool may feel like a “foreign import”, which would then reduce trust and acceptance by the target population.

·       Patients may perceive it as “less relevant” to their cultural context, further impacting the quality of data collected.

Retaining the original visual design of a COA without adapting it to the reading norms and visual expectations of the target locale adds unnecessary cognitive burden. This affects comprehension, response accuracy and engagement. This could ultimately undermine the validity and reliability of the data collected.

The Cognitive Burden from Script-Specific Features

Each writing system has unique visual and processing demands. When a questionnaire retains the “look and feel” of its source design, often based on Latin/English conventions, but it presented in a very different script, several problems emerge:

Script Density and Visual Crowding

Chinese, Japanese and Korean:

·       These scripts are more visually dense, e.g. Chinese hanzi characters or Japanese kanji have a higher visual complexity per glyph compared to the Latin letters.

·       Western layouts often use more white space because Latin letters are “lighter” and more spaced by design.

·       If a Chinese, Japanese or Korean translation is forced into a layout optimised for Latin script, it may look cramped or overwhelming to readers, causing eye strain and slowing down reading.

Tamil of Georgian:

·       Scripts like Tamil have intricate curves and loops. Georgian has rounded forms and low contrast between characters.

·       If the original design has tightly packed lines or small fonts suited for Latin script, these scripts can become harder to parse, increasing visual fatigue.

Directionality Issues

Hebrew, Arabic, Persian and Urdu:

·       Original LTR layouts, such as having question stems left-aligned, answer options on the right, clash with Arabic’s natural RTL flow.

·       Keeping an LTR layout in an Arabic questionnaire forces the brain to switch back and forth between reading directions, introducing processing dissonance.

·       RTL readers may also expect navigational cues like page numbers and instructions on the opposite side.

Orthographic Depth and Reading Speed

Cyrillic (e.g. Russian, Ukrainian):

·       Although Cyrillic is left-to-right (LTR), its letterforms are visually denser and more angular than Latin. If the line spacing or font size are not adjusted, it can feel “heavier” to read.

·       Certain typographic conventions in Cyrillic-language documents differ, such as the use of italic or bold styles, and ignoring this can affect readability.

Armenian:

·       Armenian script has a unique rhythm with its distinct letterforms and ligatures. Therefore, a Latin-script layout may not respect its natural line breaks or grouping preferences, increasing the effort to follow the text smoothly.

Cultural Conventions Around Forms

Japanese:

·       Japanese readers may expect vertical text in some formal documents, or specific mark-up for emphasis, such as furigana or brackets.

·       Western-style Likert scales (Left-to-right horizontal response options) may not align with culturally preferred layouts, such as stacked vertical options.

Korean:

·       Hangul is highly geometric and blocky. If a Western questionnaire has wide left margins but narrow right margins, it may unbalance the Korean text visually, making it harder to process questions and options.

Functional Literacy and Familiarity

Even among literate populations, people are more fluent in processing information that visually aligns with what they encounter in daily life, such as public forms, government documents and leaflets about health. When a clinical questionnaire “looks foreign”:

·       Respondents expend additional effort to interpret structural cures, such as where the question ends and the options begin.

·       Respondents may hesitate or lack confidence in their responses, especially in medical contexts where clarity is critical.

Understanding the Cognitive Burden

The cognitive burden is compounded when:

·       The visual gestalt of the form clashes with the processing habits of the target script, like the visual density, the flow and the directionality.

·       The design ignores typographical and cultural norms of how information is typically structures and consumed in that language.

Good eCOA design goes beyond simple translation and conceptual equivalence. It also needs to take into account typographic and design adaptation for the linguistic and visual-processing expectations of each writing system.

Thank you for reading,

Mark Gibson

Stanhope, United Kingdom, June 2025