IPA's commitment to the development of more culturally appropriate
tests for various countries, including the United States, addresses an
important issue. At present, I believe there are considerable cultural
biases associated with many existing instruments, which adversely affect
the diagnosis and effective care of older patients who may be unlike the
samples with which these measures were developed. Of equal concern, there
is a lack of proper normative data available to be used in reaching meaningful
judgments and conclusions about the assessment and care of patients from
various cultural or language groups.
Working in a diverse community, comprised of a large number of elderly
individuals, has presented challenges to University of Miami neuropsychological
and geriatric assessment teams in the development of culturally fair tests.
For instance, one of the crucial steps in the appropriate translation of
test instruments is the pretranslation, the back-translation, and the committee
translation by a group of people fluent in the language the tests are to
be translated into (based on a modification of Brislin’s [1970,1980] procedure
as fully described in Loewenstein et al. [1994]). A further step is to
evaluate interrater and test-retest reliabilities, as well as concurrent,
construct, and discriminative validates. This is important in establishing
that the translated material is properly translated and has good reliability
and consistency across raters and over time. Moreover, studies of validity
allow researchers to determine whether the test actually measures what
it is purported to measure.
As an example of an instrument useful in cross-cultural assessment,
the development of the Direct Assessment of Functional Status (DAFS) scale
deserves mention. This instrument provides a measure of objective, behaviorally
based performance across a wide array of actual functional tasks required
for daily living. (The functional tasks include telling time, using the
telephone, counting money, writing a check, balancing a checkbook, making
change for a purchase, shopping for groceries with a written list, eating
, dressing, and grooming.) This instrument, first published in the Journal
of Gerontology (Loewenstein et al., 1989), evidences excellent reliability
and validity and is not influenced by any biases which may be inherent
to the subjective reports of dementia patients and their caregivers. Importantly,
the DAFS was published in professional scientific journals and was made
available in the public domain so it could be used by any interested scientist
or clinician. The intent was to advance knowledge and to help geriatric
patients from various ethnic and cultural groups receive better diagnostic
information, which would ultimately result in better clinical practice
and better care for these older patients.
The effort to make the scale more accessible has been successful in
that the DAFS scale has been translated into six different languages, is
used in research funded by the National Institute on Aging and by the National
Institute of Mental Health (USA), and is employed in university, research,
and clinical settings internationally. A prominent pharmaceutical company
has used the DAFS scale for international drug studies, and the University
of Miami Department of Psychiatry, in collaboration with the Wien Center
at Mount Sinai Medical Center, has distributed 450 manuals to people around
the world so that the instrument can be administered by interested professionals
in a more standardized fashion. Zanetti’s group recently (1995) reported
that caregivers were inaccurate in their estimates of patient impairment
on various subtests of the modified Italian DAFS scale based on our earlier
work with English speakers. This is an excellent line of research, but
there remains considerable work to be done. Deriving different cut-points
for impairment is a crucial element of these modified DAFS tests (Loewenstein
& Rubert, 1992, 1995).
Turning to another assessment tool, we have reported (Loewenstein et
al., 1995) that the Fuld Object Memory Evaluation (OME) is culturally fair
for both English-speaking and Spanish-speaking elderly Cuban-Americans,
and the instrument has been modified for use in different Latin American
countries as well as Europe. Further, other groups have found the Fuld
OME to be culturally fair for other diverse populations. The instrument
requires the subject to identify 10 common household items by touch and
sight, so education and cultural background tend to exert minimal biases.
Unfortunately, as found by Lopez and Taussig (1991) and Loewenstein
et al. (1993), commonly used tests of cognitive and neuropsychological
function are frequently biased for a number of Spanish-speaking groups.
Some measures are simply not salient or meaningful to these groups and
should be discarded, or new tests should be devised when working with these
populations. Some tests require modification, while others simply require
statistical adjustments and a much greater array of normative data.
The DAFS scale has been successful in large part because an administration
and the instruction manual is readily available in the public domain. Major
testing companies, however, have copyrighted their test materials, and
usually they cannot be translated into actual forms without a company’s
written permission. When translations are allowed, exporting them to outside
clinicians and laboratories is frequently discouraged. It has been my understanding
(as a psychologist, not an attorney) that while it is acceptable to many
companies that copyrighted test materials be translated by test examiners
as they go along, an attempt to create a written version of these translations
could be a potential infringement of copyright law. As a result, standardized
administration of tests that are critical for accurate assessment and treatment
may be subject to significant error because of the individual variability
in translating test instructions and the wide variations in bilingual language
proficiencies.
At present, there are a number of translations of widely used test instruments
that have been merely translated and disseminated to other laboratories.
Unfortunately, the process of good formal back-translation and committee
translation, as well as reliabilities and validities of these measures,
are frequently not established. Equally important is an appreciation that
Cuban-Americans, Puerto Rican-Americans, Mexican-Americans, and people
from a wide array of Latin American and other Spanish-speaking countries
represent different cultural groups and different idioms and variations
in language usage. A test normed on one particular group does not automatically
generalize to other Spanish-speaking populations; tests normed on cultural
groups in the United States do not automatically generalize to country-of-origin
populations.
To address this important issue, perhaps IPA could work toward identifying
more instruments used with older adults that are in the public domain and
could collaborate with major test publishers. This effort could be a joint
venture to identify populations that could open new markets to test publishers,
with IPA encouraging the highest degree of quality control in the course
of making tests available.
In the final analysis, the older adults that we geriatricians diagnose
and care for are worthy of no less than our best efforts.
David A. Loewenstein. PhD
Associate Professor of Psychiatry
University of Miami School of Medicine
Miami, Florida, USA
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research. Journal of Cross-Cultural Psychology, 1, 185-216.Brislin,
R.W. (1980). Translation and content of analysis
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