Refining the Stroke Risk Screening Scales (SRSS) Through Two-Round Cognitive Interviews with Stroke Survivors and Healthcare Providers in Thailand.

BACKGROUND: Accurate stroke risk screening requires instruments that are both clinically valid and easily understood by end users. Although the Stroke Risk Screening Scales (SRSS) demonstrated strong content validity, challenges related to item interpretation and response processes may compromise measurement accuracy. This study aimed to examine these barriers and identify strategies to enhance the clarity, accuracy, and usability of the SRSS.

METHODS: A qualitative cognitive interviewing approach was conducted with 30 purposively sampled participants, including 15 individuals with stroke and 15 healthcare providers. Each participant completed two interview rounds, with the same 30 participants re-interviewed in Round 2 (conducted within one month of Round 1) to confirm whether revisions made after Round 1 addressed the barriers identified, yielding a total of 60 interviews. Data were collected using a semi-structured verbal probing guide to explore participants' understanding, reasoning, and response processes across 30 SRSS items. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis based on Braun and Clarke's framework. Rigor was ensured through independent coding, iterative codebook development, triangulation, and maintenance of an audit trail.

RESULTS: Two overarching themes emerged: (1) interpretation and response barriers, including technical terminology, ambiguous measurement units, recall difficulties, misaligned response options, lack of skip logic, and cultural mismatches; and (2) evidence-based refinement strategies to improve usability. Participants recommended simplifying terminology, incorporating descriptive examples, aligning question stems with response options, implementing skip logic, and standardizing measurement units and thresholds. These findings highlighted critical gaps between clinical terminology and lay understanding that may affect response accuracy.

CONCLUSION: Cognitive interviewing identified key interpretive and structural limitations in the SRSS and provided actionable, user-informed strategies for refinement. These findings offer preliminary response-process evidence supporting the interpretability and usability of the SRSS among stroke survivors and healthcare providers, and highlight the importance of user-centered pre-testing in the development of screening tools for diverse populations. Further psychometric evaluation in larger and more diverse samples is needed to establish the instrument's reliability, validity, and clinical applicability.