Clinical Outcome Assessments (COAs) are designed to capture the patient’s voice: how they feel, function and experience life with a health condition. However, one critical factor is often overlooked: culture. Culture influences what people say. But it is more than that; it shapes how they think, how they remember and how they respond to questions. This is especially so when it comes to surveys that involve subjective judgements.

Even well-designed COAs can misfire when used across cultural boundaries. Think about a seemingly simple question, such as “How much has pain interfered with your social life?”. This might elicit vastly different answers and this might not be because of actual pain differences, but because of cultural differences in interpreting pain, social life and self-expression.

This article examines how cultural norms shape the experience of cognitive burden in COAs and why culturally sensitive assessment design is essential in global and multicultural contexts.

The Illusion of Neutral Questions?

COAs are often created in one cultural context and then translated into others. Apart from the real issues of cultural coating and cultural stripping, translation alone does not guarantee that the intent, tone or social meaning of the question is preserved. Language is deeply embedded in culture, as are translation and cognition.

Consider the question:

“In the past two weeks, how much has pain interfered with your ability to complete social, work-related, and self-care activities that are important to you?”

To a respondent in the USA, this may read as a direct and familiar line of inquiry. But to someone from a high-context culture like Japan or Saudi Arabia, it could feel emotionally intrusive, socially inappropriate or too abstract to answer precisely.

Low-Context and High-Context Cultures

Anthropologist Edward Hall distinguished between low-context and high-context cultures to explain different communication styles.

·       Low-context cultures, such as USA, Germany or the UK, favour explicit, direct communication. Respondents from low-context cultures expect questions to spell out exactly what is being asked. Complex items are often deconstructed mentally into logical steps.

·       High-context cultures, such as Japan, China, Arab countries, rely more on implicit cues and shared understanding. Communication is often indirect and meaning may be read “between the lines”, Personal topics may be softened or avoided to maintain social harmony.

In a COA setting, this means:

·       Low-context respondents often engage in analytic reasoning, breaking complex questions into components,

·       High-context respondents may interpret the intent of the question rather than just the literal wording, sometimes prioritising what is socially appropriate over what is strictly true.

Cultural Preferences in Response Formats

Surveys often use Likert scales, e.g. ‘1’ for ‘strongly disagree’ to ‘5’ ‘strongly agree’ or numerical rating scales, e.g. ‘0-10’. However, cultural attitudes toward self-expression affect how these are used.

Likert Scales:

·       In Western cultures, people frequently use the full scale, including the extremes.

·       In East Asian and collectivist cultures, there is often a central tendency bias, where people avoid extremes to appear modest or non-confrontational.

Numerical Scales:

·       Western participants often treat scales like interval measures, with each number representing a defined degree of change.

·       In other cultures, numbers may be viewed symbolically, not mathematically. A ‘5’ might be selected as a ‘safe’ choice, rather than as a midpoint.

This means that researchers could misinterpret middle-range scores as mild symptoms, when in fact they reflect cultural moderation, not mild experience.

Emotion, Disclosure and Social Desirability

In individualistic societies, self-expression and emotional honesty are often encouraged. A person might freely admit, “I have been very depressed” or “Pain makes it hard to see my friends”.

In contrast, collectivist cultures often emphasise social harmony, family duty and emotional restraint. Admitting weakness or personal hardship may carry stigma or dishonour. This means that respondents may:

·       Soften their responses, such as selecting ‘somewhat’ instead of ‘a lot’

·       Neutralise negative feedback, especially in interactions with authority, such as with a CLINRo when health professionals and researchers are administering the assessment.

·       Tailor answers to expectations along the lines of “What does the doctor want me to say?”

This phenomenon is known as the social desirability bias, can distort COA results, especially in face-to-face or institutional contexts.

Memory Styles and Time Perception

Cognitive burden often includes memory demands, patients are asked to reflect on the “past week” or “last two weeks”. However, memory itself is culturally influenced.

·       In Western contexts, people often use episodic memory, recalling specific events and dates, such as “Last Saturday, I missed a family dinner because of fatigue”.

·       In high-context cultures, memory may be more holistic, based on general impressions or feelings, such as “Lately, I have not been going out much.”

Similarly, time perception varies. While COAs often specify linear intervals, such as “the past 7 days”, some cultures are attuned more to cyclical or situational rhythms, like seasons, festivals or phases of daily life.

If a patient does not conceptualise time in weeks or months, they may struggle to recall experiences “accurately” within those frames.

The Role of Context

Patients are not answering COA questions in a vacuum. They answer them in their own contexts: a clinical, a research study, or a waiting room. Cultural attitudes toward authority and institutions shape how respondents perceive and complete these assessments.

In hierarchical cultures, patients may feel uncomfortable contradicting doctors or admitting non-compliance. A COA, even if anonymous, might be treated like a formal evaluation rather than a personal expression. In more egalitarian cultures, patients may see COAs as a chance to advocate for themselves and express dissatisfaction or discomfort freely.

Designing Culturally Sensitive COAs

To ensure COAs are inclusive and meaningful across cultures, simple translation is not enough. The following best practices help reduce cultural misalignment:

1.       Linguistic Validation (when performed carefully): This is intended to go beyond word-for-word translation. At its best, it engages native speakers and cultural experts to assess tone, clarity and appropriateness. In itself, this should be a serious research activity, rather than being reduced to a checkbox activity.

2.       Being Culturally Sensitive from the Outset: think about incorporating examples that can easily be adapted to other cultural settings. For example, instead of “usual activities”, more culturally resonant examples could be used:

·       Helping with family meals

·       Gathering at a community centre (which is adaptable to local cultural settings like the mosque, the temple, the synagogue)

·       Taking children to school.

3.       More Flexible Response Formats: Consider visual analog scales, pictorial options (smiling/sad faces) or verbal descriptors tailored to meet local norms.

4.       Mode of Delivery: In some populations, self-administered surveys may be unfamiliar or intimidating. Interviewer-administered formats can build rapport and clarify misunderstandings, especially when matched by language and culture.

Clinical assessments aim to quantify subjective experience, but subjectivity is always culturally mediated. A well-designed question for one population might feel invasive, confusing or irrelevant in another.

Culture influences not only what people experience but how they express it, remember it and evaluate it. Recognising and adapting to these differences can make health data more accurate and equitable and give every patient a better chance to be heard.

In global healthcare, cultural sensitivity is a scientific and ethical necessity. It is not just a courtesy.

Thank you for reading,

Mark Gibson

Stanhope, United Kingdom, June 2025