Assessment of the Equivalence of the
Spanish and English Versions of the
Quality of Inpatient Care
sHospital Survey on the
Margarita P . Hurtado, January Angeles, Steven A. Blahut,
and Ron D. Hays
Objective. To describe translation and cultural adaptation procedures, and examine
the degree of equivalence between the Spanish and English versions of the Agency for
Healthcare Research and Quality’s (AHRQ) Consumer Assessments of Healthcare
Data Sources. Cognitive interviews on survey comprehension with 12 Spanish-
speaking and 31 English-speaking subjects. Psychometric analyses of 586 responses to
the Spanish version and 19,134 responses to the English version of the H-CAHPS
survey tested in Arizona, Maryland, and New York in 2003.
Study Design. A forward/backward translation procedure followed by committee
linguistically appropriate. Responses to the two language versions were compared to
evaluate equivalence and assess the reliability and validity of both versions.
Data Collection/Extraction Methods. Comparative analyses were carried out on
the 32 items of the shortened survey version, focusing on 16 items that comprise seven
composites representing different aspects of hospital care quality (communication with
nurses, communication with doctors, communication about medicines, nursing serv-
ices, discharge information, pain control, and physical environment); three items that
rate the quality of the nursing staff, physician staff, and the hospital overall; one item on
intention to recommendthe hospital.Theother 12items usedintheanalysesaddressed
mainly respondent characteristics. Analyses included item descriptives, correlations,
internal consistency reliability of composites, factor analysis, and regression analysis to
examine construct validity.
respect to item–scale correlations, factor structure, content validity, and the association
between each ofthe seven qualities ofcare composites with both the hospital rating and
intention to recommend the hospital. Internal consistency reliability was slightly, yet
significantly lower for the Spanish-language respondents for five of the seven compos-
ites, but overall the composites were generally equivalent across language versions.
r Health Research and Educational Trust
Conclusions. The results provide preliminary evidence of the equivalence between
the Spanish and English versions of H-CAHPS. The translated Spanish version can be
used to assess hospital quality of care for Spanish speakers, and compare results across
these two language groups.
Key Words. Survey translation and adaptation, patient survey, language equiva-
lence, hospital care quality, Spanish-language survey
The United States is an increasingly diverse country where 45 million people,
at home. Among the more than 35 million Hispanics/Latinos who represent
the largest minority group, approximately 28 million speak Spanish at home
(U.S. Census Bureau 2003). In addition to facing language and cultural bar-
riers, a large proportion of Latinos live below the poverty level and have low
literacy skills (Ramirez and De la Cruz 2002), placing them at increased risk
for receiving low-quality care. Disparities in access and quality related to
language and racial/ethnic differences have been consistently documented
(Smedley, Stith, and Nelson 2003), supporting the need for multiple language
versions of consumer surveys to accurately assess the quality of care received
by those whose main language is not English.
In this article, we describe the cultural adaptation and translation proc-
ess, and present the results of our analysis of the equivalence between the
English- and Spanish-language versions of the Consumer Assessments of
Healthcare Providers and Systems (CAHPS
of patient experiences with inpatient care. H-CAHPS was developed in re-
sponse to a hospital performance public reporting initiative launched by the
Centers for Medicare and Medicaid Services (CMS) and the Agency for
Healthcare Research and Quality (AHRQ) in 2002. It required the develop-
ment of a standardized survey instrumentthat would allow forcomparisonsof
quality of care across hospitals. H-CAHPS is a product of AHRQ’s CAHPS
program to develop surveys that capture patient experiences with health care,
design reports to present the results, and design quality improvement ap-
s) Hospital Survey (H-CAHPS
Address correspondence to Margarita P. Hurtado, Ph.D., M.H.S., American Institutes for Re-
search, 10720 Columbia Pike, Suite 500, Silver Spring, MD 20901. January Angeles, M.P.P., is
the American Institutes for Research when the article was submitted, is now with Olitzky Whittle
LLC, Marriottsville, MD. Ron D. Hays, Ph.D., is with the UCLA Department of Medicine/
Division of General Internal Medicine and Health Services Research, Los Angeles, CA.
Spanish and English Equivalence of the CAHPS
proaches based on the survey results. As was the case for the first CAHPS
Health Plan Survey (Weidmer, Brown, and Garcı ´a 1999), the CAHPS team
has developed a Spanish version of the hospital survey to allow users to
include the many Hispanics in the U.S. who mainly speak Spanish.
The goal of this article is to compare the measurement properties of
the Spanish and English versions of the H-CAHPS survey. We precede the
psychometric analysis with a brief description of the procedures used for the
survey translation and cultural adaptation, including a summary of the results
of the cognitive interviews used to test the conceptual equivalence of the
Spanish version of the H-CAHPS survey that preceded the field test. Unlike
some other studies that examine the measurement properties of a translated
survey instrument subsequent toand independentlyfromtheoriginalversion,
in this article we simultaneously assess and compare the measurement prop-
erties of the source English version with the translated Spanish version.
Development of the Spanish Version of the CAHPS Hospital Survey for the Pilot Study
The Spanish translation and cultural adaptation of the original English-lan-
guage H-CAHPS survey was conducted following an initial set of procedures
established by the CAHPS cultural comparability team. First, a professional
translator translated the questionnaire from English to Spanish. Second, an-
other independent professional translator, blinded to the original source
questionnaire, was provided with the Spanish translated version and asked to
back-translate it into English. Third, a professional translation reviewer ex-
amined the products of the two translations, provided comments on the
Spanishtranslation and notedproblemsidentifiedfrom thereview oftheback
translation and the original source document. Subsequently, a translation re-
view committee of bilingual researchers with experience in the development
of health surveys and translations examined the original Spanish translation
and the translation reviewer’s comments. The committee reviewed each item
with respect to the quality of the translation and its appropriateness for use
with culturally diverse Spanish-speaking populations. A consensus process
was used to agree on any changes to the items and, when appropriate, the
committee provided recommendations for decentering revisions to the Eng-
lish language source document that would result in a better translation and
adaptation of the survey. As part of the review, the committee also flagged
survey instructions and items that could be difficult for some respondents
2142HSR: Health Services Research 40:6, Part II (December 2005)
because of cultural differences, literacy level, or other reasons. These were
investigated using cognitive testing of the Spanish version and addressed by
modifying or deleting the problematic items.
The CAHPS Hospital Survey Pilot Study
The H-CAHPS survey was field tested in Arizona, Maryland, and New York.
A total of 132 hospitals volunteered to participate. The sample included adult
medical or surgical patients with at least one overnight stay, who were dis-
charged betweenDecember 2002 and January 2003, and were still alive at the
time of the survey; and, obstetric patients discharged between November
2002 and January 2003, who, along with the baby delivered, were still alive at
the time of the survey. Patients were excluded from the sample if they were
under 18 years old; were admitted for psychiatric or substance abuse treat-
ment, or for observational purposes; died or delivered a baby who died; or, if
they were not discharged to a home-setting after the hospital stay.
The data were gathered from the administration of the original 66-item
version of the survey, which was longer than the 32-item version analyzed
here. The 32 items were selected based on the results of the psychometric
analysis of responses to the English version, and other conceptual consider-
ations (Keller et al. 2005). Our analysis of responses to the Spanish version to
examine its measurement properties and equivalence to the English version is
items designed to measure seven domains of hospital quality——communica-
tion with nurses (three items), communication with doctors (three items),
communication about medicines (two items), nursing services (two items),
discharge information (two items), pain control (two items), and physical en-
vironment (two items). The other items are three rating items on the quality of
the nurses, of the physicians, and of the hospital overall; and one item meas-
uring the intention to recommend the hospital. Each report item is measured
using a four-point Likert-type scale ranging from ‘‘never’’ to ‘‘always,’’ while
Data Quality and Item Analysis. After taking into account validly miss-
ing responses because they did not apply to that respondent, we calculated
Spanish and English Equivalence of the CAHPS
Until recently, there were no standardized guidelines for survey trans-
lation and adaptation procedures, as noted in a recent review conducted by
the U.S. Census Bureau (2004). The cultural adaptation and translation of the
CAHPS surveys being developed to assess consumer reportsof qualityof care
at different sites including hospitals, physician offices, dialysis facilities, and
nursing homes. As part of this process, the CAHPS team is developing guide-
lines for the translation and cultural adaptation of CAHPS surveys. They are
being designed so that they are useful to AHRQ as well as other organizations
wishing to develop other translations of CAHPS surveys. The development
and testing of the Spanish version of the CAHPS Hospital Survey is part of an
iterative process that the CAHPS team is undertaking to define the guidelines.
Preparation of this manuscript was supported through a cooperative agree-
ment (2U18HS09204-07) from the Agency for Healthcare Research and
Ron D. Hays was also supported in part by the UCLA/DREW Project EX-
PORT, NIH-National Center on Minority Health and Health Disparities
(P20-MD00148-01), the UCLA Center for Health Improvement in Minority
Elders/Resource Centers for Minority Aging Research, NIH- National Insti-
tute ofAging(NIA)(AG-02-004),anda program projectgrantfrom NIA (P01-
AG-2067901). We would like to acknowledge Beverly Weidmer who led the
Spanish translation of the H-CAHPS survey; Guillermo Solano-Flores and
Robert Weech-Maldonado for their participation in the translation review
committee; Roger Levine, Patricia Gallagher, and Beverly Weidmer who led
the cognitive testing; and, Karen Frazier for her analysis of responses to open-
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