15 General introduction 1 researchers and policymakers have focused on promoting (digital) health literacy as a means to address the digital divide. The so-called ‘digital divide’ in which digital health systems and technologies are predominantly accessed and used by individuals with a higher education and higher health literacy, is of particular concern as people with lower education and fewer resources generally have an increased risk of developing chronic conditions and more often need ongoing medical care (39). Hence, while current healthcare is shifting and increasingly relies on remote healthcare and digital healthcare technologies and services, individuals with limited access to digital technologies may experience challenges in obtaining timely and reliable health information, seeking appropriate medical advice, or miss out on opportunities to adopt healthy behaviours. Consequently, this growing digital divide has the potential to widen health inequities and exclude digitally disadvantaged individuals (40, 41). This issue is not new. In fact, the WHO has recognized the digital divide, with risk of digital exclusion and unequal access, as one of the biggest challenges posed by the digital transformation of healthcare (42, 43). While access within the digital transformation is often seen from the dimensions of material access, referring to the physical access to digital technologies such as computers, smartphones, and internet connectivity, access is considered a multifaceted phenomenon that encompasses various dimensions of access, including, material access, skills access and motivational access (44). This means that, even if access is available, disparities may still exist if people do not possess the proper competence to use the digital health technologies and services needed to effectively to use the technology (skills access). The emergence of diverse digital health technologies necessitates individuals to navigate through portals, actively engage with apps, remain motivated to use self-monitoring devices, interpret collected data, assess information reliability, and effectively communicate with digital health systems. This additional set of skills and abilities has been conceptualized into eHealth literacy. Shedding light on and addressing eHealth literacy needs of individuals is paramount to providing appropriate support and to develop eHealth that fit people’s eHealth literacy needs (45, 46). The eHealth Literacy Questionnaire (eHLQ) is increasingly used globally as comprehensive person-centred instrument to measure eHealth literacy. However, despite the ongoing digital transition in the Netherlands a comprehensive Dutch person-centred instrument to measure eHealth literacy is lacking. The third access dimension, motivational access, relates to the personal motivation, attitudes, and willingness to engage with digital technologies. People with lower socialeconomic positions or limited health literacy are seldomly actively involved in eHealth development, resulting in interventions that fail to meet their needs, motivation, attitude towards eHealth and eHealth literacy needs (47, 48). Involving individuals with low socio-economic positions or limited health literacy in participatory design seems logical to develop eHealth interventions that address their (unmet) needs. However, effective involvement of these groups in participatory design is often hindered by
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