219 7 Dutch version of the eHealth Literacy Questionnaire 7. Digital services that suit individual needs (four items) Each item is scored on a 4-point scale (strongly disagree, disagree, agree, strongly agree). The questionnaire was developed in Danish and English simultaneously “to support researchers, developers, designers, and governments to develop, implement, and evaluate effective digital health interventions” (35). As such, the eHLQ has been used to understand people’s interaction with eHealth devices (34, 36, 37), to evaluate the association between eHealth literacy and health outcomes (38) and to inform the adaptation of health technologies (39). The eHLQ has been shown to have strong construct validity, reliability, is easy to use (35, 40, 41) and is intended to be used by policy makers, eHealth developers and researchers. It can be used in a wide range of settings including community health or hospitals and was designed for selfadministration by pen and paper or by interview to ensure inclusion of persons with visual, reading or other difficulties. The questionnaire is supported by an instruction page including an explanation of terms used in the questionnaire. Validity assessment Use of a questionnaire in a novel linguistic setting requires translation, cultural adaption and validity assessment of the questionnaire, in order to determine that its properties have not been compromised and are equivalent to the original instrument (42). In the field of questionnaire validity testing, there is a growing acceptance of the view that the validity testing of self-reported instruments is as an accumulation and evaluation of different sources of validity evidence (43). As such, validation includes several supportive arguments on validity, rather than relying on factor analysis or regression analysis only (44, 45). The standards for Educational and Psychological Testing (in short, ‘the Standards’) are a set of guidelines which can be used to guide evaluation of validity evidence (46). The Standards, considered best practice in the field of psychometrics, proposes five sources of evidence: 1) test content; 2) response process (i.e., respondents’ cognitive processes when responding to the items, such as understanding the instructions, interpreting the items as intended); 3) internal structure (i.e., the extent to which the items conform to constructs and constructs are conceptually comparable across subgroups and with repeated administration); 4) relations to other variables, and 5) consequences of testing (i.e., the robustness of the proposed instrument use including intended benefits, indirect effect and unintended consequences). By using evidence on content, response and internal structure as a framework, we build upon previous validation studies of the original instrument and systematically use different sources of validity. We used this evidence to inform the development of a Dutch version of the eHLQ and assess its properties. Relations to other variables (4) and consequences of testing (5) remain beyond the scope of this study. Relevance and study aim In line with global developments, the Netherlands is transforming its healthcare system and investing in various forms of eHealth. Accelerated by the COVID-19 pandemic, eHealth is increasingly adopted and implemented across various disciplines in primary
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