224 7 Chapter 7 preferred to literal translations (i.e., ‘those who need it’, ‘measurements about my body’, ‘organise’). Content validity was explored using scripted probes. Lastly, cultural adaptation was needed for some terms included in the terminology list. Results on test content and response process Fourteen cognitive interviews were held. The age of the participants ranged between 27 and 73 years old (median age 61); ten participants were male; six were considered low educated; six indicated that they did not have affinity with digital technology. Their previous eHealth experiences were mainly smartphone and computer use. Some also had a digital blood pressure device or used an online patient portal from their healthcare provider (see Additional file 1 for an overview of respondent’s characteristics). Respondents’ comprehension of the Dutch eHLQ was satisfactory as they were able to adequately comment on their responses with respect to each item. Respondents generally understood the response options and were able to distinguish among them, although some participants desired additional scoring option ‘not applicable’ for items referring to ‘problems with my health’ and ‘all the health technology I use’. Respondents commented on limited applicability, unclear reference and problems with wording or tone for 12 items. In addition, a problem in resonance with local worldviews was found in four items. No problems were found regarding unclear perspective, recall problems or clarity of response options (see Additional file 4). Wording or tone. From the items marked for additional exploration based on the cultural adaption in the translation phase, four items were classified as problematic due to problems with wording or tone. The Dutch word for the word ‘organise’ (NL ‘ordenen’) in the item ‘organise my health information’ was confused with ‘sorting things in/on colour or shape’. Other wording problems included ‘take care of my health’, ‘work together’ and ‘monitor’. Limited applicability. Limited applicability was seen in two ways 1) items concerning health problems (i.e., people without health problems), 2) items on use of digital health services (i.e., people not using digital health services). Unclear reference. Four items were marked by an unclear reference. Participants were unsure whether an item referred to their own health or health in general (i.e., ‘health problems in general or my health problems’; item 11 and 20). The majority also struggled with the word ‘nuttig’ in item 6 (English translation ‘work for me’), indicating that it was too vague. Despite the terminology list, participants who were less familiar with eHealth were unsure what health technology and health technology services included, and wondered whether it also included telephone and email. Resonance with local worldviews. Cognitive interviews also revealed a problem in resonance with worldviews in 8 items. Participants who frequently used eHealth privately or professionally, expressed their wish to have ‘all technology work together’ (item 23) and have information about their health always ‘available to those who need it’ (item 3), but had had no such experience. Participants less familiar with eHealth
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