Improving Food Frequency Questionnaires: A Qualitative Approach Using Cognitive Interviewing

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Abstract

In an attempt to improve data quality and ease of administration of standard self-administered food frequency questionnaires, various alternative approaches were tried for inquiring about frequency of consumption, portion size, seasonal intake, and food preparation. Evaluation consisted of a cognitive interviewing method in which respondents verbalize their thought process while completing several variations of a questionnaire. Interviewers observed and asked follow-up probe questions to evaluate problems or inconsistencies verbalized by respondents. Consensus and judgment by interviewers and observers suggested several problematic features of food frequency questionnaires: formatting of questions about frequency and portion size; computing average frequencies for aggregated food items or for foods eaten seasonally; comprehension of many items; and ordering of foods. These findings led to cognitive refinement and innovations, which included detailed questions regarding preparation or use of low-fat varieties or other alternatives to help better describe specifics of intake for some foods; questions on seasonal intake for several foods; inclusion of portion size ranges; and additional response categories for frequency of intake. Cognitive interviewing is an important step in pinpointing cognitive problems in dietary questionnaires. J Am Diet Assoc. 1995; 95:781-788.

Section snippets

General Methods

In each of two iterative phases, conducted 2 months apart, 24 different participants between 50 and 70 years of age were recruited by a community newspaper advertisement and word of mouth to participate in a 2-hour interview. Each participant was paid $50. We attempted to recruit equal numbers of men and women, but made no attempt to stratify by or collect data on other demographic characteristics. For phase 1, 11 men (mean age=61.3 years; range=51 to 73 years) and 13 women (mean age=63.6

Phase 1: Design

Questionnaires developed for phase 1 contained an abbreviated 43-item food frequency questionnaire based on the HHHQ (1), (33). Eight variants of the questionnaire were designed to test different approaches, which we describe later. Each respondent was asked to complete three of these questionnaires in the 2-hour period.

Portion Size

In all cases, people tended to skip portion size questions after completing frequency. Of the three approaches to portion size (Fig. 1), the one providing ranges of portion size within the columns for small, medium, and large appeared easiest for respondents to understand and complete. The meaning of the word, “helpings,” to describe portion size was unclear to respondents.

In the standard HHHQ format, the reference medium portion size is placed to the left of the “S,” “M,” and “L” columns (for

Phase 2: Design

The intent of phase 2 was to develop a questionnaire incorporating the most successful approaches from phase 1 and to continue experimenting with format and wording. We developed two questionnaires, each with a complete list of foods (100 items based primarily on the HHHQ questionnaire) intended to capture intake of most nutrients and commonly consumed foods in the United States from 1976 to 1980. Each respondent was asked to complete one questionnaire in the cognitive interview.

Findings from

Portion Size

Portion sizes in ranges appeared to be preferable to approaches that used a reference medium portion size. Although wordier, this method allowed respondents to select a portion size disassociated with the terminology “small,” “medium,” or “large.” The reference medium portion size approach with the portion size in the “M” column was also satisfactory; respondents were able to choose a portion size and did not confuse the reference with “S” as in the standard HHHQ approach. As in phase 1, many

Discussion

Our findings suggest that, among the many tasks required to develop a food frequency instrument, focusing on the respondent's perceptions of the meaning of the questions is fundamental to good questionnaire design. Listening to and then probing respondents as they verbalize their thought processes while completing a food frequency-type questionnaire is a sobering experience. We were forced to reconsider fundamental issues in questionnaire design to obtain the best data from the most people.

Applications

Researchers who design new dietary instruments should conduct cognitive interviewing to pinpoint problems encountered by respondents. Our findings suggest approaches that we believe may facilitate the collection of more useful dietary data from older men and women. We did not, however, examine validity of the portion size or frequency estimates. Thus, we plan to conduct a validation study of the final version of this cognitively designed food frequency questionnaire using multiple days of food

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