Measuring autonomy and respect: a qualitative, cross-cultural adaptation of the Mothers Autonomy in Decision Making scale and Mothers on Respect index instruments in Danish

Abstract
Objective
Decision-making is important in user-involved maternity care and patient experience instruments Mothers Autonomy in Decision Making scale (MADM) and Mothers on Respect index (MORi) are used internationally to measure the user involvement quality and users’ experiences of autonomy and respect. This study aimed to translate and qualitatively adapt the original MADM and MORi instruments to the Danish language and culture.
Methods
A forward and backward translation using a standard guideline. Subsequently, qualitative interviews to refine the translation and cultural adaptation by pilot testing the scales.
Results
The translation process showed cultural differences linked to linguistic variations between Danish and English. Cognitive interviews with 14 diverse pregnant women revealed challenges in women's understanding of decision-making in maternity care. Changes in wording and assisting descriptive texts were made. Further, the order of the MADM items was changed to improve the understanding of decision-making.
Discussion
Primarily, the discussion concerns how decision-making can be understood in the context of maternity care and why women's understanding of decision-making in Danish maternity care in the MADM scale items was challenged.
Conclusion
The qualitative pilot test using cognitive interviews after translation of the instruments was a valuable method for cultural adaptation providing important knowledge on women's understanding and perceptions of item contents. The cognitive interviews provided a comprehensive understanding of decision-making and contributed to a thoroughly worked Danish version of the MADM and MORi instruments.