Intended for healthcare professionals

Education And Debate

Reaching beyond the white middle classes

BMJ 2004; 328 doi: (Published 10 June 2004) Cite this as: BMJ 2004;328:1433
  1. Petra M Boynton, lecturer in health services research (,
  2. Gary W Wood, lecturer in psychology2,
  3. Trisha Greenhalgh, professor of primary health care1,
  4. Questionnaire Clinic
  1. 1Department of Primary Care and Population Sciences, University College London, London N19 5LW
  2. 2Department of Education, University of Birmingham, Birmingham B15 2TT
  1. Correspondence to: P M Boynton
  • Accepted 17 March 2004

Apparently simple questions can easily be misunderstood or cause offence in disadvantaged groups. But such problems can be avoided by careful design, piloting, and administration

Most published questionnaire research has been done on university students or in business or healthcare settings in Europe and north America.1 2 This bias leaves us with many unanswered questions about large and often disadvantaged sections of the population. In this article, we consider how to overcome the problems with accessing disempowered and socially excluded groups, cross cultural issues, and participants whose physical or mental health may interfere with their ability to complete a questionnaire. We also discuss the training and support of researcher staff. Researchers should also bear in mind the general principles of questionnaire design, administration, and piloting covered in the earlier papers in this series.3 4

Understanding and meaning

The meaning of a question may be obvious to you and your research staff, but this does not mean all participants will interpret it similarly. Ambiguous questions will lead to responses that do not accurately capture participants' views2 or to them not bothering to respond.5

The greater the social distance between researcher and participant, the greater the risk of misunderstandings. A common problem is when researchers use abstract concepts but participants interpret these literally. For example, a questionnaire seeking to measure emotional wellbeing might include a question “Are you blue?” but some participants may interpret this as an inquiry about their physical health (with blue referring to skin colour or a mark on the body). Whenever you ask about an abstract concept, include a prompt or example, and take careful note of people's reactions during the pilot phase.

Phrases that researchers use routinely may not be familiar to participants or may have alternative (and even opposite) meanings in the real world. Most …

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