Reaching beyond the white middle classes
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7453.1433 (Published 10 June 2004) Cite this as: BMJ 2004;328:1433All rapid responses
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We read the three articles edited by Professor Greenalgh and authored
by Boynton et al.(1,2,3) with great interest. The “Hands-on guide to
questionnaire research” has brought to light a very important issue, an
issue worth serious reflective engagement.
The validation, standardisation and piloting of the questionnaire on
participants who are representative of the definitive sample are a “must”,
whether the researchers have constructed their own questionnaire or are
using an existing instrument.(1,2) However, even so, an analysis of 195
evaluative patient satisfaction studies revealed that, with few
exceptions, the study instruments in this sample demonstrated little
evidence of reliability or validity.(4)
While there are still many challenges facing research in the
development of a valid and reliable survey instrument, research, even more
so, faces a larger challenge, the challenge of convincing its researchers
of the importance of instrument translation when the original version of
the chosen questionnaire is in a different language than the one used in
the population under investigation.
A key reason for using a previously validated and published
questionnaire in different languages is to enable international
comparisons, thus serving as a control of sorts. Second, in an era in
which the growing numbers of immigrants pose new policy issues, there is
an increasing need for research of these populations, together with
research into the indigenous population. Furthermore, the need to
aggregate data from two or more cultures in clinical trials regarding the
efficacy and effectiveness of procedures and medications explains the rise
in demand for translated instruments, much less the need for such
instruments.
For the above-mentioned reasons, therefore, we can see that the data
collection effort often requires the development of a controlled study
instrument in two or more languages. Concerning the latter, however, we
equally must assert that such research methods become viable only if the
multiple versions of the instrument are sufficient in the evaluative terms
of semantic/ idiomatic/ experiential/ and conceptual equivalence.(5) Non-
equivalent instruments, in contrast, can lead to non-comparable
measurements and therefore to biased results. A proper goal, in regards to
a proper methodology, should show that the differences in results should
be attributable only to the differences between participants, and not to
discrepancies in how the questions are perceived due to an inadequate
translation. This being so, the translation procedure, therefore, plays an
integral role in the overall validity and reliability of the research.
It is our suggestion that, often, researchers underestimate the
importance of adequately translating a questionnaire; hence, they are
usually quite unfamiliar with the issues involved therein. Also, we have
found that researchers are sometimes unaware of the implications with
regards to questionnaire reliability and validity due to an inadequate
translation procedure. We suggest, therefore, that although using a
previously validated and published questionnaire might seem convenient
time and resource-wise, in the actual exercise, however, it might be,
highly consumptive of staff and budgets. In our view, it is important for
researchers to realise that adopting and adapting an existing instrument
for developing a multilingual or foreign language questionnaire is not an
easy task. Moreover, in so realising this, because many researchers, not
overly informed or concerned with this fact, will often scant on
translation costs by translating it themselves, or by translating the
questionnaire with the aid of some colleagues who are not professional
translators, they will end up with inadequate research results. Also, we
want to stress that because researchers will often not start the
questionnaire design until too late in the course of the research, so that
when translation problems arise they are hindered by deadlines and budgets
constraints, the quality of the research results are compromised.
The above comments outline our experiences in adopting and adapting
one international and two country-specific validated and published(6,7,8)
questionnaires in Greece and Albania.
References
1 Boynton PM, Greenhalgh T. Hands-on guide to questionnaire research:
selecting, designing, and developing your questionnaire. BMJ 2004;328:1312
-5.
2 Boynton PM. Hands-on guide to questionnaire research:
administering, analyzing and reporting your questionnaire. BMJ
2004;328:1372-5.
3 Boynton PM, Wood GW, Greenhalgh T. Hands-on guide to questionnaire
research: Reaching beyond the white middle classes. BMJ 2004;328:1433-1436
4 Sitzia J. How valid and reliable are patient satisfaction data? An
analysis of 195 studies. Int J Qual Health Care 1999 Aug;11(4):319-28.
5 Guillemin F. Cross-cultural adaptation of health-related quality of
life measures: literature review and proposed guidelines. J Clin Epidemiol
1993 Dec;46(12):1417-32.
6 Grol R, Wensing M, Mainz J, Jung HP, Ferreira P, Hearnshaw H,
Hjortdahl P, Olesen F, Reis S, Ribacke M, Szecsenyi J; European Task Force
on Patient Evaluations of General Practice Care (EUROPEP). Patients in
Europe evaluate general practice care: an international comparison. Br J
Gen Pract 2000 Nov;50(460):882-7.
7 Matsumoto M, Inoue K, Kajii E. Rural practice evaluation: how do
rural physicians evaluate their working conditions? Aust J Rural Health
2001 Apr;9(2):64-8.
8 Rovithis E, Antonakis N, Bathianaki M, Markaki A, Trigoni M, Lionis
C. Description and survey of the current situation (chapter 3). In: Lionis
C (ed). Making Primary Health Care effective in every day practice: a
handbook for use by the health professionals of the Health Centres and
Peripheral Surgeries (in Greek). PESYP Crete: Heraklion, 2003:45-100.
Competing interests:
None declared
Competing interests: No competing interests
Questionnaire Clinic
Since this hands on guide to questionnaires has been published in the
BMJ, I've been overwhelmed with enquiries about further teaching and
support in questionnaire design.
As a result, we are setting up a series of 'Questionnaire Clinics' to
help those struggling with designing, distributing, or analysing their
questionnaire. The first one will run this July (details below), with
further Clinics being held later in the year.
The first Questionnaire Clinic will run on Wednesday 21 July, from
9.30-4pm. Cost £120 per person including lunch.
The Clinic will cover:
* Designing your questionnaire
* Ethics, research governance and questionnaires
* Increasing your response rates
* Managing and analysing your questionnaire data
* Reporting your questionnaire study.
We invite delegates to bring with them copies of any questionnaires they
are currently working on, and we will run sessions during the day to
identify key areas where you can improve your measure or study.
For further details contact Petra Boynton p.boynton@pcps.ucl.ac.uk or
Marcia Rigby m.rigby@pcps.ucl.ac.uk
And thank you to all the people who took the time to comment on the
series - your feedback is much appreciated!
with best wishes
Petra
Competing interests:
I'm the author of the questionnaire paper series.
Competing interests: No competing interests