reliability and validity in qualitative research pdf

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Validity, reliability, and generalizability in qualitative research

Lawrence leung.

1 Department of Family Medicine, Queen's University, Kingston, Ontario, Canada

2 Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, Canada

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Nature of Qualitative Research versus Quantitative Research

The essence of qualitative research is to make sense of and recognize patterns among words in order to build up a meaningful picture without compromising its richness and dimensionality. Like quantitative research, the qualitative research aims to seek answers for questions of “how, where, when who and why” with a perspective to build a theory or refute an existing theory. Unlike quantitative research which deals primarily with numerical data and their statistical interpretations under a reductionist, logical and strictly objective paradigm, qualitative research handles nonnumerical information and their phenomenological interpretation, which inextricably tie in with human senses and subjectivity. While human emotions and perspectives from both subjects and researchers are considered undesirable biases confounding results in quantitative research, the same elements are considered essential and inevitable, if not treasurable, in qualitative research as they invariable add extra dimensions and colors to enrich the corpus of findings. However, the issue of subjectivity and contextual ramifications has fueled incessant controversies regarding yardsticks for quality and trustworthiness of qualitative research results for healthcare.

Impact of Qualitative Research upon Primary Care

In many ways, qualitative research contributes significantly, if not more so than quantitative research, to the field of primary care at various levels. Five qualitative studies are chosen to illustrate how various methodologies of qualitative research helped in advancing primary healthcare, from novel monitoring of chronic obstructive pulmonary disease (COPD) via mobile-health technology,[ 1 ] informed decision for colorectal cancer screening,[ 2 ] triaging out-of-hours GP services,[ 3 ] evaluating care pathways for community psychiatry[ 4 ] and finally prioritization of healthcare initiatives for legislation purposes at national levels.[ 5 ] With the recent advances of information technology and mobile connecting device, self-monitoring and management of chronic diseases via tele-health technology may seem beneficial to both the patient and healthcare provider. Recruiting COPD patients who were given tele-health devices that monitored lung functions, Williams et al. [ 1 ] conducted phone interviews and analyzed their transcripts via a grounded theory approach, identified themes which enabled them to conclude that such mobile-health setup and application helped to engage patients with better adherence to treatment and overall improvement in mood. Such positive findings were in contrast to previous studies, which opined that elderly patients were often challenged by operating computer tablets,[ 6 ] or, conversing with the tele-health software.[ 7 ] To explore the content of recommendations for colorectal cancer screening given out by family physicians, Wackerbarth, et al. [ 2 ] conducted semi-structure interviews with subsequent content analysis and found that most physicians delivered information to enrich patient knowledge with little regard to patients’ true understanding, ideas, and preferences in the matter. These findings suggested room for improvement for family physicians to better engage their patients in recommending preventative care. Faced with various models of out-of-hours triage services for GP consultations, Egbunike et al. [ 3 ] conducted thematic analysis on semi-structured telephone interviews with patients and doctors in various urban, rural and mixed settings. They found that the efficiency of triage services remained a prime concern from both users and providers, among issues of access to doctors and unfulfilled/mismatched expectations from users, which could arouse dissatisfaction and legal implications. In UK, a care pathways model for community psychiatry had been introduced but its benefits were unclear. Khandaker et al. [ 4 ] hence conducted a qualitative study using semi-structure interviews with medical staff and other stakeholders; adopting a grounded-theory approach, major themes emerged which included improved equality of access, more focused logistics, increased work throughput and better accountability for community psychiatry provided under the care pathway model. Finally, at the US national level, Mangione-Smith et al. [ 5 ] employed a modified Delphi method to gather consensus from a panel of nominators which were recognized experts and stakeholders in their disciplines, and identified a core set of quality measures for children's healthcare under the Medicaid and Children's Health Insurance Program. These core measures were made transparent for public opinion and later passed on for full legislation, hence illustrating the impact of qualitative research upon social welfare and policy improvement.

Overall Criteria for Quality in Qualitative Research

Given the diverse genera and forms of qualitative research, there is no consensus for assessing any piece of qualitative research work. Various approaches have been suggested, the two leading schools of thoughts being the school of Dixon-Woods et al. [ 8 ] which emphasizes on methodology, and that of Lincoln et al. [ 9 ] which stresses the rigor of interpretation of results. By identifying commonalities of qualitative research, Dixon-Woods produced a checklist of questions for assessing clarity and appropriateness of the research question; the description and appropriateness for sampling, data collection and data analysis; levels of support and evidence for claims; coherence between data, interpretation and conclusions, and finally level of contribution of the paper. These criteria foster the 10 questions for the Critical Appraisal Skills Program checklist for qualitative studies.[ 10 ] However, these methodology-weighted criteria may not do justice to qualitative studies that differ in epistemological and philosophical paradigms,[ 11 , 12 ] one classic example will be positivistic versus interpretivistic.[ 13 ] Equally, without a robust methodological layout, rigorous interpretation of results advocated by Lincoln et al. [ 9 ] will not be good either. Meyrick[ 14 ] argued from a different angle and proposed fulfillment of the dual core criteria of “transparency” and “systematicity” for good quality qualitative research. In brief, every step of the research logistics (from theory formation, design of study, sampling, data acquisition and analysis to results and conclusions) has to be validated if it is transparent or systematic enough. In this manner, both the research process and results can be assured of high rigor and robustness.[ 14 ] Finally, Kitto et al. [ 15 ] epitomized six criteria for assessing overall quality of qualitative research: (i) Clarification and justification, (ii) procedural rigor, (iii) sample representativeness, (iv) interpretative rigor, (v) reflexive and evaluative rigor and (vi) transferability/generalizability, which also double as evaluative landmarks for manuscript review to the Medical Journal of Australia. Same for quantitative research, quality for qualitative research can be assessed in terms of validity, reliability, and generalizability.

Validity in qualitative research means “appropriateness” of the tools, processes, and data. Whether the research question is valid for the desired outcome, the choice of methodology is appropriate for answering the research question, the design is valid for the methodology, the sampling and data analysis is appropriate, and finally the results and conclusions are valid for the sample and context. In assessing validity of qualitative research, the challenge can start from the ontology and epistemology of the issue being studied, e.g. the concept of “individual” is seen differently between humanistic and positive psychologists due to differing philosophical perspectives:[ 16 ] Where humanistic psychologists believe “individual” is a product of existential awareness and social interaction, positive psychologists think the “individual” exists side-by-side with formation of any human being. Set off in different pathways, qualitative research regarding the individual's wellbeing will be concluded with varying validity. Choice of methodology must enable detection of findings/phenomena in the appropriate context for it to be valid, with due regard to culturally and contextually variable. For sampling, procedures and methods must be appropriate for the research paradigm and be distinctive between systematic,[ 17 ] purposeful[ 18 ] or theoretical (adaptive) sampling[ 19 , 20 ] where the systematic sampling has no a priori theory, purposeful sampling often has a certain aim or framework and theoretical sampling is molded by the ongoing process of data collection and theory in evolution. For data extraction and analysis, several methods were adopted to enhance validity, including 1 st tier triangulation (of researchers) and 2 nd tier triangulation (of resources and theories),[ 17 , 21 ] well-documented audit trail of materials and processes,[ 22 , 23 , 24 ] multidimensional analysis as concept- or case-orientated[ 25 , 26 ] and respondent verification.[ 21 , 27 ]

Reliability

In quantitative research, reliability refers to exact replicability of the processes and the results. In qualitative research with diverse paradigms, such definition of reliability is challenging and epistemologically counter-intuitive. Hence, the essence of reliability for qualitative research lies with consistency.[ 24 , 28 ] A margin of variability for results is tolerated in qualitative research provided the methodology and epistemological logistics consistently yield data that are ontologically similar but may differ in richness and ambience within similar dimensions. Silverman[ 29 ] proposed five approaches in enhancing the reliability of process and results: Refutational analysis, constant data comparison, comprehensive data use, inclusive of the deviant case and use of tables. As data were extracted from the original sources, researchers must verify their accuracy in terms of form and context with constant comparison,[ 27 ] either alone or with peers (a form of triangulation).[ 30 ] The scope and analysis of data included should be as comprehensive and inclusive with reference to quantitative aspects if possible.[ 30 ] Adopting the Popperian dictum of falsifiability as essence of truth and science, attempted to refute the qualitative data and analytes should be performed to assess reliability.[ 31 ]

Generalizability

Most qualitative research studies, if not all, are meant to study a specific issue or phenomenon in a certain population or ethnic group, of a focused locality in a particular context, hence generalizability of qualitative research findings is usually not an expected attribute. However, with rising trend of knowledge synthesis from qualitative research via meta-synthesis, meta-narrative or meta-ethnography, evaluation of generalizability becomes pertinent. A pragmatic approach to assessing generalizability for qualitative studies is to adopt same criteria for validity: That is, use of systematic sampling, triangulation and constant comparison, proper audit and documentation, and multi-dimensional theory.[ 17 ] However, some researchers espouse the approach of analytical generalization[ 32 ] where one judges the extent to which the findings in one study can be generalized to another under similar theoretical, and the proximal similarity model, where generalizability of one study to another is judged by similarities between the time, place, people and other social contexts.[ 33 ] Thus said, Zimmer[ 34 ] questioned the suitability of meta-synthesis in view of the basic tenets of grounded theory,[ 35 ] phenomenology[ 36 ] and ethnography.[ 37 ] He concluded that any valid meta-synthesis must retain the other two goals of theory development and higher-level abstraction while in search of generalizability, and must be executed as a third level interpretation using Gadamer's concepts of the hermeneutic circle,[ 38 , 39 ] dialogic process[ 38 ] and fusion of horizons.[ 39 ] Finally, Toye et al. [ 40 ] reported the practicality of using “conceptual clarity” and “interpretative rigor” as intuitive criteria for assessing quality in meta-ethnography, which somehow echoed Rolfe's controversial aesthetic theory of research reports.[ 41 ]

Food for Thought

Despite various measures to enhance or ensure quality of qualitative studies, some researchers opined from a purist ontological and epistemological angle that qualitative research is not a unified, but ipso facto diverse field,[ 8 ] hence any attempt to synthesize or appraise different studies under one system is impossible and conceptually wrong. Barbour argued from a philosophical angle that these special measures or “technical fixes” (like purposive sampling, multiple-coding, triangulation, and respondent validation) can never confer the rigor as conceived.[ 11 ] In extremis, Rolfe et al. opined from the field of nursing research, that any set of formal criteria used to judge the quality of qualitative research are futile and without validity, and suggested that any qualitative report should be judged by the form it is written (aesthetic) and not by the contents (epistemic).[ 41 ] Rolfe's novel view is rebutted by Porter,[ 42 ] who argued via logical premises that two of Rolfe's fundamental statements were flawed: (i) “The content of research report is determined by their forms” may not be a fact, and (ii) that research appraisal being “subject to individual judgment based on insight and experience” will mean those without sufficient experience of performing research will be unable to judge adequately – hence an elitist's principle. From a realism standpoint, Porter then proposes multiple and open approaches for validity in qualitative research that incorporate parallel perspectives[ 43 , 44 ] and diversification of meanings.[ 44 ] Any work of qualitative research, when read by the readers, is always a two-way interactive process, such that validity and quality has to be judged by the receiving end too and not by the researcher end alone.

In summary, the three gold criteria of validity, reliability and generalizability apply in principle to assess quality for both quantitative and qualitative research, what differs will be the nature and type of processes that ontologically and epistemologically distinguish between the two.

Source of Support: Nil.

Conflict of Interest: None declared.

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• Issues of validity and reliability in qualitative research
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• Helen Noble 1 ,
• Joanna Smith 2
• 1 School of Nursing and Midwifery, Queens's University Belfast , Belfast , UK
• 2 School of Human and Health Sciences, University of Huddersfield , Huddersfield , UK
• Correspondence to Dr Helen Noble School of Nursing and Midwifery, Queens's University Belfast, Medical Biology Centre, 97 Lisburn Rd, Belfast BT9 7BL, UK; helen.noble{at}qub.ac.uk

https://doi.org/10.1136/eb-2015-102054

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Evaluating the quality of research is essential if findings are to be utilised in practice and incorporated into care delivery. In a previous article we explored ‘bias’ across research designs and outlined strategies to minimise bias. 1 The aim of this article is to further outline rigour, or the integrity in which a study is conducted, and ensure the credibility of findings in relation to qualitative research. Concepts such as reliability, validity and generalisability typically associated with quantitative research and alternative terminology will be compared in relation to their application to qualitative research. In addition, some of the strategies adopted by qualitative researchers to enhance the credibility of their research are outlined.

Are the terms reliability and validity relevant to ensuring credibility in qualitative research?

Although the tests and measures used to establish the validity and reliability of quantitative research cannot be applied to qualitative research, there are ongoing debates about whether terms such as validity, reliability and generalisability are appropriate to evaluate qualitative research. 2–4 In the broadest context these terms are applicable, with validity referring to the integrity and application of the methods undertaken and the precision in which the findings accurately reflect the data, while reliability describes consistency within the employed analytical procedures. 4 However, if qualitative methods are inherently different from quantitative methods in terms of philosophical positions and purpose, then alterative frameworks for establishing rigour are appropriate. 3 Lincoln and Guba 5 offer alternative criteria for demonstrating rigour within qualitative research namely truth value, consistency and neutrality and applicability. Table 1 outlines the differences in terminology and criteria used to evaluate qualitative research.

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Terminology and criteria used to evaluate the credibility of research findings

What strategies can qualitative researchers adopt to ensure the credibility of the study findings?

Unlike quantitative researchers, who apply statistical methods for establishing validity and reliability of research findings, qualitative researchers aim to design and incorporate methodological strategies to ensure the ‘trustworthiness’ of the findings. Such strategies include:

Accounting for personal biases which may have influenced findings; 6

Acknowledging biases in sampling and ongoing critical reflection of methods to ensure sufficient depth and relevance of data collection and analysis; 3

Meticulous record keeping, demonstrating a clear decision trail and ensuring interpretations of data are consistent and transparent; 3 , 4

Establishing a comparison case/seeking out similarities and differences across accounts to ensure different perspectives are represented; 6 , 7

Including rich and thick verbatim descriptions of participants’ accounts to support findings; 7

Demonstrating clarity in terms of thought processes during data analysis and subsequent interpretations 3 ;

Engaging with other researchers to reduce research bias; 3

Respondent validation: includes inviting participants to comment on the interview transcript and whether the final themes and concepts created adequately reflect the phenomena being investigated; 4

Data triangulation, 3 , 4 whereby different methods and perspectives help produce a more comprehensive set of findings. 8 , 9

Table 2 provides some specific examples of how some of these strategies were utilised to ensure rigour in a study that explored the impact of being a family carer to patients with stage 5 chronic kidney disease managed without dialysis. 10

Strategies for enhancing the credibility of qualitative research

In summary, it is imperative that all qualitative researchers incorporate strategies to enhance the credibility of a study during research design and implementation. Although there is no universally accepted terminology and criteria used to evaluate qualitative research, we have briefly outlined some of the strategies that can enhance the credibility of study findings.

• Sandelowski M
• Lincoln YS ,
• Barrett M ,
• Mayan M , et al
• Greenhalgh T
• Lingard L ,

Twitter Follow Joanna Smith at @josmith175 and Helen Noble at @helnoble

Competing interests None.

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Understanding Reliability and Validity in Qualitative Research

Related Papers

Ana Trujillo Zapata

Evidence-based nursing

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In general practice, qualitative research contributes as significantly as quantitative research and both try to find the same result; the truth. Qualitative research, also known as naturalistic inquiry, evolved inside the social and human sciences refers to theories on interpretation and human experience. The use of validity and reliability are common in quantitative research and currently, there are ongoing debates regarding whether the terms are appropriate to evaluate qualitative studies. Although there is no universally typical terminology and standards used to measure qualitative studies, all qualitative researchers comprise strategies to enhance the credibility of a study throughout the research design and implementation. The main aim of this article is to provide the concepts of validity and reliability and to ascertain that it is possible for qualitative research to be properly valid or reliable.

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With reference to definitions of validity and reliability, and drawing extensively on conceptualisations of qualitative research, this essay examines the correlation between the reliability of effort to find answers to questions about the social world, and the validity of conclusions drawn from such attempts. This is to point out the fundamental position to the role of theory in relation to research; as an inductivist strategy qualitative research tries to confer the correspondence between reality and representation. The problem of validity and reliability in qualitative research is entwined with the definition of qualitative research and the possibility to mirror this in practice to make a qualitative research properly valid and reliable. That presents both challenges and chances to qualitative researchers; yet, with taking into consideration qualitative criteria in social research, achieving validity and as well as reliability in qualitative research is not impossible.

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The idea of reliability in research refers to the repetition or reinforcements of the degree of findings given under the same experiment condition performed by the other researchers and thus leading a wider research community to accept the proposed generalizations. Reliability being the more often quoted part of quantitative research ensures and plays a vital part in guaranteeing the credibility of the qualitative research because not only it tests the integrity of the researcher but also has a wide and direct implication when incorporated in practice. This research paper attempts to highlight the problems associated with the understatement of reliability in qualitative research, its appropriateness, and ways through which it can attain more credible status at par with quantitative research. KEYWORDS: Reliability, Qualitative Research, Construct, Quantitative

The idea of reliability in research refers to the repetition or reinforcements of the degree of findings given under the same experiment condition performed by the other researchers and thus leading a wider research community to accept the proposed generalizations. Reliability being the more often quoted part of quantitative research ensures and plays a vital part in guaranteeing the credibility of the qualitative research because not only it tests the integrity of the researcher but also has a wide and direct implication when incorporated in practice. This research paper attempts to highlight the problems associated with the understatement of reliability in qualitative research, its appropriateness and ways through which it can attain more credible status at par with quantitative research.

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• Published: 20 May 2024

Validity and reliability of the Persian version of food preferences questionnaire (Persian-FPQ) in Iranian adolescents

• Zahra Heidari 1 ,
• Awat Feizi   ORCID: orcid.org/0000-0002-1930-0340 1 &
• Fahimeh Haghighatdoost 2  

Scientific Reports volume  14 , Article number:  11493 ( 2024 ) Cite this article

Metrics details

• Epidemiology
• Health care
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The assessment of dietary intakes and habits using reliable and youth-specific measurement tools during adolescence is essential. The aim of the present study was to culturally adapt and investigate the psychometric properties of the Persian version of the food preferences questionnaire (Persian-FPQ) among Iranian adolescents. This methodological cross-sectional study was conducted among 452 Persian-speaking adolescents, living in Isfahan, Iran. Translation of the FPQ was performed using forward–backward method. Intra Class Correlation (ICC) and Cronbach’s α were used to assess test–retest reliability and internal consistency, respectively. Construct validity was investigated by using exploratory factor analysis (EFA). Divergent validity was determined using correlation analysis with Kessler Psychological Distress Scale (K-10). Known-group validity was assessed based on differences in mean food preference score between boys and girls and different categories of body mass index (BMI). The internal and external reliabilities for the Persian-FPQ were in the range of good to excellent in all domains (Cronbach’s α: 0.76–0.96 and ICCs: 0.982–0.998). Boys had higher scores of food preferences than girls, indicating good known-group validity. Construct validity evaluated by EFA led to extraction of seven factors (“Vegetables”, “Fruit”, “Dairy”, “Snacks”, “Meat/Fish”, “Starches” and “Miscellaneous foods”), explaining 37.8% of the variance. Divergent validity revealed significant negative correlations between five sub-scales of the Persian-FPQ and psychological distress. The Persian version of the FPQ is a reliable and valid instrument with applicability in a broad range of the population of Persian-speaking adolescents for assessing food preferences in community-based research projects.

Introduction

Eating habits are related to the wide varieties of attitudes and behaviors such as food acceptance, food selection, food consumption, and food waste in eating area which they are considered as “conscious, collective and repetitive behaviors affect people acts regarding selection, consumption of specific foods or diets in the context of effective social and cultural factors in their society 1 . Adolescence is an important developmental life part where health behaviors are often constructed and stabilized as habits. Unhealthy eating habits including snacking on foods with high energy and low intakes of fruit and vegetables are particularly common adolescents' habitual diets. These dietary behaviors have important effects on both short- and long-life term of physical, physiological and psychological health conditions. Eating behaviors and habits developed during childhood and adolescence stage tend to continue until adulthood 2 . Food preferences are the qualitative evaluative attitudes that people tend toward foods and diets and also how much people like and dislike them. Quantitative food preference measurement has been a part of the field of food habits 3 . Food acceptance or palatability has been shown to be a major predictor of eating habits. Additionally, food preferences differ across ethnicities, in part because culture influences the range of foods to which young children are exposed. Several studies showed that the socioeconomic status, ethnicity and culture affect food choices and eating habits of children and their families or caregivers 4 , 5 ; similarly food preferences have been analysed in terms of number of demographic variables, including race, gender, geography, age, taste physiology, and many disease states.

Each region of the world has specific characteristics that play a role in dietary and other lifestyle habits of the population, which may change during the time span. It was shown that dietary habits have changed in the Eastern Mediterranean region during the past four decades; in which the intake of fat, particularly saturated fat, sweetened beverages, and free sugar, has dramatically increased, and concurrently the intake of fiber, fruits and vegetables decreased. This, in turn, leads to increasing risk factors for non-communicable diseases particularly cardiovascular disease, diabetes, obesity and cancer 6 . These changes are more pronounced in school-aged children in which children skip healthy habits such as breakfast eating and substitute it by many snacks and unhealthy foods 7 .

Recently in modern life, people are highly aware about the quality of food they consumed, and interrelationship of environmental factors and its health effects on food products in which this affects the consumers’ concerns on healthier lifestyle and environmental issues and finally on how they select and buy food products based on their perspectives and attitude toward food quality 8 . Recent changes in food and dietary habits in developing nations have attracted a special attention for up-to-date evaluation in food preference and diet behaviors particularly among adolescence. Such examinations should be initiated with adolescents as they are in a critical stage of developing in their own attitudes towards many habits and among them nutrition as a whole and experiencing independence in food choice during school hours 7 . The possible reasons for unhealthy eating habits are changes in lifestyle, industrialization, social determinants, and environment from childhood to adolescence 9 .

Accordingly, there is rigorous need to evaluate the patterns of eating habits available among adolescence. Most available food preference questionnaires evaluate adult populations eating behaviors such as mostly used original and modified Food Choice Questionnaire (FCQ) and some sex-specific tools 10 , 11 , while someone examine the youth habits 12 . Some other created instruments evaluate the specific preference for foods with high fat and caloric content 10 , 11 . Several studies on evaluating adolescents’ preference for food have been conducted based on qualitative methods 13 , 14 , 15 , 16 . For quantitative research, one appropriate tool is Steptoe’s Food Choice Questionnaire (FCQ) 13 . Several adjustments have been made to the scale to expand the factors or to accommodate a number of factors for a specific population other than the UK population among whom it was used originally 14 , 17 , 18 .

Previous efforts to develop valid and reliable food preference instruments for school aged children were not able to cover all factors associated with the child’s food preferences 7 , 19 . There is only one questionnaire for measuring food preference in adolescents without specific psychometric evaluations 20 . There is no instrument that measures willingness to consume specific food items that has been developed for use within adolescent population worldwide particularly the one available instrument also covers some food items that is applicable for specific geographic areas. Taste and food preferences as interrelated factors are important potential predictors or antecedents of dietary behaviours change and food intake 21 which may affects strongly human future health 22 . Concerning adolescents unhealthy dietary behaviours that may be a leading cause of adolescent obesity, which is estimated to reach 1 billion by 2025 and increasing other non-communicable diseases and the adolescence age is a critical phase of development, transitioning between childhood and adulthood 23 , a better understanding of how taste factors influence food consumption and dietary habits in this population would aid in the design of dietary strategies for health promotion. Accordingly, reliable and youth-specific measurement tools are needed not only for evaluating of the food preference, dietary intake and habits in this population but also for assessing its predictive roles in mental and physical outcomes.

In the current study, as the first over the world we aimed to culturally adapt, translate and evaluate the psychometric properties of food preferences questionnaire (FPQ) developed by Smith et el. 20 and expand its content to cover other foods which are commonly consumed by Iranian adolescents. Therefore, we evaluated internal and test–retest reliability and different validity aspects of the extended FPQ.

Study design and participants

This methodological cross-sectional study was conducted between May 2021 and June 2022 among 452 aged 11–18 years old Persian-speaking adolescents in Isfahan, a largest city in centre of Iran. The adolescents who contributed to our study were from high schools in different educational districts of Isfahan through multistage cluster random sampling. Isfahan has 6 educational districts, of which 4 districts (including districts 1, 2, 3 and 4) were randomly selected as the first‑stage cluster. Then, 10 schools (5 for girls and 5 for boys) were randomly selected from educational districts (2 from district 3 and 4 from district 2 and 2 from each other educational districts). Due to the covid-19 pandemic, the questionnaires were distributed and completed both electronically and in printed forms. At first, the questionnaires were reviewed and approved officially by the central education department of Isfahan province. Then, the link to the electronic version of the questionnaires was officially sent to the headmaster of the selected schools through administrative automation. Then the headmaster informed the teachers about the objectives and content of research and sent them the electronic link of the questionnaires. After that, the teachers put the link of the questionnaires in the virtual class group (that was created in one of the social media networks covering all students of the selected classes) and requested them to complete the questionnaires. Some headmasters of selected high school agreed to conduct the survey by printed forms. On the other hand, online electronic link to the questionnaires along with the explanation of the purpose of the research, guides on how to complete the questionnaire and consent to participate in the study were prepared on the Porsline website (link: https://survey.porsline.ir/n/survey/203178/build/ ). We included only those students who lived in Isfahan city and without major psychological and cognitive problems and physical illness at the time of sample recruitment. Finally, the data of 452 students were used in data analysis, which was used to evaluate the construct, divergent and known-group validities of the questionnaire. All students received enough information about the study and also provided informed consent to participate in our study. This study complies with the Declaration of Helsinki and was performed according to ethics committee approval. The protocol of our study was ethically approved by the National Institute for Medical research Development (NIMAD) (Research project No:982938, ethical approval No” IR.NIMAD.REC.1398.062).

The food preferences questionnaire (FPQ)

Smith et al. developed a questionnaire to obtain information about preferences of various food items from adolescents and adults 20 . It comprised a list of 62 food items which primarily was based on the other tool specifically designed for children 24 . Participants were asked about how much on average they enjoy eating each food item. The FPQ assesses preferences for the six categories of food items (vegetables—18 items, fruit—7 items, meat/fish—12 items, dairy—10 items, snacks—9 items, starches—6 items). For each food item, a six-point Likert scale was used as follows: (1) dislike a lot, (2) dislike a little, (3) neither like nor dislike, (4) like a little, (5) like a lot, and (6) not applicable (For any food that the respondent does not know or remember having tried before). This questionnaire also includes two other questions which evaluate (1) adhering to any specific eating plan (Do you identify as any of the following? (Vegan, Vegetarian, Pescetarian (no meat, but eat fish and/or shellfish) and None of the above options)) and (2) having food allergy (Are you allergic to any of the food items such as Peanuts?) Sub-scales of the questionnaire showed moderate to good external reliability (ICCs = 0.61 to 0.95). Internal reliability was reasonable for all food groups (vegetables: α = 0.89; fruit: α = 0.84; meat or fish: α = 0.81; dairy: α = 0.77; and snacks: α = 0.80) 20 , 25 . It is worth to noting that during the adaptation and validation process, we added several other food items according to Iranian culture to the FPQ-62, which will be explained in the next section.

Translation and content validity

Permission was obtained from the initial developer (Andrea Smith, University College London, London) and the methodology recommended by Beaton et al. was followed to translate the FPQ-62 from English into Persian language 26 . In the forward stage, two completely fluent expert translators translated items of questionnaire into Persian. One of the translators had knowledge on the concept of the questions, but the second one was unaware of the items in the original instrument. Then, a unified version was prepared by the translators. After that, the final form was backward translated into English by two other translators to compare with the original version based on conceptual balance. After a careful review by researchers (A.F. & F.H.), necessary changes were made and the provisional Persian version of the FPQ questionnaire was prepared. After translating the questionnaire into Persian language, the content validity was evaluated qualitatively by a team of dietitians. The results of this phase are summarized in Table 1 . Some food items were removed because they are not consumed in Iranian culture (such as bacon, whose consumption is forbidden in Islam). Some uncommon items were replaced with common counterparts in Iranian diet. For example, the types of Iranian cheese were considered in detailed categories and included in the questionnaire instead of those in the original version. Finally, frequently-used food items in Iran were added to complete the existing food items. These changes led to an initial draft containing 93 food items for the Persian language version.

Psychometric analysis of the Persian-FPQ

Construct validity.

The factor structure of the Persian-FPQ was examined using the exploratory factor analysis (EFA) on 452 adolescents. Kaiser–Meyer–Olkin (KMO) measure of sample size adequacy (values > 0.7) and Bartlett’s test of sphericity (P < 0.05) for evaluating factorability were examined before conducting EFA 27 . During EFA, principal component extraction approach was used along with orthogonal Varimax rotation for interpretability. The number of factors was guided by eigenvalues more than 1 and Scree plot. We retained items with loading values greater than 0.20 for getting both acceptable aspects of interpretability and correlation between items and their related factors. According to the loaded items in each factor, each extracted factor was labeled. We computed the relevant score of each sub-scale (factor) for each participant by summing up of related items multiplied by their loading values.

Known-groups validity

Known-groups validity was assessed based on the Persian-FPQ ability to discriminate between girls and boys and adolescents in body mass index (BMI) groups in terms of food preferences. BMI was categorized into four groups using sex-specific. BMI for age percentile curves developed by the World Health Organization (underweight (less than or equal to 5th percentile), normal weight (between 5 and 85th percentiles), overweight (between 85 and 95th percentiles), and obese (equal to or more than 95th percentile)) was used 28 . We hypothesized that there would be a significant difference in terms of food preference scores between girls and boys 19 and BMI groups. Accordingly, the known-groups validity of the measure is supported if distribution of the Persian-FPQ items is significantly different between considered groups. We distributed the Persian-FPQ questionnaire to 270 girl and 182 boy students and compared their responses. We tested difference in mean score of each sub-scale between gender groups using independent samples t‑test and across BMI groups by one-way analysis of variance (ANOVA). Normality of continuous data was evaluated using Kolmogorov–Smirnov test and Q-Q plot.

Divergent validity

Divergent validity was evaluated using Pearson correlation coefficients between the score of each Persian-FPQ sub-scale and the Kessler Psychological Distress Scale (K-10). We hypothesized that there are negative correlation between some Persian-FPQ dimensions such as fruits and vegetables with psychological distress 29 , 30 , 31 . The K-10 is a 10-item questionnaire that is used to measure psychological distress 32 . The questions in this instrument ask how frequently in the past month the participant has felt tired out for no good reason (Q1), nervous (Q2), so nervous that nothing could calm them down (Q3), disappointed or hopeless (Q4), restless or fidgety (Q5), so restless that they could not sit still (Q6), depressed (Q7), so depressed that nothing could cheer them up (Q8), feeling that everything was an effort (Q9), and feeling worthless (Q10). Responses to each question were scored in a five-point Likert scale as (1) None of the time, (2) A little of the time, (3) Some of the time, (4) Most of the time, (5) All of the time. The total score of k-10 varies from 10 to 50 and a higher score indicates greater psychological distress. The validity and reliability of the Persian version of this questionnaire has been assessed and confirmed earlier (Cronbach’α = 0.83) 33 , 34 .

• Reliability

To investigate internal consistency and test–retest reliability of Persian-FPQ, 50 adolescents were recruited. Participants were asked to complete the Persian-FPQ measure at two separate days with an interval of 7–10 days. To evaluate test–retest reliability, the intra class correlation coefficient (ICC) coefficient with 95% confidence using two-way mixed model was estimated. We considered the ICC values less than 0.5 as poor, 0.5–0.75 as moderate, 0.75–0.9 as good and more than 0.9 as excellent reliability 35 . We also used Cronbach’s α coefficient in order to evaluate internal consistency and values between 0.70–0.8, 0.8–0.9 was considered as acceptable and good, respectively and more than 0.9 as excellent internal reliability 35 . The extent of the “ceiling and floor effects” was calculated by assessing the distribution of the Persian-FPQ scores.

Ceiling and floor effects

Floor and ceiling effects are defined as the proportion of respondents respond/choice the highest (ceiling) or lowest (floor) possible score of items of a questionnaire and it subscales measuring the sensitivity and coverage. We followed the criteria ≥ 15% as indication of occurring each aspect of floor and ceiling effects 35 .

Other measurements and statistical analysis

Additional data about weight, height, gender, and education level were also collected. In this paper, quantitative and qualitative variables were expressed as mean ± SD and number (precent), respectively. In all statistical analyses P-value < 0.05 was considered as significant level. All analyses were conducted using SPSS software (version 16; SPSS Inc., Chicago, IL, USA).

Ethics approval and consent to participate

All students received enough information about the study and also provided informed consent to participate in our study. The protocol of the study was ethically approved by the National Institute for Medical research Development (NIMAD) (Research project No:982938, ethical approval No” IR.NIMAD.REC.1398.062).

Participant characteristics

A total of 452 adolescents, including 270 (59.7%) girls, participated in the current study. The mean ± SD age was 15.7 ± 1.78 and 14.97 ± 1.66 years for girls and boys, respectively (P > 0.05). About 26% of the participants were obese or overweight. Nearly 93% of the participants did not follow a specific diet. The prevalence of food allergy was estimated to be around 27.41% and 15.93% among girls and boys, respectively (P < 0.01). The mean ± SD psychological distress score was 16.24 ± 10.59 and 10.70 ± 8.87 for girls and boys, respectively (P < 0.01) (Table 2 ).

Construct validity was evaluated by using EFA. We identified seven dimensions from Persian-FPQ measure based on 90 food items: (1) a ‘vegetables’ factor, characterized by high interest to green pepper, garlic, cabbage, celery, onion, turnip, broccoli, beetroot, bell pepper, red peppers, green beans, peas, spinach, mushrooms, carrots, salad leaves (e.g. lettuce), raw tomatoes, tomato paste, corn, and cucumber; (2) a ‘fruit’ factor, which characterized by high interest to cucumber, apricots, cherry, yellow plum, tangerine, pomegranate, peaches, grape, sour cherry, sweet lemon, oranges, dew melon, mulberry, cantaloup, kiwi, strawberries, watermelon, apples, fig, melon, persimmon, and sour green plum; (3) a ‘dairy’ factor, which characterized by high interest to cream, plain low-fat milk, plain full fat milk, porridge, other types of milk (such as cocoa milk), butter, rice-pudding (rice-milk), plain biscuits, eggs, mast, Haleem, and cheese; (4) a ‘snacks’ factor, which characterized by high interest to plain biscuits, salty snacks, chocolate, ketchup, chocolate biscuits, mayonnaise, ice cream, cake, chewable jelly chocolates, sausages, chips, and cream cheese; (5) a ‘meat/fish’ factor, which characterized by high interest to fatty fish, low-fat fish, beef burgers, smoked salmon, lamb, white meat burger, beef, chicken, tinned tuna, ham and eggs; (6) a ‘starches’ factor, which characterized by high interest to whole meal baguette bread, baguette bread without bran, plain boiled rice, traditional bread without bran, traditional whole meal bread, rice and beans, bran cereal, breakfast cereal, potatoes, and baked legumes; (7) finally, a ‘Miscellaneous foods’ factor, which characterized by high interest to avocadoes, margarine, custard, other cheeses (such as parmesan cheese), grapefruit, and parsnips. These factors were accounted for 8.17%, 7.46%, 5.20%, 4.90%, 4.74%, 4.45%, and 2.96% of total variance, respectively. A KMO value 0.847 and P < 0.05 for the Bartlett’s test confirmed data viability for conducting a reliable factor analysis in terms of sample size adequacy and factorability.

Table 3 provides the factor loadings of seven extracted factors from Persian-FPQ items. It should be noted that in the process of construct validity, the lentil soup item was removed due to its low factor loading. We also combined different types of yogurts and two types of cheese (i.e. Iranian white cheese and Traditional cheese) for better interpretability.

Known-groups and divergent validity

For known-groups validity evaluation we compared mean score of Persian-FPQ’s subscales between gender and BMI groups (Table 4 ). Mean ± SD of all the extracted subscales of the Persian-FPQ was significantly higher in boys than girls (P < 0.05). However, no significant difference was observed in terms of the mean value of Persian-FPQ subscales in BMI groups, except for the fifth subscale i.e. ‘meat/fish’ factor. The mean of this factor for obese teenagers was significantly higher than other groups (P = 0.025).

Divergent validity was confirmed by significant negative correlations between five Persian-FPQ subscales (i.e. vegetables, fruit, dairy, meat/fish and starches) and psychological distress measure (P < 0.01) (Table 4 ).

Reliability analyses

The reliability analysis results and descriptive statistics for the seven Persian-FPQ scales are shown in Table 5 . The ICC coefficient for the total score of the Persian-FPQ suggests strong test–retest reliability (ICC = 0.998, 95% CI 0.996 to 0.999; P < 0.001). The ICC coefficients for the extracted subscales including “vegetables”, “fruit”, “dairy”, “snacks”, “meat/fish”, “starches” and “Miscellaneous foods” were estimated to be more than 0.9 indicating excellent test–retest reliability.

Cronbach’s alpha coefficient to indicate item internal consistency for each scale is presented in Table 5 and all scales showed satisfactory results (varied from 0.76 (good) to 0.96 (excellent)). The Cronbach’s alpha coefficient 0.957 for the total score of the Persian-FPQ suggests excellent internal consistency.

Ceiling and floor effect

The percentage of respondents scoring at the highest level (i.e., ceiling effect) was between 0.4 to 9.7% for all subscales, while the percentage of participants scoring at the lowest level i.e., less than 1% (floor effect) was minimal for all subscales. These results indicate high sensitivity and coverage of our validated questionnaire at both ends.

In the current study, the psychometric properties of the Persian version of FPQ were evaluated. To the best of our knowledge, the Persian-FPQ is one of the few versions of fully validated questionnaires to measure food preferences among adolescents. The results of this study showed that the Persian version of FPQ has excellent test–retest reliability and internal consistency. Boys had higher scores of food preferences than girls, indicating good known-group validity. Applying factor analysis for evaluating of construct validity led to seven factors (“vegetables”, “fruit”, “dairy”, “snacks”, “meat/fish”, “starches” and “Miscellaneous foods”) in terms of food preferences. The instrument also showed satisfactory divergent validity.

Internal and test–retest reliabilities in the current study were evaluated through the Cronbach’s α and ICC coefficient, respectively. All subscales' ICC exceeded 0.9, and all Cronbach’s α were between 0.7 to 1, suggesting strong test–retest reliability and internal consistency of Persian- FPQ. The results of test–retest reliability of the Persian-FPQ showed higher reliability than a similar earlier study (test–retest coefficients ranged from 0.61 to 0.95) 20 . The Persian-FPQ questionnaire in the present study showed acceptable internal consistency nearly at the same levels which were observed in the previous study (vegetables: α = 0.89; fruit: α = 0.84; meat or fish: α = 0.81; dairy: α = 0.77; and snacks: α = 0.80) 20 . We calculated Cronbach’s α for starches subscale as 0.773 which is a more acceptable value compared to the previous study (α = 0.68) 20 .

The evaluation of construct validity of the Persian-FPQ led to extraction of seven factors (“vegetables”, “fruit”, “dairy”, “snacks”, “meat/fish”, “starches” and “Miscellaneous foods”), explaining 37.8% of the total variance. Although. the factor structure of the FPQ was not completely and formally evaluated in the original English version using EFA 20 ; however, the suggested domains by Smith et al. and Wardle et al.' s studies were comparable with our findings 20 , 24 . In Smith 's study, 6 dimensions have been reported (vegetables: 18 items; fruit: 7 items; meat or fish: 12 items; dairy: 10 items; snacks: 9 items and starch: 6 items) 20 . In Wardle 's study, four factors have been extracted and named as “Vegetables” (comprised mainly from broccoli, cabbage, carrots, cauliflower, green beans, mushrooms, onions, parsnips, salad greens and tomato), “Desserts” (comprised mainly from cream, cakes, pastries, fruit pie, sponge pudding, custard and dairy desserts), “Meat and Fish” (comprised mainly from beef, lamb, pork, chicken, bacon, fried fish, white fish and oily fish), and “Fruit” (comprised mainly from apples, bananas, citrus fruits, grapes, peaches, strawberries, fruit juice), explaining 24% of the variance 24 . In addition to the different number of items used, participants’ age may explain these contradictory results. Indeed, older children are adequately qualified to express their preferences and direct questions about their food preference may provide more accurate responses 36 , 37 , 38 . In support of this, in Smith et al.’s study, which was conducted on 18–19 y twins, identified factors are more similar to ours rather than those identified in Wardle et al.’s study, which was conducted on 4-y children. Other contributory determinants for the construct validity might be geographic, socio-economic status, culture and racial dependency of food preferences.

We examined the known-group validity based on sex and BMI categories. The Persian version of FPQ well discriminated boys and girls; in which scores of food preferences were all significantly higher among boys. Similarly, in Caine‐Bish et al.'s study, boys preferred meat, fish, and poultry foods over girls. However, in contrast with our study, fruits and vegetables were more frequently preferred by girls rather than boys in their study 19 . A similar report was also found in another study, so that girls liked fruit and vegetables more than boys and boys liked fatty and sugary foods, meat, processed meat products and eggs more than girls 39 . Food preferences are influenced by various factors such as taste preference, food availability and accessibility 40 , 41 . For instance, in a cross-sectional study on 225 children, fruit and vegetable availability was the sole predictor of high fruit and vegetable preferences 41 . Therefore, the inconsistency between different studies might be explained, at least to some extent, by such environmental factors. Regarding BMI, we did not observe a significant difference in terms of food preference scores between BMI subgroups, except for the meat/fish dimension, which was more preferred by obese students. this is in accordance with a positive relationship between meat and overweight/obesity in adolescents 42 .

We examined the divergent validity by examining the correlation between scores of psychological distress and dimensions of Persian-FPQ questionnaire. We observed significant negative correlations between five Persian-FPQ subscales (i.e. vegetables, fruit, dairy, meat/fish and starches) and psychological distress measure. Although, higher preference does not necessarily mean higher intakes, our findings are in line with those which showed an inverse association between higher consumption of these food groups and mental disorders. It has been shown that higher intakes of carbohydrate, cobalamin found in dairy products and meats, and fruit and vegetables which are rich in antioxidant, and essential vitamins for mental health are associated with lower risk of mental disorders 12 , 34 , 43 , 44 , 45 , 46 .

Study strengths and limitations

The strengths of our study are the large number of food items that cover broad food preference-range of Iranian adolescent population and maybe some other countries with similar food and nutrition cultural habits. We also evaluated majority of important aspects of validation process led to provide a reliable and valid questionnaire for community-based research projects. Our study has some limitations that should be highlighted. Due to a part of our survey has been conducted through online media, the response the questionnaire items by children may be influenced by their parent’s attitude towards family, social and health desirability. Although we tried to include wide verities of food items in order to provide highest coverage of potential foods candidate for consuming by Iranian adolescents however, we did our study in center of Iran and it is recommended to do it over the different geographic region for enhancing its generalizability. Despite these potential limitations, we believe that the results our study provide important information for public health stakeholders, policy makers, and researchers.

Conclusions

Previous studies over the world focused on developing valid and reliable food preference instruments for school aged children were not able to cover all or at least majority of common consumed food items regarding the child’s food preferences and in other hand there was no valid instrument for food preference evaluation in Iranian children. Our study introduce a reliable and valid measure for evaluating food preferences with highest coverage of food items that not only applicable in Persian-speaking adolescents’ population but also for school aged children worldwide. The Persian-FPQ is self-report and easy to understand and due to the lack of questionnaire in this field, this tool now can be used in research projects in public health domains in association with other medical and health conditions experienced by children and in nutritional epidemiology. Unhealthy food preference patterns in school-age children affect negatively food consumption and diet intakes lead to increase obesity and chronic diseases in future in this population. Such validated instruments introduced in our study helps interventions concentrating on the improvement of a healthy food environment aimed at enhancing food preferences from childhood stages.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

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Acknowledgements

We would like to express our special thanks to Dr. Andrea Smith for her permission to use the original version of the food preference questionnaire that we extended and validated it in current study.

This study was funded by the National Institute for Medical Research Development (NIMAD grant number: 982938).

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ZH: methodology, software, formal analysis, writing—original draft. AF: conceptualization, methodology, investigation, writing—review and editing, funding acquisition, supervision. FH: methodology, writing—review and editing.

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Heidari, Z., Feizi, A. & Haghighatdoost, F. Validity and reliability of the Persian version of food preferences questionnaire (Persian-FPQ) in Iranian adolescents. Sci Rep 14 , 11493 (2024). https://doi.org/10.1038/s41598-024-61433-4

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DOI : https://doi.org/10.1038/s41598-024-61433-4

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