Unlocking Acceptability: Our Swedish Questionnaire Adventure

Hello there! Let me tell you about something pretty cool we’ve been working on. You know how sometimes you try to introduce something new, maybe a new way of doing things at work or a new health program, and it just… doesn’t land? People don’t use it, they don’t stick with it, and it doesn’t quite work as planned. Turns out, a massive reason for this is something called ‘acceptability’. If the folks who are supposed to deliver or receive an intervention don’t find it acceptable, well, it’s probably not going to be as effective as you hoped.

Think about it – if a new healthcare approach feels like a huge burden, or people don’t quite get how it works, or they just don’t feel good about it, they’re less likely to engage. Simple, right? The clever folks at the Medical Research Council totally get this and stress that evaluating acceptability is super important when developing and implementing complex healthcare interventions.

The tricky part? Measuring acceptability hasn’t always been straightforward. There’s been a bit of a muddle, with different studies doing things differently, and frankly, a lack of agreement on what ‘acceptability’ even truly means! This makes it tough to compare notes across different interventions and studies.

Luckily, some brilliant minds, Sekhon and colleagues, stepped in and developed the Theoretical Framework of Acceptability (TFA). It’s been a game-changer in healthcare research, giving us a common language and structure to think about acceptability. Building on this framework, they even created a generic questionnaire – a tool we could potentially use to actually *measure* this elusive concept. This questionnaire looks at seven key areas: how people feel about the intervention (affective attitude), the burden it imposes, any ethical considerations, how effective people think it is (perceived effectiveness), how well they understand it (intervention coherence), their confidence in using it (self-efficacy), and what they might have to give up to use it (opportunity costs). There’s also a general item asking about overall acceptability. Each area gets a rating on a simple 1-to-5 scale.

Now, this TFA questionnaire has been used in various settings and translated into languages like Spanish. But when we looked around for a Swedish version, ready to go and properly evaluated… crickets! Nothing validated was available. And that, my friends, is where our adventure began.

Our Mission: Bring Acceptability Measurement to Sweden

So, our mission was clear: we needed to take this fantastic generic TFA questionnaire, translate it into Swedish, make sure it felt right for the Swedish context (cultural adaptation is key!), and then give it a whirl to see how it performed. We wanted a valid and reliable tool because, as you can imagine, a wonky translation or a poorly adapted questionnaire isn’t going to give you useful information. It could completely shift the meaning of the questions, leaving you scratching your head about what you’re actually measuring.

Our team, a bunch of registered nurses and researchers with a soft spot for complex healthcare interventions and psychometric evaluations (that’s just a fancy way of saying we like testing how well measurement tools work!), rolled up our sleeves. We got permission from the original TFA questionnaire authors – always polite to ask! – and set out following some pretty rigorous international guidelines for translation and adaptation.

The Journey: Translating, Adapting, and Chatting

This wasn’t just a simple word-for-word swap. Oh no, it was a multi-stage process, a bit like a relay race with lots of checkpoints.

1. Forward-Backward Translation: We started with a professional translator going from English to Swedish. Then, a *different* professional translator went back from that Swedish version to English. This helps catch any meanings that got lost or twisted in translation. We went back and forth, discussing every little nuance until we were happy with a draft.
2. Expert Panel Review: Next, we gathered a panel of researchers who are experts in healthcare interventions. They looked at our Swedish draft to check its face validity (does it *look* like it’s measuring acceptability?) and content validity (do the items actually *cover* the different aspects of acceptability as defined by the TFA?). They gave us feedback, rating how relevant each item was.
3. Lay Panel Cognitive Interviews: This was a super important step, and frankly, one of the most insightful. We talked to healthcare professionals – both those who deliver interventions and those who receive them. We used a technique called ‘cognitive interviewing’ with a ‘think-aloud’ method. Basically, we asked them to read each questionnaire item and response option aloud and tell us exactly what they were thinking, how they understood the question, and how they’d arrive at an answer, relating it to a real intervention they’d experienced. This helps uncover if the language makes sense in a real-world setting and if people interpret the questions the way we intend. We did this in two rounds, refining the questionnaire based on their feedback. They even helped us think about how the questionnaire would work if you used it *before*, *during*, or *after* an intervention.

4. Pilot Evaluation: Finally, we put the Swedish version (let’s call it the S-TFA questionnaire now!) to a small test. We asked 16 healthcare professionals who had recently received an educational intervention to fill it out. This gave us a first look at some basic psychometric properties – things like how many questions were left blank (data quality), if the scores were spread out or all clustered at one end (targeting, ceiling/floor effects), and how well the items seemed to hang together (homogeneity).

What We Found: Good Vibes and Tricky Bits

Overall, the journey was a mix of encouraging signs and “hmm, let’s think about this” moments.

* Face Validity e Comprehensibility: The good news! Both our expert panel and the healthcare professionals we interviewed felt the questionnaire looked good, was a reasonable length, and the response options made sense. The cognitive interviews suggested that, for the most part, people understood the questions during the think-aloud process. Success on the translation and usability front seemed promising here.
* Content Validity: This was one of the tricky bits. When our expert panel rated the relevance of the items, many didn’t hit the recommended threshold. This suggests that, according to our experts, several items didn’t strongly reflect the concept of ‘acceptability’ as intended. Interestingly, there was quite a bit of variation among the experts, which really highlights that ongoing lack of consensus on what acceptability fully encompasses, even among researchers!
* Cognitive Interview Insights: The chats were invaluable. People pointed out some wording that felt a bit old-fashioned or confusing in Swedish. The meaning of ‘fair’ in relation to an intervention was particularly puzzling for some. There were also questions about who ‘moral or ethical consequences’ referred to – the patient, the professional’s values, or the organization? And even the word ‘acceptable’ itself in the final item was a bit hard for some to grapple with. We wrestled with these, discussed them extensively, but sometimes a perfect alternative just wasn’t obvious. The interviews also confirmed that not every item will fit every single intervention – you might need to pick and choose the most relevant ones, just as the original developers suggested. Using the questionnaire to assess acceptability *after* a long intervention process was also highlighted as potentially difficult, as feelings can change over time.
* Pilot Evaluation Results: Our small pilot test gave us a sneak peek at the numbers.
* Data Quality: Excellent! Very few missing answers, suggesting people could complete it.
* Targeting: This is where things got interesting. Most items showed ‘ceiling effects’, meaning a lot of people scored at the high end (4 or 5). This resulted in negatively skewed data. While it’s great that many found the educational intervention acceptable, it means the questionnaire might not be the best at picking up *improvements* in acceptability if people are already rating it highly.
* Homogeneity: Most items seemed reasonably correlated with the total score, but one item – the one about ‘moral or ethical consequences’ – had a low correlation. This suggests it might not be measuring the same underlying thing as the other items, perhaps because, as the cognitive interviews hinted, it’s not relevant for all interventions.

Why It Matters and What’s Next

So, what’s the takeaway from all this? Well, we successfully translated and culturally adapted the TFA questionnaire into Swedish, and initial evaluations of face validity and comprehensibility are positive. It seems like it *could* be a useful quick screening tool for acceptability in healthcare interventions in Sweden.

However, the content validity issues and the results from the pilot test – particularly the ceiling effects and the performance of certain items – tell us there are still some unresolved challenges. These challenges likely stem, at least in part, from that broader lack of consensus on the very definition of ‘acceptability’ that researchers have noted before.

The questionnaire’s structure, with mostly one item per dimension, is convenient but also has limitations. Single items can be less reliable and sensitive than multiple items measuring the same thing.

Based on our experience, and echoing the original developers and other researchers who’ve translated the TFA:

• Using the questionnaire requires careful consideration and possibly rewording of items to fit the specific intervention, setting, and timing (before, during, or after).
• We *strongly* recommend doing cognitive interviews with the target population whenever you use the questionnaire in a new setting or with a different intervention. It’s the best way to catch those tricky wording issues and ensure people understand the questions as intended.
• Complementing the questionnaire with qualitative data, like free-text answers or follow-up interviews, could really deepen the understanding of *why* people find an intervention acceptable (or not).
• More psychometric testing in larger samples is definitely needed for the S-TFA to fully understand its properties, especially its factor structure, validity, and reliability across different groups and interventions.
• It would also be super helpful to compare different acceptability questionnaires out there to see how they measure up against each other and refine how we measure this crucial concept.

In conclusion, our Swedish acceptability questionnaire adventure has been enlightening! We’ve built a promising tool, but the journey isn’t over. It’s a reminder that even with a great framework like the TFA, bringing a measurement tool into a new language and culture, and applying it to the messy reality of complex healthcare interventions, requires careful work, continuous evaluation, and a good dose of curiosity about how people truly experience things.

Source: Springer