The Illusion of the Expected "Light Touch" Adaptation
Intralingual adaptation of clinical outcome assessments (COAs) is a critical step in clinical research. When it happens within closely related varieties — American and British English, say — it is often treated as a minor linguistic review activity, and swiftly dealt with. Spelling is localised. A few lexical swaps are made. Perhaps an idiom is adjusted “once in a month of Sundays” (a very British idiom). Near-equivalence between the two varieties is automatically assumed. Should it be?
American and British English are mutually intelligible, but they are not used the same way in the daily lives of their speakers. Yes, there are differences in vocabulary and spelling — the bread and butter of a typical American-to-British adaptation. But the differences go further than that: register, metaphor, euphemism, and the norms around expressing illness all diverge in ways that rarely produce outright misunderstanding but enough to make the language feel unfamiliar or strange.
The only difference that ever genuinely gave me pause was the American phrase “I could care less”, which somehow means exactly the same thing as “I couldn’t care less” as it is used in Britain. It makes no sense. But that kind of confusion is the exception. The more common issue is subtler and, in the context of COAs, more consequential: resonance. Patients may understand the words, but do not recognise them as native and tend to experience difficulty in relating to them. It is more a misalignment with how they would naturally describe their experience than miscomprehension.
Common Source of Measurement Error
Most COAs used in clinical research today were developed in the United States and are written in the American manner of speech. Across English-speaking borders, COAs ask patients to describe their experience, essentially using another culture’s words and categories through a fixed set of options that may or may not reflect how they would naturally express what they are going through. When a patient struggles to relate to the wording, their answer is no longer a clean reflection of how they feel. The answer reflects the effort of trying to map their experience to language that was not written for them. That distortion then ends up in the data set and presents a measurement error.
Obvious differences are generally readily addressed: American “primary care physician” becomes British “general practitioner” or “GP”, “emergency room” becomes “A&E”, “provider” is replaced with NHS-specific roles. This kind of localisation is important, because healthcare pathways differ significantly between the two countries.
But, this only scratches the surface of a deeper cultural difference.
Beneath the Surface
More significant divergences lie in how intensity, directness, and distress are expressed.
Items originating in American English often favour directness:
“How often did you feel anxious?”
“Rate your pain.”
“How much did you have severe difficulty concentrating?”
These questions expect clear, direct answers. In Britain, people tend to soften how they describe how they feel. Understatement (“I feel a bit off”), hedging (“fairly uncomfortable”), negative framing (“mustn’t grumble”); these are not meant to be vague. They simply reflect complex politeness norms of British culture that are genuinely difficult to read from an outsider’s perspective.
Surface meaning, then, is not the same as the experienced reality. Someone in real pain may not reach for strong wording because it feels like overdoing it. At the same time, mild phrasing like “a bit rough” or “not brilliant” can mask genuine burden. Hence, it’s not really about finding a British equivalent to the American phrasing. Rather, it’s about understanding how British people express themselves about their suffering. Hence, it’s about linguistic adaptation. A simple linguistic review is often inadequate for clinical content.
This is particularly visible in mental health. “Depressed” or “anxious” do not carry the same weight in the United Kingdom as they do in North America. British patients — older ones especially — may prefer euphemisms: “feeling low”, “run down”, “bad with my nerves”. These are real ways in which British people express distress. A direct item like “Did you feel depressed?” may miss patients who would never use that word about themselves, while “feeling low” or “not quite yourself” is more likely to capture how they would naturally describe it.
Figurative Language and Interpretation
British patients often rely on metaphors, and within Britain, those metaphors can be highly local:
- “funny turns” for dizziness, fainting, or neurological events
- “chestiness” for cough, congestion, or breathlessness
- “upset stomach” for nausea, cramping, diarrhea
These are broad and context-dependent, but a native speaker reads the context immediately. In turn, patients may map multiple experiences onto a single item, or narrow it more than the COA developer intended.
Even individual words can shift meaning. “Bothered” may describe mild annoyance in American English, but in Britain it reflects more serious distress. A response choice like “quite bothered” may align with stronger categories than the COA developer likely had in mind.
Response scales are particularly unstable. “Quite”, “Fair”, “Moderate” and “Somewhat” do not map cleanly to British usage. “Quite” may be perceived as moderate in Britain and stronger in North America. “Fair” may feel neutral or mildly positive in Britain and mediocre in North America.
“Somewhat” deserves a specific mention. It is common in American-developed instruments, but it feels stylistically out of place in British English. It is perfectly understood, but it does not resonate. When it recurs across items (“somewhat difficult”, “somewhat anxious”), it creates cognitive friction without creating confusion. More familiar alternatives like “a bit” or “fairly” carry their own nuances but feel far more natural as response choices. The persistence of “somewhat” reflects a broader tendency: prioritising formal equivalence over naturalness.
Much the same could be said for “bothersome”, which appears frequently in American COAs and tends to persist into British versions without adaptation.
Other Terms That Do Not Quite Land
Many COA terms sit in this space; they are technically correct, but poorly aligned with how British people actually speak:
- provider / fatigued / distressed / yardwork / walking a block
Patients often reframe these in practice:
- “interfere with your life” → “slowed me down a bit”
- “irritable” → “a bit snappy”
- “shortness of breath” → “out of breath on stairs”
- “rate your health” → “not bad”
- “trouble sleeping” → “up and down all night”
What is happening here is that patients are not simply responding to the words on the page; they are translating them. They are meeting the text more than halfway, but doing cognitive work that should have been done during adaptation. They are left to manage all of that on their own, often because cultural adaptation has not been considered as a requirement to align British speakers with American-designed instruments.
Variation within Britain
Variation within Britain is not just a matter of accent or vocabulary; it is also about how experience gets expressed. Standardised questions assume shared meanings, but patients interpret them through local frames:
- Northern England: “it’s playing up”, “giving me jip”, “a bit rough”
- Scotland: “not right”, “away with myself”
- Wales: “not feeling myself”, “no energy in me”
- Northern Ireland: “giving me bother”, “a bit off”
In clinician-administered settings, this adds another layer. A response like “a bit off” or “not feeling myself” may be taken at face value rather than recognised as a culturally patterned understatement.
The result is a form of inequivalence within the same language: responses appear standardised, but meaning can diverge.
Generational differences matter too. Younger people may use “anxious” or “burnt out”; older patients might prefer “on edge” or “worn out”. Social background shapes this further; “difficulty concentrating” might come out as “can’t follow the telly”. This internal variation is rarely noticeable in linguistic review, but it can be significant in how COA items are understood.
Britain has a high expatriate diaspora. Multicultural English varieties add further complexity. Patients may draw on the metaphors of their heritage:
- “too much tension” (stress)
- “my heart feels heavy” (low mood)
- “thinking too much” (distress)
- “my body is weak” (fatigue)
- “I have sugar” (diabetes)
These reflect different models of illness — somatic versus psychological — as well as varying comfort with clinical labels and local norms of expression.
Patients may understand a COA item but not recognise themselves in the phrasing, and respond in ways that are clear within their own cultural context but opaque to anyone outside it.
Beyond comprehension
Adapting within the same language is far from trivial. The key question is whether the items align with how people actually express their experience.
Current linguistic validation approaches sometimes miss this. Cognitive debriefing was designed to focus on comprehension instead of resonance, tone, or pragmatic fit. A questionnaire may “work” in the narrow sense and still misalign with how patients think and convey clinically meaningful information.
This has real consequences for data integrity. Differences in scores may reflect differences in expression rather than differences in health. That is a particular problem in cross-country comparisons.
We need to reconsider how we approach intralingual COA adaptation to ensure that patients can recognise themselves in the wording of the questions. In that sense, linguistic validation should be treated as applied patient voice research: grounded in how people actually talk about their health, how they express severity, and what feels natural and “sayable”.
How Santium and GRC Health Contribute to This Space
Santium provides specialized language services focused on scientific, medical and technical content. Our British partner, Gibson Research Consultancy supports our linguistic validation efforts with cognitive debriefing of non-clinical subjects. With deep experience in psychometrics, linguistic validation and transadaptation, we focus on delivering translated materials that work as intended across languages and cultures, preserving meaning, function, usability, and measurement integrity in real-world applications.
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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.
