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Class 8

Pretesting Measures and Creating a Questionnaire

November 12, 2009

Anita L. Stewart Institute for Health & Aging

University of California, San Francisco

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Overview of Class 8

Choosing best measure(s) for pretesting Creating a questionnaire Pretesting measures - types of pretests Cognitive interviewing Designing your own pretest

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Process of Selecting Good Measures for Your Studies

Define concept (variable)

Identify potential measures

Review measures’ properties--conceptual adequacy

--psychometric adequacy

Pretest best 1-2 measures

Select final measure

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Select Best Candidate Measures to Pretest

Select best measures for all concepts in your conceptual framework

Pretest measures you plan to use – Pretest 2 measures of key concepts if

possible so you can choose the best one

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Strategies for Selecting Best Measure of “Unidimensional” Concept

Select existing measure in its entirety Select two existing measures

– Have a choice later based on psychometric results

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Strategies for Selecting Best Measure of “Multidimensional” Concept

Select existing instrument in its entirety Select subscales of only relevant domains

from existing instruments – those that meet your needs

Supplement either of the above with subscales from other measures

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What if There is No “Best” Measure?

For priority concepts with inadequate measure, select the one that is the closest in your review– Use pretest or other qualitative studies as basis to

adapt or modify For priority concepts with no measure that

meets your needs, may require development of new measure

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Documenting Measures in Your Study

Handout – sample guide to measures used in questionnaires

Before you forget – – Summarizes source of all measures to be

administered in your study

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Overview of Class 8

Choosing best measure(s) for pretesting Creating a questionnaire Pretesting measures - types of pretests Cognitive interviewing Designing your own pretest

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Considerations in Creating a Questionnaire

Introduction Statement of confidentiality Length Sections, section headings to break it up Order of questions, measures Formatting Conclusion

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Introduction: Inform respondent …

Purpose of overall study and of this questionnaire

Who is conducting the study Topics included in questionnaire Expected time to complete Assurance that participation is voluntary,

can skip any questions Specific instructions for completing

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Statement of Confidentiality

Inform respondents of extent to which their answers are protected if there are risks to confidentiality, state

them Can use section from consent form

pertaining to survey data

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Sample Statement of Confidentiality

“All information that would permit identification of individuals will be regarded as strictly confidential, will be used for purposes of evaluating the study, and will not be disclosed or released for any other purposes without prior consent, except as required by law.”

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Statement of Confidentiality (cont.)

Note that this is a very high reading level– Would need to simplify for lower SES group

“All information about you will be kept as confidential as possible. Your name will not be used in any published reports about this study.”

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Length of Questionnaire

Acceptable length depends on: Interest of respondents in topic area Health Free time of respondents

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Create Sections of Questionnaire

Break up with sections, grouped by topic (minimizes psychological burden)

Introduce new topics with– Phrases - “the next questions are about how

you’ve been feeling”

– Simple section headings, e.g.,

How You’ve Been Feeling

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Question Order

Order can affect willingness to complete survey

Begin with general questions– Easy, non-threatening, interesting, related to

purpose of study Proceed with more specific questions,

personal and sensitive questions Conclude with demographics (least

interesting, sensitive)

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Indicate How to Respond

Give specific instructions for answering questions, e.g.,– Circle all that apply

– Circle one number

– Check the box that best represents howyou feel

If no instructions, subjects will have to figure out what to do and may not do it correctly

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Formatting Self-Administered Questionnaires

Make the tasks of reading questions, following instructions, and recording answers as easy as possible for respondents – Clear instructions for indicating their answer

– Easy to track separate questions

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Principles of Formatting

Create a lot of space on page Use very light background for best contrast

– Minimize use of color as background Number all questions (unique number for each

one helps data entry) Allow sufficient space to write answers to

open-ended questions Special issues for older adults:

– Larger font size (14)– Higher contrast (black on white)

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Types of Formats: Horizontal

How would you rate your health in general?

(check one box)

Excellent Good Fair Poor

(Easy to get confused)

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Types of Formats: Respondent Writes Response Choice

For each question, write in one of the following numbers: 1 = poor

2 = fair

3 = good

4 = excellent

___ 1. How would you rate the availability of medical information by phone?

___ 2. How would you rate the length of time spent waiting at the office to see a provider?

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Types of Formats: Vertical

(circle one number)

No, not limited at all ........... 1

Yes, limited a little .......….. 2

Yes, limited a lot ...........…. 3

During the past 4 weeks, did your healthlimit you in walking one block..

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Types of Formats: Matrix

(Circle one number on each line)

How often during the past 4 weeks did your health limit you ….

No, not limitedat all

Yes,limiteda little

Yes,limited

a lot

1. Walking one block 1 2 3

2. Walking several blocks 1 2 3

3. Climbing one flight of stairs 1 2 3

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Types of Formats: Matrix with Boxes

(Check one box on each line)

How often during the past 4 weeks did your health limit you ….

No, not limitedat all

Yes,limiteda little

Yes,limited

a lot

1. Walking one block � � �2. Walking several blocks � � �3. Climbing one flight of stairs � � �

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Conclude Questionnaire

Add a brief thank you for completing the questionnaire (for their time and effort)

If questionnaire is to be mailed back, include instructions for mailing– Always include a pre-stamped, preaddressed

return envelope

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Resources for Creating Questionnaires

Mullin et al article on formatting principles

Handout: formatting tips for using WORD See sample questionnaires in class

– (sample formats)

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Overview of Class 8

Choosing best measure(s) for pretesting Creating a questionnaire Pretesting measures - types of pretests Cognitive interviewing Designing your own pretest

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Pretest in Target Population Pretesting essential for measures being

applied to any new population group– Especially priority measures (e.g., outcomes)

Pretest is to identify:– problems with procedures

» method of administration, respondent burden

– problems with questions» Item stems, response choices, and instructions

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Types of Pretests

General debriefing pretest (N=10) Large pretest (N=100)

– test measurement properties prior to major study

In-depth cognitive interviewing pretest

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Types of Pretests

General debriefing pretest (N=10) Large pretest (N=100)

– test measurement properties prior to major study

In-depth cognitive interviewing

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General Debriefing Pretest

Goal

– Identify problems with the procedures

– Estimate time needed to complete instrument

– Identify serious problems with items Procedures

– Subjects answer entire questionnaire

– At end, debrief

– Close to true task

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Sample Debriefing Questions After Administration of Survey..

Ask respondents: Were any questions confusing? Which words were hard to understand? Which questions were difficult to answer?

caused distress? Was questionnaire too long? Were instructions confusing?

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“Questionnaire” Asking Opinions About another Questionnaire/Survey

Six questions about burden of a survey– Questionnaire length

– Ease of answering questionnaire

– Negative affect burden (4 items)» Feeling embarrassed, upset, annoyed,

uncomfortable

M Zimmerman et al., Med Care, 1994;32:603-608

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4-item Negative Affect Burden Scale

How much were you annoyed by being asked these questions?

How much were you embarrassed by being asked these questions?

How much did it upset you to be asked these questions?

How uncomfortable did it make you feel to be asked these questions?

Responses: very much, somewhat, a little, not at allZimmerman M et al.1994

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Problems with General Pretests

Respondents… – often don’t understand the task.

– don’t want to appear as if they didn’t understand

– have a hard time telling you anything was wrong

– easier to say everything was fine

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Types of Pretests

General debriefing pretest (N=10) Large pretest (N=100)

– test measurement properties prior to major study

In-depth cognitive interviewing

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Large Pretest – N=100

Test psychometric properties and procedures for large-scale administration– Administer surveys– Examine item distributions, missing data– Calculate internal-consistency reliability– Conduct some preliminary validity studies

Only large-scale studies have this luxury

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Large Pretest of 4 Patient Satisfaction with Hospital Care Measures (N=2,850)

Compared 4 questionnaires on– Response rates, missing data, completion time

10 evaluation items at end of questionnaire (1-5 agree-disagree scale)– Clarity of questions, ease of finding an answer,

questions about unimportant issues, ease of completion, too long, layout confusing, lacked important questions

TV Perneger et al., Med Care 2003;41:1343-1352

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Medical Outcomes Study Measures

On long-form measures, conducted 9 full-scale pilot studies over a 1-year period– Physical functioning, health perceptions,

energy/fatigue, sleep, role functioning, pain, symptoms, family functioning, sexual functioning

Samples ranged from 50-100 each

Stewart AL and Ware JE, Measuring Functioning and Well-Being, 1992, p. 72..

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Types of Pretests

General debriefing pretest (N=10) Large pretest (N=100)

– test measurement properties prior to major study

In-depth cognitive interviewing pretest (N=5-10 each group)

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Overview of Class 8

Choosing best measure(s) for pretesting Creating a questionnaire Pretesting measures - types of pretests Cognitive interviewing Designing your own pretest

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In-Depth Cognitive Interviews

Derived from social and cognitive psychology to explore processes respondents use to answer survey questions

Goal: understand thought processes used to answer questions

Can help write/adapt questions

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Types of Problems with Questions or Response Choices

Are all words/phrases understood as intended? Are questions interpreted similarly by all

respondents? Are some questions not answered? Are any questions offensive or irrelevant? Does each closed-ended question have an

answer that applies to each respondent?– Are the response choices adequate?

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Cognitive Interviews Examine 4 Steps in Answering Questions

Comprehend question (as intended) Retrieve information - various strategies

used to recall information Judgment formation - calculate the

correct response Response - decide what to report

Sudman S et al., Thinking About Answers, Jossey-Bass, San Francisco, 1996

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Comprehend Questions as Intended

Bulk of cognitive interview pretests assess whether your items are interpreted by respondents as you intended

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Retrieve Information

Information needed to answer the question must be retrieved from memory– Episodic data – stored in detail

– Schemas – generalizations about events Frequent, routine events more likely to be

stored as “schema” with no detail

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Example of Retrieval Schema

People with chronic conditions and a lot of doctor visits tend to have “generic” memories of these visits– Multiple visits blurred together

– Could describe a typical visit but not any visit in particular

– Hard to recall how many visits

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Judgment Formation

Involves using the recalled information to estimate frequency of an event, or to decide whether one agrees or disagrees with a statement

Cues taken from the item response choices

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Response

After respondent has judged what the best answer is, decides how to respond– Accurately?

– To improve social desirability?

– To minimize embarrassment?

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Probe Interviews: Types of Probes

Interpret meaning as you intended Ease of answering – appropriate response

choices Acceptability of questions

– Culturally appropriate Clarity, difficulty Elicit socially desirable responding

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Probes to Determine if Respondents Understand Meaning as Intended

Wording of pretest item should be non-threatening:

Example: What do you think we meant by the phrase ________? – Threatening – implies there is a right answer

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More Appropriate Probe Questions to Explore Meaning

What does the word _______ mean to you?

What do you understand by _______ ? What came to mind when I asked you

_____? Ask person to paraphrase a question

– Repeat question in your own words

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Probing Meaning of a Phrase

I asked you about how the office staff treated you personally ….– What does the phrase “office staff” mean to you?

I asked you how often doctors asked you about your health beliefs? – What does the term ‘health beliefs’ mean to you?

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Probing Meaning of Phrase

After a series of questions about the person’s main job– You mentioned earlier that you had more

than one job. How did you decide which job was your main job?

DeMaio TJ et al., Answering Questions, Jossey-Bass, 1996, p. 177..

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Probing Meaning of Entire Question

Do you go to the doctor for checkups even when you’re well?– What does the word “checkup” mean to you?

– Can you rephrase this question in your own words?

Pasick RJ et al., Pub Health Rep, 2001;116:223.

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Probing Meaning of Entire Question

In the last 6 months, have you had problems getting to see a specialist? (yes/no)– Tell me more about that.– What kind of doctor do you think of as a

specialist?– If yes - What kinds of problems have you

had?

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Probing Confidence in Answer

After respondent answers a question– How confident are you in the answer you

gave? » Very confident, somewhat confident, not

confident at all

Lack of confidence is a flag for a problem

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Probing Use of Response Scale

I asked you _____ and you answered____.

What were you thinking of when you picked this answer?

Can you tell me why you picked that number for your answer?

How did you decide to choose that answer? Were you able to find the right answer to the

question from the response options?

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Probing Retrieval

How did you remember that? Did you have a particular time period in

mind? How did you calculate your answer? Can you tell me what you were thinking

when you answered this way?»Can you give me some examples?

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Probe for Acceptability

I asked you _____.– Did you find this question offensive?

– Was it distressing to answer this question?

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Probe for Acceptability (cont)

When I asked you how often you felt discriminated against by doctors because of your race or ethnicity, you answered (read answer given).– Were you offended by this question?– Do you think people would be offended by this

question?

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Probe on Difficulty: CES-D Item

“During the past week, how often have you felt that you could not shake off the blues, even with help from family and friends”– Do you feel this is a question that people would

or would not have difficulty understanding?

TP Johnson, Health Survey Research Methods, 1996

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Overcoming “Social Desirability” in Cognitive Interviews

Ask respondents whether they think others– would have difficulty answering a question

– would answer honestly

Example: – Do you think that most people would

answer this question honestly?

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Overview of Class 8

Choosing best measure(s) for pretesting Creating a questionnaire Pretesting measures - types of pretests Cognitive interviewing Designing your own pretest

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Steps in Cognitive Interview Pretesting

Identify problematic items– Develop scripted “probes” for each one

Recruit sample for cognitive interviews Administer questionnaire and probe

questions Tape record and transcribe Summarize results

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Identify Potentially Problematic Items

Optimal: a small debriefing pretest to find out potential problems

Investigator judgment– You will be good at spotting these

Identify problems with item stems and response choices

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Write Scripted Probes for Each Problem

Create a cognitive interview version of the questionnaire– Not the real questionnaire

Underneath each problem item, write a “probe” question you would ask each pretest respondent

Examples in slides and handouts

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Handouts: Sample Cognitive Interviews

Sample Cognitive Interview Protocol– Ron Hays and Leo Morales (UCLA)

» Experts at cognitive interviewing pretests

Cognitive interview protocols for Interpersonal Processes of Care study– Divided into two parts due to length – Each part: a questionnaire and the cognitive

interview questions accompanying it

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Recruiting for Cognitive Interviewing

The task of your pretest respondent is:– Answering questions (normal interview)

– Being debriefed or answering additional questions about their answers (cognitive interviewing)

Difficult to explain this during recruitment

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Recruiting for Cognitive Interviewing (cont.)

Pay subjects (if you can)– Special demand on them

If survey is long, may have to pretest different sections on different subjects– Requires more total subjects

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Recruiting Scripts for Cognitive Interviewing

Explain how their help fits into the process of creating questions

Ways to explain

– “help us learn how to ask better questions”

– “help us make questions clearer for others”

– “help us learn how we can improve this questionnaire”

– “help us find problems with the questions”

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Administer Questionnaire and Probes

Administer entire questionnaire– Or break into sections

Self-administration or interview?– Interview identifies more problems

Administer probes Audiotape entire interview including probes

– Transcribe audiotapes

RESULT: information on the entire process of administering the questionnaire

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Two Sequences to Administering Probes

Concurrent probing– Ask each probe immediately after respondent has

given answer to survey item– Advantage-information is fresh in respondent’s

mind Retrospective probing (preferred)

– Ask probes after entire interview– Advantage-able to assess standard administration of

items– Doesn’t break up the respondent’s task

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Interviewer’s Role: Spontaneous Probing

Probe on items that appear to be problematic

If a long pause in answering..– “I noticed you pausing - what came to mind

when you I asked you that question?”

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Other Cues to Problems in Face-to- Face Pretests

When administering the survey… Be aware of behavioral cues related to

specific items or to questions in general– Discomfort

– Yawning

– Looking at their watch

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Other Cognitive Interview Methods Resources

Using cognitive interviews to develop structured surveys (May 2007)– Annotated bibliography of articles describing

methods of cognitive interviews

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Homework for Class 9/10

Select best measure Create “mini questionnaire”

– Formatted for self-report, including instructions Write 4 “probe” questions of selected items

– At least one on the meaning of a word/phrase and one on adequacy of response choices

Identify source of 2 pretest “subjects” similar to those you would include in your research

– Write brief 1-paragraph script for recruiting them

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Next and Last Class

December 3 Blend of class 9 and 10