Pitfalls in Measuring the Health Status of Mexican Americans:
Comparative Validity of the English and Spanish Sickness Impact Profile
RICHARD A. DEYO, MD, MPH
Abstract: We tested a Spanish translation of the Sickness
Impact Profile (SIP) in a clinical study of low back pain, which
included non-Hispanic patients (Group I), Mexican Americans who
used the English SIP (Group II), and Mexican Americans who used
the Spanish SIP (group III). The reliability and clinical validity of
responses by these three groups were compared. Internal consisten-
cy of responses by all three groups was excellent (Cronbach's alpha
for the overall SIP = .93 - .95). When construct validity was tested
by correlating SIP scores with several clinical measures of disease
The large size and rapid growth of the Hispanic popula-
tion in the United States have prompted a surge of research
into this group's health needs and behavior. '-3 Mexican
Americans constitute the largest portion of this Hispanic
population, and are concentrated most heavily in the south-
western United States.4
For many types of health care research among Hispanic
populations, it would be helpful to have a valid measure of
health status. Several health-status measures have been
developed recently and extensively validated in general
populations and in clinical settings.5-7 All are questionnaires
which inquire about a variety of daily functions, both
physical and psychosocial. Such instruments are being used
increasingly to study the impact of medical care on health, to
improve both treatment and resource allocation decisions. If
such measurements are to be used for studies of Hispanic
populations, it is important to be sure that the Spanish
language version of a given questionnaire is as reliable and
valid as the English language version.
To facilitate cross-cultural research among US Hispanic
populations, one of these health status instruments, the
Sickness Impact Profile (SIP), has been translated into
Spanish, using a Mexican American idiom. This instrument
was designed in English, translated into Spanish, and then
independently back-translated into English by several bilin-
guals. Discrepancies were resolved, and one item which
could not be translated successfully was omitted. Weighting
of items in the scale by Mexican Americans was found to be
similar to weights used in the English version.8 This transla-
tion procedure has been cited as a model for translating
research instruments.9
As part of a study on low back pain which was to be
conducted among both Engilsh and Spanish-speaking pa-
tients, we wanted to measure functional health status before
and after our intervention. Because of the painstaking trans-
lation procedure, and because the SIP had been used suc-
cessfully in clinical studies of arthritis,'0 it seemed ideal for
this purpose.
Other investigators have noted that the internal consist-
ency of questionnaire responses by Spanish-speaking re-
Address reprint requests to Dr. Richard A. Deyo, Assistant Professor of
Medicine, Division of General Internal Medicine, Department of Medicine,
University of Texas Health Science Center, 7703 Floyd Curl Drive, San
Antonio, TX 78284. This paper, submitted to the Journal August 10, 1983, was
revised and accepted for publication November 2, 1983.
© 1984 American Journal of Public Health 0090-0036/84 $1.50
AJPH June 1984, Vol. 74, No. 6
severity, however, important differences emerged. Group I respons-
es appeared to be highly valid, while group III responses did not;
Group II responses appeared reasonably valid, but intermediate
between the other groups. These differences appear unlikely to be
due to clinical differences, interviewing, or translational problems
and seem to parallel the groups' levels of "acculturation." It may be
that certain aspects of acculturation, including familiarity with
questionnaire research, critically affect the validity of responses to
this questionnaire. (Am J Public Health 1984; 74:569-573.)
spondents is often less than that of English-speaking respon-
dents.2,9 Using a questionnaire on health beliefs which had
not been back-translated, Berkanovic found that the internal
consistency (Cronbach's alpha) of some scales was lower for
Spanish-speaking Hispanics than for English-speaking His-
panics.9 In a national survey of access to medical care,
survey instruments were carefully back-translated, and in-
cluded positively and negatively worded questions on the
same underlying attitudes. Contradictory responses to such
items were more common among Spanish-heritage respon-
dents than among Whites.2
Because of these problems, it was important to assess
the internal consistency of responses to the English and
Spanish versions of the SIP in our study. Because we
performed extensive clinical evaluations, we were also able
to assess the construct validity of both versions of the
questionnaire.
Methods
Patients and Research Activities
Patients were recruited consecutively from a high vol-
ume walk-in clinic in San Antonio, Texas as part of a study
of low back pain. All gave informed consent to participate.
Most patients seen in this clinic are indigent; those who are
employed generally hold blue collar jobs. Virtually all His-
panics attending this facility are of Mexican American
heritage.
Medical histories and examinations were performed by
housestaff physicians. Clinical data were recorded on a
standard coding form by the examining physicians. All
patients were judged to have uncomplicated mechanical low
back pain. Patients with disabling co-morbidity were exclud-
ed, so that dysfunctions measured by the SIP would be
largely due to back pain alone.
A bilingual interviewer administered the SIP and other
questions concerning demographic data and health beliefs.
Of the 120 patients enrolled, 109 were interviewed by the
same bilingual, Mexican American interviewer. Eleven pa-
tients were interviewed by one of three "Anglo" interview-
ers, two of whom were fully bilingual and had previously
resided for several years in Central America. ("Anglo" is a
common term used in the southwestern US to designate non-
Hispanic Whites.) The choice of English vs Spanish SIP was
made at the discretion of the interviewer.
Patients were re-examined and interviewed three weeks
after the initial walk-in visit. Both clinician and patient were
569
DEYO
asked to assess whether the patient's pain was better, worse,
or unchanged from the initial visit, and the SIP was repeated.
Questionnaire Measures
The SIP is a standardized questionnaire consisting of
136 items grouped into 12 categories.* Each item is a
statement describing a specific dysfunctional behavior, and
respondents indicate whether or not the item describes a
dysfunction they presently experience due to their illness.
Scores are calculated for the overall instrument, each cate-
gory, and the two dimensions using predetermined weights
based on the relative severity of each dysfunction."I
Interviewers estimated each patient's English fluency
on a five-point ordinal scale ranging from 1 (completely
fluent) to 5 (no English at all). Ethnicity was simply judged
by the interviewer as Anglo, Black, or Hispanic. The inter-
viewer also asked about any co-morbid medical conditions
(e.g., diabetes, hypertension), and recorded up to three
conditions per patient.
Validity Measures
Aspects of the medical history and examination were
used for comparison with SIP scores. Since none of these
was a direct measure of function, very strong correlations
were not expected. However, our biologic understanding of
the disease suggested that each should show some correla-
tion in a predictable direction with a valid measure of health
status, and that certain measures might correlate best with
specific subscales of the SIP. This type of "construct
validation" is necessary since there is no "gold standard" of
patient health or function.
Physicians were asked to rate the severity of each
patient's pain on a seven-point Likert scale, with one
extreme labeled "Almost no pain" (score = 1) and the other
extreme labeled "Extremely severe pain" (score = 7).
Patients made self-ratings of pain on a four-point ordinal
scale in response to the question, "how severe is your
pain?": 1 (almost none), 2 (minimal), 3 (somewhat), 4
(extremely severe). In addition to the scale rating of pain,
physicians were asked whether the patient appeared on
examination to be in severe pain (with a yes or no response).
Spine flexion was assessed by measuring the distance
from fingertip to floor on full forward flexion. Patients with
more severe back pain have limited flexion, resulting in a
greater finger-to-floor distance. Straight leg raising to pain
was recorded in degrees with the patient supine. Patients
with more severe pain, and especially those with nerve
irritation, have limited straight leg raising ability, and there-
fore achieve fewer degrees.
Our previous work suggested that SIP Physical Dimen-
sion scores showed moderate correlations with patient age,
pain severity, spine flexion, and straight leg raising. As
expected, the correlation with straight leg raising had a
negative sign.'2
For validation of the psychosocial dimension of the SIP,
we devised three questions unrelated to any SIP items, but
which we thought would distinguish patients with anxiety or
psychiatric dysfunction from other patients. We recorded
dichotomous positive or negative responses to the following
*Three of the categories (Ambulation, Mobility, Body Care and Move-
ment) are aggregated into a "Physical Dimension." Four other categories are
aggregated into a "Psychosocial Dimension" (Social Interaction, Communi-
cation, Emotional Behavior, Alertness Behavior). The remaining categories
are not aggregated in any way (Eating, Work, Sleep and Rest, Household
Management, Recreation and Pastimes).
570
questions: "Have you had any problem with 'bad nerves' or
psychiatric problems?"; "Are you worried that your back
pain is due to some serious illness?"; and "Do you feel sick
all the time?" We expected higher (more dysfunctional)
Psychosocial Dimension scores for patients with positive
responses than for those with negative responses.'2
Analysis
We divided the patients into three ethnic subgroups.
Black and Anglo respondents were combined into one group
since most spoke only English (Group I); Mexican Ameri-
cans were divided between those who took the English SIP
(Group II) and those who took the Spanish SIP (Group III).
SIP reliability of the internal consistency type was
measured with Cronbach's alpha. Test-retest reliability of
the SIP was assessed by Pearson correlation coefficients.
For validity testing, linear correlations were also performed.
For correlating age and Physical Dimension of the SIP, a
simple bivariate Pearson correlation was performed. Be-
cause a relation of age with SIP score was expected, and
because age might also be related to other biologic validity
measures, age was controlled for in assessing the other
validity correlations by means of partial correlations. For
each of the validity coefficients, 95% confidence intervals
were calculated using standard methods for either bivariate
or partial correlations.'3'4 Since several of the validity
measures were not continuous variables, or were not nor-
mally distributed, we also performed bivariate nonparamet-
ric (Spearman) correlations between each validity measure
and the appropriate SIP subscale. Although not reported
here, these correlations were very similar to the partial
correlations in nearly every instance. The major exception
was the association between number of prior episodes and
the SIP Physical dimension, which was much smaller after
controlling for age.
Results
The demographic and clinical characteristics of the
three patient groups are summarized in Table 1. Demograph-
ically, Group III respondents were older and not as well
educated; language differences were in the expected direc-
tion.
There were no substantial differences among the groups
in duration of the current episode of back pain, or in the
percentage who had previously sought care for back pain.
By four other measures of disease severity, however, there
was a consistent ordering of the three groups. Judged by
degree of spine flexion, straight leg raising, self-rated pain,
or physician's pain ratings, Group I consistently appeared to
have the most severe illness, Group III an intermediate
severity, and Group II appeared to be least severely ill.
There were no substantial differences among the groups in
number of co-morbid conditions.
Table 2 shows mean SIP scores for each group, includ-
ing the overall score, and scores for the Physical and
Psychosocial subscales. It can be seen that there is a
consistent monotonic relation between the three groups
which parallels the clinical assessment of disease severity,
i.e., Group I has the highest scores on each scale (worst
function); Group III has intermediate scores, and Group II
has the lowest scores (best function).
To assess whether the three groups seemed to experi-
ence similar types of dysfunction, we examined the individ-
ual items on the SIP which received the greatest number of
AJPH June 1984, Vol. 74, No. 6
 MEASURING MEXICAN AMERICAN HEALTH STATUS

TABLE 1-Demographic and Clinical Characteristics of Patients within Ethnic Subgroups

Patient Group

Group l: Group Il: Mexican- Group III: Mexican-

Blacks and Americans Using Americans Using
Clinical Characteristic Anglos (N = 23) English SIP* (N = 54) Spanish SIP* (N = 43)
Mean Age 42.8 34.8 50.9
Education (years) 11.4 9.6 3.7
English Fluency** 1.0 1.3 3.9
English 1st language as a child (%) 100% 16.7% 0%
English most often spoken in home (%) 100% 35.2% 16.3%
Duration of Pain (days)*** 25 20 28
Previously seen MD because of back
pain (%) 56.5 47.2 46.5
Spine flexion (inches)t 9.0 4.2 7.0
Straight leg raising (degrees) 51 76 66
Physician's pain rating4t 3.8 2.6 3.3
Patient's pain ratingftS 3.7 3.1 3.3
Number of Co-morbid Conditions 1.0 0.7 0.9
*SIP = Sickness Impact Profile.
"Fluency judged by bilingual interviewer on 5-point ordinal scale: 1 = completely fluent, 5 = no English at all.
**"For patients with chronic pain (>3 mos.) duration was coded as 99.
tFlexion measured as distance from fingertip to floor on maximum forward flexion.
#*7-point Likert Scale, 1 = almost no pain, 7 = extremely severe pain.
#*44-point Ordinal Scale, 1 = almost no pain, 4 = extremely severe pain.

positive responses within each group. The items are ranked
in Table 3 for each group according to numbers of positive
responses, with ties given equal rank. It is apparent that the
14 items had similarly high rankings among all three groups,
with most having a rank of eighth or better in every group.
This crude comparison was somewhat reassuring, since
there were no obvious qualitative differences in the com-
monly experienced types of dysfunction.
Internal consistency of the overall SIP was uniformly
high among all groups, ranging from 0.93 to 0.95. When the
Physical and Psychosocial Dimensions were examined sepa-
rately, alpha was again consistently very high, ranging from
.89 to .93 for all the ethnic subgroups.
Test-retest reliability could only be assessed for a small
group of patients-those who were rated by both themselves
and the examining clinician to be unchanged at the time of
the three-week follow-up visit. For the entire patient sample
of 120, only 10 patients met this criterion. For these 10
patients, test-retest correlation for the overall SIP was 0.88.
There were only two in Group I, making correlation mean-
ingless. There were four each in Groups II and III. For
Group II (four patients) test-retest correlation for the overall
SIP was .99, and for Group III (four patients), the correlation
was 0.85. Given the small numbers, we consider the values
for Groups II and III to be roughly similar, and the values for
all 10 patients suggest that test-retest reliability for the entire
patient sample is reasonably high.
Finally, we wished to assess the construct validity of
both versions of the SIP by correlating scores with indepen-
dent clinical measures of disease severity. Table 4 shows the
results of this analysis. Because we expected the Physical
Dimension to correlate best with measures of pain or physi-
cal limitations (supported by previous work'2) we have
displayed only the Physical Dimension correlations with
these physical measures. Likewise, we expected the Psycho-
social Dimension to correlate best with the questions about
psychiatric problems and worry (also supported by previous
work12) so for these variables, only correlations with the
Psychosocial Dimensions are displayed.
It can be seen that for Group I, most of the validity
coefficients lie between 0.24 and 0.56, placing them in the
range of moderate correlations. All these associations are in
the expected directions. The mean of all 11 coefficients
(using absolute values) is 0.35.
For Group II, the validity coefficients fall in a roughly
similar range, with most lying between .11 and .51. Again all
are in the expected direction. The mean absolute value of the
validity coefficients is 0.23.
For Group III, those using the Spanish SIP, the results
are disappointing. The range of the coefficients is lower, with
none greater than 0.32. Furthermore, three of the signs are in
directions opposite to those expected. These are for physi-
cian ratings of pain severity and for straight leg raising. Even
between the SIP physical dimension score and the patient's

TABLE 2-Mean Sickness Impact Profile (SIP) Scores by Ethnic Subgroups

Patient Group

Group l: Group II: Mexican- Group IlIl: Mexican- Significance*

Blacks & Anglos Americans Using Americans Using of Differences
Scale (N = 23) English SIP (N = 54) Spanish SIP (N = 43) between Groups

Overall SIP 24.4 15.7 18.9 p = .03

Physical Dimension 25.3 14.3 18.6 p = .007
Psychosocial Dimension 21.1 16.1 20.5 p = .32

'Analysis of variance.

AJPH June 1984, Vol. 74, No. 6 571

DEYO

TABLE 3-Items on the Sickness Impact Profile Receiving the Greatest Number of Positive Response
Rank for Rank for Mexican- Rank for Mexican-
Anglos and Americans Using Americans Using
Category Item (Paraphrased) Blacks (N = 23) English SIP (N = 54) Spanish SIP (N = 43)

Emotional Behavior Rub areas of body that hurt 1 4 5

Body Care Change position frequently 1 2 1
Home Management Not doing heavy work around house 2 6 7
Emotional Behavior Often moan and groan in discomfort 3 10 7
Body Care Kneel, stoop, or bend only by holding on to something 3 7 5
Home Management Do work around house only for short periods 4 6 5
Home Management Do less of daily work around house 4 1 2
Social Interaction Often express concern about health 4 3 3
Ambulation Walk shorter distances, stop often 4 5 6
Body Care Get in and out of chairs, bed by using a support 5 4 11
Sleep & Rest Sleep less at night 5 7 4
Ambulation walk more slowly 5 8 6
Body Care Make difficult moves with help, e.g., getting into cars, bathtubs 6 6 10
Mobility stay home most of the time 6 7 6

self-rating of pain, there is virtually no correlation (r = 0.07).
Associations with the more objective measures of spine
flexion and straight leg raising are similarly very small. Only
one of the 11 validity coefficients has 95% confidence limits
which exclude zero, even though there are almost twice as
many subjects as in Group I. The mean absolute value of the
11 coefficients is just 0.15.
In summary, it appears that responses to the SIP are
highly reliable, whether administered in English or Spanish.
The construct validity of responses by those who use the
Spanish language version, however, apepars to be poor. The
validity of responses to the English SIP by Blacks and
Anglos is very good. Valdity for Mexican Americans who
use the English version of the SIP is reasonably good but
probably is intermediate between the other groups.
Discussion
Our results add yet another caution to the growing
literature on methodologic difficulties in health care research
among US Hispanics.29"'5 Even when high levels of reliabil-
ity are achieved in a health status questionnaire, clinical
validity may not be assured for Spanish-speaking subjects.
Such findings may be important in interpreting outcome
studies of health care interventions which utilize health
status assessments. The results indicate that our own back
pain study will require an analysis stratified according to
vesion of the SIP used.
We tested the SIP in a group of patients who had not
been examined in earlier studies of the Spanish SIP, namely
Spanish monolinguals. Although the SIP appeared to per-
form well with Mexican American bilinguals,8 there is rea-
son to believe that Mexican Americans who speak only
Spanish are different from bilinguals in several ways. As in
other studies,'5 our respondents who used the Spanish
language questionnaire were older than other respondents.
They were also very poorly educated, less fluent in English,
more likely to have learned Spanish as a first language, and
less likely to speak English at home. Thus, these patients
appear to be less "acculturated" by several criteria than
Mexican Americans who responded in English and were
bilingual.
One could argue that clinical differences between the
groups might account for the differences in validity. The

TABLE 4-Construct Validity of the Sickness Impact Profile (SIP): Correlations* between Scale Scores and Clinical Variables

Patient Group

Group I: Group II: Mexican- Group IlIl: Mexican-

Blacks and Americans Using Americans Using
SIP Subscale Used for Anglos (N = 23) English SIP (N = 54) Spanish SIP (N = 43)
Correlations Validating Clinical Variables r (95% C.l.) r (95% C.l.) r (95% C.l.)

Physical Dimension Age .48 (.08,.74)" .17 (-.10, .42) .18 (-.12, .46)
Pain duration (days) .28 (-.17, .64) .07 (-.21, .34) .01 (-.31, .33)
No. previous episodes .13 (-.33, .54) .02 (-.27, .31) .13 (-.22, .45)
Appears to be in severe paint .49 (.09, .76)" .11 (-.17, .37) -.16 (-.44, .15)
Physician's rating of pain .24 (-.21, .61) .20 (-.11, .48) -.06 (-.36, .26)
Patient's rating of pain .36 (-.07, .68) .40 (.15, .60)** .07 (-.24, .37)
Spine flexion .56 (.17, .80)** .51 (.27, .69)** .14 (-.18, .43)
Straight leg raising -.30 (-.64, .17) -.21 (-.45, .06) .03 (-.28, .33)
Psychosocial Dimension Always feel sickl# .43 (.01, .72)** .42 (.17, .62)** .23 (-.08, .50)
Worried about serious illnesstt .05 (-.22, .60) .16 (-.12, .42) .28 (-.03, .54)
Psychiatric problemst4 .54 (.15, .78)" .21 (-.07, .46) .32 (.01, .57)"
Mean absolute value of all validity coefficients .35 .23 .15

-Correlations are partial correlations controlling for age in every case except the correlation between Physical Dimension and age (bivariate correlation).
-The 95% confidence intervals exclude zero; significant at p < .05.
tDichotomous variable coded 1 = no, 2 = yes; as assessed by examining physician.
**Dichotomous variables coded 1 = no, 2 = yes; as reported by the patient.

572 AJPH June 1984, Vol. 74, No. 6


Spanish respondents were older than English respondents
and perhaps their disease is different. One might expect
older patients to have greater co-morbidity, which could
affect questionnaire responses. Perhaps SIP validity is not
uniformly good across the entire spectrum of disease sever-
ity. These explanations seem unlikely, however, since pa-
tients with disabling co-morbidity were excluded, and Group
III respondents did not report more co-morbid conditions
than the other groups. Group III had by several measures a
degree of disease severity that was intermediate between
Groups I and II. If SIP validity suffered at one or both
extremes of disease severity, Groups I or II should have
shown worse validity coefficients.
Other explanations for the observed differences lie in
the translation itself or the interviewing process. Perhaps,
despite elaborate efforts, the Spanish translation is simply
not equivalent in all connotations to the English version.
Again this seems unlikely because of the very careful
translation methods and because items which could not be
successfully translated were excluded. The Spanish version,
examined by two bilingual, bicultural research assistants
who were both long-term residents of San Antonio, was
judged to be appropriate for use in this locale without
alteration. The overwhelming majority of interviews were
conducted by the same bilingual, bicultural interviewer, so
that differences in interviewing style should have been
minimal, and there should have been no perception of a
cultural distance from the interviewer by Spanish respon-
dents.
Finally, since the Spanish respondents were very poorly
educated compared to the English respondents, it may be
that their understanding of the questions, even in Spanish,
was poorer than that of English respondents. Perhaps the
interpretation of questions differs subtly despite the adequa-
cy of translation, or there are cultural response biases or
culturally different responses to the same disease condition.
For example, it may be that certain symptoms are not seen
as a legitimate reason to limit certain activities among
traditional Mexican Americans. The hard necessity of per-
forming certain tasks despite illness may vary among ethnic,
economic, or age-related subsets of the clinical population,
resulting in functional patterns that are unexpected within
the dominant culture. Furthermore, discrepancies are often
observed between patient and provider ratings of functional
ability or symptom severity.'6'7 These discrepancies may
vary with patient age, sex,'6 and perhaps ethnicity. Such
differences might also apply to the interpretation of symp-
toms and physical findings used here as validity measures,
and alter the expected correlations with questionnaire
scores.
As previously suggested, there may be differences in the
seriousness with which a questionnaire is perceived,9 the
literalness with which questions are taken, or the attentive-
ness of respondents. Spanish respondents are probably less
familiar with questionnaires and research in general, and
therefore less familiar with the spirit, intent, and assump-
tions with which they are administered. One might group all
these social and cultural explanations together by suggesting
that "acculturation" in a broad sense is a critical factor in
the validity of responses to this questionnaire. This hypothe-
sis would explain the gradient in validity coefficients that
was observed among the groups, which paralleled the gradi-
ent in their apparent degree of acculturation.
AJPH June 1984, Vol. 74, No. 6
MEASURING MEXICAN AMERICAN HEALTH STATUS
Efforts to measure "acculturation" have only recently
begun,'8"19 and it appears that further efforts in this regard
will be essential. Studies of well educated Spanish monolin-
guals, and studies of other Hispanic groups such as Cubans
and Puerto Ricans, may help in determining the relative roles
of education, cultural biases, and acculturation in the appar-
ent validity of questionnaire responses. Perhaps with studies
of this sort, we will be able to better determine the variables
which affect questionnaire reliability and validity, and to
design better cross-cultural studies.
Our data emphasize that Mexican Americans are a very
heterogeneous group, and studies of health behavior which
ignore this fact may be misleading.
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ACKNOWLEDGMENTS
Thanks to Andrew K. Diehl, MD and to Helen Hazuda, PhD, for critical
review of the manuscript; and to Margaret Carrillo and Helen Provot for
technical assistance.
This research was supported by a grant from the Robert Wood Johnson
Foundation Medical Practices Research and Development Program. The
opinions expressed are those of the author and not necessarily those of the
Robert Wood Johnson Foundation.
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