Table 3 Examples of item revision based on cognitive interviews, rounds 1 to 4

Health motivation – To determine bowel health

Item 1. I did not feel hesitant to undergo the examination.

Relevance and comprehensibility

Participants found the item less relevant since several of them expressed that they didn’t have a choice: ‘I’d rather avoid the colonoscopy, but that was not an option since I needed to undergo it’

Wording The item was difficult to answer due to the negation: ‘A bit tricky… you have to read properly’.

Change The item was reworded by removing the negation.

I felt hesitant to undergo the examination.

Relevance and comprehensibility All participants found the item easy to understand and considered it moderately relevant: ‘I knew why I had to undergo a colonoscopy, so it was a foregone conclusion’

I felt hesitant to undergo the examination.

Relevance and comprehensibility Participants described the item as redundant and as repeating a former question. One participant said, ‘It is a relevant question, but what would you use that input for if I already answered that I understand why I have to undergo the examination?’

Change No changes were made, since the research group considered the item important for the comprehensiveness of the construct Health motivation.

I felt hesitant to undergo the examination.

Relevance and comprehensibility Several participants found the item to be similar to another item, which was more positively worded: ‘It felt important for my health to undergo the examination’.

Change After discussion within the research group, it was decided that the item should tentatively be exchanged for the more positively worded item, according to the participants’ suggestion after the calculation of content validity index.

I felt hesitant to undergo the examination.

Discomfort – Impact on chronic diseases

Item 2. I was not worried that the preparations for the colonoscopy would affect my state of health.

Relevance and comprehensibility

The item was considered less relevant.

Wording The negation made it difficult to understand and answer.

Change The item was reworded by removing the negation.

I was worried that the preparations for the colonoscopy would affect my state of health.

Relevance and comprehensibility

The participants would rather answer a question about how worried they were concerning the bowel preparation, than a question about how it affected their state of health: ‘I was worried about the laxative itself.. how it would affect me’.

Change The item was removed.

Discomfort – Impact on chronic diseases

Item 3. I was not worried that stopping my regular medication would negatively affect my state of health.

Relevance and comprehensibility

Participants described the item as relevant.

Wording The item was difficult to answer due to the negation.

Change The negation was removed.

I was worried that stopping my regular medication would negatively affect my state of health.

Relevance and comprehensibility

The item was described as relevant by the participants: ‘I can understand that if you have medication, it’s a relevant question’.

Wording The item was difficult to answer if you didn’t have any medication.

Change The answer alternative ‘I have no medication’ was added, as suggested by participants.

I was worried that stopping my regular medication would negatively affect my state of health.

Wording One participant stated, ‘I have medication, but uh.. I didn’t have to stop taking it.

Change The answer alternative ‘I have no medication/I have medication but did not have to stop’ was added.

I felt worried that stopping my regular medication would negatively affect my state of health.

No problems reported.

I was worried that stopping my regular medication would negatively affect my state of health.

Discomfort – Bowel preparation

Item 4. My sleep was not affected by the bowel cleansing (laxation).

Relevance and comprehensibility

Participants considered the item less relevant.

Wording The item was difficult to understand since it could be interpreted as referring to sleep being both positively and negatively affected.

Change The wording was ‘not affected’ was replaced by ‘negatively affected’.

My sleep was negatively affected by the laxative.

Relevance and comprehensibility

The item was hard to answer because participants’ sleep was disturbed by different causes: ‘The anxiety affected my sleep. You might think that I needed to go to the toilet, but I didn’t, it was my dreams that woke me up’.

Wording The item was easy to understand.

My sleep was negatively affected by the laxative.

Relevance and comprehensibility

Participants continued to try to interpret what the item referred to: ‘The question probably refers to toilet visits at night..?’

Change The research group decided to keep the item due to the conceptual comprehensiveness, despite possible inconsistent answers.

My sleep was negatively affected by the laxative.

Relevance and comprehensibility

Participants expressed that the item was highly relevant: ‘The night before was difficult, I slept less than 4 hours due to toilet visits. In the morning I lacked energy’.

Change Due to ambiguities based on relevance, the item was retained pending the response from the content validity index calculation.

My sleep was negatively affected by the laxative.

Information – Topic of conversation

Item 5. It was easy to talk about having a colonoscopy with others outside of the healthcare system

Relevance and comprehensibility

Participants considered the item irrelevant. One participant, who had undergone the procedure several times, commented, ‘Many people don’t know what a colonoscopy is, let alone how it is done’.

Change The cited reflection and the item’s lack of relevance led to removal of the item.

Understanding – Worries

Item 6. Before the colonoscopy, I felt confident about how the procedure would be conducted.

Relevance and comprehensibility The item was perceived as highly relevant, and the participants expressed the importance of information before the procedure.

Before the colonoscopy, I felt confident about how the procedure would be conducted.

Relevance and comprehensibility All participants found the item easy to understand and answer and perceived it as relevant.

Wording One participant stated that ‘you can’t be sure about anything’ and this remark highlighted the need for exploring the word ‘confident’ in the next round of cognitive interviews.

Before the colonoscopy, I felt confident about how the procedure would be conducted.

Wording Participants were asked specifically about the wording and gave several suggestions, such as ‘well prepared’, ‘informed’ and ‘sure’.

Change According to a suggestion from participants, ‘confident’ was changed to ‘informed’.

Before the colonoscopy, I felt informed about how the procedure would be conducted.

No problems reported.

Before the colonoscopy, I felt informed about how the procedure would be conducted.