Importance of Piloting a Questionnaire on Sexual Health Research

Wilderness and Environmental Medicine, 17, 295 296 (2006) Letter to the Editor Importance of Piloting a Questionnaire on Sexual Health Research To the Editor: Over the past few years there has been a growing interest in the importance of pilot studies in health science research.1 Pilot studies should provide insight into the research issues being studied and/or provide information about relevant field questions and about the logistics of the field inquiry. These 2 functions of the pilot study are not the same because the term pilot study has 2 distinct meanings: first, feasibility studies, that is, ‘‘small-scale version[s], or trial run[s], done in preparation for the major study’’2; and second, pretesting one’s research instrument.3 We conducted a pilot study among 10 trekker guides in Nepal prior to attempting a larger study of the sexual behavior among such guides. The main aims of this pilot study were to test and refine the research question, the methods, and the tools for data collection with respect to both the contents (quality) of the data and the procedures to be followed. Because little research exists on sexual health issues in Nepal, particularly related to trekking guides, there were no existing questionnaires or interview schedules that could be used in a public health study of the sexual health and behavior of this population. A questionnaire was, therefore, drafted on the basis of a previous project conducted by one of the authors,4 our review of the literature on sexual health, and previous sexual health questionnaires used in other countries. The questionnaire consisted of 10 parts, starting with demographic details of the respondents, and continuing with sections on, for example, attitudes towards sexual health, sexual relationships with foreign women, and smoking and drinking habits. Based on this descriptive analysis and feedback from the research participants, we highlight here some of the issues and lessons learned from the pilot study. ● The pilot study suggested that the guides (9 of 10 participants) liked having the questionnaire written in Corresponding author: Padam Simkhada, Department of Public Health, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom (e-mail: [email protected]). Note: A copy of the questionnaire is available from the corresponding author. ● ● ● ● ● ● 2 languages (English and Nepali); they felt that completing the questionnaire allowed them to practice or test their English. Using 2 languages meant that the questionnaire was nearly double the word length, which resulted in methodological problems. In lifestyle or health promotion studies in industrialized countries, it is common practice to ask about the number of units of alcohol consumed in a certain period. However, in Nepal, where people use a lot of home-made alcohol with varying alcohol levels, a unit of alcohol is impossible to establish. As in all studies involving more than 1 language, there are issues of translation.5 For example, ‘‘drunkenness’’ has 2 distinct translations in Nepali, 1 meaning mildly drunk and 1 meaning very drunk or ‘‘legless.’’ Some of the sexual behaviors, although easily translatable in Nepali, do not make sense to all. Thus, ‘‘oral sex’’ needs to be described rather than just translated. Sometimes the terminology in Nepali is obscure/odd, and in everyday language it is easier to simply use the English term. In our questionnaire, the term ‘‘anal sex’’ was substituted for the Nepali translation. The question on drug misuse was not effective because no one admitted to drug use in the questionnaire. Informal discussions with respondents and other guides, however, suggested that smoking marijuana is a fairly widespread practice among these individuals. We conclude that this question was too sensitive. It is common practice in Nepal to smoke hashish (marijuana), but people are reluctant to admit it due to fear of legal reprisal. Feedback during the pilot study (from all participants) suggested that the original title, ‘‘Sexual Behavior Among Young Nepalese Trekking Guides,’’ was too sensitive. The title was therefore changed to the more general ‘‘Reproductive Health and Personal Behavior Survey Among Trekking Guides in Nepal 2005.’’ We asked in the pilot if people had used a condom during their last intercourse. When they replied ‘‘yes,’’ we intended for the participants to next answer a question about why they had done so. If they had not used a condom during their last intercourse, we meant for them to answer the question ‘‘Why not?’’ However, what happened was that nearly all respondents answered both questions. We suspect this was 296 Letter to the Editor because the instructions were unclear, and after a long discussion we decided to change the question to ‘‘On occasions you used condoms, why did you do so, and on occasions you didn’t, why didn’t you?’’ This meant that all respondents were expected to answer both, because the first question included the multiple choice answer ‘‘I never use condoms,’’ and the latter one had as possible answers ‘‘I always use condoms.’’ ● In Nepali the symbols ‘‘⫻’’ (a cross) and ‘‘⻫’’ (a tick) have different connotations. A cross is associated with a negative answer and a tick with a positive one. Common questionnaire instructions in English are ‘‘Please tick one of the boxes’’ or ‘‘Please put a cross in the box.’’ We had to change the instructions to make it clearer to the respondents what we wished for them to do. Department for International Development, Safe Passages to Adulthood Programme, coordinated by the University of Southampton. Translation issues are to be expected when working with 2 languages and cultures.5 However, some of the issues that occurred in our pilot study were unexpected, even though the first 2 authors are both Nepalese. For example, the notion of ticks and crosses is culturally specific. Conducting a pilot study is a crucial element of a good study design, and it is very helpful to pilot a newly designed questionnaire. Questions need to be culturally appropriate to be of use in public health research. References Acknowledgment. We would like to thank all participants. We acknowledge Dr. Roger Ingham and Nicole Stone at Southampton University and trekking companies at Nepal for their support. The fieldwork of this study was enabled through small grants from the UK Padam Simkhada Department of Public Health University of Aberdeen, Scotland Prakash Bhatta Research and Action Nepal (RAAN) Nayabazar Kathmandu, Nepal Edwin R. van Teijlingen Public Health & Dugald Baird Centre University of Aberdeen Medical School Scotland 1. Van Teijlingen ER, Hundley V. The importance of pilot studies. Soc Res Update. 2001;35. Available at: http:// www.soc.surrey.ac.uk/sru/SRU35.html. Accessed January 11, 2006. 2. Hundley V, van Teijlingen E. The role of pilot studies in midwifery research. RCM Midwives J. 2002;5:372–374. 3. Cohen L, Manion L. Research Method in Education. London: Rutledge; 1989. 4. Bhatta P. Sexual Behaviour of Trekking Guides: An Analysis of Knowledge of Condom Use and STDs and HIV/AIDS in Nepal [unpublished Master’s thesis]. Kathmandu, Nepal: Tribhuvan University; 2003. 5. Birbili M. Translating from one language to another. Soc Res Update. 2000;31. Available at: http://www.soc.surrey. ac.uk/sru/SRU31.html. Accessed April 12, 2006.