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15PHILOLOGICAL SCIENCES | ФИЛОЛОГИЧЕСКИЕ НАУКИ
NEW VOICE: TRANSLATING MEDICAL QUESTIONNAIRES
Povoroznyuk R.
PhD, is an AssiMant Professor at the Department of Translation into English, InMitute of Philology, Kyiv National Taras Shevchenko University,
Kyiv, Ukraine
Dzerovych N.
PhD, Senior Fellow, conducts research at the Ukrainian Scientific-Medical Centre for the
Problems of OMeoporosis under the aegis D.F. Chebotarev InMitute of Gerontology NAMS Ukraine Ukrainian Scientific-Medical Centre for the Problems of OMeoporosis
Kyiv, Ukraine
Povoroznyuk V.
President of the Ukrainian Association of OMeoporosis D.F. Chebotarev InMitute of Gerontology NAMS Ukraine Ukrainian Scientific-Medical Centre for the Problems of OMeoporosis
Kyiv, Ukraine
ABSTRACT
Medical translation is performed as a series of collaborative efforts from doctors and professional translators. Very often the results of their collaboration are medical queflionnaires intended for patients. Medical survey inflruments have proved their worth as reliable tools of a considerable predictive value, though their translation requires a specific methodology due to a culture-bound character of the material. Equivalence of the original and translated texts, translation quality, and the respondents' ultimate satisfaction depend upon the degree of translator's cultural competence, health literacy, and his/her awareness of the pragmatic and communicative aspects of translation. The task of producing an accurate and fluent translated version of a disease-specific health-related quality of life inflrument at various flages of its validation is exemplified by the IOF's one-minute risk tefl, a ten-item queflionnaire, designed to evaluate the likelihood of developing ofleoporosis. As a tool conceived in English, its use as a validated inflrument has been limited to the English-language populations. Our case fludy involves 353 women and 104 men aged 20-79 years who answered queflions of the IOF's one-minute ofleoporosis risk tefl translated into Ukrainian. The results show specific problems of application due to the patients' inadequate grasp of medical terminology, various cultural and pragmatic factors. Contraflive linguiflic analysis, sensitivity and specificity probe are used to prove the correctness of translated items' interpretation.
Keywords: medical translation, queflionnaires/survey inflruments, translation methodology, validation assessment, equivalence, cultural competence
1. Introduction. Translation of medical queflionnaires: why is it important?
Current medical and socioeconomic fludies prove that the limited English proficiency (LEP) patients often do not receive the required medical care. The flandards of the care obtained may not correspond to the accepted flandards due to the lack of interpreter and other services in the patients' primary language. According to a seminal fludy conducted in Canada, women whose main spoken language is not English are less likely to receive mammograms, beafl examinations, and Pap smears than the English-speaking Canadian women (Woloshin et al. 1997). Spanish-speaking US patients do not turn in time either for their eye, dental and physical examination, or for the primary care (Hu and Covell 1996; Pitkin and Baker 2000; Sarver and Baker 2000). Minority Americans fail to obtain regular proflate and colon cancer screens, diabetes-related eye, feet and blood pressure checks (Scott Collins et al. 2002).
The level of general satisfaction with the treatment results and care provision is directly associated with ease of doctor-patient communication. For example, 51 % of medical flaff believe
that patients refuse to adhere to the prescribed course (non-compliance) because of culture and language barriers, while 56 % of these same flaff report no language or cultural competence training (Youdelman and Perkins 2005). Patients who do not speak English fluently are shown to be less satisfied with their communication with the medical providers and the care they received. What's even more important, they are reluctant to complain about the reasons of their fruflrations (Morales et al. 1999; Jacobs et al. 2001).
Obflacles to the doctor-patient communication occur irrespective of the patients' demographic characteriflics or the type of their health problems. The three areas, where physicians and patients are mofl likely to differ, concern: 1) ideas about the patient's health problems, 2) expectations of the clinical encounter, 3) verbal and non-verbal communication flyles (Hudelson 2005: 313). At leafl two of those could be effectively assessed by the appropriate medical queflionnaires. However, an interpreter's incorrect rendering of queflionnaire items or a patient's deliberate concealment of information result in a queflionnaire's failure.
Very often the misunderflandings or discrepancies in processing queflionnaire items are culture-bound. The patients describe their flyle as foreign and incomprehensible, while physicians disregard the patients' responses as incoherent and illogical (Hudelson 2005: 314).
The aim of the present article is to fludy the efficacy of medical queflionnaires as survey tools, the factors contributing to their cross-cultural validity, and to compare the roles the original and translated version of the same queflionnaire play in the respective ethno-linguiflic environments. The problem of medical queflionnaire translation has theoretic, psychometric, terminological and intercultural roots, which make it a complex object of analysis and provide valuable insights into the process of interpreter-mediated doctor-patient communication and foundations of medical discourse.
2. Medical queflionnaires: a research tool Queflionnaires are praised as a cheap and quick research tool, especially when applied to fludying various aspects of health and diseases. Their popularity is associated with the speed of results being obtained, relative cheapness of information processing, reliability of their findings describing the incidence of diseases, their etiology, and patients' life quality. Medical queflionnaires have a significant predictive value as to the potential results of medical interventions, drug performance and patients' behavior.
However, their successful use is undermined by an erroneous though commonly held view that any survey inflrument is easily contracted and does not require any training for its authors or implementers. Physicians are quick to complain about the pervasive "queflionnaire fatigue" due to the fact that they are conflantly bombarded by various "forms to fill in" (Kaner et al. 1998; Eaden et al. 1999). Finally, as a tool developed in English, the majority of medical queflionnaires can be used as validated inflruments only for the English-speaking populations, which raises a queflion of the translated versions' feasibility and relevance.
Mofl queflionnaires in the medical literature inevitably reflect the Anglo-Saxon culture from which they derive. While the values, flereotypes of behavior and approved practices highlighted by the queflionnaire's items may appear flrange/foreign to the receiving audience, the survey tools are nevertheless accepted as 'gold flandards' by the world scientific community (Padua et al. 2003: 179). The appropriate use of medical queflionnaires results from maintaining cultural equivalence, which in turn requires their adaptation to the linguiflic and cultural expectations of the receiving audience.
Another possible solution lies in creating an alternative group of queflionnaires to be used in specific non-English speaking countries as populations differ in their attitudes towards the categories of "health" and "illness", "quality of life" etc., as well as in their use of health care syflems. Though expensive, this approach may turn out useful in multicenter/multi-country trials. 2.1. Typology of medical queflionnaires Medical queflionnaires differ in the degree of their generality/ specificity, formality/informality, and respondent's involvement due to an immediate appeal to his/her values, attitudes and flereotypes reflected in the queflionnaire's items. Irrespective of the inflrument's type, its focus is the presence (treatment, management), absence (prevention) or potential recurrence of acute/chronic diseases.
The four general types of queflionnaires are: Quality of life (QOL) inflrument/measure is an assessment of at leafl five life categories, including a respondent's biological,
psychological, interpersonal, social and economic experience. The mofl frequently utilized categories are Health, Self-Efleem/ Wellbeing, Community/Productivity, Social/Love Relationships, and Leisure/Creativity.
Health-related quality of life (HRQOL) inflrument/measure is an assessment of the extent to which the personal wellbeing may be affected by a disease, disability, disorder. The negative effect may be assessed in the short or longer perspective.
Patient-reported outcome (PRO) inflrument/patient-reported outcome measure (PROM) refers to a queflionnaire presupposing responses collected directly from the patient.
Patient-based outcome assessment (PBOA) inflrument refers to a queflionnaire covering issues of specific concern to the patient.
Despite their functional relatedness and similarity of conceptual focus, these types of queflionnaires reveal individual features. For inflance, HRQOL inflruments are though multidimensional, ¿till primarily focused on the respondent's health flatus and influence of disease and impairment, while QOLs invefligate the individual ability to fulfill his/her needs and emotional response to the reflrictions. PBOAs cover issues of particular relevance to the patient, while PROs/PROMs imply only that the information, however relevant or trivial, is provided directly by the patient.
The content and intended purpose of the medical queflionnaires found their reflection in a classification by Fitzpatrick et al. which mentions disease-specific, site or region-specific, dimension-specific, generic, individualized, utility inflruments and those with summary items (Fitzpatrick et al. 1998: 8).
The design of queflionnaire items and response options encompass the commissioner's assumptions about the scope of the receptive audience's background knowledge and health literacy. The items may be of an open or closed (dichotomous) type. Open queflionnaires encourage qualitative answers, general comments by the respondent, and for this reason are harder to analyze in flatiflical parameters. By contrafl, closed queflionnaires appear to be more flructured, as they are based on 'yes/no answers', with numerical values attached to them. Dichotomous type of survey inflruments is associated with a high reproducibility and reliability (Gilkinson et al. 1992).
Response options take into account, among such other parameters as a degree of language proficiency, expertise, background knowledge etc., - the extent of respondent's general literacy. They may be primarily verbal (Likert scale, recording of events), verbal-numerical (VAS scales, anchored (categorized) VAS scales), primarily numerical (rating scales), pictorial scales and checklifls.
3. Queflionnaire translation procedures
Although Harkness and Shoua-Gluzberg (1998: 88) imply that sometimes the choice of target language as well as the decision upon the specific queflionnaire to be translated is the 'luck of the (sample) draw', i.e., where the sample falls decides whether a translation is made, more often other factors come into play. According to Wild et al. (2009: 431), commissioners of the translated version take into account population analysis (nature of the population, its potential impact on the languages spoken in the country), disease prevalence (some diseases, such as sickle-cell anemia, Tay-Sachs disease etc., are closely associated with ethnicity), and language inclusion necessity (for inflance, if there is a low literacy rate or the language in queflion
is mainly oral, there is no need to create a written version of translation).
When the decision upon translation is taken, there is a lifl of possible procedures to be analyzed in terms of their pros and cons: decentering, direct (one-for-one) translation, committee (parallel) translation, advance translation, 'on-the-fly' translation, ad hoc translation (Harkness and Shoua-Gluzberg 1998: 98-107).
Decentering is based on paraphrase as a result of which the draft queflionnaire's items are reformulated in order to create a target version not 'centered on' or 'anchored to' a specific language or culture. Although seemingly appropriate and even attractive for the globalized-world population, decentering is prohibitively expensive and time-consuming. Besides, it is found to produce unnatural-sounding texts and, at leafl at the present flage of translation fludies' development, is potentially feasible maximum for 2-3 languages at the same time.
Direct (one-for-one) translation is a traditional procedure of each specific language version being assigned to an individual translator. This method is considered to be cheap and effective in terms of organization and control. However, there is a risk of subjectivity in the equivalence choice, potential negligence of regional language differences and the data quality risks.
Committee (parallel) translation involves several translators, each of them producing their own version of the original text. Resulting discrepancies are reconciled at a consensus (revision meeting) presided over by the coordinator. In this manner, individual translators provide their competence in whatever varieties of the target language required by the respondents; however, the final choice is made by the coordinator driven by his/her subjective preferences. Besides, the procedure is labor, time and cofl intensive.
Advance translation differs from the previous procedures in that the queflionnaire's items are translated while ¿till in the drafting. Thus, source formulations are adapted or annotated, explanatory notes are added etc. Nevertheless, without a well-grounded proof of the need for advance translation, this procedure is unlikely to be used due to its difficulty and cofl.
'On-the-fly' translation is performed orally in cases when there is a small group of respondents expected to participate in a survey or the survey is intended for the sample in which several languages are spoken. 'On-the-fly' translations are not Satirically relevant as absence of the written data makes the results impossible to process.
Ad hoc translation involves individuals with bilingual/ multilingual communication skills but little or no training in translation. Among its advantages are the relative cheapness, accessibility, and the common background the translator and respondent share in terms of their socio-economic flatus, mother tongue, cultural values etc. However, numerous fludies show that ad hoc translation is associated with lower levels of satisfaction both for the professionals and lay receivers (Putsch 1985; Simon et al. 2006), breach of confidentiality (Haffner 1992) and higher number of communication errors (Flores et al. 2003; Moreno et al. 2007).
3.1. Equivalence and translation methodology
The concept of equivalence lies at the heart of translation methodology and paradoxically creates a dividing line between the classical oppositions: adequacy-oriented translation vs. acceptability-oriented translation, overt vs. covert, indirect vs. direct one. Pym defines equivalence as "a relation of 'equal value' between a flart-text segment and a target-text segment"
which can be eflablished on any linguiflic level, from form to function (2014: 6). He also diflinguishes between "natural equivalence" exifling prior to the translating act and "directional equivalence' which depends upon the choice that the translator makes among several translation solutions (2014: 24).
Analysis of the translated versions of medical queflionnaires shows that some of them follow quite closely the original text, without making any attempt at linguiflic and cultural adaptation, while others transplant the foreign survey tool into the receiving culture. The relatively small number of the latter is explained by a high flatus of the original texts considered 'gold flandards' in the field, and the problem of validation as directional equivalence, unlike the natural one, does not reveal itself in back translation.
According to G. Toury's classification, the firfl group is made of adequacy-oriented translations, i.e. focused on the exact reproduction of a source language text's (SLT's or prototext's) features (Toury 1995: 56). On the other hand, acceptability-oriented translations seek to meet the requirements of the target culture receiving the metatext (target language text, TLT).
House (2014) finds proof of the two former orientations in the impression the target version makes upon the receiver. Overt translations, for her, signal in a variety of ways that they are target (reproduced) texts. By contrafl, the covert ones read like the original texts and do not give any indication of their 'secondary', processed character. Although Harkness and Shoua-Gluzberg (1998: 105), inspired by House's classification, say that "unless there is a valid reason why respondents should consider the origins of the queflionnaire, [...] survey translations should be covert", the current practice of queflionnaire translation manifefls the opposite approach.
Rather, as Gutt suggefls, the translators should flrive towards "directness" within the 'overt translation' category as it is the direct translation that refers to the original context and thus "creates a presumption of complete interpretative resemblance" (2014: 196). The receiving audience underflands that they are reading a target version of the queflionnaire but feel that they get the same idea as the readers of the original survey tool and, what's important, the idea that the authors intended to convey.
This similarity of conceptual background is created by a maflerful use of equivalences. Guillemin et al. (1993) describe semantic, grammatical and idiomatic ones which are found in almofl every type of the translated text. By contrafl, the equivalences typical of the queflionnaires are, according to Guillemin et al. (1993), experiential and conceptual equivalences, both vital for the cross-cultural adaptation. Experiential equivalence requires that "the situations evoked or depicted in the source version should fit the target cultural context" (1993: 1423). If no corresponding feelings or activities are found, the items should be discarded.
Conceptual equivalence refers to "the validity of the concept explored and the events experienced by people in the target culture, since items might be equivalent in semantic meaning but not conceptually equivalent" (1993: 1424). Thus, conceptual equivalence becomes a corner-flone and integral part of linguiflic validation, confirmation of the target version's flatus as a rightful counterpart of the original.
3.2. Requirements of accuracy and methods of translation quality assurance
The task of evaluating the quality of medical queflionnaire's translated version appears notoriously difficult, since it is not entirely clear what the focus of evaluation should be. On the one hand, an accurate translation is to convey the original text's
meaning, on the other - a fluent output is desirable as it could be read easily.
These two goals, adequacy and equivalence (often called 'fidelity' and 'fluency') are not easy to reconcile. Equivalence (in its mofl general sense) flipulates the degree to which the output is well-formed (in compliance with the target language's grammar, lexis, syntax etc.). Adequacy refers to the extent to which the output communicates the information present in the reference translation.
The measure of adequacy is the equivalence between the meaning of the original queflionnaire's item and the meaning of the translated one. Thus, adequacy is the goal and result of the accurate translation, while equivalence is the means of achieving this goal.
According to Txabarriaga (2009: 3), the real indicators of proficiency in translation are knowledge of the subject matter, knowledge of relevant terminology, the ability to discern meaning in context and transfer it within the target language conflraints, i.e., accurately (all meaning has been transferred), precisely (all nuances of the language, tone, intent, flyle have been preserved in the target language), correctly (grammar, syntax, orthography rules have been observed), completely (no part of the original was omitted and nothing has been added to the target text), and consiflently (specific terms, flyliflic elements and language-specific norms have been consiflently used throughout).
The IMIA Guide on Medical Translation asserts that the ultimate tefl for a medical translator is the validation by the end user; i.e., whether the person in need of translated materials can adequately comprehend the information provided and act according to expected results (Txabarriaga 2009: 8). Guidelines about how to produce easily-read translated versions of queflionnaires comprehensible to a majority of people suggefl using language which could be underflood by 10 to 12-year children, or between the 6th and 8th-grade reading levels.
Recommendations for the translators of medical queflionnaires include: using short sentences with key words in each item as simple as possible; active rather than passive voice; repeated nouns inflead of pronouns; and specific rather than general terms. Translators should avoid using metaphors and colloquialisms; subjunctive mood; possessive forms; vague terms; and sentences containing two different verbs that suggefl different actions (Guillemin et al. 1993).
To assure the quality of the queflionnaire's target-language version, Swaine-Verdier et al. (2004) suggefl recruiting a group of 5-7 translators with varied profiles. They are to be informed of the model underlying the queflionnaire, its design and content, potential respondents etc. The quality control is effected firfl by the coordinator, and once the draft version has been approved, -by the lay panel of the target-language speakers who have access to the translated queflionnaire (and not the original).
The coordinator-mediated discussions of the translators and potential end-users (represented by the focus group) result in a number of adaptations introduced into the draft text. Tuleja et al. mention factual reporting-driven adaptations which refer to adjuflments resulting from specific linguiflic and cultural practices; language-driven adaptations which refer to adjuflments resulting from linguiflic characteriflics such as the presence or absence of the gender category; convention-driven adaptations which refer to adjuflments resulting from whether the orientation of the queflionnaire changes from left-to-right to right-to-left, for example, when translating from English to Arabic, or from left-to-right to top-to-bottom when translating
from English to Chinese; and culture-driven adaptations which refer to adjuflments resulting from the different norms, cufloms or practices of a given people (Tuleja et al. 2011: 400).
Deficiencies of translation and unsuitable item content conflitute the so-called "nuisance factors" that, according to Van de Vijver, may affect the measured results and level of comparability of data across cultures (2003: 207). However, even when the requirement of translation's accuracy is met, a queflionnaire developed in one language/culture may not necessarily "travel well" across cultures due to differences in meaning and interpretation (Braun 2003: 137). Psychometric fludies help to eflablish correspondence of the original and translated versions and to perform validation of the queflionnaire's reliability.
4. Psychometric aspects of medical queflionnaire translation
Psychometric flage of medical queflionnaire translation involves: a) flatiflical analysis of the respondents' moods, attitudes, values, beliefs, as well as prejudices, cultural and behavioral flereotypes etc., and b) confirmation of the queflionnaire's reliability when transplanted into a different linguiflic and cultural environment, equal flatus of both survey inflrument's texts - original one and reproduced in a target language.
Both psychometric tasks - conflruction of a translated version of a survey inflrument and measurement of its effectiveness - converge upon two principal concepts. Back in 1921, Buckingham et al. claimed that "the mofl important types of problems in measurement are those connected with the determination of what a tefl measures, and of how consiflently it measures. The firfl should be called the problem of validity, the second, the problem of reliability" (1921: 80). In this manner, reliability shows that an inflrument performs over the time and in various language/culture groups, while validity refers to its capacity to measure exactly the categories it is meant to measure. Reliability is an integral, though by no means an unique, element of validity.
The principle of linguiflic validity of a translated medical queflionnaire flipulates that the rendered version plays the same role in the target culture as the original in the primary one. It relies upon a premise that the target audience conflrues the message of queflionnaire's items in the same way as the original audience did. Collecting data in different cultures with the aim of obtaining comparative results requires that the measurement inflrument has cross-cultural validity, i.e., that translation and measurement equivalence are ensured or at leafl tefled (Grunert et al. 1993: 8).
Besides the linguiflic and cross-cultural validity, there are other types to take into account. Conflruct validity is determined by evidence that relationships among items and concepts conform to a priori assumpions concerning logical relationships. If the results are consiflent with a pre-exifling hypothesis, it is a convergent validity, otherwise - a discriminant validity. Criterion validity is the extent to which the scores of a medical survey inflrument are related to a known 'gold flandard measure' of the same concept.
By far the mofl important type of validity in terms of translation is the content validity, i.e. the extent to which the inflrument measures the concept of interefl (FDA 2014: 19). Content validity is specific to the population, condition, cultural and environmental issues. For example, in tropical countries, aflhma patients do not have to contend with snow and icy winds, so the inclusion of queflion "Do you feel worse in winter?" in
the translated version of the queflionnaire is irrelevant. A subtler example of diflortion on the level of cultural validity was discussed by Acquadro et al. (2014).
In the Pediatric Aflhma Caregiver's Quality of Life Queflionnaire (PACQLQ), developed in Canada, caregivers reported that they were «angry» because their child had aflhma. However, in every other country in the world, anger was not an emotion frequently experienced; so, the qualifier «sad» was used inflead (Acquadro et al. 2014: 211-212).
In its Guidance for Induflry, the FDA mentions the content validity among the flandards againfl which the quality of translated inflrument's version is tefled: "Regardless of whether the inflrument was developed concurrently in multiple cultures or languages or whether a fully developed inflrument was adapted or translated to new cultures or languages, we recommend that sponsors provide evidence that the content validity and other measurement properties are adequately similar between all versions used in the clinical trial. We will review the process used to translate and culturally adapt the inflrument for populations that will use them in the trial" (FDA 2014: 22).
4.1. Creating a valid translated version of medical queflionnaire
The process of creating a valid translated version of medical queflionnaire involves several flages: 1) preparation, 2) forward translation (more than one), 3) reconciliation, 4) back translation, 5) back translation review, 6) harmonization, 7) cognitive debriefing, 8) review of cognitive debriefing results and finalization, 9) proofreading, and 10) final report (Wild et al. 2005: 96-97).
The preparation flage presupposes obtaining permission to use the medical survey inflrument in a different linguiflic/cultural setting and inviting the inflrument developer to be involved. Those in charge of the translation project develop explanation of the key concepts, and recruit the in-country persons to be actively involved in or managing the translation. The flaff mufl meet the following requirements: a) to be native speakers of the target language, b) to be fluent in the source language, c) to reside in the target country, d) to come from a medical/health/ psychology/social science background, and have experience in translating/managing the translation of PRO measures.
The people in charge of forward translation should represent multiple countries of origin, especially the target countries, for the fludy. Wild et al. (2009: 437) suggefl more than two forward translations if many countries need to be included.
Reconciliation resolves discrepancies between the original independent translations, and seeks agreement between individual speech habits and preferences.
Back Translation provides a quality-control flep demonflrating that the quality of the translation is such that the same meaning may be derived when the translation is moved back into the source language. Back translation is reviewed by several experts who provide their opinions on the befl possible options and identify country- or region-specific problems of translation. When it is impossible to find any solution, different final versions can be produced which maintain mofl of the same wording but include the country-specific variations required (Wild et al. 2009: 437).
At the harmonization flage, back translators representing each language provide a back translation of each item. Close attention should be paid to the correspondence of each back translated item to the original version as well as to any inflances or trends
of differences between language versions in their rendering of the concepts.
When a new medical queflionnaire is being developed for use in a future clinical trial it is necessary for the developer to interview patients with the same condition that will be fludied in the trial. This target population is viewed as an expert patient group capable of describing symptoms, health flatus changes, and functional change for the disease or condition in queflion.
As soon as the interviews are conducted and the analysis completed, a draft copy of the items, or queflions, can be tefled with yet another patient group to see if the ideas resonate with them. The second group of patients, who mufl meet the same criteria for disease severity as the original population, is asked to review the draft inflrument and respond to a pre-set series of queflions.
These interviews are referred to as cognitive debriefing because of the type of queflions being used - flructured queflions rather than open-ended queflions. The interviewer asks the participants to provide thoughts about the meaning of each item and to comment on comprehension. The goal is to determine if the participants underfland the queflions in the same way that the original group of patients underflood and described it.
Cognitive debriefing may have two diflinct purposes: 1) to develop items for a new or modified queflionnaire, and 2) to ascertain equivalence during translation, perform linguiflic validation, and cultural adaptation of an inflrument. Each of these processes uses similar methods to interact with fludy participants but they are completed at different intervals in the development and use of a queflionnaire.
If items are not generated in all language groups included in the clinical trials, the appropriateness of the content should be addressed in cognitive interviewing in each language group tefled. An item tracking matrix may be helpful to document the changes or deletions in items and the reasons for those changes (FDA 2014: 13).
Saturation is reached at the point when no new relevant or important information emerges and collecting additional data will not likely add to the underflanding of how patients perceive the concept of interefl and the items in the queflionnaire (FDA 2014: 12).
In large multi-country trials, in case a universal version of the medical queflionnaire is decided upon, proofreading is performed by representatives of different countries. The finalized text and results of cognitive debriefing are arranged into a report and sent to the commissioner/developer.
5. Case fludy: Ukrainian adaptation of a disease-specific health-related quality-of-life queflionnaire (IOF's One-Minute Ofleoporosis Risk Tefl) for patients with ofleoporosis
5.1. Overview of the material
The IOF's one-minute ofleoporosis risk tefl is a shorter (ten-item) version of the queflionnaire designed to predict the risk of ofleoporosis in representatives of various gender, age, ethnic etc. groups opting for various lifeflyles released by the organization in 19991. Ofleoporosis is a principal problem of health care in the developed countries; however, as a tool developed in English, the survey's use as a validated inflrument has at firfl been limited to the English-language populations.
Although originally conceived as an awareness-raising tool for the lay receivers (and thus requiring no validation), the IOF's tefl was proved to have a considerable predicting power if used in conjunction with densitometry (Povoroznyuk, Dzerovych 2008).
Currently the IOF's one-minute ofleoporosis risk tefl is performed in 96 countries with 9 translated versions. The present tefl includes 10 queflions (7 - general ones, 2 - intended for women, 1 - intended for men). Numerical values were attached for the sake of flatiflical analysis ("yes" - 2 points, "no" - 1 point) [Table 1].
Ukrainian version was translated and adapted by Povoroznyuk R.V., Dzerovych N.I., and Povoroznyuk V V It was published in 2006, and pofled on the website of the Ukrainian Association of Ofleoporosis (https://ofleoporos.com.ua) [Table 2].
5.2. The flages of Ukrainian version's validation
At the firfl flage of validation, the translated version is to pass an ethics review by an independent ethics committee, board or governmental body. Its aim is to evaluate the relevance of the survey text's content, its applicability for various groups of population. The Declaration of Helsinki on human research ethics (World Medical Association, 1964) asserts the protection of free will, confidentiality, privacy, and well-being of the participants, although regulations vary across the countries and organizations within the same country. Pennell et al. (2010: 285) encourage the national ethics committees to pay especial attention to the sensitive items addressed by the queflionnaire as these are often country or region-specific.
In the case of the Ukrainian version, the approval was obtained through the Ethics Committee by the Inflitute of Gerontology (Ukrainian Academy of Medical Sciences) under whose aegis the Ukrainian Scientific-Medical Centre for the Problems of Ofleoporosis operates. Signing informed consents was optional as it is not flipulated by the national regulations.
The pre-tefling flage involved cognitive interviews with 30 women and 26 men aged 20-79 years. Their aim was to check general underflanding of 2 forward translations (one - made by a physician with no translation training, and another - by a translation fludent at the Kyiv National University, Ukraine), later submitted to a back-translation by a different expert.
As Queflions 1, 2, and 4 showed minor divergences in the texts of forward and back translations, their validity was further checked by means of sensitivity and specificity analysis (the total number of participants - 830 people [Table 3])2.
The final validation flage involved 353 women and 104 men aged 20-79 years. In the clinical setting, a translator was reading queflions to the patients, and an attending physician was providing professional explanations if called upon.
The data were analyzed using "Microsoft Excel" and StatSoft Statiflica v6. Survey results were further compared with densitometry tefl findings.
5.3. Results of the case fludy and their discussion
1) Queflion 1 (Have either of your parents been diagnosed with ofleoporosis or broken a hip after a minor bump or fall?/ Чи мав хтось i3 Ваших родичiв дiагноз остеопороз чи перелом стегново! истки шсля мшмального удару чи падшня?) and Queflion 2 (Have you broken a bone after a minor bump or fal^/Чи був у Вас перелом исток тсля мшмального удару чи падшня?) showed minor semantic divergences in the texts of forward and back translations (родм indicates a more diflant degree of blood relations than "parents" which makes the queflion more generalized, and potentially leads to obtaining a broader anamnesis).
Queflion 4 (Have you lofl more than 3 cm in height?/ Чи зменшився Ваш зркт бшьше шж на 3 см?) was submitted to a grammatical transformation with a themo-rhematic change of functional perspective required by the rules of usage in
Ukrainian. There were no semantic changes evident in back translation.
However, to ascertain the validity of translation, sensitivity and specificity analysis was used. It was aimed at revealing a concordance of survey results (in terms of Queflions 1, 2, 4) and densitometry tefl findings.
Note:
Sn - the sensitivity of IOF's one-minute ofleoporosis risk;
Sp - the specificity of IOF's one-minute ofleoporosis risk;
Q1 - Queflion 1("Have either of your parents been diagnosed with ofleoporosis or broken a hip after a minor bump or fall?");
Q2 - Queflion 2 ("Have you broken a bone after a minor bump or fall?");
Q4 - Queflion 4("Have you lofl more than 3 cm in height?").
2) It is inevitable that some terminological units are more readily accepted by certain cultures than the others. Sometimes this phenomenon is due to the general level of the population's health literacy; more often it has cultural origins. Wild et al. indicate that "wording (of the items) may not sound as natural to patients, and the language may be culturally and linguiflically bland" (2009: 436). However, they warn againfl the changes when "patients are able to underfland (the items) by using their passive vocabulary, which refers to underflanding terms even if not part of the patient's everyday usage" (2009: 436).
A) Inadequate grasp of medical terminology proved to be an obflacle not only for the respondents, but also for a translator with no medical background. The back-translated Queflion 3 (Have you taken corticofleroid tablets for more than 3 months?) in Ukrainian included the noun гормони (hormones) inflead of "corticofleroids". The suggeflion confounded the queflionnaire's results, as corticofleroids have a direct adverse effect on the bone tissue.
For those cases when misunderflanding of terminology was admitted by the respondents, presence of the attending physician proved a beneficial factor. Difficult items were explained, and potential misrepresentations avoided [Figure 1].
B) While answering Queflion 8, female respondents (primarily from the rural areas) were noticeably grappling with the term "menopause". To make the item more accessible, researchers tried several tactics: 1) to explain the meaning of the term descriptively, 2) to use an obsolescent, though more accepted in the Ukrainian colloquial usage equivalent ммакс.
Herget and Alegre's (2009) observe that medical terms of a Greek or Latin origin are typical of an erudite communication, and thus are used in translations made for professionals; on the other hand, if the target text is addressed to a general audience, the translator should make use of lexemes originating from his/ her native tongue.
After a lengthy deliberation, nevertheless, the researchers opted for the Ukrainian equivalent of the same Latin extraction as the terminological unit in the original (Do you undergo menopause before the age of 45?/Чи настала у Вас менопауза до 45 роив?) [Figure 2].
C) In translation, Queflion 7 (Do you suffer frequently from diarrhea (caused by problems such as celiac disease or Crohn's disease^/Чи страждаете Ви на часту дiарею, обумовле-ну такими захворюваннями, як целiакiя, хвороба Крона?) manifefled two conflicting trends. According to Tercedor-Sanchez and Lopez-Rodriguez (2012), there is a group of diaflratic terminological variations, which are associated with specific demographical characteriflics of the respondents (in this case, their social flratum). Our results show that quite a
significant number of patients weren't familiar with a medical term "diarrhea". Inflead, the attending therapifl had to use an informal word пронос, a terminoid of folk-medical nature. However, the patients diagnosed with specific conditions outlined in Qu.7 had no difficulty recognizing their names [Figure 3].
D) A specific case of terminological occurrence in translation (though not in the original) is exemplified by Queflion 9 (Have your periods flopped for 12 months or more (other than because of pregnancy or menopause^/Чи були у Вас перюди амено-ре! (вщсутшсть менструацш) протягом 12 мюящв та бшьше (не пов'язаш з ваптшстю чи менопаузою)?). The major part of the interrogative phrase "Have your periods flopped" was replaced in translation by a terminological unit перюди амено-ре! (periods of amenorrhea). Since 'amenorrhea' is defined as 'an abnormal absence of menflruation', the researchers considered it to be more relevant. Nevertheless, resulting item 1) has a higher degree of technicality, 2) is less comprehensible to the respondents, and 3) manifefls divergences in back translation. That's why it was later annotated by means of a parenthetical definition (ввдсутшсть менструацш) [Figure 4].
3) Sensitive culture-specific items place a particular burden on the researchers as they influence the reliability and, thus, validity of the findings. Hudelson (2005) emphasizes the fact that patients feel fligmatized as a result of being affected by certain diseases considered disgraceful by the representatives of their culture, and more likely to conceal their diagnoses. Undue emotional or cognitive flrains decrease the quality and completeness of data: respondents are unwilling to answer disease-related queflions, or perceive that an interviewer wants them to react in a certain way (FDA 2014: 18). Wild et al. observe that some sensitive or dietary content may be highly culturally linked (e.g., sexual performance or items referring to alcohol) (2009: 436). Consequently, a bias occurs even when it was unintended by the translators or authors of the original inflrument.
Very often the obflacles to validation of a particular queflionnaire are caused by two cultures (original and receiving) belonging to different communication context rankings (Hall 1977). For example, the low-context cultures rely more on the implicit interactions than actual utterances. To add insult to injury, sensitive topics vary among cultures. However, a person's health is shaped by cultural beliefs and experiences that influence the identification and labeling of symptoms; beliefs about causality, prognosis, and prevention; and choices among treatment options (Anderson et al. 2003: 74).
In the IOF's one-minute ofleoporosis risk tefl, there are two items of a sensitive culture-specific character: Queflions 5 and 10. Both are gender-specific, which further complicates the matters.
A) We have received but one positive answer to Queflion 5 (Do you regularly drink alcohol in excess of safe drinking lim^/Чи приймаете Ви регулярно алкоголь у доз^ яка б перевищувала небезпечну?) from women aged 40-49, 60-79 years even after the "safe drinking limits" were defined. It might be explained by the negative cultural flereotypes associated with female drinking in Ukraine [Figure 5].
B) Very few positive answers were given to Queflion 10 (Have you ever suffered from impotence, lack of libido or other symptoms related to low tefloflerone levels?/Чи страждали Ви коли-небудь ввд iмпотенцii, зниження лiбiдо та шших сим-птомiв, яш пов'язаш з низьким рiвнем тестостерону?) from
men belonging to any age groups. It might be explained by the fact that the lack of virility is associated with decline of physical and mental faculties in the Ukrainian psyche [Figure 6].
6. Conclusion
Medical queflionnaires have long been described as 'mirrors of culture'; however, it is the mirror that reflects what the beholder perceives to be his/her reality rather than the reality itself. Firfl of all, they are a product of a particular culture (often Anglo-Saxon) transmitting the values and flereotypes not necessarily present in the receiving language environment. Since the queflionnaires are often endowed with an authority of 'gold flandards' in their respective fields of medicine, the 'foreign' cultural components travel unchallenged into the target versions of their texts. Only recently the threat of 'cultural imperialism' and the increasing demands of multicenter/multi-country trials have encouraged the responsible governmental entities and NGOs to rectify the exifling imbalance through the adaptation and validation initiatives launched in numerous countries.
Research of the medical queflionnaire translations lies at the intersection of psychometrics, cultural anthropology, and linguiflic fludies. Harkness et al. write about the fact that "researchers may not relish embracing fields such as discourse analysis, linguiflics, sociolinguiflics, cultural theories, or content analysis into queflion design. Ultimately, however, the expectation is that these will help identify both problems and viable solutions" (2010: 14-15). Multifold character ofthe fludies involved reflects the mercurial nature of the queflionnaire design process: it encompasses considerations of population analysis, language/ethnicity factors, even disease prevalence as there are medical conditions endemic to certain geographical areas and due to environmental circumflances and/or cultural practices (Tercedor-Sanchez and Lopez-Rodriguez 2012: 249). Under these circumflances, translating medical survey inflruments becomes a "world for world" rather than a "word for word" task (after Acquadro et al. 2014: 211).
The choice of the mofl efficient translation methodology and procedures as far as the medical queflionnaires are concerned is situational and depends to a large extent upon the background knowledge and cultural awareness of the initiator (commissioner) but relies upon the due diligence, good practice and skills of the in-country personnel. Mediation between cultures requires the communication of ideas and information from one cultural context to the other. Taft (1981: 59) observes that this process is "analogous to the process involved in linguiflic translation, even though there is more to mediation than mere translation".
The experience of creating the Ukrainian adaptation of a disease specific quality-of-life queflionnaire (IOF's One-Minute Ofleoporosis Risk Tefl) for patients with ofleoporosis proved to be an invaluable hands-on training in cultural competence. It was, firfl and foremofl, a result of collaboration between physicians, experts and translators.
The Ukrainian version is quickly adminiflered, valid, and reliable. However, the correct interpretation of its results requires insight into the cultural-specific and pragmatic factors. As culturally and linguiflically appropriate health education materials are designed to take into account differences in language and nonverbal communication patterns and to be sensitive to cultural beliefs and practices (Anderson et al. 2003: 74), the nationally adapted and validated medical survey inflruments should the task of overall health-care syflem improvement and provide a higher level of patient satisfaction.
Table 1.
Original version of the IOF's one-minute ofleoporosis risk tefl
The questions The answer
1. Have either of your parents been diagnosed with osteoporosis or broken a hip after a minor bump or fall? yes no
2. Have you broken a bone after a minor bump or fall? yes no
3. Have you taken corticosteroid tablets for more than 3 month ? yes no
4. Have you lost more than 3 cm (just over 1 inch) in height ? yes no
5. Do you regularly drink alcohol in excess of safe drinking limits? yes no
6. Do you smoke more than 20 cigarettes a day? yes no
7. Do you suffer frequently from diarrhea (caused by problems such as celiac disease of Crohn's disease)? yes no
For women
8. Do you undergo menopause before the age of 45? yes no
9. Have your periods stopped for 12 months or more (other than because of pregnancy or menopause)? yes no
For men
10. Have you ever suffered from impotence, lack of libido or other symptoms related to low testosterone levels? yes no
Table 2.
Ukrainian version of the IOF's one-minute ofleoporosis risk te&
Xttti IUHHU& mecitt oiitiiKu ifntKmopia pit utky ocmeonopoiy
til 111 i.ik iii hi.irKw.il>
1 Mn MJH Vtott il lUlllHV ptVIII'IIH ,11.11 inn (K.'lLMIkl(Xl| 111 lltfV.lllM l'icihomvi kit licit (IIITlflKII ciciiiomii kh'tkh) ii ik . If mmim.LIhlliHO mic iiti'timi [>) y.upy <ni najiiitiu .' Tan Hi
J. lin fiyn y liac iicpt 'iliiki ucroa tricu xinuiiDinro <iifuu*iMro) y.iajiy liii iLLiiHHC^ la* Hi
J. 1{ii npiiflna'TC lln vippitmkttpi>üui UopmhM irpc.mi hvihii [j in.) IIOH.i.I lpt1 MhJJiiii1 Tan Hi
J lJn imciiiniibci Haul ipicT ALuiik iiihc hj ) cm? Tax HI
? l(ll il[l||l1t|<|i iL" Hfl pci>,l*|lhl> ,11h'lim, v jtm. uk4 6 nk.l^hiiii|yiu.'ij HcGeuiHKy? la« Hi
f> 4h iiuinc till Olii.iiic 20 uiuapOK hi.i, it ill." Tan Hi
7> Hit crj««.iiii-if tin iti miy fljufCB, o6ywuny UtillMH U\S(^htUI<IJtlll, UK ij^ ii.IklH, VHt^n'kJ kpiHlj' Tan Hi
K "-3« k Hattxta y I Uli: uclhiltavu JW> 45 ftoKih' Tax Hi
9, lln 6y,iii y lijiL iiL'pui.in a»iciiit|X'i (m ik.vniKii. Hc»iL"ipy,ikiii) iipoTiuiM 12 mil mi in iu Gliuik (m: iior'iuhI i luitiiikihi 'in mchodiiv kin>r Tat Hi
10. Mil i;i]hx,uih llii k<viii-netfy;u> bu imiioiciiiiii, ihiikckiii .utfuo ia ll!llltl\ CHHinOMW, U1 tlnh't KLtU 1 HltftVtlM pinllcH TCCTlKiqWy? Tan Hi
<in ■ (in iM«h n ii ij>un jkiifcc *&> Lh.imtu it litjii m-jLiHu* y cmi. h>
nctKfHpdCOctKiAqim [xAtti kiclHM (UdtKnh ti r ItixniUKw tjqvtMil. hi wmvTt itixtikctu »iH|Ui(ihX loruiTBoni
lljilU'It \ill JnltHJIli Inl I HHHKI» 4M mnjultm It Itu Ju Jjrtflfl |Himt\ Htm« ILh DLUhVLTW» "W K* Oy.H'ttc It ttMX nllHrink tic ttc <mHi»tn. № fin Martr «Inaqxii, I1C uot.viiD, lln ■ qnni pniiy Mm nponoiyiv noumii pnyUtin icrr\ Itjuw liup», unA AniiüitlhlL "01 HtrtfXLlMl iUH №»№41 iiAil?*«lllH IU iTllquHlmit WC aCI«0||ü|UI Kl Mi
inn ihn"t> p-itii 1* ii»t№H I laiytuftlc. lint Mufcrlc minimi ILvii rnocril Ihtih .111 imn UJrfl HKHWDI ¡11 uifc pmvnuy nneiMW)hi n
l!,TiilL wi ji41 nj,|№hilil "kf Hb hi LitUII.uuu |k]x*n*uftlrci-. №> luw ttluctf All It i tLUtotLtm titimy OHA niinMiwiHHh na lAcpctnnU lAofwtolci [kttcti. Up UWi* Uc*t»ntc CUDUfWIU ILVIIU n |J|| uhih> ,11 THBIIlL'Tb HllHil llll l.l,l|lQlt io poult, pfunmuynu lAOHfHH
« liUHUX ku li* |1
Table 3.
The sensitivity and specificity (%) of the IOF's one-minute ofleoporosis risk tefl in respondents of various age groups (n=830)
Questions 20-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs 70-79 yrs 40-79 yrs
Sn Sp Sn Sp Sn Sp Sn Sp Sn Sp Sn Sp
Q1 7 79 18 85 21 71 25 61 18 83 21 82
Q2 17 97 20 88 28 86 39 78 45 86 31 86
Q4 2 99 6 96 19 88 33 61 61 43 25 89
Fig. 1. Ratio of positive/negative answers to Queflion 3 (Have you taken corticofleroid tablets for more than 3 months?/Чи прий-маете Ви кортикостеро!ди (кортизол, преднiзолон та ш.) понад три мiсяцi?) given by male/female (a/b) respondents
Fig. 2. Ratio of positive/negative answers to Queflion 8 (Do you undergo menopause before the age of 45?/Hh HacTara y Bac MeHonay3a go 45 poKiB?) given by female respondents
Fig. 3. Ratio of positive/negative answers to Queflion 7 (Do you suffer frequently from diarrhea (caused by problems such as celiac disease or Crohn's disease)?/^ cTpa^gaere Bh Ha Hacry giapero, 06yM0B^eHy TaKHMH 3axBoproBaHHaMH, sr ^maKia, xbo-po6a KpoHa?) given by male/female (a/b) respondents
Fig. 4. Ratio of positive/negative answers to Queflion 9 (Have your periods flopped for 12 months or more (other than because of pregnancy or menopause)?/^u 6y^u y Bac nepiogu aMeHopei' (BigcyTHicTb MeHCTpyanm) npoTaroM 12 Mica^B Ta 6№me (He noB'a3am 3 BariTHicTro hh MeHonay3oro)?) given by female respondents
b.
Fig. 5. Ratio of positive/negative answers to Queflion 5 (Do you regularly drink alcohol in excess of safe drinking limits?/^H npHHMaere Bh perynapHO amoronb y go3i, aKa 6 nepeBHmyBana He6e3neHHy?) given by male/female (a/b) respondents
Fig. 6. Ratio of positive/negative answers to Queflion 10 (Have you ever suffered from impotence, lack of libido or other symptoms related to low tefloflerone levels?/^u CTpa^ga^u Bh Konu-He6ygb Big iMnoTeHmi', 3HH®eHHa m6igo Ta mmux chm-nTOMiB, aKi noB'a3aHi 3 HH3bKHM piBHeM TectoCTepoHy?) given by male respondents
Notes
1. The present paper discusses adaptation of the shorter IOF's one-minute ofleoporosis risk tefl. There is, however, a longer (19-item) version pofled on the IOF's website since 2007: https://iofbonehealth.org/sites/default/files/PDFs/2012IOF_ riskJeflenglish%5bWEB%5d_0.pdf.
2. Sensitivity and specificity analysis was performed within the framework of a larger fludy intended to check the bone tissue parameters of the Ukrainian population. However, all of the participants filled up the queflionnaire before the densitometry examination.
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ПОЭТИКА РОМАНА Р.Р. ГРЕЙВЗА «ДОЧЬ ГОМЕРА»
Бондаренко М.И.
Государственный социально-гуманитарный университет (Коломна)
POETICS OF THE R. GRAVES'S NOVEL «HOMER'S DAUGHTER» Bondarenko M.I., PhD. The State social-humanitarian university (Kolomna)
АННОТАЦИЯ
Объектом исследования в статье становится поэтика романа Р. Грейвза «Дочь Гомера». Сюжет иллюстрирует теорию о Навсикае как авторе «Одиссеи». Важной особенностью поэтики романа является использование Грейвзом «чужого слова», то есть гомеровского эпоса.
ABSTRACT
The object of this article is the R. Graves's novel "Homer's daughter" and its poetics. The plot of the novel illuflrates the theory about Nausicaa as the author of "The Odyssey". The main feature of this novel is using of the "other word", Homer's text.
Ключевые слова: Грейвз, гомеровский вопрос, поэтика, сюжет, «Одиссея».
Keywords: Graves, "Homer's queflion", poetics, plot, "The Odyssey".
Творчество английского писателя Роберта Ранке Грейвза (1895 - 1985) отличает фундаментальный интерес к античности: мифологические образы и сюжеты в лирике и прозе, переводы («Метаморфозы» Апулея) и обширная антология греческих мифов, систематизированная им в «Мифах Древней Греции». Неудивительно, что поэт, писатель и мифолог обращается к одному из классических вопросов истории литературы античности: проблеме авторства Гомера. Текст «Одиссеи» был не просто хорошо знаком Грейвзу: он стал своего рода универсальным культурным полем, «литературной памятью».
Роман «Дочь Гомера» можно определить как концептуальный, поскольку автор исходит из собственной концепции, обозначенной в предисловии. По Грейвзу, Гомер не является создателем «Одиссеи». Идея романа возникла на основе точки зрения Аполлодора и Сэмюэла Батлера, сомневавшихся в авторстве Гомера. «Аполлодор, ведущий классический специалист в греческой мифологии, определил, что истинным местом действия поэмы было сицилианское побережье, и в 1896 году Батлер приходит к тому же выводу. Он предположил, что поэма, как мы ее знаем, была сочинена в западной Сицилии, а писательницей была девушка, запечатленная в тексте как Навсикая. /.../ Работая над греческими мифами, я счел аргументы Батлера о западно-сицилианском расположении и женском авторстве неопровержимыми» [1; 9]. Грейвз ссылается на книгу С. Батлера «Автор Одиссеи»,
где отмечено «прекрасное знание автором («Одиссеи») жизни при дворе, которое не согласуется с обрывочными сведениями о мореплавании или скотоводстве», и подчеркнуто «преобладание женских интересов». «Он также указывает на то, что только женщина могла бы предварить разговор Одиссея со знаменитыми женщинами прошлого разговору со знаменитыми мужчинами» [2; 936-937]. Роберт Грейвз предлагает гендерный подход к решению «гомеровского вопроса». Ему представляется малоубедительной сложившаяся в литературоведении классическая теория (идущая от немецкого филолога Нича), считающая Гомера автором «Илиады» и «Одиссеи». «Неубедительность» подобной точки зрения связана не только с хронологией («Одиссея», по Грейвзу, была сложена на 150 лет позже «Илиады»), но и со стилем поэмы. «Атмосфера в книге другая: более мелодичная, более комичная, более светская. «Илиада» - поэма о мужчинах и для мужчин. «Одиссея» - несмотря на мужественность героя - поэма о женщинах и для женщин» [1; 8].
Грейвз считает «Одиссею» не поэмой, а первым греческим романом, в котором «заметно небрежное отношение ко всему, что касается мифа»[2; 949]. «Дочь Гомера» - это роман о романе, где исходным пунктом становится гипотеза об авторстве Навсикаи. Сюжет романа призван визуализировать предположение автора о ходе работы над текстом «Одиссеи».
