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Issue Guatemala is a culturally and linguistically diverse country. Mayan languages are primarily spoken languages; few people know their written form. Health features and outcomes are difficult to assess due to the lack of validated instruments in these languages. Description of the Problem A cluster randomized trial to improve hypertension control is being conducted in 36 municipalities where Mayan languages are spoken in addition to Spanish. Instruments for measuring study outcomes were developed in Spanish and cross-culturally adapted into five Mayan languages following WHO's methodology. First, data were gathered on the proportion of people only fluent in a Mayan language in each district. We prioritized those Mayan languages spoken by more than 20% of the non-Spanish speaking population: Achí, K'iche', Kaqchikel, Tz'utujil and Mam. Second, forward translation to the Mayan languages was conducted by a local healthcare professional, who verbally recorded each instrument. The study team identified key words and concepts to guarantee content equivalence. Third, back-translation was conducted by two independent healthcare providers, who were blinded to the original instruments. The research team formally compared the original questionnaires with the back-translated versions to ensure they were conceptually equivalent and culturally adapted. Discrepancies were corrected as needed. Finally, local interviewers were trained on how to accurately use the written Spanish questionnaires and the Mayan language verbal recordings. Results By following this methodology, we achieved cross-culturally adapted instruments to improve the information-gathering process in communities where only Mayan languages are spoken. Lessons Having culturally adapted tools will allow researchers to reach a broader range of the target population, obtain more accurate information, and take into account participants' culture and cosmovision. Key messages Translating questionnaires to people’s native language allows researchers to obtain more accurate information in a standardized way and better understand participants’ culture and cosmovision. The described methodology is beneficial for conducting research in linguistically diverse countries. It promotes effective and inclusive communication among researchers and participants.

Translating instruments into multiple Mayan languages for a hypertension T4 study in Guatemala