A framework for understanding modifications to measures for diverse populations.

Eliminating health disparities among ethnic minorities and vulnerable older populations is a national priority (Smedley, Stith, & Nelson, 2003; U.S. Department of Health and Human Services, 2000). To accomplish this goal, it is essential to understand factors that contribute to these disparities (National Institute on Aging, 2011). Research on health disparities and its determinants among ethnic minorities and vulnerable older populations necessitates use of self-report measures. However, many of these widely-used measures were developed and tested on mainly white, young and middle-aged, well-educated samples. These measures may have limitations when used in studies of minority or lower-socioeconomic status (SES) older adults included in health disparities and minority aging research. A substantial amount of research has attempted to address these issues over the past 15 years, including systematic efforts by the Resource Centers for Minority Aging Research (RCMARs) (Stahl & Hahn, 2006); also see preface for an overview of RCMAR contributions in measurement in diverse older populations (Teresi, Stewart, & Stahl, 2012). There are published guidelines on methods for examining the conceptual and psychometric adequacy of measures in ethnically diverse populations (Collins, 2003; Hahn & Cella, 2003; Johnson, 2006; A.M. Napoles-Springer, Santoyo-Olsson, O'Brien, & Stewart, 2006; A.M. Napoles-Springer & Stewart, 2006; A.L. Stewart & Napoles-Springer, 2003; Teresi, Stewart, Morales, & Stahl, 2006). There also are systematic reviews examining the conceptual or psychometric adequacy of particular concepts and measures in diverse populations (Coates & Monteilh, 1997; A.L. Stewart & Napoles-Springer, 2000) including older adults (Mui, Burnette, & Chen, 2001; Mutran, Reed, & Sudha, 2001). However, when problems are found with measures in diverse population groups, there are no guidelines on what to do next. Once a measure has been determined to be inappropriate for minority or lower-SES participants, researchers have three options. One is to use the measure “as is” without modification and articulate the limitations. This abides by the tenet of administering measures as published which some believe preserves score reliability and validity (Juniper, 2009). However, if a measure is not suitable for a population, scientific inferences derived from it may be compromised. A second option is to create a new measure de novo. Developing a new measure is fraught with challenges, including having the expertise, time, and resources to develop and test a new measure, which may not be practical for most health disparities researchers. Methods for developing new measures to be culturally sensitive involve a mixed-methods approach that includes concept development, writing items, pretesting, revising, field testing, and conducting psychometric analysis to derive final measures. Although there are no general guidelines for developing new measures in minority populations, several publications provide detailed examples of these steps (Jackson, 1996; Krause, 2006; A. L. Stewart, Napoles-Springer, Gregorich, & Santoyo-Olsson, 2007). The third option is to modify or adapt an existing measure. There is a delicate balance between trying to retain the strength of an existing measure, which may have undergone extensive development and testing, but clearly will be problematic, and making modifications which may or may not work. Furthermore, there are very few practical guidelines on how to go about making those modifications. In multi-national research, measures developed in English must be translated for use in non-English speaking countries. In guidelines for multi-national studies, adaptations are an integral part of the translation process, e.g., items may be modified to achieve “semantic” equivalence (Aaronson et al., 1992; Beaton, Bombardier, Guillemin, & Ferraz, 2000; Bullinger et al., 1998). However, these guidelines give little attention to issues in modifying measures when no language translation is needed. This paper attempts to address this gap by providing a framework for modifying measures to improve their reliability and validity in health disparities research involving ethnically and racially diverse populations. The goal of such modifications would be to increase the likelihood that the modified measure has comparable meaning, reliability, and validity as the original measure, but in a new population group. The issues raised here pertain primarily to addressing differences from mainstream populations (on which original measures were tested) in socioeconomic status, race/ethnicity, language, and literacy. Issues of modifications based on these types of group differences are relevant to health disparities studies of adults of all ages. Occasionally, modifications are made to adapt a measure specifically to be more appropriate for older adults (Thiamwong, Stewart, & Warahut, 2009; Vanderplas & Vanderplas, 1981). We describe three issues: 1) reasons for considering modifications – why a modification would be needed; 2) the basis for modifications – information that can be used to make the modifications; and 3) possible types of modifications. We conclude with recommendations for assessing modified measures and for reporting results of these assessments.