239 7 Dutch version of the eHealth Literacy Questionnaire source and impact of these intricacies and make well-substantiated amendments to eight items. In addition we formulated several recommendations to support the use, administration and interpretation of the eHLQ (see Table 6). Our approach can be considered an amalgamation of an ideographic approach (i.e., the participant is considered a unique individual with a unique life history) and a nomothetic approach (i.e., the participant is an exemplar of a population with corresponding traits). From an ideographical perspective, the qualitative component of cognitive interviewing is used to understand how items are interpreted by an individual and how this is affected by previous experiences in medical and psychosocial domains (e.g., previous positive experience in using eHealth, previous diagnosis, healthcare use, etc.). From a nomothetic perspective, items scores and latent factor structures are a result of subjects being an exemplar of a given population with (assumed) corresponding personal traits and behaviours and whose behaviour can at least partially be explained following certain rules. This strong nomothetic approach forms the foundation of psychometric evaluation, with use of standardized methods and statistical analysis as the basis. As such, our combined approach allows us to understand in more depth how items are interpreted by individuals, and to combine this information with generalized findings from the CFA to inform the final instrument. Hence, this mixed-method approach creates a conjunction between ideographic and nomothetic perspectives in instrument design and underlines the importance of considering both approaches in the understanding of complex constructs such as eHealth literacy. An important strength of our research is that we followed a systematic, uniform translation approach and aligned our validity assessment with initial validation studies. This uniform process facilitated international comparison and helped to understand whether a validity issue has arisen during the translation process or can be considered an item characteristic and deemed acceptable. We undertook several steps to ensure validity during the translation and cultural adaption process. First, the translation process followed a rigorous translation procedure including forward and backward translations. Second, we used the Translation Integrity Protocol developed by the developers of the original instrument, using detailed specification of item intents and consensus meeting with the consensus team and developers. With this we ensured that the items in the Dutch version captured the same meaning and difficulty level compared to the original questionnaire and the subsequent translations into twenty other languages. Third, we carefully documented all steps of the process, and ensured that both the developers and people with clinical, research and linguistic expertise were engaged in the translation process. Fourth, we analysed the cognitive interviews following an analysis framework and discussed results with the consensus team. Limitations and strengths A drawback of our study is that the study sample from study 2 is drawn from an existing study population. Although using an existing sample is a cost-effective sampling method and has resulted in a large sample to draw conclusions, using an existing sample has some limitations. First of all, the single administration of the eHLQ did not allow for a test-retest comparison to provide further evidence on the stability
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