Improving comprehension and accuracy of health questionnaires using pictorial descriptions.

To the editor: The study of " Cross-cultural adaptation and health questionnaires validation: revision and methodological recommendations " by Ramada-Rodilla et al., 1 published recently in your journal, raises an important issue relevant to the health and well being of large groups within the population. Research, screening, and diagnosis of certain health problems rely heavily on written materials that require the patient's ability to understand and respond to health questionnaires and other written assessment tools. The accuracy and precision of these results might be compromised when low literacy exists, creating communication problems when participants respond to written consents, questionnaires, and/or screening tools. 2 The majority of these communication problems can be attributed to disparities caused by lower levels of education, lack of language proficiency, low literacy, and cultural differences. 3,4 As a result of these disparities, the needs of these groups are not well-understood and inconclusive and somewhat conflicting results exist among a large number of interventions that focused on identifying Cartas al editor and reducing disparity. It is possible that we are missing critical components necessary to substantially reduce the impact of these disparities, due to our inability to obtain accurate responses (e.g., true/false results) when using self-assessment screening tools. This assessment disparity issue likely contributes to evaluation differences obtained between and within ethnic groups, which affect the final results of surveys and interventions, and therefore impact health needs planning and early intervention strategies. While it is crucial to recognize the importance and need of cross-cultural adaptation in validating questionnaires , as well as adopting systematic processes to improve the assessment, it is also necessary to consider some potential disadvantages. Customizing a previously validated questionnaire requires full testing to determine its validity and reliability, which requires significant time and resources. After the new questionnaire has been created and tested, it is very possible that the results cannot be compared with the original data, thereby missing the opportunity of cross-comparisons. Additionally, customization might work only for a select group of individuals and for other groups validation is still required. There are a large number of screening tools that have already been translated into Spanish and have been standardized with available data from Spanish speakers. In these cases, one strategy that might help to keep the original translation without requiring cultural adaptation involves adding pictorial descriptions to the original written questions. In our studies, we found that by adding pictorial descriptions …