Cognitive interviewing validation of the Chinese version of the neurogenic bladder symptom score.

Background: The neurogenic bladder symptom score (NBSS) has been widely used to specifically measure symptoms and consequences of neurogenic bladder (NB). The cognitive interviewing (CI) is effective in assessing item clarity and identifying key issues related to the comprehension of the instrument. We aim to translate the NBSS into Chinese and use the CI approach to explore the thought processes of patients with NB in responding the Chinese Version of the NBSS, identify and modify the factors hinder the thought processes to enhance the face validity of the NBSS. Methods: The translation of the NBSS into Chinese was conducted with the guidance of the recommended frameworks. Patients with NB were recruited by purpose sampling. CI with the combination of thinking aloud and verbal probing techniques were used to explore thought processes. The interviews were transcribed and analyzed based on Tourangeau four-stage response model. Results: Two rounds of CI were carried out. The problems of comprehension, judgement and response mapping were identified in 8 items. Four items were revised based on the results of the interview. The revised items were verified and eventually integrated into the final version. Conclusion: The Chinese Version of the NBSS was easy to comprehend and use. The use of CI methodologies can increase the comprehensibility and cultural applicability of the NBSS, providing the evidence for the development of a clearer and more appropriate questionnaire.

Adaptation and psychometric assessment of a sexual and reproductive empowerment scale in Arabic among refugee and non-refugee adolescent girls.

BACKGROUND: Sexual and reproductive empowerment (SRE) is an important determinant of women's and girls' health yet measuring it is complex due to cultural and domain-specific variations. This study describes the process of adapting an SRE scale consisting of four domains (self-efficacy; future orientation; social support; and safety) and testing its psychometric properties among Arabic speaking adolescent girls in Lebanon. METHODS: An SRE scale developed in a Western context was adapted in four steps: (1) reviewing the scale and selecting culturally appropriate domains for translation to standard Arabic; (2) conducting cognitive interviews with 30 11-17-year-old adolescent girls in Lebanon; (3) administering the scale to 339 refugee adolescent girls who participated in an early marriage intervention; and (4) conducting confirmatory factor analysis (CFA) on the data to assess the scale's psychometric properties. RESULTS: The original model for the 13-item, four-domain adapted scale demonstrated poor fit in CFA. After iteratively removing two items, scale properties were improved, albeit were not optimal. The validity and reliability results for the self-efficacy domain were acceptable. Cognitive interview data revealed that Arab adolescent girls understood self-efficacy in relational terms, recognizing that autonomous decision-making is not necessarily favored but is influenced by parents and family. CONCLUSIONS: This study presents an effort to customize an SRE scale for use in studies on the health of adolescent girls in an Arab cultural context. Findings from cognitive interviews highlight the importance of taking into consideration relationality in adolescent sexual and reproductive decision-making. The self-efficacy domain in the adapted scale demonstrates acceptable psychometric properties and is recommended for use in health studies to capture SRE.

Cross-cultural adaptation of the empowerment scale of pregnant women in China context: An integrative method of translation and linguistic validation.

AIM: To translate the Empowerment Scale for Pregnant Women (ESPW) into Chinese and to assess its linguistic validity. METHODS: The integrative method of the translation process, the Delphi technique, and cognitive interviews were used to implement cross-cultural adaptation and enhance comprehensibility and linguistic validation. This study recruited 14 experts in the expert review and cognitively reviewed 15 pregnant women. RESULTS: The two-round Delphi method created agreement on cultural applicability. The results of content validity achieved good levels: The item-level content validity index (CVI) ranged from 0.78 to 1.00, and the scale-level content validity index, calculated using two different formulas, were 0.97 and 0.81, respectively. Kappa values ranged from 0.74 to 1.00. Pregnant women could understand most of the items and response options in the cognitive interview. The revisions to the wording were made based on suggestions from experts and pregnant women. CONCLUSION: The prefinal simplified Chinese ESPW was semantically and conceptually equivalent to the English version, which was well prepared for further psychometric tests in the next stage of cross-cultural adaptation. PATIENT OR PUBLIC CONTRIBUTION: This comprehensive method successfully developed a Chinese tool to measure the empowerment of pregnant women, indicating the international applicability of this tool and the methodological scientific nature. The simplified Chinese ESPW has the potential to support the identification of empowerment levels of pregnant women and the evaluation of the effectiveness of health education and promotion programmes.

Response processes for patients providing quantitative self-report data: a qualitative study.

OBJECTIVE: To identify factors that influence response processes for patients providing quantitative self-report data. Secondly, due to the lack of integrative and explanatory models in this area, to develop a model of patients' response processes that can guide what to look for when considering validity evidence and interpreting scores on individual items. METHODS: Participants (n = 13) were recruited from a specialized substance use disorder treatment clinic and interviewed while responding to items from a clinical feedback system implemented for routine outcome monitoring in that setting. The interview approach was based on cognitive interviewing. Data collection and analysis were inspired by a grounded theory approach. RESULTS: We identified several variables that influenced the participants' response processes. The variables were organized into five categories: context-related variables; item-related variables; response base variables; reasoning strategies; and response selection strategies. We also found that the participants' responses for many items were affected by different aspects of the response process in ways that are relevant to interpretation but not necessarily discernible from the numerical scores alone, and we developed response categories to capture this. CONCLUSION: The findings suggest that patients providing quantitative self-report data encounter conditions in the response process that challenge and influence their ability to convey meaning and accuracy. This results in responses that for many of the items reflect messages important for interpretation and follow-up, even if it does not appear from the numerical scores alone. The proposed model may be a useful tool when developing items, assessing validity, and interpreting responses.

Design and development of a new pictorial tool to facilitate communication around advance care planning.

BACKGROUND: Advance care planning (ACP) aims to ensure that people with chronic or advanced disease receive medical care that is consistent with their values and preferences. However, professionals may find it challenging to engage these patients in conversations about the end of life. We sought to develop a pictorial tool to facilitate communication around ACP. METHODS: This was a three-phase study. In phase 1, we used the nominal group and Delphi techniques to achieve expert consensus regarding the conceptual content of the tool. In phase 2, a professional cartoonist was commissioned to create a series of cartoons representing each of the content areas resulting from the Delphi process. The pictorial tool was then administered (phase 3) with a sample of individuals with advanced/chronic disease to explore whether the cartoons were easy to understand and conveyed the intended message. RESULTS: Following a three-round Delphi process, consensus was reached regarding a set of 12 key content areas that should be considered in the context of an ACP interview. The cartoons created to represent each of the 12 areas were then reviewed and ordered so as to reflect the typical stages of an end-of-life care interview. After administering the pictorial tool with 24 frail older adults with advanced/chronic disease, changes were made to 9 of the 12 cartoons. CONCLUSIONS: The new pictorial tool comprises a set of 12 cartoons that can guide professionals as they seek to engage frail older adults with advanced/chronic disease in conversations about the end of life and ACP.

Cognitive interviewing to assess and adapt three measures of mental health symptoms among people living with HIV in Rakai, Uganda: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL).

Mental health is conceptualized differently across cultures, making cross-cultural validation of screening tools critical. In Uganda, we used cognitive interviewing to assess and adapt three scales for measuring psychological distress: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL). We recruited 12 people living with HIV from the Rakai Community Cohort Study (RCCS) and interviewed seven potential users of the scales (four RCCS survey interviewers and three local health workers). Data were analyzed systematically using a team-based matrix approach. The HSCL was generally well understood, with minor clarifications needed. The Thinking a Lot Questionnaire was also well understood, though differences between "how much" and "how often" required specificity. Both included local idioms of distress from prior adaptations. The PHQ-9 performed less well, with many questions interpreted variably or showing unclear local applicability, especially among people living with HIV. For example, questions about trouble concentrating were misunderstood, focusing on examples like newspapers rather than the broader issue of concentration. Future research should explore the validity and utility of commonly used instruments as mental health research expands in Africa.

How do patients interpret and respond to a novel patient-reported eastern cooperative oncology group performance status (ECOG)?

PURPOSE: Performance status is an important concept in oncology, but is typically clinician-reported. Efforts are underway to include patient-reported measures in cancer care, which may improve patient symptoms, quality of life and overall survival. The purpose of this study was to gain a preliminary understanding of how patients determined their physical performance status based on a novel patient-reported version of the Eastern Cooperative Oncology Group Performance Status (ECOG) scale. METHODS: We conducted qualitative interviews, including concept elicitation and cognitive interviewing as part of the Patient Reports of Physical Functioning Study (PROPS) to investigate how participants selected their answers to a novel patient-reported ECOG. Participants were administered the patient-reported ECOG and asked to describe devices and modifications used to keep up with daily activities. RESULTS: Participants generally understood the ECOG as intended. Participants with recent changes in status had some difficulty selecting an answer. Most participants used modifications and assistive devices in their daily lives but did not incorporate these into their rational for the ECOG. CONCLUSION: The potential benefits of a patient-reported ECOG are numerous and this study demonstrates that participants were able to understand and answer the patient-reported ECOG as intended. We recommend future evaluation for the most-appropriate recall period, whether to include modifications in the ECOG instructions, and if increasing the number of response options to the patient-reported ECOG may improve confidence when providing an answer.

Cognitive testing of the Children's Palliative Outcome Scale (C-POS) with children, young people and their parents/carers.

BACKGROUND: The Children's Palliative Outcome Scale (C-POS) is being developed using best methodological guidance on outcome measure development, This recommends cognitive testing, an established method of item improvement, prior to psychometric testing. AIM: To cognitively test C-POS within the target population to establish comprehensibility, comprehensiveness, relevance and acceptability. DESIGN: Cross-sectional cognitive interview study following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and Rothrock guidance on outcome measure development. Cognitive interviews were conducted using 'think aloud' and verbal probing techniques. SETTING/PARTICIPANTS: Children 5-⩽17 years old with life-limiting conditions and parents/carers of children with life-limiting conditions were recruited from 14 UK sites. RESULTS: Forty-eight individuals participated (36 parents; 12 children) in cognitively testing the five versions of C-POS over two to seven rounds. Content and length were acceptable, and all questions were considered important. Refinements were made to parent/carer versions to be inclusive of non-verbal children such as changing 'share' to 'express' feelings; and 'being able to ask questions' to 'having the appropriate information'. Changes to improve comprehensibility of items such as 'living life to the fullest' were also made. Parents reported that completing an outcome measure can be distressing but this is anticipated and that being asked is important. CONCLUSION: Cognitive interviewing has facilitated refinement of the C-POS, especially for non-verbal children who represent a large proportion of those with a life-limiting condition. This study has enhanced the face and content validity of the measure and provided preliminary evidence for acceptability for use in routine practice.

The e-cigarette assessment for youth-Revised (EAsY-R): Preliminary results of a pilot study of measure refinement via cognitive interviewing.

The prevalence of youth vaping has, in a relatively short time, become an "epidemic." In the wake of such labeling by the Surgeon General, a number of important examinations of vaping have been conducted. These have largely focused on high school and college-age youth as this demographic shows the greatest prevalence of use. Nonetheless, no measure has been made available which might allow for the comprehensive assessment of quantity and frequency of vaping among this age group, thus aiding in standardization across settings. The current study utilized cognitive interviews with high school and college-age youth who use vaping devices to inform the preliminary development of such an assessment. The sample consists of eight students between the ages of 15 and 24 (Mage = 18.75, SD = 2.73, 62.5% female, 75.0% Hispanic/Latino/a/x, 100.0% White). Interviewing and measure refinement were conducted in a two-phase iterative fashion. Suggestions made during cognitive interviews resulted in the refinement of assessed content type, updated categories and pictures of vaping devices, as well as updated and age-relevant terminology. Further, instructions were streamlined, and assessment items and multiple-choice options were refined to maximize clarity and to minimize participant confusion. The result of this study, the E-Cigarette Assessment for Youth Revised, is a unique tool for standardizing examinations of the quantity and frequency of vaping behaviors among high school students and college-age youth.

The paranormal health beliefs scale: an evaluation using cognitive interviewing.

Paranormal health beliefs denote the inclination to endorse illusory supernatural notions about well-being and treatment. These ideations are important since they potentially influence perceptions of health and allied behaviors. Noting this, researchers in Italy developed and verified the Paranormal Health Beliefs Scale (PHBS). Despite initial promising outcomes, the construct and measurement properties of the PHBS have remained under investigated. This is likely due to the fact that the instrument draws heavily on traditional Italian social, political, and religious influences and is overly culturally specific. Hence, items do not generalize well across populations and nationalities. Acknowledging these factors, this study used cognitive interviewing (think aloud protocol and concurrent probing) to assess the suitability of the PHBS for general use. Concurrently, the intention was to identify necessary modifications that would enhance scale performance. Fourteen interviewees (eight males and six females), evenly distributed across two rounds, participated. Round 1 focused on comprehension and perception of the PHBS. Cognitive interviews identified issues with culturally particular content/points of reference, phraseology, and wording. To address these a modified version of the PHBS was produced. Round 2 then examined the effectiveness of changes. Analysis revealed fewer concerns, although difficulties with ambiguity, complex terminology, and response scale appropriateness persisted. Overall, interviews indicated that a focus on illusory (rather than paranormal) health beliefs would improve scale utility. Methodologically, cognitive interviewing provided invaluable insights into the effectiveness of the PHBS and identified ways in which researchers could adapt the instrument for use with other cultures.

How patients with insomnia interpret and respond to the consensus sleep diary: a cognitive interview study.

OBJECTIVE/BACKGROUND: The Consensus Sleep Diary (CSD) is widely used to assess subjective sleep. Psychometric evaluations and focus-groups support its validity and clinical usefulness, but further research into its validity is needed. The aim of the study was to evaluate a Swedish translation of the CSD regarding test content and response processes in patients with insomnia. PATIENTS/METHODS: In connection with translating the CSD into Swedish, we used cognitive interviewing to evaluate test content and the response process, that is, how people make decisions when responding to survey items. Cognitive interviews were conducted with 13 primary health care patients with insomnia disorder (mean age, 49 years; SD 15.5). Iterative, reparative analysis was used to investigate test content. Descriptive deductive analysis was used to investigate interview transcripts for the themes of the cognitive model: comprehension, retrieval, decision process, and judgement. Together, the themes explain the response process when responding to a patient-reported outcome measure. RESULTS: The overall comprehension of the CSD could be affected by poor adherence to the instructions (comprehension). Patients had difficulty with recall if they did not complete the diary immediately in the morning and just before bedtime (retrieval). They could have problems deciding how to respond to certain items because they imbued sleep-related concepts with extra meaning (decision process), and had trouble finding response alternatives nuanced enough to describe their experience of sleep and tiredness (judgement). CONCLUSIONS: This study contributes knowledge on how the instrument is perceived and used by care-seeking patients with insomnia. In this context, the CSD exhibits known flaws such as memory lapses if the diary is not filled in directly in the morning. To increase the accuracy of patients' responses, therapists should support patients in reading the instructions.

Development and adaptation of the Emotion Regulation Skills Questionnaire for adolescents.

INTRODUCTION: The ability to effectively regulate one's emotions is important for adolescent mental health. However, extant assessments of how adolescents regulate their emotions can be expanded upon in several ways, including incorporating more strategies (e.g., cultural and spiritual) and positive emotions, and being informed by adolescents and expert consultation during the development process. Thus, our study aimed to improve the construct validity of an emotion regulation measure by adapting and refining the Emotion Regulation Skills Questionnaire (ERSQ) into an adolescent self-report. METHODS: We recruited 24 13-17-year-olds (12 males; 11 females; 1 gender fluid) via social media advertisement in the United States in 2020. We used an iterative qualitative approach in which we combined expert consultation, cognitive interviewing with adolescents, and top-down and bottom-up coding to review and provide feedback on the ERSQ. RESULTS: Findings of thematic analysis showed that a need for clarity in wording and inclusion of strategy examples across all sections of the ERSQ was needed. Adolescents also identified the need to replace the Silly/Excited section with a more age-appropriate positive emotion section. CONCLUSION: Findings indicate cognitive interviewing can be successfully completed in a virtual format when necessary, youth utilize a wider range of strategies to maintain or upregulate positive emotions than what is represented in current measures, and use of qualitative methods may have reduced construct underrepresentation and construct-irrelevant variance in the adapted ERSQ.

Development and evaluation of an educational resource for parents of children with 22q11.2 deletion syndrome about the psychiatric manifestations of the condition.

Parents of children with 22q11.2 deletion syndrome (22q11DS) report concern about the psychiatric manifestations of the condition, but typically receive little information about this in clinical encounters and instead find information about it elsewhere. We developed an educational booklet about the psychiatric manifestations of 22q11DS and assessed its utility among parents of children with the condition. First, six parents of individuals with 22q11DS completed cognitive interviews to review an established generic booklet about the genetics of psychiatric conditions-and to suggest 22q11DS-specific adaptations. We used these suggestions to develop a novel booklet specific to psychiatric conditions and 22q1DS. Then, before and 1-month after reading the novel 22q11DS-specific online booklet, 73 parents of children with 22q11DS (with/without psychiatric conditions) completed validated scales (measuring empowerment, stigma, intolerance of uncertainty), an adapted version of a scale measuring worry about their child developing psychiatric illness, and purpose-designed items assessing perceptions of understanding of 22q11DS and mental illness, confidence in recognizing early signs, etc. After reading the 22q11DS online booklet, participants' feelings of empowerment increased (p = 0.002), while feelings of worry about their child developing psychiatric illness decreased (p = 0.05), and they reported better understanding 22q11DS and mental illness, and increased confidence in recognizing early warning signs. There is potential benefit in broadly distributing this educational booklet to parents of children with 22q11DS.

Development of the Canadian Eating Practices Screener to assess eating practices based on 2019 Canada's Food Guide recommendations.

In 2019, Health Canada released a new iteration of Canada's Food Guide (2019-CFG), which, for the first time, highlighted recommendations regarding eating practices, i.e., guidance on where, when, why, and how to eat. The objective of this study was to develop a brief self-administered screener to assess eating practices recommended in the 2019-CFG among adults aged 18-65 years. Development of the screener items was informed by a review of existing tools and mapping of items onto 2019-CFG recommendations. Face and content validity were assessed with experts in public health nutrition and/or dietary assessment (n = 16) and individuals from Government of Canada (n = 14). Cognitive interviews were conducted with English-speaking (n = 16) and French-speaking (n = 16) adults living in Canada to assess face validity and understanding of the screener items. While some modifications were identified to improve relevance or clarity, overall, the screener items were found to be relevant, well-constructed, and clearly worded. This comprehensive process resulted in the Canadian Eating Practices Screener/Questionnaire court canadien sur les pratiques alimentaires, which includes 21 items that assess eating practices recommended in the 2019-CFG. This screener can facilitate monitoring and surveillance efforts of the 2019-CFG eating practices as well as research exploring how these practices are associated with various health outcomes.

Assessing comprehension of the Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) questions through cognitive interviewing.

OBJECTIVES: PATH, "Parenting/Pregnancy Attitudes, Timing, and How Important," is a method for providers to engage in a person-centered discussion about reproductive desires. This study sought to assess patient understanding of and receptivity to PATH questions. STUDY DESIGN: Cognitive interviews were conducted with young adult (aged 18-29 years) patients at a federally qualified health center in New York (n = 10). RESULTS: Participants demonstrated clear comprehension and comfort with the PATH questions. IMPLICATIONS: These data provide needed person-driven support for the Centers for Disease Control and Prevention and the Society of Family Planning's recommendation to implement PATH questions as a patient-centered method for discussing an individual's reproductive desires.

Testing Inclusive Language Revisions of the Breastfeeding Attrition Prediction Tool Using Cognitive Interviewing: A Pilot Study.

BACKGROUND: Recent calls-to-action have recommended the use of gender-inclusive language in the field of human lactation research and clinical care. However, little empirical evidence about parental acceptance and understanding of this new terminology exists. RESEARCH AIM: To assess understanding and acceptance of an inclusive language revision of the Breastfeeding Attrition Prediction Tool (BAPT). METHODS: This was a prospective qualitative study consisting of two phases, a survey followed by cognitive interview. Pregnant people (N = 16) were recruited from the Vermont Special Supplemental Nutrition Program for Women, Infants, and Children, which uses the BAPT as a standard of care. The study team revised the BAPT (e.g., changed terms like "breast milk" to "human milk"). Study participants completed the Revised BAPT and then participated in a cognitive interview by phone to assess their understanding and acceptance of revised, inclusive language. RESULTS: Most inclusive language was well understood and accepted by participants. Proposed revisions to the survey to replace terms like "breastfeeding" with other terms like "chestfeeding" or "bodyfeeding" were more difficult for participants to understand and were not well accepted. CONCLUSIONS: While it is clear that language in human lactation research and clinical practice should be revised to be more gender inclusive, specific inclusive terms elicit different levels of understanding and acceptance. Inclusive language options should be tested with target populations and more research is needed in this area.

Evaluating cannabis exposure in survey items: Insights, strategies, and remaining challenges identified from cognitive interviewing.

Background: The diversity in characteristics of cannabis products and behavior patterns make evaluation of cannabis exposure in population-based, self-report surveys challenging. Accurate identification of cannabis exposure and related outcomes necessitates a thorough understanding of participants' interpretations of survey questions assessing cannabis consumption behaviors. Objectives: The current study utilized cognitive interviewing to gain insight on participants' interpretation of items in a self-reported survey instrument used to estimate the quantity of THC consumed in population samples. Methods: Cognitive interviewing was used to evaluate survey items assessing cannabis use frequency, routes of administration, quantity, potency, and perceived "typical patterns" of use. Ten participants ≥18 years (n = 4 cisgender-men; n = 3 cisgender-women; n = 3 non-binary/transgender) who had used cannabis plant material or concentrates in the past week were recruited to take a self-administered questionnaire and subsequently answer a series of scripted probes regarding survey items. Results: While most items presented no issues with comprehension, participants identified several areas of ambiguity in question or response item wording or in visual cues included in the survey. Generally, participants with irregular use patterns (i.e., non-daily use) reported more difficulty recalling the time or quantity of cannabis use. Findings resulted in several changes to the updated survey, including updated reference images and new quantity/frequency of use items specific to the route of administration. Conclusion: Incorporating cognitive interviewing into cannabis measurement development among a sample of knowledgeable cannabis consumers led to improvements in assessing cannabis exposure in population surveys, which may otherwise have been missed.

Content validation of a daily patient-reported outcome measure for assessing symptoms in patients with Small Intestinal Bacterial Overgrowth.

PURPOSE: The aim of this study was to generate evidence supporting the development and content validity of a new PRO instrument, the Small Intestinal Bacterial Overgrowth (SIBO) Symptom Measure (SSM) daily diary. The SSM assesses symptom severity in SIBO patients, with the ultimate goal of providing a fit for purpose PRO for endpoint measurement. METHODS: Qualitative research included 35 SIBO patients in three study stages, using a hybrid concept elicitation (CE)/cognitive interview (CI) method with US patients, ≥ 18 years. Stage 1 included a literature review, clinician interviews, and initial CE interviews with SIBO patients to identify symptoms important to patients for inclusion in the SSM. Stage 2 included hybrid CE/CI to learn more about patients' SIBO experience and test the draft SSM. Finally, stage 3 used CIs to refine the instrument and test its content validity. RESULTS: In stage 1 (n = 8), 15 relevant concepts were identified, with items drafted based on the literature review/clinician interviews and elicitation work. Within stage 2 (n = 15), the SSM was refined to include 11 items; with wording revised for three items. Stage 3 (n = 12) confirmed the comprehensiveness of the SSM, as well as appropriateness of the item wording, recall period, and response scale. The resulting 11-item SSM assesses the severity of bloating, abdominal distention, abdominal discomfort, abdominal pain, flatulence, physical tiredness, nausea, diarrhea, constipation, appetite loss, and belching. CONCLUSIONS: This study provides evidence supporting the content validity of the new PRO. Comprehensive patient input ensures that the SSM is a well-defined measure of SIBO, ready for psychometric validation studies.

Value of cognitive interviewing in the development of the weight stigma in healthcare inventory.

BACKGROUND: Despite the detrimental effects of weight stigma in healthcare, there is no widely validated measure comprehensively examining such experiences. OBJECTIVE: We aimed to develop and pilot test an inventory to measure patient experiences of weight stigma in healthcare, and to ensure our items were easily understood. PATIENT INVOLVEMENT: During our iterative design process, patients assessed whether our inventory items were easy to understand and we included an open-ended comments question. METHODS: We compiled items from pre-existing tools assessing experiences of weight stigma in healthcare, and developed our own novel items. We conducted field pre-testing with a convenience sample of 48 patients at a Midwest academic internal medicine clinic. We utilized an iterative design process whereby respondents provided feedback on our inventory, we analyzed the data and made revisions, and then repeated the cycle. RESULTS: Respondents found some of the language in our items confusing; expressed reluctance to speculate on the motivations of healthcare providers; had difficulty with "double-barreled" questions; found some questions vague; and expressed the desire to have weight addressed in clinical encounters neither too much nor too infrequently. We altered items appropriately, and in subsequent rounds of data collection they were easier to understand. DISCUSSION: Patients found many common weight stigma survey items and some of our novel items confusing. Our modified inventory reduces patient confusion and enhances data quality. PRACTICAL VALUE: Our study demonstrates the value of cognitive interviewing. Furthermore, the WSHCI will be a useful tool for clinicians and research teams seeking to measure weight stigma in healthcare but first needs to be validated in a larger sample. FUNDING: This study was supported by the Physician Scientist Training Program, Diabetes Center T32 (DK112751), and the Clinical and Translational Science Award grant funded from the National Institutes of Health (UL1TR002537).