The ATA Chronicle - November/December 2021 - 21

trials.1
These instruments
can include clinical outcomes
assessments, such as
patient-reported outcomes,
clinician-reported outcomes,
observer-reported outcomes,
or similar questionnaires.
Basically, cognitive
debriefing is the process by
which a questionnaire or
other assessment is tested
among representatives of the
target population and target
language group. Ideally, this
takes place during faceto-face
interviews. The
purpose is to verify that the
translations of all items on
the questionnaire will be
understood in the same way
across target populations
and regions. The U.S. Food
and Drug Administration
requires cognitive debriefing
to show content validity for
all submitted translations.
For instance, suppose an
American company develops
a questionnaire for adult
patients with Hepatitis B
consisting of 10 questions
with multiple response
options. The questionnaire
originally targets American
patients who live in the U.S.
and speak American English.
Now suppose the researchers
involved in the study want to
use the same questionnaire
in Vietnam to collect data
from Vietnamese patients
with the same medical
condition. This will require
the questionnaire to be
translated into Vietnamese.
Since patients in the U.S.
and those in Vietnam don't
share the same language,
culture, or even certain
concepts, conducting a
cognitive debriefing will
help the researchers bridge
that gap to ensure that all
respondents have an equal
experience.
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Patient questionnaires
vary in length. The average
length of the source text can
be 300 words, although I was
once asked to work with a
4,000-word questionnaire
and another time to debrief
only 66 words. No matter
how short or long, any
questionnaire developed in
one part of the world to be
used in another part may
carry linguistic, cultural,
and conceptual features that
present challenges when
translated into another
language.
Prior to the cognitive
debriefing phase, companies
always invest much time
and energy into translating
a questionnaire. The
translation process usually
involves two forward
translators and two back
translators. Drafts are
often exchanged between
translators, project
managers, and developers
before a final, harmonized
version is approved.
However, no one can be sure
this final translation will
be understood by the target
audience without first testing
it on them.
Bridging Cultural Barriers
One major purpose of
cognitive debriefing is to
determine if the target
population would find
certain words, phrases, or
concepts inappropriate or
confusing. For example, one
question in English from a
questionnaire I worked on
for patients in hospice care
read: " Do you believe in God
or someone or something
greater than yourself? "
During the translation phase,
a translator, aware that a
majority of people in Vietnam
are Buddhist, translated it as:
" Quý vi. có tin vào Đức Phâ. t,
hay người nào đó, hay điều
gì đó lớn hơn bản thân quý vị
không? " ( " Do you believe
in Buddha or someone or
something greater than
yourself? " ). However, during
the cognitive debriefing
phase, I realized that some
patients who were Christian
didn't find this relevant.
We ended up changing it to:
" Quý vị có tin vào Đức Phật,
Đức Chúa, hay một đấng tối
cao, hay người nào đó, hay
điều gì đó lớn hơn bản thân
quý vị không? " ( " Do you
believe in Buddha or God or
a supreme being or someone
or something greater than
yourself? " ).
Another example is the
term " block, which appeared
in the following question:
" Can you walk more than
one block? " The meaning
is clear in English, but
the literal translation of
it into Vietnamese can be
problematic. A cognitive
debriefing revealed that
while the literal translation
of " block " as " tòa nhà "
was understood by
Vietnamese patients living
in an urban setting, it was
not understood by others
living in rural areas where
street blocks are generally
nonexistent. For this, a
culturally appropriate
translation could be: " Quý
vị có thể đi được hơn 100 mét
không? " ( " Can you walk
more than 100 meters? " ).
In many cases, even a
translation commonly used
in mass media can offend a
certain group. For example,
the word " questionnaire " or
" survey " can be translated
into Vietnamese as " Bản Điều
Tra " ( " probing text " ). This
translation is not wrong,
but through a cognitive
debriefing we learned
that many patients found
this translation offensive.
Why? Since the word " Bản
Điều Tra " can imply an
interrogation, people with
a medical condition would
generally react negatively
because they would consider
this type of questioning an
invasion of their privacy.
Bridging Linguistic
Barriers
For patient questionnaires,
ensuring that a term in
the source text will be
understood the same
way in the target text is
extremely important. A
mistranslation that leads
to a misunderstanding
of a term could result in
medical complications or the
rejection of an entire clinical
research project.
I find translating adverbs
of frequency or adverbs
of intensity from English
into Vietnamese most
challenging. For example,
response options such as Not
at all, A little bit, Somewhat,
Quite a bit, and Very much
for the question " In the
last seven days, how much
did mouth or throat sores
interfere with your usual
or daily activities? " are
difficult to translate. There
are Vietnamese equivalents
for these words, but there's
a great deal of disagreement
among translators since
adverbs of frequency or
intensity in Vietnamese
can vary from their English
counterparts. For instance,
the translated term " Khá
nhiều " in Vietnamese can
mean either " Somewhat " or
" Quite a bit. "
In this case, a cognitive
debriefing is very helpful
as it allows the patient's
American Translators Association 21
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