An innovative approach to cognitive interviewing to culturally adapt epidemiologic questionnaires

Social and Scientific Systems (SSS) adapted four epidemiologic questionnaires for a study of DDT exposure and pregnancy loss in rural South Africa. To ensure an accurate translation into Tshivenda, we faced two challenges: (1) assessing the questions for clarity and comprehensibility; and (2) evaluating the content for relevance to the local culture. To accomplish this we adapted cognitive interviewing techniques for use with members of the local population who are bilingual in Tshivenda and English.

Typically, in cognitive interviewing the interviewer asks the question, and then debriefs subjects on how they answered to assess how well they understood the intended meaning. This process usually involves audio recording and transcription, and can be time consuming and costly. We replaced this practice with a more direct, structured, and simplified pen-and-paper method of recording subjects' feedback, allowing us to evaluate and revise the questionnaires more quickly.

English-speaking, supervisory field staff were trained to use this modified method with local bilingual field interviewers as subjects to evaluate over 400 questions and response categories. Approximately half of the questions generated comments from one or more of the subjects; about half of these comments revealed areas requiring significant clarification or revision for cultural relevance. Bilingual interviewers then pre-tested revised English questionnaires on local, bilingual volunteers, yielding additional feedback and further revisions. In the final step bilingual interviewers pre-test Tshivenda instruments with Tshivenda-speaking volunteers. Utilizing this innovative approach, SSS is able to collect epidemiologic data with clear, culturally-relevant instruments regardless of the population's primary language.