Testing the acceptability and comprehensibility of a questionnaire on existential and spiritual constructs in a secular culture through cognitive interviews

In this paper, we present how we used structured, iterative rounds of qualitative cognitive inter-views to test the acceptability and comprehensibility of a questionnaire on existential and spiri-tual constructs. We intended to use the questionnaire in a digital cohort survey in Denmark. We conducted the translation and cultural adaptation according to the World Health Organization guidelines. Fourteen individuals with various demographic backgrounds and disease states participated in cognitive interviews according to an interview guide. Think aloud and prob-ing (improvised and scripted) were used. Interviews were conducted through four iterative rounds with adjustments to the questionnaire in between rounds. We analyzed data through a deductively driven directed content analysis with a predefined theoretical framework. The method successfully provided evidence for improvement of the questionnaire as issues identi-fied during interviews decreased in iterative rounds of testing as hypothesized. Acceptability and comprehensibility were satisfactory. However, some participants had difficulty continuing to think aloud during the interviews. The authors argue that this difficulty, at least in part, was caused by participants being reluctant to verbalize existential and spiritual thoughts as these topics may be sensitive and considered highly personal in the Danish secular culture. Allowing the participant to wane off in thinking aloud and instead increasing improvised probing might be a solution to mitigate this challenge.