Allison P Squires

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Background: As health services research (HSR) expands across the globe, researchers will adopt health services and health worker evaluation instruments developed in one country for use in another. This paper explores the cross-cultural methodological challenges involved in translating HSR in the language and context of different health systems. Objectives: To describe the pre-data collection systematic translation process used in a twelve country, eleven language nursing workforce survey. Design and settings: We illustrate the potential advantages of Content Validity Indexing (CVI) techniques to validate a nursing workforce survey developed for RN4CAST, a twelve country (Belgium, England, Finland, Germany, Greece, Ireland, Netherlands, Norway, Poland, Spain, Sweden, and Switzerland), eleven language (with modifications for regional dialects, including Dutch, English, Finnish, French, German, Greek, Italian, Norwegian, Polish, Spanish, and Swedish), comparative nursing workforce study in Europe. Participants: Expert review panels comprised of practicing nurses from twelve European countries who evaluated cross-cultural relevance, including translation, of a nursing workforce survey instrument developed by experts in the field. Methods: The method described in this paper used Content Validity Indexing (CVI) techniques with chance correction and provides researchers with a systematic approach for standardizing language translation processes while simultaneously evaluating the cross-cultural applicability of a survey instrument in the new context. Results: The cross-cultural evaluation process produced CVI scores for the instrument ranging from .61 to .95. The process successfully identified potentially problematic survey items and errors with translation. Conclusions: The translation approach described here may help researchers reduce threats to data validity and improve instrument reliability in multinational health services research studies involving comparisons across health systems and language translation.

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Drawing from role theory, this study sought to explore the effects of assuming a new role on Latina community health workers (CHW) participating in a cervical cancer prevention program in a new Latino immigrant community located on the East Coast of the United States. Through a series of in-depth, Spanish language interviews with the 4 participants, the researchers explored the process and effects of assuming and enacting the CHW role through a narrative analysis approach. Themes that emerged from the analysis included "Reasons for becoming a promotora," "Vision and reality of the role," "Structuring interactions: The hierarchy of knowledge transmission," and "Transforming identities." Findings showed that assuming the CHW role had transformative effects on the participants that, in the end, allowed them to reconcile disparate aspects of their own immigrant identities. The findings have multiple implications for designing prevention programs employing CHWs and immigrant community strengthening.

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Objective: To describe the systematic language translation and cross-cultural evaluation process that assessed the relevance of the Hospital Consumer Assessment of Healthcare Providers and Systems survey in five European countries prior to national data collection efforts. Design: An approach involving a systematic translation process, expert review by experienced researchers and a review by 'patient' experts involving the use of content validity indexing techniques with chance correction. Setting: Five European countries where Dutch, Finnish, French, German, Greek, Italian and Polish are spoken. Participants: 'Patient' experts who had recently experienced a hospitalization in the participating country. Main OutcomeMeasure(s): Content validity indexing with chance correction adjustment providing a quantifiable measure that evaluates the conceptual, contextual, content, semantic and technical equivalence of the instrument in relationship to the patient care experience. Results: All translations except two received 'excellent' ratings and no significant differences existed between scores for languages spoken in more than one country. Patient raters across all countries expressed different concerns about some of the demographic questions and their relevance for evaluating patient satisfaction. Removing demographic questions from the evaluation produced a significant improvement in the scale-level scores (P = .018). The cross-cultural evaluation process suggested that translations and content of the patient satisfaction survey were relevant across countries and languages. Conclusions: The Hospital Consumer Assessment of Healthcare Providers and Systems survey is relevant to some European hospital systems and has the potential to produce internationally comparable patient satisfaction scores.

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Background: Heart failure (HF) places a disproportionate burden on ethnic minority populations, who experience poorer outcomes. Hispanics are particularly susceptible to the consequences of HF. Self-care, which encompasses adherence to diet, medication and symptom management, can significantly improve HF outcomes. Yet the availability of culturally-appropriate interventions are limited. Purpose: To culturally adapt a self-care intervention for use in a sample of Hispanic older adults with HF, translate instruments into Spanish and establish cultural relevance content validity. Methods: The ADAPT-ITT framework guided translation of a cognitive-behavioral, self-care intervention to a culturally-appropriate program for Hispanic older adults with HF. First, focus groups of Hispanic older adults with HF were conducted to elicit the reactions to existing patient education materials and guided the cultural adaptation of the intervention materials by bilingual experts. Instruments were translated into Spanish. Cultural relevance and translation accuracy were measured by calculating a modified Kappa score for each instrument. Results: Focus group feedback revealed that culturally-appropriate content that focused on favorite foods and incorporated social support was needed: My daughter prepares meals.we need to know about low salt in our food.tortillas.chorizo. Participants expressed willingness to participate in a group program and preferred a local community setting that is "easy to get to.". Translated instruments were reviewed by a panel of 7 bilingual experts and found to be culturally relevant (S-CVI Kappa scores >.77) and accurately translated for Hispanic population (Translation TS-CVI Kappa scores >.74). Discussion: The ADAPT-ITT framework is a feasible method to culturally adapt a HF self-care intervention. Since health disparities that older Hispanics with HF face are shaped by multiple socioeconomic and cultural factors, availability of a culturally-appropriate self-care intervention may facilitate the development of the skills necessary for better self-care and improve HF outcomes in ethnically-diverse populations.

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Background: Studies of the nursing work environment are increasingly common in developed countries, but few exist in developing countries. Because of resource differences between the two contexts, researchers need to clarify what aspects of the work environments are similar and different. Objectives: To study the perspectives of Mexican nurses about their work environments to determine similarities and differences to results from developed world studies. Design: A secondary, directed content analysis of qualitative data from 46 Spanish language interviews using workplace-oriented themes. Setting: Purposively selected Mexican states from four regions of the country that reflect the country's socioeconomic differences. Participants: Practicing Mexican nurses with at least 1. year of clinical experience and currently working in nursing. Participants were recruited through convenience and snowball sampling techniques. Methods: Initial data collection occurred in 2006 and 2008 during a broader study about professionalization processes that occurred in Mexican nursing between 1980 and 2005. The secondary, directed content analysis focused on an in-depth exploration of a central theme that emerged from the two original studies: the workplace. The directed content analysis used themes from the global nursing work environment literature to structure the analysis: professional relationships, organizational administrative practices, and quality of care and services. Results: The three themes from the global literature were relevant for the Mexican context and a new one emerged related to hiring practices. By category, the same factors that created positive or negative perceptions of the work environment matched findings from other international studies conducted in developed countries. The descriptors of the category, however, had different conceptual meanings that illustrate the health system challenges in Mexico. Conclusions: Findings from this study suggest that studies that seek to measure nursing work environments will most likely apply in Mexico and other Latin American or middle-income countries. Instruments designed to measure the work environment of nurses in these countries may prove relevant in those contexts, but require careful adaptation and systematic translations to ensure it.

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Research that links macro-level socioeconomic development variables to health care human resources workforce composition is scarce at best. The purpose of this study was to explore the links between nonnursing factors and nursing workforce composition through a secondary, descriptive analysis of year 2000, publicly available national nursing human resources data from Mexico. Building on previous research, the authors conducted multiple robust regression analysis by federal typing of nursing human resources from 31 Mexican states against macro-level socioeconomic development variables. Average education in a state was significantly associated in predicting all types of formally educated nurses in Mexico. Other results suggest that macro-level indicators have a different association with each type of nurse. Context may play a greater role in determining nursing workforce composition than previously thought. Further studies may help to explain differences both within and between countries.

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