235 7 Dutch version of the eHealth Literacy Questionnaire Data triangulation study 1 and study 2 and final revision Evidence from both studies and all sources was collected, combined and triangulated. Table 5 presents a summary of the evidence collected for the three sources of validity evidence (i.e., test content, response process and internal structure). Overall, no large response process problems were found, the items were interpreted as intended, and the internal structure was equivalent to the original eHLQ with acceptable to good model fit indices. The items which were flagged based on the cognitive interviews were compared with the results from the CFA and invariance testing and discussed during a final consensus meeting. Closer examination of the items contributing to non-invariance among the subgroups for current diagnosis showed that item 11 (’I often use technology to understand health problems’) had the largest contribution. Two other items were identified as ‘problem resonance worldview’ based on the cognitive interviews, indicating that people with a diagnosis probably interpret the item as referring to their own health, whereas those without a diagnosis probably interpret the item as referring to ‘health in general’. As such, interpretation of these items may depend on presence of a current diagnosis or not. Likewise, the items contributing to non-invariance between the age subgroup could be differently interpreted based on healthcare use as the older group probably had more healthcare use experience overall. Closer examination of the non-invariance among the subgroups showed that four of the five items load to domain 4 ‘feel safe and in control’. While no problems were encountered in the cognitive interviews, the observed partial invariance and inconsistency in scoring patterns could point towards a difference in interpretation. Eight items were amended following discussion of the findings and flagged items with the consensus team and developers. In addition, we formulated several recommendations for those using the eHLQ that can support the use, administration and interpretation of the eHLQ (see Table 6).
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