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has no back function in order to keep users from ‘getting lost’ in the questionnaire and having to decide on a ‘completion-strategy’. This may have had a positive effect on the experience participants had with completing the Dutch version of the TTSQ compared with the experiences participants had with completing the paper-based PSC [1]. A few participants of the study, with both adequate and inadequate health literacy, described in Chapter 2 of this thesis, expressed negative feelings towards the use of questionnaires in a health care setting after they had completed the paper-and-pencil-based PSC [1]. These results confirmed the negative feelings of patients towards the use of questionnaires which were described earlier in the literature [27-31]. Yet none of the participants in the evaluation studies of the Dutch version of the TTSQ described in Chapter 4.1 and 4.2 were negative about the use of questionnaires in a health care setting. In fact, a few participants in these studies expressed that they normally did not like to be asked to complete questionnaires, but they did not mind completing this one. They could even think of positive effects which the use of this questionnaire could have on the quality of physical therapy.
The low literacy designers of the TTSQ talked about people with low literacy being insecure, having low self-esteem, being ashamed about and trying to hide their low literacy. This corresponds with what had already been described in the literature about the effects low literacy can have on people [32,33]. To the best of the knowledge of the researchers of the current research project though, no earlier studies have revealed the specific problems patients with low literacy experience with regard to completing health-related questionnaires. The problems low literacy people face cause them to be hard-to-reach as participants in research [34,35], especially when questionnaires are involved. This may be an explanation for the low percentage of low (health) literacy people being included in the evaluation studies of both the Dutch version of the PSC, described in Chapter 2, and the Dutch version of the TTSQ, described in Chapter 4.1 and 4.2, in comparison with the percentage of people with low (health) literacy in the Dutch population [36]. Despite all efforts the researchers put into developing recruitment strategies and choosing methodology in a way that would accommodate people with low (health) literacy, not many such people were reached. A lot of insight that was gained during the current research project in perspectives of low literacy people on the use of questionnaires, came from the information the ten designers
General discussion
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