271 General discussion 9 skills (6, 7). However, it is essential to acknowledge that in this digital era patient empowerment must be accompanied by adequate health and eHealth literacy to enable individuals to make well-informed decisions (6). Patients who possess a high degree of empowerment but lack adequate health or eHealth literacy may make risky health choices, leading to adverse outcomes and increased healthcare costs (8). For instance, a patient with asthma monitoring their lung function using a peak flow meter to self-monitor might decide to use their reliever medication when their peak flow values are low. While this decision reflects patient empowerment, the patient may lack understanding of the distinction between a reliever and a maintenance inhaler, potentially causing harm in the long run (8). We integrated empowerment principles in the design of the persuasive game ‘Ademgenoot’ to support people with asthma in their medication adherence, alongside patient education on the difference between maintenance and reliever inhaler (chapter 2). We applied personal goal attainment in combination with a behaviour feedback mechanism to motivate patients to adhere to their maintenance inhaler and thereby empower them in doing so. In chapter 3 we focused on people with asthma and limited health literacy, to improve their understanding and organization of medication intake by visualizing the medication’s effects on the body and the relationship between usage and symptoms. Hence, eHealth interventions should incorporate principles of empowerment, but at that same time be mindful of differences in health and eHealth literacy that enable people to make well-informed and reasoned choices. In chapter 7, we adapted a widely used instrument for measuring eHealth literacy to the Dutch context, providing a valuable tool for understanding users’ eHealth literacy needs in the design, development, and evaluation of eHealth solutions (Challenge one, General introduction). Also in our design research for people with asthma and limited health literacy (chapter 3), we were mindful of their eHealth literacy needs, as people with limited health literacy generally have little experience with digital health technologies and services (9). We carefully addressed their eHealth literacy needs through coconstructing stories, experience prototyping, and utilizing simplified visuals and illustrations to explain complex physiological processes in the final prototype of the app. In summary, while patient empowerment and the use of eHealth to support selfmanagement have the potential to improve health outcomes and reduce healthcare costs, it is crucial to be mindful of individuals’ health and eHealth literacy needs. Tools like the eHLQ can help identify eHealth literacy needs and provide tailored support to individuals with limited eHealth literacy. This support can include training and education to enhance eHealth literacy, assistance from healthcare professionals in effectively utilizing eHealth resources, technology-enabled learning experiences (e.g., an interactive game used to teach people to navigate a patient portal) and involving individuals with limited eHealth literacy in the development of eHealth solutions.
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