Clinical Outcome Assessments (COAs) are designed to be tools for investigating the experiences of patients, how a study treatment works and the quality of life of the patient. They are essential measures in clinical studies. When COAs are poorly localised, they can introduce inconsistencies in responses, misinterpretations of the items and inaccuracies in the data collected. These issues happen when translations do not capture the original intent of the item, response choices are ambiguous, or cultural differences are ignored. The net result is that errors of localisation are likely to reduce the validity and reliability of patient-reported data in global studies.

The principle of the three ‘Cs’ that are vital in successful localisations are:

·       Clarity

·       Cultural fluency and

·       Conceptual equivalence.

Each of these is especially pertinent to the cross-cultural treatment of figurative language, such as idioms and metaphors in COAs. This is where there is often no direct equivalent in the target language or where a literal translation would be nonsensical or misleading. In the source language, it is easy to understand why idioms and metaphors are used, because:

·       They convey the item in a way that is relatable to patients

·       They use familiar imagery

·       They capture subjective experiences, how patients themselves describe their symptoms.

Frequently, the idioms used in COAs can be traced directly back to the RWE Patient Voice research whose purpose was to discover patients’ insights into living with a given illness. During these interviews, participants may use an idiom or a certain turn of phrase that is then captured, frozen and transported into the wording of an item in the COA. The following examples contain idioms that I have seen in real Patient-Reported Outcome measures that I have rephrased here:

·       “How often do you feel like you are waiting for the other shoe to drop?”

·       “On your worst days, to what extent does your pain feel like a burning fire, a stabbing knife, or a heavy weight?"

·       “How often do you feel that your mind is like a fog?”

These are examples of figurative language in the source that I have seen translated, word-for-word, into target languages. For decades now, I have been interested in paremiology, which is the study of figurative language. I have a tragic hobby of collecting idioms, metaphors and proverbs from many languages. I have notebooks full of them. What draws me to this area is how figurative language can both diverge across languages in terms of the imagery and vocabulary employed in these phrases, but also how they converge because they reflect the commonality of basic human experience.

Consider the following:

·       English: Don’t count your chickens before they hatch

·       Turkish: Dereyi görmeden paçayı sıvama. ("Don’t roll up your trousers before seeing the river.")

·       French: Il ne faut pas vendre la peau de l’ours avant de l’avoir tué. ("Don’t sell the bear’s skin before you’ve killed it.")

And:

·       English: Love me, love my dog

·       Mandarin: 爱屋及乌 (Ài wū jí wū) ("Love the house and also the crows on it.")

·       Arabic: من أحب الورد أحب شوكه. ("Whoever loves the rose, loves its thorns.")

These invoke wildly different images to convey the same human experience. They diverge from each other in wording, yet they converge because they are describing what is the same human experience. Anybody anywhere could relate to them. Where possible, idioms need to be translated with cultural equivalents in mind, like those included here. They should not be translated literally. It sounds absurd to state this, but we have seen plenty of idioms that really have been translated literally – and into dozens of languages. The outcome of this is that the participant is confronted with nonsense. Try and make sense of the following:

This is not the yellow from the egg.

It doesn’t cut the Gordian knot

nor does it break three legs onto a duck.

You can’t have the butter and the money for the butter,

or swim and keep your clothes on.

Translating literally just makes a hole in the water instead.

It makes the participant wander around the hills of Úbeda

because there is no bird on the roof.

Do you fish the idea?

If you do, let’s bitter the sour apple

and get back to our sheep.

As you will have guessed, these are idioms from other languages that I have translated directly into English. I bet you can glean a tiny bit of narrative, but, apart from that, they don’t make much sense, do they? That is exactly how word-for-word literal translations of figurative language appears to participants in real clinical studies.

I understand why figurative language is used in COAs, but if not translated appropriately, it can be alienating and damaging.

One solution could be to avoid using figurative language altogether. Developers, at the earliest stage, need to be thinking about international harmonisation and cultural equivalence before they have even drafted the first item.

We need to be taking for granted two near certainties (or laws?) for any COA: the first is that it will, sooner or later, be used in a clinical setting that is different to where it was conceived and validated. The second law is that it will, at some point, undergo a process of localisation. I suspect that idioms are integrated into COA items with not much consideration other than the tool’s immediate clinical need. Using lazily translated idioms can backfire. Instead of having an item that reads ‘the weight of the world on your shoulders’, a neutral alternative could be used, such as ‘overwhelmed’ or ‘too many problems to handle’. The idiom is not necessary. In fact, when thinking beyond the source context, the idiom becomes a folly.

By using clear, neutral phrasing that replaces figurative language, the likelihood increases that all participants will understand the item in the same way.

Thank you for reading.

Mark Gibson

Cologne, Germany, October 2024