223 7 Dutch version of the eHealth Literacy Questionnaire shows the cognitive processes of the interviewee, while also being able to reflect on ambiguous or problematic items in detail (58, 59). To minimize the cognitive burden on participants, the interview was divided in 3 parts. Participants first completed the first 11 items, thinking aloud, and then responded to scripted probes. This process was repeated for the next two sets of 11 items. Participants received a 20-euro gift card for their participation. Debriefing sessions were held among the researchers to reflect on the interviews and the interview guide, and to include emergent probes (scripted probes) based on previous interviews. For example, if multiple participants felt an item was ambiguous or unclear, a scripted probe was added to the interview guide to examine the item further. Data analysis Interviews were analysed through an item-to-item review, guided by the first three stages of Hacomb’s six-stage model (60). We audio recorded the interview and took notes during the interview (step 1), held debriefing sessions after a set of three interviews (step 2), and had three researchers familiarize themselves with the data (step 3). Responses relevant to item interpretation were then transcribed, organized per item, compiled for all participants and reviewed item-per-item. For the item-peritem review, responses were compared to the item-intent guide, carefully examining whether the items were understood as intended. Item response problems were coded following the problem item classification coding scheme by Knafl and colleagues, classifying problematic items based on the type of problem encountered (61). The coding scheme included the following code categories: (a) limited applicability; referring to a comment on groups of people or situations for which the item is or would not be appropriate (b) unclear reference; referring to lack of clarity regarding what aspect, condition or situation the item is intended to address, (c) unclear perspective; pointing towards problems in clarity regarding the perspective from which the items should be answered and (d) problems with wording or tone. We also assessed clarity of response options, recall problems and resonance with local worldview (57). Results study 1 Cultural adaptation during translation process During the translation process several items required cultural adaption to appropriately reflect their meaning in Dutch. First, English expressions such as ‘make technology work for me’, ‘works together’ ‘find my way’ and ‘have good conversation’ lack meaningful direct translation into Dutch. Alternative translations were tested and included as scripted probing during the cognitive interviews. Second, nuances between ‘sure’ and ‘confident’ and ‘good conversations about health’ and ‘take part in conversations about health’ were discussed and explored further during the cognitive interviews, to ensure content validity and sufficient contrast between the items. Third, back translation deviated somewhat from the original wording, as more common phrasings were
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