Validating the EQ-HWB-9 in long-term care recipients and carers: a qualitative study from Slovenia

Abstract

Background: The EQ Health and Wellbeing 9 (EQ-HWB-9) is the short form of an experimental generic measure developed to extend preference-based measurement beyond health-related quality of life, for use in economic evaluation across health care, social care, long-term care and public health. Evidence on its content validity among long-term care recipients with complex needs and carers remains limited. This study examined the content validity of the Slovenian EQ-HWB-9 among long-term care recipients with complex needs and carers and explored preferences for selected modifications between the original (‘experimental’ v1.1, 2022) and modified (‘experimental modified’ v1.2, 2024) versions. Methods: One-to-one cognitive interviews using verbal probing were conducted in Central Slovenia from June to August 2025 with long-term care recipients and carers acting as proxies. Participants reviewed the Slovenian modified EQ-HWB-9 (self-complete [care recipients] or proxy 1 version [carers]) and were probed on comprehensibility, relevance, and comprehensiveness. Selected items and questionnaire design features were compared between the original and modified versions, including control and mobility wording, response scale labels, item order, and item stem format. Results:The final sample comprised 27 participants (14 care recipients and 13 carers), including 11 dyads and five individual participants. The EQ-HWB-9 was considered relevant, acceptable in length and sufficiently comprehensive. Activities, mobility, exhaustion, loneliness, sad or depressed, and pain items were generally well understood, while concentrating or thinking clearly, anxiety, and control were more difficult to interpret, particularly for care recipients. Participants preferred placing activities before mobility, while no clear overall preferences emerged for control or mobility wording. Preferences for response scale labels and item stem format were mixed. Conclusions: The Slovenian modified EQ-HWB-9 was generally considered relevant and acceptable by longterm care recipients with complex needs and carers. Several items may require clearer wording to improve comprehension among care recipients. Findings on the proposed modifications were mixed, with the clearest support for placing activities before mobility. Some difficulties may also reflect the demands of cognitive interviewing in populations with complex long-term care needs. The findings support further refinement of the EQ-HWB-9.