Table 1.

Tourangeau four-stage response model framework

Stage	Description
Comprehension	Involves problems with the interpretation of the HRQoL dimensions, where participants encounter problems understanding or have misunderstandings of words, phrases, or response options. Issues may arise due to ambiguous wording or unfamiliar terms
Recall	Involves problems with the retrieval process, encompassing challenges such as using an incorrect time frame for information retrieval and difficulties in recalling relevant information that aligns with the measure’s specified time frame
Judgment	Involves problems with assessing the information retrieved, including drawing upon irrelevant information or inadequate evaluation, potentially leading to under or over-reporting of health states. This stage is often closely linked to comprehension, as it entails the evaluation of recalled information to determine its relevance to the specific question and is influenced by how the question was understood in the first place
Response Mapping	Addresses issues with the response categories, such as dissatisfaction with the provided options or inappropriate application of them (e.g., selecting multiple options when only one is permissible, or reluctance to choose any). It also includes cases where the stated answer (verbal protocol data) is misaligned with the chosen answer (survey response data), reflecting a disconnection in the final stage of the survey

(Adapted from Lay, K. et al. [45])