Sample characteristics

In total, 17 respondents (65% females) were interviewed (Table 3). Respondents’ age ranged from 27 to 76 years. All respondents had at least 10 years of education. There were office workers and manual workers. Some of the respondents were retired. Respondents had uni- and multi-malleolar fractures. Additionally, one respondent had an open fracture. The fractures were mainly treated with open reduction and internal fixation. One respondent received a fibula nail, and one was treated with syndesmosis screws. The ASA score ranged from one to three. Some of the respondents presented with several comorbidities, e.g., one respondent had diabetes mellitus, hypertension, asthma, and morbid obesity. Another suffered from polyarthritis, hemochromatosis, and hypothyroidism.

Table 3 Respondents characteristics (n = 17), stratified into three main groups according to recovery phase after surgery. Respondents’ number were given based on the chronological order of the interviewsComprehensionComprehensibility of instructions

Table 4 summarizes the predetermined categories deducted from Tourangeau’s 4-step model with selected quotations from responders. Most respondents found the instructions brief and easy to understand. Respondent 4 (r4) missed today’s date on the questionnaire, although, he had completed it on the consent form: “Didn’t read instructions very thoroughly. There were not that many instructions. It was self-explanatory.” Another respondent (r16) had completed it incorrectly, but correctly on the consent form. There was some confusion regarding instructions on bilateral fractures. This was sorted out once the respondent read the instructions again. See Additional file 3 for additional quotations on each category.

Table 4 Predetermined categories deducted from Tourangeau’s 4-step model and selected quotations from responders used in the analysesFeasibility

The respondents reported that the questionnaire was easy to understand and didn’t take too long time to fill out. There weren’t any complicated words or phrases. One respondent (r3) commented that item 1 and 15 should be next to each other as these were related: “But if you take number … question number 1 and put it right above 15, then like “I have pain in my foot. Ehh yes. And how much pain do you have?” Right? It’s a bit like that. So those two should be one after another.” Another respondent (r9) would like to have the questionnaire in Nynorsk (one of two official Norwegian written languages). Almost all patients did not circle the appropriate side on top of page 2. The reason was that they missed the instructions: “I don’t know why I didn’t see it. It clearly says …” (r9).

Comprehensibility of the items in MOXFQ

In general, the respondents did not identify any major problems with the language or intent of the items. There were slightly different interpretations of the word pain. One respondent (r3) believed this to be a very harsh word, e.g., related to the moment she fractured her ankle. Two other respondents (r2 and r16) denied that they had pain and described it as discomfort. Respondents also reflected upon the type of pain, or the situations they experienced it: “pain is difficult to describe, if it is due to surgery or weightbearing, or just stiffness after you have used it” (r3).

For item 2, respondents commented that long distances were dependent on the person, and measured this in how many hours they could walk. One respondent (r9) was confident that she walked longer than other people at her age and suggested that the items could be worded such that they specified the activity according to the individual. For item 9, which addressed patients’ feeling of self-consciousness regarding their ankle, the general understanding of the question was if they were worried about others opinion about their foot. One different interpretation on the question was if other people cared about them: “… Others are interested in how I’m doing, and …” (r17). The word “usually” in item 15 caused slight difficulty in one respondent, where she believed the question to be asking about the status before the injury: “… like usually, as in prior to surgery then? It says the last four weeks. So usually is like in the old days …” (r3).

Retrieval of relevant informationThe pain domain of the MOXFQ

The respondents described various relevant experiences for all items in the pain domain, i.e., item 1, 11, 12, 15, and 16 (Additional file 4). Late-phase recovery respondents reported that the items were relevant, but less now when compared to earlier in the recovery stage since they were less bothered by pain now. The patients that had the surgery less than one year ago, i.e., early- and middle-phase recovery respondents, found the items more relevant. For instance, on item 1: “Yes, I’ve experienced that sometimes. However, mild and brief” (r13). Similar descriptions were also reported for item 15. The respondents found item 11 highly relevant, but usually they believed this pain to be related to the level of exertion during the day: “My foot is worse in the evening, depending on what I’ve done during the day. Like yesterday, two hours of padel [a racket sport that combines tennis and squash], then I had to limp to the bathroom later” (r7). The two remaining items in this domain, i.e., item 12 and 16, the respondents had more diverse experience as not all respondents reported that they had experienced shooting pain or had trouble sleeping: “Sometimes when I’ve gone to bed … Sometimes I wonder if it is the screws that … When I’m laying sideways, that the screws somehow … That I feel them” (r9).

In general, the respondents believed that the construct pain was covered by the items in the pain domain. They experienced other bodily pain when asked about additional relevant experiences with pain, e.g., pain in the thigh and hip when rolling over in bed due to the cast. They also mentioned stiffness and pain due to swelling of the foot and ankle, or that the swelling led to pain when wearing shoes: “Stiffness. I can feel it here. It’s just like there’s a band attached here and it’s tightening.” (r15).

The walking/standing domain of the MOXFQ

Respondents that were interviewed shortly after surgery indicated problems recalling relevant episodes for the walking/standing domain, i.e., item 2 to 8, as they were not allowed weightbearing yet. Respondents from later recovery phases were more likely to share relevant experiences for items in this domain (Additional file 5): “I’ve walked downtown to [city], and then walked around there for a bit. Of course, you would always feel some discomfort, but not like it’s the end of the world!” (r16). Item 8, asking about the use of bus or car, had less relevance for people living on the countryside since they were dependent on using the car for everyday tasks in the first place.

When asked about other relevant limitations related to mobility, respondents commented that they experienced stiffness and pain when they were about to start walking again after resting or sitting still for a while. Additionally, some would feel pain in the other foot when walking long distances or if they have been standing still for a while.

The social interaction domain of the MOXFQ

The items included in the social interaction domain (item 9, 10, 13 and 14) were intended to measure limitations in social interaction. Two of these items, item 9 and 10, referred to self-consciousness about their foot/ankle and the use of footwear, respectively. These items emerged as less relevant to the respondents since not all were able to share relevant thoughts or experiences regarding these issues (Additional file 6). Respondent 13 shared her thoughts when interacting with children shortly after surgery, where she was worried about the impression she would leave for her young students if they saw her ankle “… Lately, the weather has been nice, and you’ve been using summer shoes and summer clothes … when you’re working as a teacher, and I’m on a primary- and lower secondary school, then sometimes I’ve been thinking: “poor kids if they [laughs] … have to look at this half-swollen foot after a day with a lot of walking and stuff”, but …” (r13).

The respondents were asked to recall other important experiences that had an impact on the social interaction due to the ankle fracture. The burden of being dependent on others was mentioned, e.g., having to leave his children with his divorced wife, or asking a parent to help with grocery shopping. Another example was refraining oneself from going to a festival due to fear of a new injury.

Recall

A recall period of four weeks was acceptable for the respondents, except when replying to the survey at early stages since they would experience a considerable improvement within a short time span: “… there was a huge difference for … at least for me … Four weeks ago, then it was one week after surgery. At that point things were miserable and painful … Now it is sort of … What should one base it on? … Because it says, “during the past 4 weeks” and there is a progression in it … The first two weeks were definitely worst. Then things started to stabilize a bit and …” (r11). Respondents later in the recovery process felt things were more stable and that it was easier to remember specific and relevant episodes related to their ankle fracture.

JudgementGeneral aspects of the MOXFQ

In general, respondents reported that the questionnaire was helpful in assessing the respondents’ experiences after the ankle fracture. The respondents in late recovery phase and those that had experienced very little pain and limitations after the injury did not find the questionnaire as relevant: “… And for me, I just replied “no” to everything because I don’t have pain. So, there’s nothing that limits me because of that … No matter what situation they ask me about here, then it’s not because of pain that prevents me from doing it …” (r6). The questionnaire was also experienced as less relevant for respondents in early recovery phase. Respondents had difficulties replying to items concerning limitation in mobility related to pain since they were not allowed to put weight on the operated foot, thereby limiting the relevance of the instrument: “Because all the questions were based on pain. That the pain was the limitation, but I don’t feel that the pain was restricting me because … because I had to use crutches and I couldn’t walk without the crutches and put full weight on my foot, so I never reached the point where it was the pain that hold me back” (r13).

When asked about the adequacy of the instrument to cover important aspects concerning the impact from the ankle fracture, respondents pointed out the lack of questions asking about psychological well-being, worrying thoughts regarding surgery and the complications from surgery, or “the feeling of uselessness” (r15). One patient summed it up: “… So here, it’s like pain and discomfort, but it doesn’t really ask about how I’m really doing” (r7). Beyond the questions in the MOXFQ, respondents experienced other physical symptoms, e.g., stiffness, swelling or heaviness in the foot.

Domains of the MOXFQ

The assessment of pain was difficult for some respondents. For instance, when late-phase recovery respondents were asked about the relevance of pain related to their ankle fracture, they would reveal that they didn’t have pain, but perhaps discomfort at certain situations: “For me pain is … then it hurts in a way. I don’t have it. I might feel discomfort … Great pain, that’s when I broke my ankle and could feel the vomit. Then it was painful …” (r3). Others would think that “the pain that I had was probably related to surgery” (r1). One respondent from the middle recovery phase reported how the ankle fracture affected him at work, e.g., that his inability to stand or walk for longer periods prevented him from doing his normal chores.

Items in the MOXFQ

The cognitive effort used to evaluate the relevance of each item was generally feasible, supported by the respondents’ motivation to attempt answering all items. Respondents from the late recovery phase had good scores when examining the replies on the questionnaire, as the question mostly addressed pain and pain-related limitations: “I replied rarely or none on most of them … That says something about the use of words or … It might be correct, but it is the use of words to describe pain that I have an issue with. I, that don’t have pain …” (r2). Respondents from this phase would add that they experienced other difficulties, e.g., discomfort or problems fitting normal shoes due to a swollen foot.

Respondents from the middle recovery phase experienced minor problems, although a few also had none to very little problems based on the scoring on the questionnaire (r6 and r10). They experienced pain related to weightbearing, walking in stairs, or after extensive use. One respondent described an alteration in the character of pain with more sudden intense pain now: “… It’s painful now. Those pains. I didn’t notice that too much during the first half year. But now, this is bothering me. But you sort of get used to it. That “ohh! Now I must change position”, and it appears like POFF!” (r17). She experienced it every day and was contemplating on rarely or most of the time as the final response. Additionally, this sudden intense pain was considered most important when replying to item 15, as it was the most prominent pain, though, she did have a milder, constant ache.

Item 9 and 10 were the only items in the questionnaire that were not related to pain. A large number of respondents were not preoccupied with the opinion of others on their ankle or footwear. The males were generally negative to these items and suggestions on removing them were mentioned. An older male respondent was very clear about the irrelevance of this question as he was “entirely indifferent” (r15) to what others might think of his foot. However, one respondent disclosed some discerning thoughts about footwear and dresses: “When you arrive with a nice dress and then … sneakers. But in fact, this is fashion now, now others are doing it, those that didn’t injured their foot … But that’s just now, so I hope that … one day I can wear proper shoes, but I can’t as long as I have those screws there” (r5). The same respondent also found item 9 relevant to some degree: “Because you could see pretty well that the ankle was … was much bigger den the other, right? You don’t do that when you have pants on … But if you have a skirt and pantyhose on, then you’ll spot it … So, I’ve thought about it, even though self-conscious might not be the correct term” (r5).

Item 8, which ask about the need to catch the bus or use a car instead of walking due to pain, caught the attention of some of the respondents living on the countryside. They found it difficult to answer the question as they needed a car to get around independent of the injury. One respondent thought it was slightly odd to be asked such a question and believed this question to be better suited for respondents living in the cities: “These are questions for people living in [large city], I reckon … Here, I must use a car [chuckles] if you know what I mean … I use a car anyways … Because If I were to go to the store, well, then I would take the car. I don’t bother walking four kilometers back home with …” (r3).

Response

Item 7, that asked about the avoidance of standing for a long time due to pain, had one missing response. During the interview, the respondent had to stop and think about it for some time when filling out the questionnaire because “I don’t stand that much, you know, so I haven’t thought about it” (r5). She was asked to elaborate on her thought process and the reason for the missed response: “… because I was thinking of work. But then I don’t stand that much at work. Like when I’ve been to airports, then I’ve avoided standing for longer periods. I would rather go sit down … It has just become a part of me, I think … I think it was just forgetfulness…” (r5). The same respondent also had some remarks on item 13 since the question addressed limitations in both work and everyday activities due to pain, and she struggled to pick a suitable response option: “… since I have an office job, it doesn’t prevent me from doing my job. But daily activities … Maybe you should split them?” Respondent 3 also presented the same reluctancy when replying to this item.

Respondents selected multiple responses on some items. For instance on item 6, which included hard and rough surfaces in the question, the respondent selected one response per adjective describing the surface: “… hard surfaces I don’t mind. I walk well on asphalt. But if there’s a slope, or especially a steep downhill, then you get this bend and you must sort of limit yourself a little…” (r15). Another item that had multiple response options selected was item 15. This respondent was still early in the recovery phase and found it difficult to pick one response option due to the use of the word usually in the question, with reference to some days the pain would be better than other days: “When it starts to hurt, then it really hurts” (r12).