218 7 Chapter 7 usage among people who were lower educated (16, 17). This so-called digital divide in which digital systems are more frequently used by people with higher education is of particular concern as people with lower education and fewer resources generally more often need ongoing medical care (11, 18). As such, academics have expressed concerns that ongoing digitalization of the health landscape may ultimately result in increasing health inequities and exclusion of those who are digitally disadvantaged (15, 19, 20). This issue is not new (20-22). 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 (23). Measuring eHealth literacy Adequate assessment of eHealth literacy is instrumental in bridging the digital divide. Over the years, several instruments have been developed to measure eHealth literacy (24-28), with the eHealth Literacy Scale (eHEALS) the most commonly used (25, 28) due to its early development. The eHEALS measures perceived skills in finding, evaluating, and applying electronic health information related to health problems using firstgeneration internet based health services (25, 29). The instrument does, however, not fit with the evolving concept of eHealth literacy and today’s broad scope of digital technologies which requires a wider range of competences (30, 31), like entering data in patient portals or health apps on a smartphone (30, 32). The Digital Literacy Instrument (DLI) was developed to overcome these limitations. Data collected have shown validity and reliability in a Dutch sample (24, 28). However, the instrument is performancebased and covers individual skills in digital health technology use, without capturing broader interactions with health technologies and services, including motivation to engage with digital health technologies. The eHealth Literacy Questionnaire To overcome the shortcomings of the eHEALS, the eHealth Literacy Questionnaire (eHLQ) was developed. The 35-item eHLQ is based on the eHealth Literacy Framework (eHLF), developed in 2012 with patients and medical professionals during a systematic concept mapping process (33). This framework includes individual factors that are necessary to use eHealth (e.g., engagement in own health), system factors (e.g., access to digital services that work) and user–system interaction factors (e.g., motivation to engage with digital services). The constructs were conceptualized into seven conceptually distinct dimensions that present a multifaceted understanding of eHealth literacy and are measured by the eHLQ (34, 35): 1. Using technology to process health information (five items) 2. Understanding of health concepts and language (five items) 3. Ability to actively engage with digital services (five items) 4. Feel safe and in control (five items) 5. Motivated to engage with digital services (five items) 6. Access to digital services that work (six items)
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