Jing* is sitting in front of her laptop, brows furrowed, shoulders tight, as she tries to decipher a page on a hospital website. Jing is the caregiver for her partner; she is trying to understand if her partner may be eligible for a new treatment since he is not responding to conventional therapies.

Jing is sure she’s found the right page on the site; however, she feels increasingly confused and frustrated as she reads it. The page is hard to understand due to its chaotic mix of highly technical terms and awkward wording.

What “family nursing personnel” really means is critical because the website says that the patient must have “family nursing personnel” to be eligible for the treatment, as they will be responsible for monitoring any side effects. In different circumstances, Jing might’ve found some of the odd wording silly or even funny, but she is not in the mood for that now. The responsibilities and workload as a caregiver are already weighing on her shoulders.

Language and cultural barriers

You might be wondering, “Why can’t Jing just look elsewhere? Perhaps other sites have better content?” Unfortunately, Jing will likely encounter similar challenges on other websites and has limited options.

Jing was reading the page in Simplified Chinese. The version you just saw is commonly called a “back translation”. As the name implies, the text is translated from English to Simplified Chinese, then back to English. Back translation gives a sense of how the meaning of the translated words might be different from the original text.

The original English version of the site that Jing is looking at said “caregiver.” Because there are no direct translations of the term in Chinese, the site translated “caregiver” into “家庭护理人员,” which reads similar to “family nursing personnel.” The translated term deviated considerably from “caregiver” and confused Jing.

Jing’s experience is not uncommon. More than 28 million people in the U.S. have reported that they speak English “less than very well.”¹ This language barrier poses a significant challenge to equitable access to health-related information, as North American health and medical resources are primarily in English. Like Jing, many people have to navigate translated information, even on leading hospitals’ websites or patient resources from major pharmaceutical companies. They are no strangers to the need to connect the dots between scattered information.

The current state of translation

Most hospitals and pharmaceutical companies have existing processes for making resources in multiple languages. The processes often involve automated tools or support from translation agencies. However, the resulting translations don’t always resonate with the intended audience. While the words may be correct, the message often falls short due to a lack of consideration for cultural nuances. For example, the tone might be off, images might convey different meanings, or the language can be ambiguous or inappropriate. To address this, cultural adaptation is essential.

What is Cultural Adaptation and how is it relevant to healthcare?

While translation focuses on converting text from one language to another, cultural adaptation goes beyond translation by aiming to elicit the same understanding as the original content. Cultural adaptation achieves this effect by making culturally informed modifications to words, concepts, imagery, and design.² Cultural adaptation offers an opportunity for key health-related information to resonate with patients and caregivers who speak another language.

Just like in Jing’s story, certain healthcare terms used in English, like “caregiver,” might not have direct translations in other languages. It’s essential to find suitable replacements for these terms or offer additional explanations to ensure the message remains clear after translation.

In addition to healthcare terms, many cultural references cannot be directly translated. For example, in a study that looked into the cultural and linguistic adaptation of diet-related text for Hispanic adults living in the U.S., many participants found the direct translation of “junk food” to “comida chatarra” to be inappropriate or incorrect. One participant stated, “‘Comida chatarra’ is like you are despising that food.” Instead of using direct translations to Spanish, participants recommended keeping the English term as it is widely understood among Spanish speakers in the U.S. and feels more appropriate.³ Other studies have identified similar needs for cultural adaptation and modifications for effective communication.⁴ Nonetheless, integrating cultural adaptation into the formal process of building patient and caregiver resources is not yet standard practice in the healthcare sector.

Applying Cultural Adaptation

One of the barriers to adopting cultural adaptation is its inherent complexity. Anthropologists and social scientists have proposed various frameworks of cultural adaptation in past decades. However, few of these frameworks have transitioned from academic settings to the practical workflows of those responsible for developing resources for patients and caregivers. Professionals in hospitals and pharmaceutical companies often face tight timelines and limited resources when creating such materials.

Implementing cultural adaptation requires a nuanced understanding of the subject and familiarity with the organization’s existing workflow. There is an unmet need to help organizations implement cultural adaptation in a way that doesn’t compromise productivity or limited resources.

This is where service design comes in.

Service design can help organizations like hospitals and pharmaceutical companies to culturally adapt patient-facing resources by:

Identifying the best practices and prominent frameworks of cultural adaptation that align with the organization’s broader patient communication goals.

Integrating cultural adaptation into existing workflows by collaborating with the creators of patient-facing materials and other stakeholders such as Medical, Legal, and Regulatory (MLR) advisors.

Distilling key cultural adaptation considerations suitable for the specific audience and content.

Building specific and concrete tools for creators of patient-facing materials to enable consistent adaptation.

Cultural adaptation aims to enable clear communication across cultural barriers by striving to understand how others perceive the world. Integrating cultural adaptation into the translation workflow is a concrete step toward making health and medical information more accessible and equitable for caregivers like Jing, and patients like her partner.

*Jing is a fictitious character. Her story was inspired by the author’s experience with online translated health content.

1. People That Speak English Less Than “Very Well” in the United States. (2020, April 08). United States Census Bureau. https://www.census.gov/library/visualizations/interactive/people-that-speak-english-less-than-very-well.html

2. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of abnormal child psychology, 23(1), 67–82. https://doi.org/10.1007/BF01447045

3. Cameron, L. D., Durazo, A., Ramírez, A. S., Corona, R., Ultreras, M., & Piva, S. (2017). Cultural and Linguistic Adaptation of a Healthy Diet Text Message Intervention for Hispanic Adults Living in the United States. Journal of health communication, 22(3), 262–273. https://doi.org/10.1080/10810730.2016.1276985

4. Shan, Y., Xing, Z., Dong, Z., Ji, M., Wang, D., & Cao, X. (2023). Translating and Adapting the DISCERN Instrument Into a Simplified Chinese Version and Validating Its Reliability: Development and Usability Study. Journal of medical Internet research, 25, e40733. https://doi.org/10.2196/40733