Semantics bias in cross-national comparative analyses: is it good or bad to have “fair” health?

Health and Quality of Life Outcomes, May 2016

The Health Behavior in School-aged Children is a cross-national study collecting data on social and health indicators on adolescents in 43 countries. The study provides comparable data on health behaviors and health outcomes through the use of a common protocol, which have been a back bone of the study sine its initiation in 1983. Recent years, researchers within the study have noticed a questionable comparability on the widely used item on self-rated health. One of the four response categories to the item “Would you say your health is….?” showed particular variation, as the response category “Fair” varied from 20 % in Latvia and Moldova to 3–4 % in Bulgaria and Macedonia. A qualitative mini-survey of the back-translations showed that the response category “Fair” had a negative slant in 25 countries, a positive slant in 10 countries and was considered neutral in 9 countries. This finding indicates that there are what may be called semantic issues affecting comparability in international studies, since the same original word (in an English original) is interpreted differently across countries and cultures. The paper test and discuss a few possible explanations to this, however, only leaving to future studies to hold a cautious approach to international comparisons if working with the self-rated health item with four response categories.

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Semantics bias in cross-national comparative analyses: is it good or bad to have “fair” health?

Schnohr et al. Health and Quality of Life Outcomes Semantics bias in cross-national comparative analyses: is it good or bad to have “fair” health? Christina W. Schnohr 0 Inese Gobina 2 Teresa Santos 1 Joanna Mazur 7 Mujgan Alikasifuglu 6 Raili Välimaa 5 Maria Corell 4 Curt Hagquist 9 Paola Dalmasso 8 Yeva Movseyan 3 Franco Cavallo 8 Saskia van Dorsselaer 10 Torbjørn Torsheim 11 0 Department of Public Health, University of Copenhagen , P. O. Box 2099, Copenhagen , Denmark 1 William James Center for Research/ Instituto Superior de Psicologia Aplicada-ISPA , Lisbon , Portugal 2 Department of Public Health and Epidemiology, Riga Stradins University , Riga , Latvia 3 Arabkir Medical Centre-Institute of Child and Adolescent Health , Yerevan 0014 , Armenia 4 Folkhälsomyndigheten , 830140 Östersund , Sweden 5 Department of Health Education, University of Jyväskylä , Jyväskylä , Finland 6 Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University , 34 303, Fatih, Istanbul , Turkey 7 Institute of Mother and Child , Kasprzaka 17a str., Warsaw , Poland 8 Department of Public Health and Paediatrics School of Medicine, University of Torino , Via Santena, 10126 Turin , Italy 9 Fakulteten för hälsa, natur- och teknikvetenskap, Karlstad University , 651 88 Karlstad , Sweden 10 P. O. Box 7253500, AS, Utrecht , The Netherlands 11 Institut for Samfunnspsykololgi, Kristie Bergiesgatan, Unversity of Bergen , Bergen , Norway The Health Behavior in School-aged Children is a cross-national study collecting data on social and health indicators on adolescents in 43 countries. The study provides comparable data on health behaviors and health outcomes through the use of a common protocol, which have been a back bone of the study sine its initiation in 1983. Recent years, researchers within the study have noticed a questionable comparability on the widely used item on self-rated health. One of the four response categories to the item “Would you say your health is….?” showed particular variation, as the response category “Fair” varied from 20 % in Latvia and Moldova to 3-4 % in Bulgaria and Macedonia. A qualitative mini-survey of the back-translations showed that the response category “Fair” had a negative slant in 25 countries, a positive slant in 10 countries and was considered neutral in 9 countries. This finding indicates that there are what may be called semantic issues affecting comparability in international studies, since the same original word (in an English original) is interpreted differently across countries and cultures. The paper test and discuss a few possible explanations to this, however, only leaving to future studies to hold a cautious approach to international comparisons if working with the self-rated health item with four response categories. Health Behavior in School-aged Children (HBSC); International comparison; Self-rated health; Measurement variance; Translation - Findings – The item on self-rated health is a widely used indicator of health status as well as a predictor of health outcomes. – International studies compare results from questionnaire surveys using the English version of self-rated health. – The present study documents how the item responses vary across languages, which is not noticed in an English back translation. – Hence, studies comparing self-rated health across different languages are likely to be affected by variation due to semantics bias. Introduction The Health Behaviour in School-aged Children (HBSC) is a large cross-national survey consisting of questionnaire data on adolescents from 43 countries in Europe and North America. The survey was initiated in 1983, and for more than 30 years, the HBSC has provided researchers and policy makers with important knowledge on young people’s health and health behaviour. Validation of items in relation to comparability is an ongoing process for all studies within public health research, and in particular for international studies. Thus, international studies should continuously work for improving the validity of their questionnaire, and doing © 2016 Schnohr et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. so by scrutinizing the translations of the items in use. Many studies within public health makes use of a general item on a person’s self perceived health, since it has shown to relate to various health behaviours, and has shown to be strongly associated to morbidity and mortality [ (...truncated)


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Christina Schnohr, Inese Gobina, Teresa Santos, Joanna Mazur, Mujgan Alikasifuglu, Raili Välimaa, Maria Corell, Curt Hagquist, Paola Dalmasso, Yeva Movseyan, Franco Cavallo, Saskia van Dorsselaer, Torbjørn Torsheim. Semantics bias in cross-national comparative analyses: is it good or bad to have “fair” health?, Health and Quality of Life Outcomes, 2016, pp. 70, 14, DOI: 10.1186/s12955-016-0469-8