Having identified the issues considered relevant and having made some decisions regarding the format of the questions, the next stage is to convert the items into questions. It should go without saying that questions should be brief, clearly worded, easily understood, unambiguous, and easy to respond to. However, the experience of many investigators is that seemingly simple, lucid questions may present unanticipated problems to patients, and that all questions should be extensively tested on patients before being used iri a large study or a clinical trial.
The book by Sudman and Bradburn (1982) focuses on wording and designing questionnaires. The following suggestions are merely a sample of the many points to consider.
1. Make questions and instructions brief and simple. Ill patients and the elderly, especially, may be confused by long, complicated sentences.
2. Avoid small, unclear typefaces. Elderly patients may not have good eyesight.
3. Questions that are not applicable to some patients may result in missing or ambiguous answers. For example, "Do you experience difficulty going up stairs?" is not applicable to someone who is confined to bed. Some patients may leave it blank because it is not applicable, some might mark it "Yes" because they would have difficulty if they tried, and others might mark it "No" because they never need to try and therefore experience no difficulty. The responses cannot be interpreted.
4. If potentially embarrassing or offending questions are necessary, consider putting them at the end of the instrument or making them optional. For example, the FACT-G has a question about satisfaction with sex life, but precedes this with "If you prefer not to answer it, please check this box and go to the next section."
5. Avoid double negatives. For example, a question such as "I don't feel less interest in sex (Yes/No)" is ill-advised.
6. If two or more questions are similar in their wording, use underlining, bold or italics to draw patients' attention to the differences. For example, questions 4 and 5 of the SF-36 are very similar apart from the underlined phrases "as a result of your physical health" and "as a result of any emotional problems".
7. Use underlining and similar methods also to draw attention to key words or phrases. For example, many of the instruments underline the time frame of the questions, such as "during the past 7 days".
8. Consider including items that are positively phrased as well as negatively phrased items. For example, the HADS includes equal numbers of positive and negative items, such as "I feel tense or 'wound up'" and "I can sit at ease and feel relaxed."
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