Danish Translation and Validation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR).

Danish Translation and Validation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Int Urogynecol J . 2025 Dec 13;37(5):1289–1295. doi: 10.1007/s00192-025-06481-8 Danish Translation and Validation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) Greta Puriene 1 , Sofie Ronja Petersen 2 , Bashayir Said Muse Issa 3 , Saskia Denise Marxen 1 , Mette Hulbaek 1, 4, ✉ Author information Article notes Copyright and License information 1 Department of Women’s Health, University Hospital of Southern Denmark, Aabenraa, Denmark 2 Department of Clinical Research, University Hospital of Southern Denmark, Aabenraa, Denmark 3 Department of Gynecology and Obstetrics, University Hospital of Odense, Odense, Denmark 4 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark Handling Editor: Symphorosa Shing Chee Chan Editor in Chief: Maria A. Bortolini ✉ Corresponding author. Received 2025 Oct 22; Accepted 2025 Nov 24; Issue date 2026. © The Author(s) 2025 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13226375  PMID: 41389267 Abstract Introduction The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR) is a validated tool for assessing sexual health in women with pelvic floor disorders, divided into sections for sexually active (SA) and not sexually active (NSA) women. Although widely used, it has not yet been implemented in Denmark. This study aims to translate and validate the Danish translation of PISQ-IR. Methods Following the IUGA PISQ-IR Translation Protocol, the Danish version was approved and distributed digitally to women with pelvic floor disorders recruited from four hospitals in Denmark. Participants completed PISQ-IR, PFDI-20, PFIQ-7, and ICIQ-UI questionnaires both at baseline and 10-days retest. Internal reliability, test–retest reliability, and criterion validity were tested, followed by confirmatory (CFA) and exploratory factor analysis (EFA). Results Of 305 invited women, 201 (66%) completed the PISQ-IR; 82 (NSA) and 119 (SA). In general, internal reliability was good (Cronbach’s alpha > 0.8). Test–retest reliability was acceptable (ICC 0.59–0.89 NSA; 0.54–0.83 SA). Criterion validity was better in the SA group but below standard. CFA showed acceptable factor loadings but poor fit indices (RMSEA 0.177 NSA, 0.096 SA; TLI 0.660 NSA, 0.840 SA). EFA revealed a three-factor solution (NSA) and two-factor solution (SA), with high uniqueness in several items, correlating with the low fit in the CFA. Conclusions The Danish PISQ-IR showed good internal consistency and test–retest reliability, supporting its use in Denmark. However, low fit indices and factor loadings in several items suggest the need for further revision. Supplementary Information The online version contains supplementary material available at 10.1007/s00192-025-06481-8. Keywords: Sexual dysfunction, PISQ-IR, Urinary incontinence, Pelvic organ prolapse, Anal incontinence Introduction Sexual health is a vital aspect of women’s overall and, especially, psychological well-being, directly impacting quality of life [ 1 ]. Women with pelvic floor dysfunctions (PFDs), including pelvic organ prolapse (POP), urinary (UI) and anal incontinence (AI), are especially predisposed to sexual dysfunction (SD), with a prevalence of up to 50–83% [ 2 ]. Unfortunately, despite a high prevalence, sexual health issues are often left undiagnosed in urogynecological practice. However, questionnaires can help assess sexual health in the setting of PFDs [ 3 ]. The International Urogynecological Association (IUGA) sponsored a multicenter international study to revise the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12) into a new, revised version (PISQ-IR), presented in 2013 [ 3 ]. PISQ-IR was designed for use in a multi-cultural environment and for sexually active (SA) and not sexually active (NSA) women. The PISQ-IR consists of 20 questions, which are divided into two sections: SA and NSA women. It assesses various domains of sexual function, such as desire, arousal, lubrication, orgasm, satisfaction, and pain (for SA women) and sexual interest, concerns about intimacy, and the impact of PFD symptoms on sexual health (for NSA women) [ 3 ]. The PISQ-IR’s comprehensive nature and its ability to assess sexually active and inactive women make it a valuable tool in both clinical practice and research settings for evaluating the impact of PFDs on women’s sexual well-being [ 4 ]. The questionnaire is now validated and used in many countries worldwide, including Poland, France, Spain, Germany, the Netherlands, and other European countries [ 4 – 8 ], but it has yet to be validated in Denmark. The successful implementation of the PISQ-IR in clinical practice and research contexts depends on the availability of instruments that are psychometrically robust and culturally sensitive, with rigorous translation and validation procedures. This study aims to culturally adapt and validate the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-IR) in a Danish context among women with PFDs. Methods Permission to translate the questionnaire into Danish was obtained from the IUGA Working Group on February 27, 2020, and the IUGA PISQ-IR Translation Protocol [ 9 ] guided this study. Translation and Adaptation of the Original English PISQ-IR into Danish An expert group of four clinicians specializing in gynecology and sexology, along with one female patient partner, were appointed. Two members of the expert group each translated the original questionnaire into Danish. The two versions were discussed and merged to produce a single unified adaptation. The translators had sufficient knowledge about women’s sexual health and the anatomical terms used in the questionnaire. Another expert group member and co-author performed cognitive interviews (CI) in one-on-one sessions with patients from the target group. According to the applied probe technique proposed by the WHO in 2016 [ 10 ], the interviewee initially completed a paper-based questionnaire and was later interviewed about each question. Probes like “How did you respond to this question?”, “Why did you respond this way?”, and “How did you understand this question?” were asked during the interview, and any discrepancies were explored and discussed. After completing 14 interviews, the expert group reviewed all participant feedback and adjusted the translation accordingly. A native English speaker with sufficient knowledge of women’s sexual health and anatomy was appointed to translate the questionnaire back to English. This initial back-translation was discussed with the IUGA board on a few points; (1) The translation and cultural adaption of several wordings and descriptions of the phenomena “prolapse” and (2) The translation of the answering cathegories “somewhat agree” and “somewhat disagree.” Point (2) was accepted by the Board as initially translated and cultural adapted. Point (1) was extended by the interviewer and a member from the expert group to grasp all aspects of the symptoms. This translation was substantiated with a few further cognitive interviews, after which the expert group, including the patient partner, approved the refined and culturally adapted translation. This final version was accepted by the IUGA Board on January 26, 2022. Psychometric Testing of the Danish Translation Data Collection Participants were recruited from four hospitals in Denmark. Eligible participants were introduced to the study during visits to the outpatient clinic, and upon acceptance, written consent was obtained. To enroll, participants had to present with complaints of UI and/or AI and/or POP, be aged 18 or older, not be pregnant, and be able to read and understand Danish. Participants were excluded if suffering from vulvodynia, painful bladder syndrome or chronic pelvic pain. Data were collected using digital questionnaires instead of paper versions, as a survey among purposive respondents ( n = 53) at the two largest sites indicated that respondents preferred this method (89% for the online version). Besides the PISQ-IR, the digital baseline questionnaire included the following scales used for the criterion validity analysis: The short form of the Pelvic Floor Distress Inventory (PFDI-20 [ 11 ], the Pelvic Floor Impact Questionnaire−7 (PFIQ-7) [ 11 ], and the Urinary Incontinence – ICI module (ICIQ-UI) [ 12 ]. These questionnaires for the evaluation of POP and UI have been validated into Danish. Until the initiation of the trial, there were no validated Danish questionnaires for bowel disorders. Questionnaires were sent twice—at baseline and for retest. Baseline questionnaires were sent at the latest within 2 days after the hospital visit, with a reminder sent 3 days later if no response was received. Questionnaires for retest were sent 10 days after the baseline questionnaire had been answered, and a reminder was sent 3 days after if no response was received to the retest questionnaires. Unanswered baseline questionnaires were considered a withdrawal of consent. Apart from data collected by questionnaires, additional clinical and physical findings below were collected from the electronic patient record system—weight; height; gravity (number of pregnancies); parity (number of births > 24 weeks gestation); deliveries (vaginal/caesarean); menopausal status (for postmenopausal with and without hormone replacement therapy); prior pelvic surgery (-ies); pelvic floor (Oxford gradient scale, clinical diagnosis of POP and/or UI and/or FI); prior nonsurgical treatment; current treatments (anticholinergic, pelvic floor exercises, biofeedback, formal physical therapy, pessary); medical history (diabetes, neurological diseases (defined as history of Parkinson’s disease, multiple sclerosis, spinal lesions, stroke, dementia, or depression (with or without SSRI use)). A flow chart of the testing can be found in the Supplementary Material Fig. 1 . Data Storage Data were collected and stored using REDCap (Research Electronic Data Capture), an electronic data capture tool that ensured secure data storage in accordance with ethical standards [ 13 , 14 ]. Statistical Analysis Statistical analysis was performed using Stata BE version 18. Baseline distribution and clinical characteristics were described, and analyses were calculated separately for NSA and SA groups, as recommended [ 9 ]. Numeric variables were presented as mean and standard deviation (SD) or median and interquartile range (IQR), depending on the distribution. Categorical variables were presented with absolute and relative frequencies. Item distribution and nonresponse levels were evaluated, including the identification of floor and ceiling effects, as well as an assessment of missingness. For the presentation of the mean scores, the transformed sum was used [ 15 ]. The internal reliability of the sub-scales and scales was evaluated by generating Cronbach’s alpha, and acceptable internal reliability was considered if the alpha was above 0.60 [ 16 ]. Bartlett’s test of sphericity and Kaiser–Meyer–Olkin measure of sampling adequacy were checked for a confirmatory factor analysis [ 17 ]. Fit indices were measured: the root mean squared error of approximation with a good fit considered under 0.05 and the Tucker–Lewis index with a desired result > 0.95 [ 18 ]. Test–retest reliability was estimated by calculating the intra-class correlation (ICC), with values under 0.5 considered as poor reliability, 0.5–0.75 as moderate, 0.75–0.9 as good, and greater than 0.9 as excellent [ 19 ]. Criterion validity was assessed between the condition-specific and condition-impact scales in both the NSA and SA groups of the PISQ-IR [ 3 ] and the total scores of PDFI-20, PFIQ-7, and ICIQ-UI. To assess it, Spearman’s rank correlation coefficient was used. Scaling was done according to the original validation study [ 3 ] and can be found in Supplementary Material: Dimensions, scales, and items within . Post Hoc Analysis: Exploratory Factor Analysis (EFA) Owing to an unconfirmed solution for the confirmatory factor analysis, we conducted EFA to evaluate the dimensions of the instrument within the study sample. We estimated factor loadings for three underlying factors and used a promax rotation to allow for some non-orthogonality. Ethics The study was conducted in accordance with the Code of Ethics of the Declaration of Helsinki [ 20 ]. All patients provided their informed written consent before participating in the study, which was reconfirmed by completing the digital questionnaire. According to Danish law, approval from the National Committee on Health Research Ethics was not required, as no biomedical intervention was performed. Permission to store and manage data was approved by the Danish Data Protection Agency (Jnr 19/46391). Data was collected and stored in accordance with the Law on Data Protection in Denmark and the European General Data Protection (GDPR) (Jnr 19/46381 and 19/46397). Results Translation and Cultural Adaptation Interviews were conducted between March 2020 and December 2021. Discussions within the expert group and original authors led to a final version, which the IUGA approved in January 2022. The cultural adaptation process did not result in any change to the item content. The Danish version can be found in Supplementary Material, Fig. 2 . Psychometric Testing A total of 305 women were invited, and 201 (66%) completed the PISQ-IR. A total of 82 (41%) were not sexually active (NSA), while 119 (59%) were sexually active (SA). The mean age in the NSA group was significantly higher, compared to the SA group (respectively 67.3 ± 11.6 and 54.7 ± 14.1 years). In total, 143 women were postmenopausal (78 in the NSA and 65 in the SA group). There was no difference in BMI between groups (26.3 ± 4.0 (NSA) 27.0 ± 4.6 (SA)). A total of 127 participants were diagnosed with one PFD (97 with POP, 28 with UI, and 2 with FI), while 61 were diagnosed with multiple PFDs (56 with POP/UI, 2 with POP/FI, 1 with FI/UI, and 2 with all three diagnoses). All clinical and demographic characteristics of the study population are shown in Table 1 . Table 1. Clinical and demographic characteristics of the study population NSA SA Total Invited 305 Baseline (%)—participation 86 (42) 121 (58) 207 (100) PISQ-IR Completed PISQ-IR (%) 82(95) 120 (99) 202(98) Not complete PISQ-IR (%) 4 (5) 1 (1) 5 (2) Retest (%)—participation 68 (81) 63 (52) 131 (64) Completed retest (%) 68 (100) 61 (97) 129 (98) Not complete retest (%) 0 2 (3) 2 (2) Age years (mean) 67.3 ± 11.6 54.7 ± 14.1 59.8 ± 14.5 BMI (mean ± SD) 27.0 ± 4.6 26.3 ± 4.0 26.6 ± 4.3 Postmenopausal * ( n = x) 78 65 143 Gravidity number ± SD 2.7 ± 1.7 2.5 ± 1.1 2.6 ± 1.4 Parity number ± SD 2.3 ± 1.0 2.4 ± 1.1 2.3 ± 1.0 Vaginal delivery number ± SD 2.2 ± 1.0 2.2 ± 1.1 2.2 ± 1.0 Caeserian section number ± SD .13 ± 0.4 .16 ± 0.5 .14 ± 0.4 Oxford grading scale 0/No contraction 1 1 2 1/Flicker 3 10 13 2/Weak 16 19 35 3/Moderate 6 12 18 4/Good 10 8 18 5/Strong 2 4 6 Missing (%) 48 (56) 67 (56) 115 (56) Clinical diagnosis of POP 123 156 279 Cystocele 61 74 135 Cystocele degree 1 19 18 37 Cystocele degree 2–3 41 55 96 Cystocele degree 4 1 1 2 Cystocele degree unknown 0 0 0 Rectocele 35 43 78 Rectocele degree 1 13 15 28 Rectocele degree 2–3 22 28 50 Rectocele degree 4 0 0 0 Rectocele degree unknown 0 0 0 Vaginal prolapse 27 39 66 Vaginal prolapse degree 1 7 9 16 Vaginal prolapse degree 2–3 16 23 39 Vaginal prolapse degree 4 4 2 6 Vaginal prolapse degree unknown 0 5 5 Urinary incontinence (UI) 55 70 125 Unknown type 1 5 6 Urgeincontinence 15 11 26 Stressincontinence 23 38 61 Mixed urinary incontinence 16 16 32 Fecal incontinence (FI) 4 3 7 POP/UI/FI POP only 40 57 97 UI only 7 21 28 FI only 1 1 2 POP/UI 26 30 56 POP/FI 1 1 2 FI/UI 1 0 1 POP/UI/FI 1 1 2 Missing 9 9 18 Prior pelvic surgery 41 55 74 No prior pelvic surgery 44 63 107 Missing 1 3 4 Prior nonsurgical treatment 57 69 126 No prior nonsurgical treatment 28 51 79 Missing 1 1 2 Current treatments Anticholinergic medication 10 9 19 Pelvic floor exercises 4 12 16 Formal physical therapy 5 13 18 Biofeedback 0 0 0 Pessary 33 25 58 Tibial nerve stimulation 7 6 13 Local estrogen medication 72 69 141 None 5 31 38 Medical history Diabetes 3 2 5 Neurological diseases # 86 4 90 Depression (with SSRI use) 13 6 19 Depression (without SSRI use) 2 4 6 None 70 104 174 Sexual partner Yes (%) NA 115 (96) No NA 5 (4) Open in a new tab NSA not sexually active SA sexually active * One year after menstruation # Parkinson’s disease, multiple sclerosis, spinal lesions, stroke, or dementia Internal Reliability In the NSA group, the calculated Cronbach’s alpha showed good reliability, with a total value > 0.8 in two of the four scales. A lower result (< 0.6) was observed on scale 1. In the SA group, Cronbach’s alpha showed good reliability in all six scales. Table 2 . Table 2. Cronbach’s alpha for each scale for the NSA and SA groups Scale Number of items Cronbach’s alpha NSA group 0.8088 (total NSA group) Scale 1: condition-specific (NSA-CS) 3 0.4492 Scale 2: partner-related (NSA-PR)* 2 Scale 3: global quality (NSA-GQ) 4 0.8769 Scale 4: condition impact (NSA-CI) 3 0.8622 SA group 0.9018 (total SA group) Scale 1: arousal, orgasm (SA-AO) 4 0.7426 Scale 2: partner-related (SA-PR) 3 0.6586 Scale 3: condition-specific (SA-CS) 3 0.6592 Scale 4: global quality rating (SA-GQR) 4 0.9187 Scale 5: condition impact (SA-CI) 4 0.8436 Scale 6: desire (SA-D) 3 0.7318 Open in a new tab * Cronbach’s alpha is not measured on scale 2 as it only includes 2 items Factor Analysis—Confirmatory Factor Analysis (CFA) Factor loadings were calculated for each item on the scales. In the NSA group, most items exhibited high loadings on their factors (> 0.6), except for items 2b, 2c, and 2 d, which showed low to moderate loadings. The fit indices (root mean squared error of approximation of 0.177 and the Tucker–Lewis index of 0.660) were found below an acceptable standard. In the SA group, most items showed high loadings, except for items 9, 11, 13, 15, and 18, which had low to moderate loadings. The fit indices were better compared to the NSA group, but still fell below standard (0.096 and 0.840, respectively). Factor Analysis—Exploratory Factor Analysis (EFA) Given muliple low factor loadings and substandard fit indices in the CFA, an EFA was conducted to investigate the underlying factor structure. In the NSA group, the analysis showed a three-factor solution. Item 2c loaded moderately on multiple factors, suggesting a mixed alignment, as it is in the nature of the question (regarding PFDs). Two items (2d, 2e) in scale 1 in the NSA group (NSA-CS) showed high uniqueness (> 0.7), contributing to the low fit in CFA. In the SA group, the analysis revealed a two-factor solution. Items 8b, 8c, 9, 10, 11, 13, and 15 showed high uniqueness with values above 0.7, indicating a low fit in any of the factors. This can contribute to the explanation of low to moderate loadings in several items in the CFA. Test–Retest Reliability One hundred twenty-nine women (64%) completed the retest. In the NSA group, ICC values ranging from 0.59 to 0.89 showed moderate to good reliability. In the SA group, ICC values ranged from 0.54 to 0.83, indicating moderate to good reliability. Criterion Validity The total scores of the PFDI-20, PFIQ-7, and ICIQ-UI were used to calculate criterion validity scores, using scales NSA-CS and NSA-CI in the NSA group, as well as scales SA-CS and SA-CI in the SA group. The scales were selected on the basis of the original validation of the English PISQ-IR [ 3 ]. The SA group showed better criterion validity than the NSA group but was still considered to be below standard (Table 3 ). Table 3. Criterion validity Questionnaires Score NSA group Scale 1 (NSA-CS) Scale 4 (NSA-CI) PFDI-20 (total score) −0.073 −0.100 PFIQ-7 (total score) −0.273 −0.408 ICIQ-UI (total score) −0.071 −0.087 SA group Scale 3 (SA-CS) Scale 5 (SA-CI) (PFDI-20 (total score) 0.244 −0.163 PFIQ-7 (total score) 0.401 −0.283 ICIQ-UI (total score) 0.475 −0.284 Open in a new tab Discussion The Danish translation of PISQ-IR demonstrated good face and content validity, as well as internal and test–retest reliability, making it a useful, validated tool in urogynecological practice in Denmark. The strengths of the study include clear and systematic methods including an expert group and discussions with the original authors, a culturally adaptive process, and the involvement of a patient partner, as well as thorough psychometric testing, including validation with gold standards. However, the study also revealed several limitations. The responsiveness of 66% was lower than expected and compared to some studies [ 4 , 7 ], yet slightly higher than in the Dutch validation study [ 5 ]. One possible explanation could be the time gap between giving written consent and completing the digital questionnaire at home, as it may have contributed to a lack of motivation to participate in the study. Another explanation could be the “yes bias” or acquiescence bias reflecting the participants’ desire to be agreeable and fulfill the doctor’s expectations for participation. Participants who did not complete the questionnaire may differ from responders, for example, by having more severe symptoms, discomfort with sexual health questions, or lower digital literacy, which could limit the generalizability of our findings. On the other hand, 98% of those who responded completed the questionnaire, which can be attributed to the ease of accessing it electronically. For the test–retest reliability, only 64% of women completed the retest, suggesting a lack of interest in completing the same questionnaire again or a lack of information from recruiting personnel about the retest, which may have prevented them from completing it once more. Furthermore, in the study population, only seven women had FI, making it difficult to evaluate the tool’s fit for patients with FI. There is a need for further investigation involving more women with FI and future work calculating criterion validity should include all Danish validated questionnaires available, e.g., the newly validated Danish questionnaire about bowel disorders; International Consultation on Incontinence Questionnaire – Bowel (ICIQ-B) [ 21 ]. Overall, internal reliability was good except in the NSA scale 1 group (NSA-CS). However, this scale showed the lowest Cronbach’s alpha not only in our study but also in the Polish (0.651) [ 4 ] and German (0.64) [ 7 ] validations. The criterion validity turned out weak, which lies first in the explicit choice of reference instruments that do not directly reflect a gold standard for the intended measures, but merely a related field of outcomes. Second, an implicit explanation for low correlation is given by the weak construct stability itself: By correlating pre-matched item sets on the PDFI-20, PFIQ-7, and ICIQ-UI, a validity was precluded, as the expected construct could not be confirmed and the items might not represent the desired factors that are in turn described in the three reference instruments. The CFA did not meet the acceptable fit criteria, and EFA explained the low loadings in CFA as indicated by the substantially simplified structure. One reason might be the overly complex structure attempted to fit on the data, that might not be represented in the Danish sample. Nonresponse bias could have distorted the results of the functionality of the instrument. Further exploration suggested high uniqueness in specific items, which is especially problematic in smaller samples. Specific items, especially items 2 d and 2e in the NSA group, may require further revision or cultural adaptation. Furthermore, it could be helpful to validate the structure in a larger sample while avoiding nonresponder bias. In conclusion, all results were significantly better in the SA group, making it a robust tool to address sexual dysfunction in sexually active women. As the NSA group results appeared to be less compatible, further consideration or possible adjustments are needed. Conclusion PISQ-IR is a valuable tool addressing sexual health in women with PFDs. It showed strong correlations, good internal consistency and test–retest reliability. The Danish translation of the questionnaire, despite several limitations, including low fit indices and factor loadings that might require further investigation, has demonstrated this version as a validated tool for use across Denmark, both clinically and in research settings. Acknowledgdements We would like to thank all contributing patients and healthcare professionals from the departments of Gynecology and Obstetrics at the four hospitals of the Southern Region of Denmark especially the Departments in Aabenraa and Odense for the main support during collection of data. Many thanks to Cathy Pettit and Phillip Keudel in the translation process, to Caroline Moos for grammatical corrections of the manuscript and to the patient partner Betina Hylleberg for collaboration. Also, we would like to thank Rebecca Rogers and the IUGA Working Group for their cooperation and guidance. Supplementary Information Below is the link to the electronic supplementary material. 192_2025_6481_MOESM1_ESM.docx (115.9KB, docx) Supplementary Material Fig. 1 (DOCX 116 KB) 192_2025_6481_MOESM2_ESM.docx (12.6KB, docx) Supplementary Material: Dimensions, scales, and items within (DOCX 13 KB) 192_2025_6481_MOESM3_ESM.pdf (626.3KB, pdf) Supplementary Material, Fig. 2 (PDF 626 KB) Author Contributions G Puriene—Data Collection (psychometric test), Manuscript draft writing, Final manuscript. S R Petersen—Statistical analysis, Manuscript draft writing, Final manuscript. B S M Issa—Data collection (psychometric test), Final manuscript. S D Marxen—Data collection (cognitive interviews), Final manuscript. M Hulbaek—Project development, Data collection (psychometric test), Manuscript draft writing, Final manuscript. Data Availability Data can be made available by contacting the corresponding author. 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Supplementary Materials 192_2025_6481_MOESM1_ESM.docx (115.9KB, docx) Supplementary Material Fig. 1 (DOCX 116 KB) 192_2025_6481_MOESM2_ESM.docx (12.6KB, docx) Supplementary Material: Dimensions, scales, and items within (DOCX 13 KB) 192_2025_6481_MOESM3_ESM.pdf (626.3KB, pdf) Supplementary Material, Fig. 2 (PDF 626 KB) Data Availability Statement Data can be made available by contacting the corresponding author. 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