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process resulted in a digital application on the original iPad 1 with a 9.7-inch screen. A tablet computer was found to be the most suitable device to meet the needs of low literacy people since it has the capabilities of a computer, but it does not look like one and operating it does not require reading or writing skills. Questions on pain location and pain intensity were added to the original questions of the PSC, because users were primarily interested in reporting their complaints, not their activity limitations. Visual (videos and photos) and auditory (speech technology) support was added to enable participants to see and hear the questions which were shown on separate screens. Response items could be selected by tapping on the touch screen and plain language was used in all spoken and written texts within the TTSQ. The results of this study showed that, apart from the more ‘technical’ support, it is important to take the social and psychological aspects of completing questionnaires into account in designing for people with low literacy. Based on the lessons learned, guidelines for designing interactive questionnaires for low literacy persons were given within Chapter 3.
The last objective was to test whether the newly-developed Dutch TTSQ generated accurate information on symptoms, limitations and treatment goals of patients with diverse levels of HL in a physical therapy context and to test and compare the usability of the Dutch TTSQ and its Turkish translation. The Three-Step-Test-Interview method of Hak and van der Veer, containing both think-aloud and probing techniques, was used to get insight into the way 24 Dutch and 11 Turkish physical therapy patients with varying levels of health literacy were able to operate the TTSQ and how their answers came about. In Chapter 4.1, the accurateness of the information gathered through the Dutch version of the TTSQ in a population of physical therapy patients with different levels of health literacy and a Dutch background were evaluated. The results of this study show that the use of plain language and information and communication technology (ICT) had a positive effect on the comprehensibility of the Dutch version of the TTSQ. However, it also had some negative effects on the other four aspects of the response process: interpretation, retrieval, judgment, and response selection. Due to the plain language used, some questions missed detail, which made them multi-interpretable. Multi-interpretation was also problematic in the use of pictures as answer options for limitations in daily activities. Furthermore,
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