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Cognitive testing in 19 countries to refine WHO's Sexual Health Assessment of Practices and Experiences

Hunter EC 1 , Fine E 2 , Black K 3 , Henriks J 4 , Tofail F 5 , Morroni C 6 Show all authors , Makuch M 7 , Deering K 8 , Murad R 9 , Torpey K 10 , Balde MD 11 , Wilopo SA 12 , Nimbi FM 13 , Maina B 14 , Ahmad NA 15 , Traore LF 16 , Maung TM 17 , Olumide A 18 , Abrejo F 19 , Phuengsamran D 20 , Ddaaki GW 21 , Brunet N 22 , Brizuela V 23 , Gonsalves L 23 , Cognitive testing of a survey instrument to assess sexual practices, behaviours and health-related outcomes (CoTSIS) study group

Affiliations 

  • 1 Department of Public Health Sciences, College of Behavior, Social and Health Sciences, Clemson University, Clemson, United States of America
  • 2 School of Public Health, University of Sydney, Sydney, Australia
  • 3 Discipline in Obstetrics and Gynaecology, University of Sydney, Sydney, Australia
  • 4 School of Population Health, Curtin University, Perth, Australia
  • 5 International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
  • 6 Botswana Sexual and Reproductive Health Initiative, Botswana Harvard Health Partnership, Gaborone, Botswana
  • 7 Centro de Pesquisas em Saúde Reprodutiva de Campinas, Campinas, Brazil
  • 8 Centre for Gender and Sexual Health Equity, Vancouver, Canada
  • 9 Asociación Profamilia, BogotáDC, Colombia
  • 10 University of Ghana School of Public Health, Accra, Ghana
  • 11 Center for Research in Reproductive Health in Guinea, Conakry, Guinea
  • 12 Center for Reproductive Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
  • 13 Department of Dynamic and Clinical Psychology and Health Studies, Sapienza University of Rome, Rome, Italy
  • 14 Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health Unit, African Population and Health Research Center, Nairobi, Kenya
  • 15 Institute for Public Health, Ministry of Health Malaysia, Shah Alam, Malaysia
  • 16 Faculté de Médecine et d'odontostomatologie, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako, Mali
  • 17 Yangon, Myanmar
  • 18 College of Medicine, University of Ibadan, Ibadan, Nigeria
  • 19 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
  • 20 Institute for Population and Social Research, Mahidol University, Nakhon Pathom, Thailand
  • 21 Department of Social and Behavioral Sciences, Rakai Health Sciences Program, Kampala, Uganda
  • 22 Institute of Health Psychology, Faculty of Psychology, Universidad de la República, Montevideo, Uruguay
  • 23 Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
Bull World Health Organ, 2024 Dec 01;102(12):861-872.
PMID: 39611192 DOI: 10.2471/BLT.23.291162

Abstract

OBJECTIVE: To refine a standard questionnaire on sexual practices, experiences and health-related outcomes to improve its cross-cultural applicability and interpretability. We aimed to explore participants' willingness and ability to answer the draft questionnaire items, and determine whether items were interpreted as intended across diverse geographic and cultural environments.

METHODS: We conducted cognitive interviews (n = 645) in three iterative waves of data collection across 19 countries during March 2022-March 2023, with participants of diverse sex, gender, age and geography. Interviewers used a semi-structured field guide to elicit narratives from participants about their questionnaire item interpretation and response processes. Local study teams completed data analysis frameworks, and we conducted joint analysis meetings between data collection waves to identify question failures.

FINDINGS: Overall, we observed that participants were willing to respond to even the most sensitive questionnaire items on sexual biography and practices. We identified issues with the original questionnaire that (i) affected the willingness (acceptability) and ability (knowledge barriers) of participants to respond fully; and/or (ii) prevented participants from interpreting the questions as intended, including poor wording (source question error), cultural portability and very rarely translation error. Our revisions included adjusting item order and wording, adding preambles and implementation guidance, and removing items with limited cultural portability.

CONCLUSION: We have demonstrated that a questionnaire exploring sexual practices, experiences and health-related outcomes can be comprehensible and acceptable by the general population in diverse global contexts, and have highlighted the importance of rigorous processes for the translation and cognitive testing of such a questionnaire.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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