225 7 Dutch version of the eHealth Literacy Questionnaire had difficulties responding to these items and with understanding the items within their references and knowledge on digital health technologies. Some participants also had difficulties responding to three items from domain 7 on ‘digital services that suit individual needs’ (items 28,31 and 34) as they found it difficult to envision how technology services can adapt to someone’s skills. Only two respondents, who were professionally involved in eHealth, responded with thinking of ‘self-learning machines’ and ‘artificial intelligence’, thereby voicing the items’ intent most closely. The dissonance with local worldviews can point to differences in how items of the eHLQ are interpreted across subgroups. Differences were mainly observed based on having a current diagnosis, previous eHealth experience and educational level. Besides the above-mentioned issues, we noted that all respondents remarked on similarity of items 19 and 20, and items 22 and 30. Although there were no intent or content problems (i.e., respondents noted the nuance differences), some respondents noted that having very similar items could cause irritation and advised to include a remark on having similar items in the instructions. Study 2 – quantitative study Study 2 was performed to perform psychometric evaluation and assess internal structure of the pre-final eHLQ. The pre-final eHLQ was administered among the 1650 people participating in the FitKnip study. The size of the sample was conform the sample size requirements for factor analysis and deemed sufficient (62). Method Study 2 Participants The eHLQ was administered online among participants of the FitKnip study, as part of its baseline measurements. The FitKnip study evaluated the use of a digital health budget as an innovative way to improve population health. Participants received a digital health budget of 100 euro to purchase preselected mobile or web applications offered on the online FitKnip library. People were recruited via municipality teams and various institutions, including healthcare insurance companies, an organization for vital and healthy neighbourhoods, and patient organizations. People had to be 18 years or older, able to understand, read, and speak the Dutch language and have access to the internet, but no other in- or exclusion criteria were applied. Data collection The eHLQ was included in a battery of six questionnaires on mental and physical health, general wellbeing and health awareness, and administered online among the FitKnip participants. Participants provided digital informed consent for the entire study prior to completing the questionnaire. The questionnaire battery was sent to 2562 participants and returned by 1650 respondents within 1 month (response rate 64%). There was no missing data among the 1650 returned eHLQ questionnaires. Participants received
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