Adults with congenital heart disease and heart failure (HF) face lifelong, complex challenges. Despite improved survival, current care models often overlook their emotional, social, and long-term planning needs. Existing health-related quality of life (HRQoL) tools frequently miss key domains relevant to adult congenital heart disease (ACHD) patients, such as psychological fatigue, family dependence, and unmet support needs. Standard metrics like NYHA class and LVEF offer limited insight into their lived psychosocial burden. To explore the lived experiences of ACHD patients with HF (ACHD-HF) and identify domains to inform development of patient-centred HRQoL tools and improvements in shared decision-making and care delivery. Three focus groups (n = 22) and cognitive interviews (n = 12) were conducted with ACHD-HF patients at a UK specialist centre. Data were analysed using template analysis, guided by predefined domains (physical, psychological, social, and long-term planning) and emergent themes. Five themes reflected unmet psychosocial and care needs: (1) mental exhaustion and cognitive fatigue, (2) feeling misunderstood and emotionally invisible, (3) the burden of lifelong family dependence, (4) challenges with relationships, intimacy, and identity, and (5) uncertainty around end-of-life planning. Participants voiced the need for more meaningful communication, integrated psychological support, and structured opportunities to engage in care decisions. Patient narratives provide critical insight into care quality. Incorporating underrepresented psychosocial domains into HRQoL assessment and service planning can promote more responsive, equitable, and emotionally informed ACHD-HF care.

Resilience, the capacity to adapt positively in adversity, is a key protective factor for adolescent well-being, particularly for depression and anxiety, which are highly prevalent among adolescents in Nepal. Accurate measurement across cultural contexts is essential to identify at-risk adolescents and understand protective mechanisms. This study culturally adapted and evaluated the psychometric properties of the Child and Youth Resilience Measure-Revised (CYRM-R) and Rugged Resilience Measure (RRM) in Nepal to ensure cultural relevance, reliability, and validity. This mixed-method study focused on poverty-affected adolescents in Kathmandu, using focus group discussions, cognitive interviews, pilot assessments, and a cross-sectional survey. The findings indicated Nepali versions of CYRM-R and RRM were acceptable, comprehensible, and relevant based on qualitative feedback. Most items showed item-total correlations between 0.2 and 0.5, indicating good discrimination, and internal consistency was satisfactory (α and ω > 0.7). Exploratory and confirmatory factor analyses supported a unidimensional structure, with an alternative two-factor solution explored for CYRM-R. Test-retest reliability was moderate overall, with some subscales less consistent. Both tools demonstrated strong psychometric properties, including face, content, convergent, and known-groups validity. The Nepali CYRM-R and RRM provide culturally robust tools for assessing adolescent resilience, supporting researchers, educators, and policymakers in designing targeted interventions.

The Water Insecurity Experiences (WISE) Scales are suitable for use in high-income settings: findings from cognitive interviews and nationally representative surveys

The Osteopaths' Therapeutic Approaches Questionnaire (Osteo-TAQ) has demonstrated content, construct, and face validity across multiple jurisdictions but required cognitive validation for use in the United Kingdom (UK). To assess the cognitive content and face validity of the Australian-adapted Osteo-TAQ (Osteo-TAQ(Aus)) with practising UK osteopaths, and to determine whether any revisions were necessary. Cognitive interviews were conducted with six (n = 6) UK osteopaths using a combination of think-aloud and verbal probing techniques, informed by the Cognitive Interview Reporting Framework (CIRF). Interviews were recorded, transcribed, and analysed using team-based content analysis to identify issues of item interpretation, clarity and relevance to UK practice. Strong alignment with UK practice was demonstrated across all 36 items. No items required modification, providing positive validation evidence for cross-jurisdictional stability. Participants reported that the Osteo-TAQ(Aus) items were relevant, understandable and reflective of their day-to-day clinical practice. This study provides the first evidence of cross-jurisdictional cognitive stability for the Osteo-TAQ(Aus), demonstrating robust content validity in its country of origin and suitability for use in a UK setting. These findings support its continued use in UK-based research and professional development initiatives aimed at exploring therapeutic approaches and conceptions of practice.

Food insecurity screeners focus on identifying a financial barrier to accessing food. Other social and medical factors influence an individual's nutritional status and the need for food provision support. Yet, there are no existing tools that elicit the various life factors that influence food and nutrition needs and further identify relevant resources to address those needs. To develop the Nutrition Health Related Social Need Assessment and Referral Tool (N-HART) to facilitate individualized referrals to food and nutrition resources, based on both medical and social factors. Resources include food provision, nutrition and cookingeducation, and benefits assistance. We used a multi-phase approach to develop and refine the N-HART from March 2023 to March 2024. An initial draft of the N-HART was developed based on a literature review and field scan. Cognitive interviews with patients were used to iteratively refine the tool. The tool was developed for use across a health system, applicable to both inpatient and ambulatory settings. We conducted cognitive interviews with 15 patients at an acute care hospital in Philadelphia, PA to inform the refinement of the N-HART. The N-HART is a 13-item dual-function tool that screens for food and nutrition needs and recommends a best fit food resource type (e.g., medically tailored meals, non-tailored prepared meals, food pantry) based on an individual's needs. Cognitive interviews informed changes in N-HART framing and period of focus, and led to the elimination of some items to be as efficient and actionable as possible. With health systems focusing on HRSN, the N-HART may provide a strategy for informing more individualized nutrition referrals using a structured approach.

Physical activity is an important behavioural determinant of health that can be influenced by designing aphysical activity-friendly environment. The aim of this work was to develop survey instruments for walkability and bikeability for the prevention reporting of the federal states. As part of the project "Monitoring physical activity and promoting exercise - developing indicators for the federal states' prevention indicator system in Germany (KAB-Mon)" (01/05/2023-30/04/2026), the development and review of two instruments designed to subjectively assess the two prevention indicators walkability and bikeability were carried out in three steps. In Step1, asystematic literature review was conducted. In Step2, an expert survey followed in which 9 and 7 experts from 6 disciplines evaluated the items of both instruments using the specific criteria in an online survey. Step3 involved cognitive testing through guided interviews with atotal of 18participants. The expert survey was analysed using mean comparisons, while the cognitive interviews were evaluated descriptively. Based on the expert feedback, the walkability instrument was shortened from 16to 13items, and the bikeability instrument from 19to 14items. Following the cognitive testing, both instruments were supplemented with afifth response option ("don't know/no answer"). The instruments developed through this project provide asolid scientific approach for the subjective assessment of walkability and bikeability in the German-speaking context.

Quality of life is an important goal of care for people living with amyotrophic lateral sclerosis (ALS) and their carers. The ALS Specific Quality of Life instrument Short Form (ALSSQOL-SF) has been translated and validated in various cultural contexts, however its utility in the Malaysian cultural context has not yet been evaluated. The quality of life of 21 patients with ALS was evaluated using the ALSSOL-SF in either the English version or translated to the Malay language. A cognitive interview approach was utilized and the responses were transcribed and thematically analyzed. Culture and language-related factors affecting the application of the ALSSQOL-SF were identified. Interpretations of intimacy and religiosity varied and sometimes differed significantly from the constructs underlying the ALSSQOL-SF domains. The ALSSQOL-SF captured items from the physical domain better than those from the psycho-social and spiritual domains. Cognitive interviewing showed that patients mostly could not grasp the intended meaning of the items from the psycho-social and spiritual domains despite translation into the Malay language. There are limitations in adapting the ALSSQOL-SF for use in evaluation of QOL in Malaysian ALS patients. In the local setting a better understanding is needed about how aspects such as religion, intimacy and spiritual well-being are culturally reflected and expressed.

Cognitive interviewing of the PHQ-A for depression screening among adolescents living with and without HIV in Malawi.

"It's the future, come on!": a think aloud study exploring clinicians' use of knowledge-based AI decision support.

Development and validation of the symptom assessment scale for patients with nasopharyngeal cancer undergoing radiotherapy.

Development and validation of the Access to Contraceptive Care and Early Abortion Support Services (ACCESS) measure.

To develop a culturally and locally validated and reliable questionnaire for clinical teacher evaluation containing constructs specific to the Thai resident learning context. We followed seven steps for developing questionnaires for educational research. We generated a list of good clinical teacher attributes from a literature review and focus groups. The Delphi procedure was employed to identify the desirable characteristics for residents, involving three stakeholder groups. The content validity index (CVI) of each item was calculated. The average CVI across the items was greater than 0.8, indicating an acceptable level of reliability. Residents then underwent cognitive interviews before pilot testing of the questionnaire. Construct validity was examined using exploratory factor analysis. Reliability was measured using Cronbach's alpha analysis. We identified 44 key clinical teacher characteristics through a literature review and focus groups. After two rounds of the Delphi procedure (35 panelists), 23 characteristics were selected. An initial 23-item questionnaire was developed with a high CVI score. A total of 216 completed questionnaires evaluating 36 clinical teachers were analyzed. Exploratory factor analysis yielded a two-factor model within a 20-item questionnaire. The clinical facilitator domain contained 14 items. The professional identity support domain included six items. Cronbach's alpha of the model was 0.976. A clinical teacher evaluation questionnaire for Thai residents was developed with robust validity and reliability. This validated tool not only allows systematic assessment and improvement of clinical teaching but also provides a replicable framework for developing culturally adapted teacher evaluation instruments in other settings.

ABSTRACT Background Vaccine hesitancy amongst healthcare workers (HCWs) is a global concern, needing reliable tools to measure HCW vaccine confidence. We adapted and validated the 10-item ‘iPro-VC-Be’ tool for the Nigerian context. Research design and methods We conducted a 3-step process. First, contextual adaptation using expert round-table discussions and cognitive interviews with HCWs in Oyo and Jigawa States (12/2023-05/2024). Second, translation and back-translation to Hausa, Igbo and Yoruba, followed by HCW group discussions in each language (05/2024). Finally, testing validity in all languages, using a test-retest approach (06/2024-09/2024). Results Sixty-four participants contributed to adaptation, 25 researchers and 39 HCWs supported translations, 435 HCWs completed the first survey, and 263 completed the re-test. Of the 10 iPro-VC-Be items, 3 were unchanged, 6 had language edits, and 1 was replaced. The Cronbach’s alpha indicated good internal reliability, and overall the intraclass correlation coefficient indicated moderate re-test reliability. Confirmatory factor analysis supported goodness of fit across multiple indices, but one negatively framed item performed poorly. Items assessing confidence in vaccines and trust in government were significantly associated with HCW vaccine uptake. Conclusion The adapted iPro-VC-Be tool was valid, however, we recommend using a shorter 6-item version for Nigeria that does not include items linked to immunization resources.

As part of the ongoing overhaul of the Moroccan health-care system, clinical coordination between primary level physicians (PLP) and referral level specialists (RLS) remains crucial but under documented, especially in North Africa and the Eastern Mediterranean Region. This study aimed to assess clinical coordination levels in the Casablanca-Settat region and identify influencing factors. An analytical cross-sectional survey was conducted from April to May 2024 among a random sample of 329 public-sector physicians (186 PLP; 143 RLS) from a pool of 1637 eligible practitioners. The COORDENA-CAT questionnaire, adapted from the original COORDENA instrument developed in Latin America and refined in Catalonia, was translated into French, culturally adapted, and psychometrically validated in four steps: forward-back translation, expert review, cognitive interviews, and a pilot study confirming construct validity and reliability. Fourteen items evaluated experiences of information-sharing and clinical-management coordination, whereas one summary item captured overall perception. Sociodemographic, organizational, and interactional data were collected. A multivariable logistic regression was performed to identify factors associated with a high perception of coordination (α = 0.05). Only 30.7% respondents (18.8% of PLP vs. 46.2% of RLS) reported regularly sharing clinical information. Therapeutic coherence was limited, with just 24.3% stating that care plans were jointly defined. While 97.3% of the PLP considered referrals appropriate, only 59.4% of the RLS agreed. Overall, 27.7% of the physicians (17.2% PLP and 41.3% RLS) judged coordination "often or always" satisfactory. Independent determinants of a high perception of coordination included working at the referral level (adjusted OR (aOR) = 3.34; 95% CI: 1.60-6.97), having personal ties with the other level (aOR = 3.05; 1.54-6.04), perceiving mutual influence on practice (aOR = 2.39; 1.24-4.58), and working in an institution that facilitates coordination (aOR = 2.66; 1.37-5.17). Clinical coordination in the study region is limited, especially among PLP, due to inadequate feedback, weak formal mechanisms, and restricted specialist access. Strengthening local governance, providing secure digital tools (such as shared electronic health record and tele-expertise), organizing regular clinical meetings, and granting PLP formal recognition as care coordinators are priority strategies to enhance the continuity and efficiency of care pathways.

The shift from syntagmatic to paradigmatic associations is a developmental process occurring from approximately the ages of six to nine years and plays an important role in language development. Syntagmatic relationships refer to words that co-occur due to their mutual dependency connection (e.g., “The dog barks”). Paradigmatic relationships are words within the same category (e.g., cat, kitten). In Study 1, we tested 244 Spanish-English bilingual children in grades 1 to 3 (M age = 7.87 years, 54.5% female) enrolled in dual language programs in California, USA. Children completed a matching task in both English and Spanish featuring both syntagmatic and paradigmatic lexical associations. Results showed significantly higher accuracy for older students than for younger students, higher accuracy in English than in Spanish for both paradigmatic and syntagmatic associations, and higher accuracy in paradigmatic associations in English and syntagmatic associations in Spanish. In Study 2, we conducted cognitive interviews with a separate sample of 13 Spanish-English bilingual children (M age = 8.96 years, 46.15% female) to explore how they reasoned through their word pair choices when completing the task. Children primarily relied on paradigmatic associations, using strategies like synonymy, antonymy, and category overlap, while also employing syntagmatic associations and thematic relatedness as less frequent but important reasoning strategies. Implications for early language development are discussed.

Hand injuries can significantly impair individuals' ability to engage in essential daily and social activities, necessitating valid and culturally relevant tools to assess participation limitations. The Participation Behaviour Questionnaire (PBQ), originally developed in Persian and grounded in the International Classification of Functioning, Disability and Health (ICF), was designed to evaluate the extent of participation restrictions following hand and upper limb injuries. This study aimed to translate and cross-culturally adapt the PBQ for use among Canadian English-speaking individuals with hand injuries and assess its content validity within a Canadian clinical context. The PBQ was adapted according to Beaton's five-step guideline for the cross-cultural translation of self-report measures. Cognitive interviews were conducted with 15 patients and 22 healthcare professionals, including physiotherapists, hand therapists, surgeons, and rehabilitation researchers, using think-aloud and semi-structured methods to examine item clarity, consistency of interpretation, and cultural appropriateness. Cognitive interviews with 15 patients and 22 experts revealed 25 items requiring revision, with 88% of concerns related to clarity and comprehension. Overall, clarity issues were identified in 22 of the 37 items, resulting in 18 substantive revisions. For example, the item "I feel I have lost my autonomy" was revised to "I feel I have lost my independence in daily tasks" to improve clarity. Commonly misunderstood terms included "public transport" and "voluntary job," which were refined using culturally contextual examples. Cultural and contextual factors also influenced how participants interpreted items such as "My use of public transport" (12%) and "Engagement in voluntary work" (20%). The English-adapted PBQ demonstrated evidence of content validity based on participant feedback regarding clarity, relevance, and comprehensibility. The 18 substantive revisions enhanced cultural and linguistic appropriateness by addressing clarity in 22 of 37 items, refining ambiguous terminology, and incorporating Canadian-contextual examples where necessary. These findings represent an initial step in the overall validation process; in this pre-psychometric, single-center Canadian-English study, additional research is required to assess the instrument's psychometric properties, including construct validity, reliability, and responsiveness.

Even though ethical decision-making is a cornerstone of medical practice there is a lack of validated tools to assess ethical sensitivity among medical students, junior, and senior doctors. The aim of this study was to adapt and validate the Ethics in Health Care Questionnaire - Version 2 (EHCQ-2) for use in Portugal, ensuring its relevance in evaluating ethical sensitivity within the Portuguese healthcare context. The EHCQ-2 was translated into European Portuguese and culturally adapted through a rigorous process involving forward and back-translation, expert review, cognitive interviews with medical professionals, and pilot testing. A validation study was conducted with a sample of 156 participants, including medical students, junior, and senior doctors, to evaluate the questionnaire's reliability and validity. The adapted EHCQ-2 demonstrated good internal consistency (Cronbach's alpha = 0.74) and variable inter-rater reliability (ranging from 0.12 to 0.67 across tasks), reflecting the complexity of ethical dilemmas. Content validity was established through expert evaluation, while construct validity was supported by significant correlations between individual scenarios and overall scores (e.g., r = 0.683 for Scenario 7). Regression analysis revealed that sub-scales measuring issue identification, explanation sophistication, and value recognition collectively explained 99.6% of the variance in total scores, underscoring the questionnaire's robust predictive validity. The European Portuguese version of the EHCQ-2 is a reliable and valid tool for assessing ethical sensitivity among medical students, junior and senior doctors. Its application can enhance ethics training programs, inform curriculum development, and support efforts to improve ethical decision-making skills in future healthcare professionals. Further research should explore its longitudinal utility and applicability in diverse cultural contexts.

Many parents live with enduring health conditions; however, the impact of enduring health conditions on parenting roles is poorly understood. The aim of this study was to explore the experiences, support needs and preferences of parents in Ireland living with enduring health conditions. Data were collected using a custom e-survey, developed and refined using cognitive interviewing (n = 6). Quantitative data were analysed using descriptive statistics and group comparisons, while open-ended responses were analysed using interpretative content analysis. In total, 281 eligible parents completed the survey. Participants reported considerable difficulties with parenting tasks, particularly physically demanding tasks. Participants had limited access to formal services and many reported unmet needs and dissatisfaction with current services. Enduring health conditions have a significant impact on parenting capacity. There is a need for integrated support systems to ensure parents with enduring health conditions are supported to engage in parenting occupations and roles.

To describe the final validation processes for the final English-language tool to assess sexual function and satisfaction after gender-affirming vaginoplasty. This was a quantitative and qualitative validation study. The 32-question SatisFunction survey was distributed to 50 individuals after vaginoplasty along with the Female Sexual Distress Scale for divergent validity testing. Thirty of these 50 participants then underwent one-on-one cognitive interviews with a member of the research team. The cognitive interviews assessed the construct validity of the survey questions based on the participants' responses. A Community Advisory Board and content expert team reviewed the results of the cognitive interviews to create a final version to be further tested. The revised survey was then distributed to 100 individuals for final validation. Cognitive interviews demonstrated 99.0% concordance between participants' survey responses and verbal confirmations, supporting interpretive reliability. Strong internal consistency was observed, with each domain significantly correlating with the total score (eg, Anatomy r=0.856, Arousal r=0.767, Orgasm r=0.748; all P<.001). Expected interdomain relationships were identified, including Arousal and Orgasm (r=0.552, P<.001). Female Sexual Distress Scale-Revised scores correlated negatively with Satisfaction (r=-0.416, P<.001), Desire (r=-0.302, P=.003), Genital Self-Image (r=-0.216, P=.034), and Total SatisFunction Score (r=-0.304, P=.003), supporting divergent validity. Factor analysis supported an eight-factor structure aligning with survey domains. This survey has now been developed and validated through a seven-phase process incorporating community input, physician/surgeon and psychologist expertise, and correlation to other surveys and can be reliably used clinically and in research.

Background and Purpose: Self-management activities are essential for individuals with diabetes to effectively control their disease and prevent complications. This study aimed to culturally adapt the Diabetes Self-Management Questionnaire-Revised (DSMQ-R) into Brazilian Portuguese and to verify its content validity among patients with diabetes. Methods: A methodological study was conducted and comprised the following steps, as recommended by the literature: translation, synthesis of translations, back-translation, evaluation of the Brazilian Portuguese version by an expert committee, and pretest. The expert committee evaluated the semantic-idiomatic, conceptual, and cultural equivalences, and the content validity index (CVI) was calculated. The pretest of the instrument was conducted using cognitive interviews. Results: Nine of the 27 items of the DSMQ-R had a CVI below .80 and were thus revised and reformulated. The pretest of the Brazilian Portuguese version was conducted with 30 patients with type 1 diabetes and 30 with type 2. Participants suggested minor amendments for a better understanding of single items, resulting in the final Brazilian Portuguese version. Conclusion: The translation and cultural adaptation of the Brazilian version of the DSMQ-R were performed according to recommended standards and showed content validity evidence.