A questionnaire exploring sexual practices, experiences and health-related outcomes can be comprehensible and acceptable by the general population in diverse global contexts, and rigorous processes for translation and cognitive testing of such a questionnaire are critically important.
Participants across 19 countries were generally willing to respond to even the most sensitive questionnaire items on sexual biography and practices.
The original draft questionnaire contained problems that affected participants' willingness (acceptability) and ability (knowledge barriers) to respond fully.
The original questionnaire contained problems that prevented participants from interpreting questions as intended, including poor wording (source question error), cultural portability issues, and very rarely translation error.
Revisions to the questionnaire included adjusting item order and wording, adding preambles and implementation guidance, and removing items with limited cultural portability.
The study used a three-wave iterative cognitive interview methodology with a semi-structured field guide across 19 countries to test and refine the WHO sexual health questionnaire.
The study demonstrated that a standard questionnaire on sexual health practices and experiences can be made comprehensible and acceptable across diverse global contexts through rigorous cognitive testing and translation processes.
This research describes the process of testing and refining a World Health Organization (WHO) questionnaire designed to measure sexual health practices, experiences, and outcomes across many different countries and cultures. Researchers conducted 645 in-depth cognitive interviews — conversations where participants explain how they understand and answer survey questions — across 19 countries over one year, with people of diverse genders, ages, and backgrounds. The study used three rounds of testing, making improvements to the questionnaire between each round based on what they learned. The study found that people were generally willing to answer even the most sensitive questions about their sexual history and behaviors. However, the original questionnaire had several types of problems: some questions were worded poorly in the original language, some concepts did not translate meaningfully across different cultures (called 'cultural portability' issues), and a small number had translation errors. These problems sometimes made people unwilling or unable to answer, or caused them to interpret questions differently than intended. To fix these issues, the research team reordered questions, improved wording, added introductory text to sensitive sections, and removed questions that could not be adapted across cultures. This research suggests that it is possible to create a global survey about sexual health that is both understandable and acceptable to general populations in widely different cultural settings, but only if it goes through careful, iterative testing and translation. The findings have practical implications for public health researchers and organizations seeking to collect comparable data on sexual health across countries, as they demonstrate the specific types of problems that arise and the kinds of revisions needed to address them.
Hunter E, Fine E, Black K, Henriks J, Tofail F, Morroni C, et al.. (2024). Cognitive testing in 19 countries to refine WHO's Sexual Health Assessment of Practices and Experiences.. Bulletin of the World Health Organization. https://doi.org/10.2471/BLT.23.291162