Lost in Translation: Each Word Accurate, Yet…

Too often, health plan information is overly literal and insensitive to nuances of language, culture, and understanding. Savvy administrators can help.

Communicating health care information effectively is no longer simply a responsibility of public health departments. More than ever, program administrators, hospitals, physician groups, and health plans see that the quality of communication with patients affects client satisfaction, outcomes, and the bottom line.

Some language other than English is the primary tongue spoken by more than 14 percent of American residents — 31.8 million people. The number of people who speak Asian languages or Spanish steadily increases, while the number speaking other European languages declines. In New York and California, more than 30 percent of residents speak Spanish.

Another central issue is reading ability. Half the population reads at the eighth-grade level or lower, and poor literacy is highest among ethnic minorities. Most health information is written at a 10th- to 12th-grade level or higher, with information on the World Wide Web higher still.

In addition, language variations between and within individual countries can be enormous and, especially when the issue is health, word-for-word translations are simply inadequate. Conceptual and concrete communication are equally crucial — and ill-served by simplistic word replacement. For instance, in drug treatment literature, the Spanish word “cocaine” can change from “piedra” to “roca” depending on the intended audience’s country of origin. In women’s health, “Pap smear” is called “Papa Nicolau” in Mexico, while in Colombia people talk about “Citologia”.

Adaptation vs. translation

What makes a linguistically, historically, and culturally good translation is something the literary world has struggled with for ages — and is a question in health care translation today. “Adaptations” are making more and more sense.

An adaptation stresses the meaning of your message rather than the exact wording. An adaptation stresses an awareness and respect for both the source of the information as well as the linguistic codes and context of the audience. The translator must “adapt” the source material in such a way that it reaches, and has meaning for, its intended reading audience.

Translation requires cultural knowledge; simply replacing one word with another won’t do.

In health care, the optimal approach is for the writers of the various languages to agree up front on what they want to communicate and then write originally in their respective languages, rather than try to translate a single document. They then come together to compare texts and to make adjustments. However, this approach is seldom used in health care for two reasons — cost and legalities. It usually costs more to find writers with expertise in health care writing, especially when writing for people who can’t read any language well.

This approach also requires that the administrators of the program be comfortable with variation in text. Lawyers often wind up insisting on words that meet the letter of the law, but the words obfuscate the message.

Far more often, it goes like this: Material is written in English and passed off to a translator, who is paid by the word. Often, the budget doesn’t include doing a “back translation” — when another person reads the material and retranslates into English in an attempt to discover discrepancies. And even more rarely do budgets or administrative directions include getting feedback from the target consumer before the material goes to press.

What to look for

The key skill of a good translator is the ability to write well and to express something clearly to the target language. This includes the ability to understand the source language (the language of the original text) and the culture of the target audience. Most translators work mainly in one direction, translating into their native tongues. Even bilingual people rarely can express themselves equally well in two languages on a given subject. Many translators are far from bilingual; they may not be (and need not be) fluent in the source language.

Also, look for someone who has experience in health care materials.

Whether you’re overseeing a consultant or doing the job in-house, there are some basic guidelines for good adaptations:

1. Use appropriate examples

Consider these English and Spanish versions of instructions from a health plan guidebook explaining covered benefits:

What if you sprain your ankle playing lacrosse?

What if you travel to your home state and you have bad chest pains?

A good adaptation would be —

¿Qué ocurre si usted se tuerce el tobillo jugando al Fútbol?

¿Qué ocurre si usted viaja a su país y tiene un fuerte dolor en el pecho?

In this example, the translator changed lacrosse to soccer (fútbol) — more culturally appropriate for Hispanic readers. “Home state” was changed to “home country.” A frequent question from Hispanic consumers regarding health plan coverage is whether they are covered when traveling to their native countries.

2. Make cross-cultural comparisons

The adapted material should capitalize on the cultural knowledge of the reader. Though foreign-born consumers may become acculturated to their adopted country, many prefer to receive information in their native languages with examples from their “real life back home,” and are more receptive to messages presented in this manner. It’s a matter of comfort and respect — as well as clarity.

For example, a health plan subscriber’s country of origin will affect how he/she understands and uses the U.S. health care system. Therefore, when discussing changes in the system or explaining how to use it, try to highlight the fundamental differences between the U.S. system and the system in subscriber’s country of origin. Obviously, the pace and scope of changes and options in health care delivery systems and insurance requirements make this an area of much importance, and one that may require periodic updating. Whether your readers are newcomers to the U.S. or have lived here many years, comparisons will be appreciated.

Here is an example of English text (from a booklet on understanding managed care) that is adapted:

Health Care Is Changing in the United States: In the past, your health insurance may have covered all services. Today it is very important to know what your plan will and will not cover.

Spanish adaptation —

El cuidado de salud está cambiando en los Estados Unidos. Anteriormente el seguro cubría todos los servicios. Hoy en día es importante saber qué está cubierto y qué no está cubierto, antes de usar un servicio. Tenga presente que en los países latinoamericanos los seguros de salud son diferentes. En algunos países de latinoamerica los doctores todavía hacen visitas a domicilio, esto no existe en Estados Unidos. Pregunte antes de usar un seguro de salud.

The Spanish version above reads: “In the past, the health insurance covered all services. Today it is very important to know what is covered and what is not covered. You must have in mind that the health insurance in Latin America is very different. For example, in some Latin American countries, doctors still make home visits. This service does not exist in the United States. Ask questions before using your health care plan.”

3. Adopt and use new health care terms

When a word or phrase does not have a direct translation, the adapter can use the word or phrase in English, but should explain it. Terms such as “PCP” cannot be translated directly into Spanish, for instance, because the PCP concept is unknown to recent Hispanic immigrants. “Medicaid managed care recipients” would need to be described as “receptores de ayuda de cuidado de salud por parte del Estado” (i.e., state health care recipients).

As for primary care provider, or PCP, the appropriate Spanish description would be “medico personal” or “doctor de cabecera” (the bedside doctor). Only when PCP is adapted to a more familiar usage, would most Spanish-speaking readers understand PCP.

In such cases, translators can

  • First use the technical word in English;
  • Translate it with a relevant explanation or description; and
  • Reuse the term in English, because terms such as PCP are what they are going to hear.

Note: Low level readers rarely use dictionaries or glossaries in a text so it’s best to define all new words on the page where they appear.

4. Adapt to subgroups and avoid stereotyping

Hispanics, like most ethnic groups in North America, are not homogeneous, and a good interpreter can easily recognize the writer’s country/ region of origin when reading translated material. Although this may not render the translation incomprehensible, it does point out the need for awareness and sensitivity to idiomatic and geographic nuance.

If people who translate or adapt texts do not have a good knowledge of the different idiomatic expressions spoken in each Latin American country, they will make mistakes by using an expression unique to only one group. Stay generic or provide multiple variations of a word in parentheses.

5. Stay current to English pick-ups

Similarly, it’s crucial to be familiar with linguistic changes that occur during the acculturation process. For example, the word “soda” in Spanish is “gaseosa” but, after living in the United States for many years, many Hispanics — even though they continue speaking their native language — have adopted the word “soda.” The same applies to”Social Security,” where the literal translation would be “seguro social” and for “nurse,” which has often overtaken the Spanish “enfermera.”

6. Field test materials

Field testing material with your target audience is critical, and yet it’s least done. Focus groups or one-on-one sessions can demonstrate strengths and weaknesses of materials. The field test should be conducted by someone with experience in qualitative research methodology. When done well, a focus group requires a well-trained moderator — bilingual and preferably a native speaker of the language — to conduct the group. Lining up participants may require a professional recruiter, and the location needs to be highly accessible. Focus groups also require professionals with analytical skills (and knowledge of the participants’ culture) to decode and interpret findings. Another good approach is to work with a panel of members of a linguistic community to get their response and advice.

C’est la vie!

Steve Martin says with amazement, when talking about the French, “They have a different word for everything!” With so many words out there, it’s no wonder that things can go wrong. But in the business of health care, paying closer attention to the quality of translated material will minimize your risks and maximize results. In simple language — it’s a good thing all around.

When working with translators:

  • Ask for credentials.
  • Be sure the translator has:
    • The ability to write well to express herself clearly in the target language;
    • The ability to understand the source language and the target culture;
    • Proven knowledge of health care; and
    • An interest in helping to test materials in the field.
  • Always ask for back translations, paying special attention to content and meaning.

Christina Zarcadoolas is director of the The Center for Health Literacy and Communication Technologies at Maximus Inc., and on the faculty at the Center for Environmental Studies at Brown University, where she teaches environmental communications and public perceptions of the environment. Mercedes Blanco is a senior manager for health literacy at Maximus.