Language Translation Methods for Instruments in Research for Limited English Proficiency (LEP) Participants: (2023)

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Language Translation Methods for Instruments in Research for Limited English Proficiency (LEP) Participants: A Literature Review

As the globalization phenomenon grows, the interaction between multicultural societies and these cultures emerge leading to diversity in cultural heritage and social aptitudes. (1) Therefore, healthcare providers should be aware of disparities in the healthcare setting due to race and ethnicity. (1) The lack of translated instruments in a research study affects the low levels of recruitment and retention of participation in of minority populations. (2) The 1993 National Institute of Health (NIH) Revitalization Act mandated that minorities should be included in randomized clinical trials, identifying underrepresented minorities as American Indians, African Americans, and Latinos. (2) Research is multifaceted and scientifically driven towards the need for increased ethnic minority participation in public health. (2) Enhancing the ability to make precise scientific implications will provide an increase towards the skills that are necessary to achieve the goal of determining public health problems. (2) As a result, innovative thinking by a pool of multidisciplinary investigators that are ethnically and culturally diverse will inform the scientific effort necessary to create meaningful and substantial improvements in the public’s health, including eliminating health disparities. (2)

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(Video) Part 1: Breaking Down the Language Barrier - Translating Limited English Proficiency into Practice

The Migration Policy Institute reports that twenty-two percent (66.5 million) people ages 5 and older reported speaking a language other than English at home. (3) Among the top languages that are spoken at home is Spanish (62%), Chinese (5%), Tagalog (3%), Vietnamese, Arabic, French (including Cajun), and Korean (about 2 % each). (3) The prevalence of Spanish speakers is mainly from this being the official language in twenty-one countries. The diversity in English use and speaking ability amongst the foreign born is likely affected by their education level in comparison to those who possess a bachelor’s degree or higher than those who have a high school diploma. (4) Furthermore, many foreign-born individuals’ live long periods in the United States with Limited English Proficiency (LEP). Nevertheless, some have limited English-speaking ability or may not speak English at all, even after many years residing in the United States. (4) Despite legal protection provided under Executive Order 13166 which improves access to services for persons with Limited English Proficiency (LEP) (5), obtaining language-congruent health information may be very difficult for non-English speaking groups in the United States. (6)

Language barriers can impact on major health disparities regardless of an individual’s socioeconomic status. (6) This may lead to seeking care later, reduced quality of care, and failing to seek certain kinds of care, such as mental health, pre-natal care, and chronic care. (6) Cross-cultural research often involves a team of health care providers including physicians and nurses for translating questionnaires in an appropriate method to clinicians and health care practitioners who are mindful that unless these potential problems are addressed, their research results may be unclear. (7) There are local health departments that serve LEP groups, but restricted funding prevents these facilities from translating their elaborated health promotion materials into different languages. (6) Ina cross-cultural research setting translating questionnaires for use can present potential problems that can compromise validity and quality if questionnaires are not prepared properly. More importantly, these results can be uncertain due to improper understanding by an LEP population. (7) The specific method used for translation isn’t important moreover than the acknowledgement that the process must be appropriate and the validation process rigorous. (7)

There are various translation methods that have been used to increase the level of understanding of an LEP population regarding to what is being stated in a medical setting. The important factors to be accounted for are: 1)time, 2)cost and 3)quality. (6) Machine translation (MT) has been one of the methods implemented as a tool that uses translation models that has been trained from a great quantity of text data in the relevant languages (6); these methods reduce translation costs, but are not error-free (6). Since the process of language translation can be slow and expensive, various forms of MT have been developed. Nevertheless automatic MT systems process text translation rather fast and inexpensively, but the quality is far from a skilled translator. (8) Some studies have shown that even though there is reduced translation time with MT, the product is of lower quality, and even if speed does increase, translators often don’t like working with MT output. (8) The comparability of the results from MT translation and human translation (HT) can also lead to erroneous research conclusions due to the lack of cultural and ethnic relevant dialect so this adaptation can be challenging, thus validity can be threatened. (7) A high quality language translation can be costly, so in order to lower this cost MT has been developed as assistance so humans can work with machines in concert. (8)

Evidence has indicated that MT combined with human post editing with translators who are fluent in both the original text and target language, from the subsequent MT output produces a better quality product at less cost (6; 8). Unfortunately, translators are not always an expert in specific subject areas of the instrument like specialized medical subjects, for example, which are – difficult content areas. (7) With this in mind, a potential solution to focus on economic limitations, and guaranteeing access to health information for the public, would be for public health departments to initially translate materials using MT software followed by HT by native speakers, preferably with a public health background, and then post-editing the documents for clarity and accuracy. (6) Another method of translation consists of back-translation in which the original text is translated into the target language by one translator and subsequently translated back into the source language by an independent translator who is blinded to the original text. (7) The back-translation is preferred although it can be time consuming and expensive. (7) The validation of the translation and the psychometric analysis of the instrument are evaluated by teams of experts, bilingual individuals, or focus groups of potential research participants. (7) If this option is used, no cross-language instrument should be handled without the assurance of language equivalence offered by the blind back-translation technique. (9) Regardless of the chosen method of translation, the most important are steps are recognizing the proper translation process and conducting a rigorous validation procedure. (7)

(Video) Breaking Down the Barriers: Translating Limited English Proficiency Policy into Practice (Korean)

Cross cultural adaptation is supported by a mixture of guidelines for psychometrics can produce an acceptable end result for research comparable to the original version. (10) In order for that to occur, there would be a process proceeded by adapted steps from published recommendations to ensure equivalence between the original and the target language. (10) The psychometric properties are evaluated through analysis of internal consistency, factor analysis and other evidences of validity. (11) The existence of a common, brief, and valid instrument to assess health behaviors would be useful to understand the possible role of countries socio-cultural factors (11) unfortunately, that isn’t always the case. Perhaps, a cultural competence concept will increase acceptance and approval of cultural differences between groups. (11)

The research team should measure the translated instruments for use in several health system scenarios, for not only the technical and semantic equivalence of the survey questions, but also the inclusion of cultural relevance content in the instruments before even starting the data collection (8; 9). Furthermore, without having this evaluation done prior to start obtaining data, factor analyses post-data collection could be inconsistent and less rigorous (9). As a result of multi-disciplinary approach in research, there are five levels of cross-cultural equivalence: content, semantic, technical, criterion, and conceptual. (13; 14)

There are a few concerns when translating an instrument revolving scientific and ethical issues that can pose threats to internal validity, also known as “instrumentation”. (12; 14) Instrumentation can pose a major threat if different respondents receive a different version of the measure, making it invalid to infer that differences in the versions of the instrument are a viable alternative explanation. (12) For instance, a questionnaire was given to a Hispanic population where they were given the choice to choose between an English or Spanish version of the instrument. (9) The instrument was not back-translated due to willingness or limited capability. As a result, the data obtained suggested that Hispanics that were interviewed in Spanish responded differently to some items than the Hispanics that were interviewed in English therefore the differences can affect the conclusions of the study in regards of the level of correlation between two or more variables. (9)


1. Zong J Batalova J Burrows, M. Frequently Requested Statistics on Immigrants and Immigration in the United States. Migration Policy Institute. [Online] March 14, 2019. [Cited: June 20, 2019.]

2. Gambino C, Acosta Y, Grieco E. English-Speaking Ability of the Foreign-Born Population in the United States: 2012. United States Census Bureau. [Online] June 10, 2014. [Cited: June 20, 2019.]

3. The United States Department of Justice. Executive Order 13166. The United States Department of Justice. [Online] March 19, 2019. [Cited: June 20, 2019.]

(Video) Working with Limited English Proficient (LEP) Patients: Suzanne Zeng, PhD

4. A Comparison of Human and Machine Translation of Health Promotion Materials for Public Health Practice: Time, Costs, and Quality. Turner A, Bergman M, Brownstein M, Cole K, Kirchhoff K. 5, s.l.: Journal of Pubic Health Management and Practice, 2014, Vol. 20.

5. Translation and Validation of Study Instruments for Cross-Cultural Research. Sperber, A. Supplement 1, Beer-Sheva, Israel: American Gastroenterological Association, 2004, Vol. 126.

6. The Efficacy of Human Post-Editing for Language Translation. Green, S. Heer, J Manning, C. Paris, France: Association of Computer Machinery’s CHI 2013 Conference, 2013.

7. The Effect of Inadequate Language Translation on Hipsanics’ Responses to Health Surveys. Berkanovic, E. 12, Los Angeles, California: American Journal of Public Health, 1980, Vol. 70.

8. Developing Multiple Language Versions of Instruments for Intercultural Research. Erkut, S. 1, Wellesley, MA: Child Development Perspectives, 2010, Vol. 4.

9. A Systematic Survey Instrument Translation Process for Multi-Country, Comparative Health Workforce Studies. Squires, A Aiken, L Van den Heede, K Sermeus, W Bruyneel, L Lindqvist, R Schoonoven, L Stromseng, I Reinhard, B Brozstek, T Ensio, A Moreno-Casbas, M Rafferty, A Schubert, M Zikos, D. 2, New York: International Journal of Nursing Studies, 2013, Vol. 50.

10. Developing instruments for cross-cultural psychiatric research. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Winthrob R, Richman JA, Birz S. 5, s.l.: Journal of Nervous & Mental Disease, 1988, Vol. 176.

(Video) The Limited English Proficiency LEP Regulatory Requirements

11. Quantitative methods for verifying semantic equivalence of translated research instruments: A Chinese version of the experiences in close relationships scale. Mallinckrodt B, Wang C. 3, s.l.: Journal of Counseling Psychology, 2004, Vol. 51.

12. Cross-cultural adaptation and psychometric properties’ evaluation of the modern standard Arabic version of Cumberland Ankle Instability Tool (CAIT) in professional athletes. Korakakis, V Abassi, M Kotsifak, A Manai, H AbuEsba, A 6, San Antonio, Texas: PLoS ONE, 2019, Vol. 14.

13. Spanish Version of the Family Health Behavior Scale: Adaptation and Validation. Lanzarote-Fernandez, M Lozano-Oyola, J Gomez-de-Terrenos-Guardiola, M Vaviles-Carvajal, I Martinez-Cervantes, R Palcic Moreno, J. 5, s.l.: Int J Environ Res Public Health, 2019, Vol. 16.

14. The Spanish version of the Cultural Competence Assessment (CCA-S): Trancultural validation study and proposed refinement. Raigal-Aran, L Ferre-Grau, C Belzunegui-Eraso, A. Tarragona, Spain: Nurse Education Today, 2018, Vol. 72.

15. Efective Recruitment and Retention of Minority Research Participants. Yancy, A Ortega, A Kumanyika, S. Los Angeles, California: Annu. Rev. Public Health, 2006, Vol. 27.

16. Spechbach, H Gerlach, J Karker, S Tsourakis, N Combescure, C Bouillon, P. A Speech-Enabled Fixed-Phrase Translator for Emergency Settings: Crossover Study. Journal of Medical Internet Research. [Online] May 7, 2019. [Cited: July 1, 2019.]

17. Lee, J Pérez-Stable, E Gregorich, S Crawford, M Green, A Livaudais-Toman, J Karliner, L Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. Journal of General Internal Medicine. [Online] February 9, 2017. [Cited: July 1, 2019.]

(Video) Using Technology to Help Limited English Proficiency People

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What is LEP in translation? ›

If English is not your primary language and you have difficulty communicating effectively in English, you may need an interpreter or document translation in order to have meaningful access to programs funded by the Department of Health and Human Services (HHS).

What does LEP requirements include? ›

Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English can be limited English proficient, or "LEP." These individuals may be entitled language assistance with respect to a particular type or service, benefit, or encounter.

What is a limited English proficiency LEP plan? ›

LEP persons are those whose proficiency in speaking, reading, writing, or understanding English, as a result of national origin, is such that it would deny or limit their meaningful access to programs and services provided by the Department if language assistance were not provided.

How does an agency evaluate its current limited English proficiency LEP practices? ›

The four-factor analysis considers: (1) the number or proportion of LEP persons eligible to be served or likely to be encountered by the program; (2) the frequency with which LEP individuals are exposed to the program; (3) the nature and importance of the program, activity, or service provided; and, (4) the resources ...

Is LEP considered a disability? ›

Through the Americans with Disabilities Act (ADA) and Section 504, the protections apply equally to LEP individuals with disabilities or that are Deaf or hard of hearing (HOH). There are also many assistive technical (AT) devices that are available to LEP individuals with disabilities.

What are the LEP levels? ›

Most LEP students had an intermediate, early fluent, or fluent proficiency level. There were few differences in the proficiency levels of LEP students across the five IELA domains, with more than half of students at the early fluent/fluent level in each domain.

What is the LEP four factor analysis? ›

The four-factor analysis provides HUD a framework by which it may look at all the programs and services that the recipient provides to persons who are LEP to ensure meaningful access while not imposing undue burdens on recipients.

Why do I have LEP? ›

Why did I get a notice about the LEP? If you have been without creditable drug coverage for more than 63 days while eligible for Medicare, you may face an LEP. The purpose of the LEP is to encourage Medicare beneficiaries to maintain adequate drug coverage.

Why is it important to offer language assistance to individuals who have limited English proficiency or other communication needs? ›

Language can be a clear, profound barrier to health literacy. Language barriers and the inability to read or understand health information can pose serious health risks to individuals with limited English proficiency (LEP).

How long does it take for LEP students to learn English as a second language? ›

According to a recent study conducted by Stanford University, in two California districts that are considered the most successful in teaching English to “limited English proficiency” (LEP) students, oral proficiency takes 3 to 5 years to develop, and academic English proficiency can take 4 to 7 years.

Who are the limited English proficient students? ›

A “Limited English Proficient Student” is defined in Rule 6A-6.0901(1), FAC, as “a student whose home language is one other than English as determined by a home language survey and whose English aural comprehension, speaking, reading, or writing proficiency is below the average English proficiency level of English ...

Who enforces LEP rules? ›

Who will enforce the LEP rules? Most federal agencies have an office that is responsible for enforcing Title VI of the Civil Rights Act. To the extent that a recipient's actions are inconsistent with their obligations under Title VI, then such agencies will take the necessary corrective steps.

Does not speaking English qualify for disability? ›

It is important to note that being unable to communicate in English is not a disability in itself. It is only a factor that may increase your odds of approval for disability benefits if you are disabled and unable to work due to a certain medical condition.

What are LEP patients? ›

Nearly 25 million people in the United States (8.6 percent) are defined as limited English proficient (LEP), meaning that they speak English less than "very well." 5 Therefore, at least 8.6 percent of the U.S. population is at risk for adverse events because of barriers associated with their language ability.

Why the term LEP is problematic? ›

The LEP label implies that, regardless of how many languages a student may speak, or whatever other abilities and talents they may have, their “limited English proficiency” makes them inadequate, not only with language, but also academically.

What are examples of ELL accommodations? ›

Some accommodations to provide for ELL students in reading include reduced reading load, vocabulary instruction, pre-reading strategies, graphic organizers, and reading strategies.

What are some examples of accommodations that are provided for Ells on assessments? ›

Give multiple-choice tests. Give open-book tests. Instruct student to define/explain/summarize orally in English or in the home language (whenever feasible). Have student compare and contrast orally and in writing.

What are the 3 levels of English language proficiency? ›

The CA ELD Standards define three proficiency levels—Emerging, Expanding, and Bridging*—to describe the stages of English language development through which ELs are expected to progress as they improve their abilities in listening, speaking, reading, and writing English.

How do you test English proficiency? ›

You can register to take the TOEFL at your nearest test centre or at home. The test is administered up to six times a week at test centres or at home. The International English Language Testing System (IELTS) is widely recognized by universities and employers around the world.

What does active learning mean for LEP students? ›

Active learning is an approach to instruction that involves actively engaging students with the course material through discussions, problem solving, case studies, role plays and other methods.

What are the 3 purposes of factor analysis? ›

To definitively understand how many factors are needed to explain common themes amongst a given set of variables. To determine the extent to which each variable in the dataset is associated with a common theme or factor. To provide an interpretation of the common factors in the dataset.

What does not limited English proficient mean? ›

Limited English proficiency (LEP) is a term used in the United States that refers to a person who is not fluent in the English language, often because it is not their native language.

What does a factor analysis tell you? ›

Factor analysis is a technique that is used to reduce a large number of variables into fewer numbers of factors. This technique extracts maximum common variance from all variables and puts them into a common score. As an index of all variables, we can use this score for further analysis.

How do you get out of LEP? ›

Part D Late Enrollment Penalty Reconsideration Request Form

An enrollee may use the form, “Part D LEP Reconsideration Request Form C2C” to request an appeal of a Late Enrollment Penalty decision. The enrollee must complete the form, sign it, and send it to the Independent Review Entity (IRE) as instructed in the form.

Can LEP be removed? ›

Eliminating the Part D LEP

If you receive Extra Help, your penalty will be permanently erased. If you are under 65 and have Medicare, your LEP will end when you turn 65. If you qualify for a state pharmaceutical assistance program (SPAP), it may pay your penalty for you.

How many LEP people are in the US? ›

In 2015, the U.S. Census Bureau American Community Survey indicated that more than 25 million people had limited English Proficiency (LEP), which accounts for 9% of the U.S. population that is aged five years and older.

What is the importance of English proficiency skills and why it is important? ›

Commonly used in over 100 countries by more than 300 million people as a first language and by over 600 million as a second language, English is a “global language,” the “lingua franca of the modern era.” English skills are necessary for any country to fully benefit from global commerce; access the latest science, ...

How long does it take for English language learners to learn English? ›

A beginner can learn English in a year. That's pretty fast, although not as fast as some of the crazy 15-day promises you see online. Specifically, a year is the average amount of time it will take an adult to become fluent enough to work in English if he starts out as a beginner and studies at least 5 hours a day.

How long does it take to become proficient in a second language? ›

The next and most accurate answer is that it can take anywhere between three months to two years to learn how to speak, write, and read in a new language fluently.

How many hours does it take to become fluent in a second language? ›

According to FSI research, it takes around 480 hours of practice to reach basic fluency in all Group 1 languages.

What is an LEP plan? ›

The Department's LEP Plan serves as guidance for POs in helping to ensure meaningful access to programs and services conducted by the Department for persons who, as a result of national origin, are limited in English proficiency.

What is the highest score in English proficiency test? ›

Each section of the TOEFL test has a score range of 0 to 30, so the maximum score that you can achieve is 120.

What are the factors that affect the English proficiency of students? ›

Students with positive attitudes and high motivation level will be successful in second language learning while students with negative attitudes tend to be judgmental and ethnocentric towards the target language, making them unsuccessful in second language acquisition (Gardner & Lambert, 1972).

What are the laws around providing access to interpreters for LEP patients? ›

Under both Title VI of the Civil Rights Act and Executive Order 13166, federal entities must provide interpreter services for LEP individuals. This includes healthcare organizations receiving federal funds, such as through Medicare or Medicaid/CHIP.

What does LEP stand for in cultural competence? ›

Low English Proficiency

• LEP persons are individuals who do not speak English as their primary language and have a limited ability to read, speak, write or understand English. • LEP is associated with poorer health outcomes among Latinx, Asian Americans, and other ethnic minorities across the United States.

How do you talk to someone with a limited English proficiency? ›

use jargon, slang, acronyms, or specialized words. Use simple words that are easily translated. Also keep in mind that there may be many dialects associated with a language. Try to add expression and use appropriate pitch in your voice.


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