Spanish Translation of the Global Appraisal of Individual Needs (GAIN) Instruments - Methods, Challenges, Training, and Implementation

Spanish Translation of the
Global Appraisal of Individual
 Needs (GAIN) Instruments

  Methods, Challenges, Training,
      and Implementation
      Janet C. Titus, Liliana Bedoya
      Lucila Jiménez, Luis E. Flores,
         Diana P. Esquivel, and
             Marjorie L. Blair

Acknowledgments

‘ The development of the Spanish language GAIN
  (VGNI; Valoración Global de Necesidades
  Individuales) was supported by the Center for
  Substance Abuse Treatment (CSAT) through a
  technical assistance subcontract (270-2003-
  00006).
‘ Core Translation Advisory Group (presenters)
‘ Dharma Cortés and back translation team
‘ Serving Children and Adolescents in Need, Inc.
  (SCAN) organization and staff

How do we refer to the
Spanish-Speaking Population?
‘No good answers
‘Our group decided on “Hispanic”.
‘Hispanic – Individuals who live in the
 United States and who trace their families’
 backgrounds to (or were themselves born
 in) Spain or one of the Spanish-speaking
 nations of Latin America.
‘Significant differences between subgroups!

Substance Abuse Assessment
 in the Hispanic Population

     Liliana Bedoya, B.S.
    Chestnut Health Systems
       Bloomington, IL

Hispanic Population in the USA

‘12.5 percent of US population
  – Mexican origin         7.4 %
  – Puerto Rican origin    1.2 %
  – Cuban origin           0.4 %
  – Other (Dom., C/S Am.) 3.4 %
‘Fastest growing minority group in U.S.

Demographics

‘ Great diversity between groups
‘ Young population – median age 26 years
‘ Median Income - $33,000
‘ Education – higher drop-out rates, less likely to
  graduate from high school, more likely to have
  less than a 5th grade education
‘ Employment – less likely professional positions,
  unemployment 1.5 – 2 times national average
‘ Family structure – less likely headed by couple
‘ Language at home – over 75% speak Spanish

Cultural Values

‘Allocentrism
‘Simpatía
‘Familismo
‘Personalismo
‘Respeto
‘Machismo

Substance Use in the Hispanic
Population
‘ 38% lifetime use of illicit drugs (ages 12+)
‘ Diversity across groups –
   – lowest among Cuban (28%)
   – highest among Puerto Rican (46%)
‘ How rates compare - White (49%), African-
  American (44%), AI/AN (60%), and Asian (21%)
‘ Primary substances
   – General Hispanic population: alcohol, marijuana
   – Hispanic treatment admissions: alcohol, opiates,
     marijuana

Hispanic Adolescent
  Substance Use
‘ Lifetime use of illicit drugs (31%) and alcohol
  (45%), ages 12-17
‘ No diversity between Hispanic subgroups in
  overall illicit drug use and alcohol use
‘ How rates of lifetime illicit drugs use compares -
  White (31%), African-American (30%), AI/AN
  (47%), and Asian (32%)
‘ Marijuana is primary illicit substance (19%);
  highest use among Cuban adolescents (25%)
‘ School population – Hispanic students’ use of
  illicit drugs highest among all racial/ethnic groups,
  levels off over time

Treatment Barriers in Hispanic
Communities
‘Socioeconomic Factors
    –   Lack of health insurance
    –   Low socioeconomic status
    –   Collectivist attitude
    –   Limited education
‘Cultural Variables
    –   Fatalism
    –   Spirituality
    –   Familism
    –   Language proficiency

Treatment Barriers in Hispanic
Communities, continued
‘Psychotherapeutic Challenges
  – Client-provider relationship
  – Lack of culturally sensitive instruments
  – Language barriers

Need for Substance Use
 Assessments in Spanish
‘ Very few instruments have been translated.
‘ Most validated and normed only on non-Hispanic
  white populations.
‘ Most are epidemiological rather than treatment-
  oriented.
‘ Do not provide diagnostic info, ASAM placement,
  DSM/ICD diagnoses
‘ Need to address cultural issues (e.g., acculturation,
  values) that impact treatment and recovery.
‘ Translating “on the fly” is unreliable - quality of
  translation affects results, including whether
  someone is diagnosed correctly.

GAIN Family of Instruments

‘ Created for both treatment and research
‘ Instruments for treatment intake, follow-up,
  collateral, screening, targeted treatment
‘ DSM/ICD diagnoses, ASAM placement
‘ Study/State/Federal reporting (e.g., GPRA)
‘ Treatment planning
‘ Change in functioning, service utilization, and
  other outcomes
‘ Economic cost and benefits of treatment
‘ Evidence of scales’ psychometric integrity

Methodological Features

‘ Adolescents and adults - norms available across
  age groups and levels of care
‘ Most comprehensive is GAIN-I - 103 scales with
  demonstrated reliability, validity, shared
  data/syntax, used in over 100 sites
‘ Modularized - can use all or parts of it and
  transfer data (e.g, from screener to full
  assessment)
‘ Training and certification program, technical
  assistance/support
‘ Minimal out of pocket costs - most resources
  used to support staff development

Administration Features

‘ Paper-n-pencil or computer-administered
‘ Computerized scoring
‘ Reports: narrative interpretative, intervention-
  specific, validity, re-keying
‘ Different versions take from 20 to 120 minutes
‘ Used in many settings
‘ Administrated by paraprofessional
‘ Professionals can use/interpret it with minimal
  additional information

Translation Methodology of
  the Spanish Language
    GAIN Instruments

     Janet C. Titus, Ph.D.
    Chestnut Health Systems
       Bloomington, IL

Goals of the Spanish
Translation Project
‘ Create and field test a transdialectical Spanish
  version of the GAIN family of instruments;
  instruments should be culturally equivalent to
  original versions (maintain the original
  content and intent of each item in each
  culture).
‘ Add items pertinent to Hispanic populations
  (e.g., acculturation)
‘ Develop computer administration software
‘ Develop supportive materials (e.g., narrative
  reports, profiles, treatment-specific reports)
‘ Develop training materials

Translation Methodology

1. Translation model
2. Translator(s)
3. Testing of the instrument

Translation models

‘One-way translation (forward)
   Original Language            Target Language
‘Two-way translation
   Original Language            Target Language
   Reconcile Differences in Original Language Versions
‘Translation by committee
‘Decentering
‘Mix of the above

Translators

‘Professional bilingual translator familiar
 with the field
‘Learned Spanish and English at different
 times and in different cultures
‘Native language should be the language
 that the instrument is translated to
‘Will be instructed in the instrument’s
 domains, how the instrument will be used,
 and asked to follow a set of specifications

Pre-Testing the Instrument

             Translation Probe
‘Field test with cognitive interview
‘Bilingual individuals answer both
‘Performance checks (behaviors only)
‘Evaluation by experts
‘Note - This step can go on for several
 iterations if necessary

GAIN Spanish Translation
Methodology
‘Two-way translation model
‘Translation by committee (forward and
 back)
‘Forward translation group
  – Professional translator in field (native
    language Spanish; learned languages in each
    culture)
  – Members who represent at least 1 of 3 major
    Spanish-speaking groups in U.S. -- Mexican-
    American, Puerto Rican, Cuban-American
  – Knowledge of the field
  – Familiar with GAIN

GAIN Spanish Translation
Methodology, continued
‘Back translation group
  – Professional translator in field (native
    language English; learned languages in each
    culture)
  – Members who represent several Spanish-
    speaking groups in the U.S.
  – Knowledge of the field
  – NOT familiar with GAIN
‘Alpha test
  – Test of forward translation (while waiting for
    back translation)

GAIN Spanish Translation
Methodology, continued
‘Reconciliation of English versions
‘Translation probe
  – Field test with cognitive interviewing
  – Edit instrument and retest if necessary
‘Beta test with volunteer sites
‘Release first version to field

Translation Advisory Group
 (Forward Translation TAG)
                       Core TAG
‘ Forward translator + 5 members (grantees, CHS)
‘ Translator led translation with input from all others.
‘ Accessed wide array of resources.
‘ Identified problematic language prior to and
  throughout; added subgroup-specific language.
                       Full TAG
‘ Core TAG with grantees and professionals not
  associated with project
‘ Review and offer input on forward translation, first
  field test version, pilot version, future revisions.

Back Translation

‘Back translation team creates English
 version from Spanish translation
‘Core TAG compares English back
 translation with original English version
‘Core TAG and back translation team meet
 to resolve conceptual and language
 discrepancies and adjust Spanish language
 parallel to discrepancies.
‘Full TAG reviews

Translation Probe

‘Volunteer sites
‘Interviewers are GAIN-certified, assessed
 on skill and comfort of using both
 languages, trained on the use of the
 Spanish instrument.
‘Each site administers the assessment to 4
 bi/monolingual clients who choose to
 complete the Spanish instrument and
 translation probe; audio-taped.

Translation Probe, continued

‘Interviewer records problems with words,
 items, concepts.
‘Cognitive interview
  – Redo 1-2 sections only
  – Client paraphrases what items are saying.
‘Transcribe comments on items with
 misunderstandings, questions, answers
 changed.
‘TAG makes any necessary changes.

Beta (Pilot) Test

‘ Volunteer sites – grantees and others
‘ Training on its use
‘ Use it like any other GAIN instrument (i.e.,
  enter data, etc.).
‘ Send data to us and we analyze; adjustments
  made based on feedback and analyses.
‘ Iterative process if needed
‘ The outcome of the beta test is the birth of
  the….

First Version Released to Field

Valoración Global de Necesidades
  Individuales – GAIN-Inicial
           (VGNI-I)

Current Status

‘Forward translation done
‘Back translation and reconciliation done
‘Recruitment of sites for translation probe
 and beta testing is underway
‘Creation of computer-assisted software,
 supportive materials, training modules are
 underway.

Next Steps

‘Complete translation probe, beta test,
 distribute first generation version, refine
 over time
‘Develop remaining materials
‘Psychometric evaluations
‘Comparative studies

For Further Information

‘Visit our website at
 www.chestnut.org/LI/GAIN for
 information and files to download
 (including the instrument)
‘Contact Dr. Janet C. Titus at Chestnut
 Health Systems (jtitus@chestnut.org)
‘These slides are at
 www.chestnut.org/LI/Posters

Linguistic Challenges in
 Translating the GAIN

 Lucila Jiménez, M.A., MPhil.
   Harlem Hospital Center
        New York, NY

To Translate or Not to
Translate?

‘IDEAL: Design instruments for
 cross-cultural use
‘COMMON: Instrument designed in
 one culture, then translated and
 modified for use in other cultural
 groups.

“Meaningful” vs. Literal
Translations
‘Are language versions cross-
 culturally comparable? Do they
 measure the SAME constructs?

‘TRANSLATION GOAL:
 COMPARABILITY

Cultural Equivalence

‘SEMANTIC: meaning
‘CONTENT: relevance to population
‘TECHNICAL: reading skills, level of self-
 disclosure
‘CRITERION: interpretable within norms
 of culture
‘CONCEPTUAL: theoretical construct

Limitation of the Translation
Approach to Cross-Cultural
Comparisons
 Item coverage may be specific to
 setting, for example, it may reflect …
  – Theoretical orientation of
    developers
  – Composition of original sample:
    patients vs. community, ethnic
    groups, etc.

Challenges Encountered During
the GAIN Translation Project
‘Subgroup differences
‘No (or no clear) Spanish translation
‘English idioms
‘When to retain English
‘Spanish conventions
‘Technical language
‘Response choices
‘Terms generating much discussion

Subgroup Differences

Have your ever      ¿Ha tenido
had the following   alguna vez las
childhood           siguientes
diseases?           enfermedades de
                    la niñez?
Mumps               Paperas
                    (Farfallota)

Subgroup Differences,
continued
…moderate             …actividades
activities like       moderadas como
moving a table,       mover una mesa,
carrying              cargar comestibles
groceries, or light   (mandado, la
sports?               compra), o
                      participar en
                      deportes ligeros?

No (or No Clear) Spanish
Translation
‘Because alcohol or ‘Porque el uso de
 drug use is           alcohol o drogas
 becoming less         está menos de
 “cool.”               moda (“less cool”).
‘Feeling very         ‘Sentirse atrapado,
 trapped, lonely,
                       solo, triste,
 sad, blue,
 depressed, or         deprimido o sin
 hopeless about the    esperanza acerca
 future.               del futuro.

English Idioms

‘ …you daydreamed ‘ ...soñó despierto o
  or tried to space out trató de desconectarse
  the world a lot.      del mundo con
                        frecuencia.
‘ …gotten in trouble ‘ ...se metió en
  for being too “loud”  problemas por ser
  when you were         muy ruidoso o
  playing or relaxing.  escandaloso cuando
                        estaba jugando o
                        descansando.

English Retained

‘ “Foster home”,      ‘ “Hogar substitutos”,
  “foster parents”,     “padres substitutos”, y
  and “foster care”     “bajo el cuidado de
                        padres substitutos”

‘ “Parole officer”    ‘ “Oficial de libertad
                        condicional”

‘ “Case manager”      ‘ “Manejador de caso

Spanish Conventions

John / Brown / 42 / Mark Street / Detroit
Juan / Pérez / Calle Marco / 42 / New York
-----------------------------------------------------
Tú vs. Usted – we chose Usted
-----------------------------------------------------

Technical Language

‘ Language related to drug use/treatment,
  mental health, legal status, physical health,
  etc.
‘ Examples – Levels of treatment, DSM
  diagnoses, legal terms like “probation
  officer”, ICD diagnoses
‘ Most of this information was found on the
  Web.
‘ We have created a “dictionary” for
  interviewers with Spanish technical terms
  defined in Spanish.

Response Choices:
Same Spectrum?
‘“Always”, “Frequently”, “Half the
 Time”, “Sometimes”, and “Never.”

                 VS.

‘“Siempre,” “Frecuentemente,” “La mitad
 de las veces,” “Algunas veces”, y
 “Nunca”

Terms Generating Much
Discussion
‘Counseling: “Consejería” vs.
  “Psicoterapia”

‘Internal Distress: Distrés Interno

‘Partner: “Compañero” vs. “Pareja”

Back Translation –
How Has It Helped?
‘Confirmed the quality of the semantic
 translation.
‘Identified Spanish text that was translated
 “too literally”.
‘Identified Spanish translation errors such
 as wrong tenses of verbs (can change the
 meaning of an item).
‘Identified changes for the original English
 version.

Schreibner’s Checklist:
How Good is the Translation?
‘Omissions         ‘Grammar
‘Format            ‘Punctuation
‘Mistranslations   ‘Clarity
‘Unknown words     ‘Consistency
‘Meaning           ‘“Sound-alike”
‘Spelling           words
                   ‘Style

Resources Consulted

‘Translation Advisory Groups
‘Other Substance Abuse instruments in
 Spanish
‘Web sites – e.g., CSAT, NIDA, NIAAA,
 program sites, info from Spanish-speaking
 countries
‘Dictionaries

Development of Training on
   the Use of the VGNI

Luis E. Flores, M.A., LPC, LCDC, RPT-S
    Serving Children and Adolescents
          in Need, Inc. (SCAN)
                Laredo, TX

VGNI Training Issues: KSA’s

                  Goal of VGNI:
 Capture accurate information in a culturally and
 linguistically relevant manner in order to provide
             quality care for participants

Assessing Administrator’s
 Language Skills

‘ Level of Spanish proficiency
‘ Ability to understand local usage
‘ Using sensitivity when assessing administrator’s
  skills
      • Self-assessment
      • Use of tapes
      • Determine training needs

Knowledge of Target Population

‘ Understanding the culture
‘ Language differences
‘ Local drug terms

Assessing Client’s Language
Needs
‘ Language ability
‘ Language preference (at home, with friends; self-
  reported)
‘ Language use

Selection of Instrument(s):
To GAIN or To VGNI…

VGNI vs. GAIN

‘Highly acculturated kids
‘Low acculturated, recent immigrants
‘Most youth are bilingual with varying
 levels of conventional language
 proficiency and language use.
‘Ethnicity does not dictate instrument
 choice, but rather, language needs.

VGNI-GAIN Challenges

The most significant challenge is to collect accurate
  information from Hispanic bilingual youth with
      varying degrees of language proficiency.

Ability to Communicate Based
on Client’s Needs
‘Usted vs. tú
‘Use of parentheses
‘Ability to match
 client’s language
  –   Code-switching
  –   Using slang words
  –   Using Spanglish words
  –   Regional words

Whatever the Client Understands

‘Code-switching
    • Entonces la teacher te dijo que no podías ir
      al bathroom.
    • Ya no quieres usar, but is kind of hard to
      stop.
‘Slang Words
    • Estabas bien agüitado (you were very
      down, sad depressed).
    • La droga que mas te gusta es la soda, pero
      usas mas la mota.

Examples

‘ Use of Spanglish
   – Quitear for quitting
   – Parkear for parking
   – Ponerlo pa’ tras for putting it back
‘ Use of words in English
   –   El probation officer
   –   Mis foster parents
   –   La teacher
   –   Food stamps
   –   Cool
   –   Pimp

Words Appropriate for
Particular Groups

‘Carro, coche, auto, máquina for car
‘Autobus, guagua, camion for bus
‘Lentes, gafas, espejuelos for glasses
‘Padrote, chulo for pimp

Socioeconomic/Political Issues

‘Poverty
  – recreation and leisure
  – living arrangements
  – transportation, immigration

Recommendations for
Qualified Administrators
‘Personalismo: use of breaks, introductions,
 warmth
‘Matching client language
‘Usted and Tú adjustments
‘Explain and clarify in the client’s identified
 language(s); watch for acquiescence,
 confusion.
‘Ask and learn.

Other Issues/Needs

‘Lack of qualified bilingual clinicians
  – Train paraprofessional staff such as
    community health workers.
‘Matching ethnicity when possible

Lessons Learned from the
 Alpha Implementation
      of the VGNI

       Diana Esquivel, B.A.
 Serving Children and Adolescents
       in Need Inc. (SCAN)
           Laredo, TX

Alpha Implementation

‘ While waiting for the back translation of the
  VGNI, we implemented the forward translation at
  several volunteer sites who serve Spanish-
  speaking adolescents.
‘ The goal of the administrations was to get early
  feedback on the quality of the translation.
‘ This presentation focuses on information learned
  from its administration at a social service agency
  in Laredo, TX.

Using the GAIN in Laredo, Texas

 Serving Children and
 Adolescents in Need (SCAN)
‘Non-profit organization that focuses
 on fostering the healthy development
 of families in communities along the
 Texas-Mexico Border region
‘Operates various programs addressing
 substance abuse, homelessness,
 developmental disabilities, running
 away behaviors, and child abuse and
 sexual assault
‘Provides prevention, intervention,
 outpatient and residential treatment,
 shelter and advocacy services, and
 community-building strategies

Using the GAIN in Laredo, Texas,
continued
SCAN, Inc. focused its efforts on assessing
the effectiveness of the drug treatment
programs offered by the agency.
  –Staff administered the GAIN to a 99%
   Hispanic population.
  –To meet the linguistic needs of every client,
   program staff administered the GAIN by
   directly translating the content into Spanish.
  –PROBLEM- Items and valid responses may
   have been lost in the translation.

Administering the English GAIN
to a Spanish-Speaking Population
‘148 participants between the ages of 13
 and 17
‘Approximately 75% of the assessments
 were administered using code-switching.
‘Approximately 10% of the assessments
 were administered completely in Spanish.
‘Any necessary Spanish translations were
 done “word for word”.

Use of Code-Switching

‘Each item was asked verbatim in English,
 then certain phrases were translated
 directly into Spanish.
‘Phrases were translated into regional
 Spanish and local slang terms to ensure
 participants understood the content.
‘Staff listened and monitored participant’s
 responses to ensure understanding.

Implementation of the VGNI

‘Determine Spanish skills of interviewer
 and comfort using VGNI
‘Assess language needs of participant
  –   Where are they from?
  –   How long have they been in the States?
  –   What language do they speak at home?
  –   What is their language preference for
      completing the interview?

Participant Demographics

‘Alpha testing
  – 8 participants
  – 3 participants were assessed fully in Spanish
  – 5 participants were assessed using code
    switching
  – 14 to 17 years old
  – Resided in the United States on average 9
    years
  – Spoke only Spanish at home
  – Considered English their second language

Participant Feedback

‘Some items are difficult to understand.
    – Items on custody, legal problems, vocation
    – Items on mental health
‘ Some words are difficult to understand.
  – Desempeño, Perturbaron, Reside, Seguimiento
  – Préstamo estudiantil
‘ It takes too long.
‘ Uncomfortable being referred to as Usted
 (respectful form of you) as opposed to Tú
 (casual form of you)

Interviewer feedback

‘ Interviewers were mostly comfortable
   conducting the interview in Spanish.
‘ The VGNI took longer than the GAIN.
‘ Some of the Spanish terminology/items
   used in the VGNI were too difficult for
   clients to understand.

Interviewer feedback, continued

‘They would prefer to use “tu” rather than
  “usted”.
‘They would prefer more colloquial terms
  in the VGNI.

Benefits of the Spanish
Assessment

‘Clients were more comfortable speaking in
  their preferred language.
‘The ability to match the participants’
  language allowed better comprehension
  and therefore the collection of more
  accurate data.

Group Discussion