In the Santium Language Series, we have so far explored how languages are structured and how they reflect the cultures in which they are used. In this article, we are taking a slightly different approach.
Rather than looking at Finnish as another agglutinative language, we use it to examine a more practical question: what happens when language structure begins to influence how clinical outcome assessments are interpreted and answered?
This article is a collaborative contribution from Mark Gibson, a specialist in non-clinical cognitive debriefing and the founder of Gibson Research Consultancy, Santium’s long-time validation partner. Mark’s perspective brings an additional layer to this series, linking linguistic structure with how native respondents actually process and answer items in practice.
Clinical outcome assessments are designed to measure patient experience in a consistent and comparable way. That objective assumes that meaning can be carried across languages without changing how a question functions. In practice, this assumption is not always tested as directly as it could be.
Finnish provides a useful way to explore this. It is structurally different from English in ways that make certain ambiguities difficult to preserve in translation. As a result, choices must be made that are linguistically correct, yet may influence how respondents understand and respond to an item.
The purpose of this article is to use it as a lens. The same issues arise, to varying degrees, in many languages. Join us in this exploration of the Finnish language.
A Brief History of Finnish
Finland lies at the northern edge of Europe, covered with forests and lakes, and marked by long winters, spectacular northern lights, and a history lived in the orbit of larger powers.
The people who inhabited this region in earlier periods were Finno-Ugric-speaking communities whose descendants would give rise to the Finnish language. Finnish belongs to the Uralic language family, which is distinct from the Indo-European languages that dominate most of Europe. It is closely related to Estonian and more distantly to Hungarian, but it developed along its own path in the northern Baltic region.
For much of its history, Finnish existed primarily as a spoken language. Local communities used it in everyday life across different parts of the country, while formal administration, education, religion and law were conducted in other languages. From the 12th century onward, Finland became part of the Swedish kingdom, and Swedish became the language of power, government, schooling and trade. Finnish remained the language of the majority, but it was not widely used in official written contexts.
This division lasted for centuries. Written Finnish began to emerge in the 16th century, when Mikael Agricola produced translations of religious texts. This laid the foundations of an early written standard, while Finnish began, slowly, to enter literacy, religion and education.
In the early 19th century, Russia took control of Finland, and it became an autonomous Grand Duchy within the Russian Empire. This change opened space for a stronger national movement. Intellectuals, writers and scholars increasingly promoted Finnish as a language of culture, literature and public life. Oral poetry, folklore and regional traditions were gathered and elevated into national symbols. The Kalevala, compiled by Elias Lönnrot, became especially important as a literary work and as a statement that Finnish could carry the weight of a national language.
By the late 19th and early 20th centuries, Finnish was standardized, taught in schools and used increasingly in administration alongside Swedish. When Finland became independent in 1917, Finnish was already firmly established as one of the country’s central languages.
Today, Finnish is spoken by about 5.5 million people, mainly in Finland, with communities in Sweden and elsewhere. It is often cited as one of the more challenging languages for English speakers, and is classified by the Foreign Service Institute (FSI) as a “hard” language requiring extended study to reach professional proficiency.
When Finnish Changes the Question
Clinical outcome assessments (COAs) are widely used in clinical trials and in health technology assessments, to help shape regulatory decisions. For these tools to be reliable, they need not only to be well designed and robustly tested, but also to work equally well across different languages and cultures.
The general expectation for translation is that intended meaning is conveyed from one language to another. In practice, this assumes that the underlying meaning of a question can be preserved with relatively small adjustments to wording. But this assumption does not always hold.
It is important to be precise about where the risk is. In most cases, a qualified translator will not produce an incorrect or unnatural-sounding translation. The challenge is different. Some languages require the translator to make distinctions that are not fully specified in the source text. These choices are linguistically correct, yet they may narrow or shift how a question is understood. In this sense, the issue is to resolve the ambiguity present in the original wording.
This becomes particularly visible in languages that are structurally different from the source language. Finnish is one such example. In this article, we use Finnish to examine where current approaches to translation, linguistic validation and adaptation sometimes fall short.
Differences in language structure can lead to small but consistent shifts in how questions are interpreted. In clinical research, these shifts have the potential to influence how patients respond and, ultimately, impact the quality of the data collected in multinational trials.
The Finnish Case System
A useful place to begin is to show how Finnish builds meaning.
Finnish has 15 primary grammatical cases (word endings). Just for context, this is more than Arabic with 3 cases, German with 4, Russian with 6, but fewer than Hungarian with 18, or the Caucasus language, Tsez, which has 64!
Agglutination: building meaning by stacking cases
Finnish is an agglutinative language. Unlike English, which distributes meaning across separate words, word order and context, Finnish does much of this work by adding endings to the base of a word using a rich case system, flexible word order and the absence of articles.
These features make it more difficult to carry over meaning because even endings that look correct can shift how that meaning is interpreted. As a result, translators must make interpretive choices about what, specifically, the English question is asking.
This is not always clear. Items in clinical outcome measures are often phrased ambiguously, presented without context, and sometimes written in poor grammar. English allows meaning to be inferred from context, whereas other languages, like Finnish, require these relationships to be made more explicit.
In practice, translators are given semantic definitions of items, but detailed information about what exactly the question is intended to measure is rarely shared. Then, necessary linguistic choices are made without visibility into the underlying construct.
Below are some examples of how word endings build meaning and why Finnish words can get very long.
Example
A single Finnish word can contain information that would take a whole phrase to express in English. The choice of case determines relationships, such as location, direction and context. In English, these distinctions are typically conveyed using separate words like prepositions (“in”, “on”, “of”, “from”, etc.).
In this example, observe how the root word pöytä (table) changes depending on the relationship being expressed:
pöydällä (“on the table”)
pöydässä (“in the table”, rare, but structurally distinct)
pöydältä (“from the table”)
pöydälle (“onto the table”)
pöydässäni (“in my table”)
pöydältänikin (“even from my table”)
Finnish Does Not Tolerate Ambiguity
Returning to clinical outcome assessments, when choices in word endings do not align with the intended meaning, responses to questions about where a symptom occurs or under what conditions will likely drift from the concept the question was designed to measure. Consider the following examples:
Example 1
English
“Do you have back pain?”
An English speaker would not parse this question anatomically. It could mean pain anywhere in the back area or pain affecting the back. In English, this question tends to be intentionally ambiguous with Yes and No response options and acts as a screener.
Finnish
This looks simple. A translator will produce something like this:
Onko sinulla kipua selässä?
Literal translation: “Is there pain on/with you in the back?”
onko = “is there?” / “do(es) … have?” (question form of on = “is”)
sinulla = “on you” / “at you” (literally: “with you”, adessive case)
kipua = “pain” (partitive case → “some pain”)
selässä = “in the back” (inessive case → “inside the back”)
Grammatically and semantically, this translation is correct, natural and entirely acceptable. The important point is that Finnish requires specificity, and the choice of selässä (“in the back”) introduces a specific spatial interpretation that is not fully defined in the English source.
The translator, being fluently bilingual in both languages, can correctly interpret the surface meaning of the original item as pain affecting the back area. Concept definitions supplied to the translator by the client often provide context to help with this, but were not designed to convey what makes the question clinically meaningful. Hence, the translator has to make a choice from locative case options that reflect the original question as closely as possible yet narrow its meaning.
This is not a translation error, but it could introduce a clinically meaningful shift. A result of forcing a structurally required choice when the source text does not offer enough information for a conceptually equivalent translation.
Example 2
English
“Where do you feel pain?”
Finnish
Again, a simple locative English question. In Finnish, this question can be phrased using different cases:
Missä tunnet kipua?
Literal translation: “Where is the pain felt?”
Focus is on location, which requires specificity in the answer that is not prompted in the question.
Mistä tunnet kipua?
Literal translation: “From where do you feel pain?”
Focus is on the source/origin.
Both reflect the English question. The translator made linguistically valid choices. A non-expert or an uninformed reviewer is unlikely to worry about the difference, but only one of these translations will fit the intended construct.
Example 3
English
“How often did you feel tired?”
Finnish
For Finnish, this is underspecified, even if the time frame is provided.
Kuinka usein tunsit väsymystä?
Literal translation: “How often have you felt tired/fatigued?”
kuinka usein = how often
tunsit = you felt (past)
väsymystä = tiredness (partitive → ongoing/unspecified amount)
Interpretation 1: Episodic fatigue
Patient asks:
“You mean, how often I feel tired in between feeling okay?”
The answer is based on specific instances of noticeable fatigue.
Interpretation 2: Continuous fatigue differentiated by severity
Patient asks:
“You mean, generally tired or severely tired?”
The answer is based on overall or varying levels of persistent fatigue.
This is routinely borne out in cognitive debriefing studies in Finnish where participants are sensitive to these subtleties. Even small differences in wording can affect how patients interpret the questions and respond to them.
When self-reported outcome measures lack clinically meaningful specificity in the source item, translations into languages like Finnish require patients to resolve that ambiguity themselves. This often leads to mixed response logic that reduces comparability and complicates data analyses.
Absence of Articles
These effects are not limited to spatial relationships.
Unlike English, Finnish does not use definite articles (‘the’) or indefinite articles (‘a’). The distinction between “a symptom” and “the symptom” is only inferred from context.
In many types of content, this does not create difficulty. In clinical outcome assessments, this has implications for items that rely on precise reference:
- Is the question asking about a specific episode or a general tendency?
- Is the symptom being introduced or revisited?
- Does the patient interpret the item as episodic, habitual or cumulative?
Because so many COAs originate in English, articles contribute to these distinctions. In Finnish, this reference has to be inferred. A patient may understand the question as referring to the most recent pain, the worst pain, or their typical experience, depending on how the item is anchored in context.
This becomes particularly relevant when items are presented in isolation, as they often are in electronic formats, or when the intended reference depends on earlier questions or instructions. In such cases, the absence of articles can introduce variability in how Finnish speakers interpret what the item is asking them to report.
Again, this does not mean that the translation is incorrect or unclear. The wording may be entirely natural and appropriate. The issue is that the absence of explicit reference markers can lead Finnish speakers to anchor the item differently, and this will affect comprehension, recall and response comparability.
Word Order Flexibility
Because grammatical relationships are encoded in word endings in Finnish, word order is more flexible than in English. Changing the order of words does not usually affect grammatical correctness, but it can shift emphasis and meaning:
Example
English
Change in word order changes the meaning:
“The patient experiences pain.”
“Pain experiences the patient.”
Finnish
Change in word order does not change the meaning, but it does move emphasis.
Potilas kokee kipua.
Literal translation: “(The) patient experiences (some) pain.”
Emphasis is on the patient who is experiencing pain.
Kipua potilas kokee.
Literal translation: “Pain, (the) patient experiences.”
Emphasis is on pain, which is experienced by the patient.
Both sentences are grammatically correct, but the information structure differs. In clinical outcome measures, this becomes relevant because items are designed to be interpreted consistently. Variations in word order can subtly influence how Finnish speakers prioritize or frame the information presented in the question.
In practice, professional translators usually default to neutral, canonical word order, and reviewers working within the same team will normalize anything that sounds marked or stylistically unusual. With English as the source language, this often happens with compromises to preserve measurement intent.
The greater risk enters through an independent third-party review carried out with little or no context about the purpose behind the wording. Without reference to conceptual definitions and cognitive interview feedback, reviewers and editors tend to start improving the text stylistically to demonstrate linguistic and editorial value, instead of first asking why the translation was phrased that way in the first place. Deliberate, construct-preserving wording is easily marked as defective simply because it is sometimes less polished, less colloquial, or does not conform to a reviewer’s stylistic preference or sense of linguistic elegance.
Standard Language vs. User Experience
Finnish has two broad forms that are relevant here: the standard written language (kirjakieli) and the spoken varieties often grouped under puhekieli. Both of these forms can differ considerably in vocabulary and structure.
Kirjakieli is used in formal contexts, including clinical materials, regulatory documentation and most patient-facing instruments. This creates a familiar tension in COA development.
Formal language supports consistency, traceability and regulatory acceptability. Studies in health literacy around the world have shown that more familiar and colloquial language supports immediate comprehension, ease of processing and engagement.
The tension is especially pronounced in Finnish because the distance between written and spoken forms can be substantial. Register choice in Finnish becomes an important design decision because a translation can be entirely correct in standard written Finnish and still sound less natural to a speaker answering quickly, unaided and without explanation.
This does not mean that clinical outcome measures should be written in colloquial Finnish. The point is that register choice becomes a measurement decision since the most formally acceptable wording is not always the wording that best supports the patient voice. If the wording is too formal, respondents may process it more slowly or anchor it less naturally to their own experience. If it is too colloquial, consistency and acceptability may be harder to maintain across settings. The scoring algorithms must be able to support this.
Digital Constraints in Finnish Context
eCOA platforms introduce additional challenges to COA localization, adaptation and deployment. Screen size, character limits, and interface design can constrain how text is displayed. Finnish words can be long, and variation in line structure or visual grouping can interact with word order and alter perceived emphasis.
In Finnish, where meaning is often encoded in long, complex words, such constraints can interfere with comprehension. Line breaks may split suffixes from stems, the truncation of words might remove critical information within the word, and abbreviations can distort meaning.
Visual and structural features of COAs affect data quality. For agglutinative languages like Finnish, these issues are beyond cosmetics. They can affect the integrity of meaning by changing how Finnish speakers attend to and process them.
Implications for Linguistic Validation
In many respects, Finnish highlights a limitation in how translation and linguistic validation are often approached. Standard workflows, particularly those followed in large institutions, assume that once wording is accurate and broadly aligned with the source concept, equivalence has been achieved.
In languages such as Finnish, this assumption falls short. Finnish pushes beyond the scope of current industry guidelines for translation, conceptual equivalence and cognitive debriefing.
The most prominent implications for linguistic validation are:
Awareness of word formation (morphology): Validation processes need to account for the meaning carried in suffixes and not just lexical choices.
Precision of case selection: Case marking should be assessed in relation to the intended construct, not only for grammatical correctness.
Interpretation in context: Cognitive debriefing must pay attention to how respondents interpret items, especially where the source wording leaves relationships implicit.
Interface-sensitive design: eCOA adaptation must consider how digital presentation interacts with linguistic structure and respondent processing.
Register and user experience: The balance between standard and colloquial language must be considered in terms of how it supports comprehension and response consistency.
These considerations are not unique to Finnish, but the language offers an easier way to see them. The broader point is that equivalence is not secured by linguistic accuracy alone. It depends on how respondents understand the item and how consistently they apply that understanding when answering.
Finnish in Sweden: Does it Matter?
Finnish as spoken in Sweden does not require treatment as a separate language, and standard Finnish will often be sufficient for many types of content. A shared written language does not, however, remove the need to validate that the instrument still works in a different cultural context.
As a recognized minority language in Sweden, Finnish is used within a distinct healthcare, administrative and bilingual environment. The grammar of the language remains the same, but patterns of terminology, register and everyday reference are influenced by life in Sweden rather than Finland.
This distinction is relevant to only some instruments. For symptom-based items and other questions that do not depend heavily on local systems or service structures, standard Finnish can perform adequately. The issue becomes more relevant when an instrument refers to healthcare access, service use, administrative processes or other experiences that are interpreted through the surrounding institutional context.
Linguistic validation should not be concerned solely with surface comprehension, but with whether items are understood within the patient’s lived context of care. The question, then, is whether the translated instrument still functions as intended for respondents living in that setting. In Sweden, a Finnish translation may be linguistically correct and fully comprehensible. However, depending on the content, it may still require validation to confirm that it remains contextually appropriate for Finnish speakers in Sweden.
Finnish in Sweden therefore exemplifies a broader principle in COA deployment. Shared written language does not guarantee equivalence of use. What matters is whether respondents interpret and respond to the instrument in ways that remain aligned with the intended construct in their own lived context.
What We Learn
Finnish demonstrates that languages differ not only in vocabulary, but also in how they organize meaning. In Finnish, meaning is often constructed within words, with complex layers that encode relationships, context and nuance.
In this context, Finnish is not an outlier so much as a reminder that equivalence is not secured by translation alone. This raises a wider question. If shifts in meaning can occur even when a language has been translated carefully and reviewed by qualified professionals, how confident can we be in the current validation processes that focus mainly on linguistic correctness, general conceptual agreement and surface clarity?
Whenever a target language requires ambiguity to be resolved, translation becomes more than a matter of wording. It becomes part of how the item functions. Translators are not trained in this, and neither are the majority of reviewers. The language services industry and its sponsors, therefore, need to work more closely together to improve clarity in source text and to validate adapted wording before a complex translation is used in a high-stakes trial.
If you’ve missed previous editions of the Santium Language Series, you’ll find them here – catch up!
How Santium contributes to this space
Santium specializes in translating and adapting complex, high-stakes content where precision matters. Gibson Research Consultancy specializes in non-clinical cognitive debriefing. We ensure that meaning is preserved across languages, dialects, and contexts. Our workflows combine subject-matter expertise, structured review, and in-country validation to align language with how it is actually used and understood. This is particularly important in environments where small shifts in wording can affect interpretation, usability, or outcomes. Santium’s role is to manage that complexity so that translated language remains reliable, consistent, and fit for purpose.
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Mark Gibson
Owner & CEO | Gibson Research Consultancy
I am the founder of Gibson Research Consultancy (GRC Health), a Leeds-based consultancy established in 2008 to support multilingual, patient-centred research in international settings. My background is in qualitative research and health communication spanning different healthcare and cultural contexts. I write about linguistic validation, health communication, patient-centred research, and the wider methodological issues that affect how qualitative research is carried out and understood. I am also a contributing author to Santium Language Series.
