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Chapter 5 RESEARCH CONTEXTS VERSUS REAL LIFE CLINICAL PRACTICE SETTINGS Research may show benefits of using PROMs in clinical practice \[38,39\], but these results do not necessarily apply to all ‘real life clinical settings’, since people with low health literacy are generally overrepresented in patient populations but underrepresented in research populations \[35\]. Especially in research that involves the use of questionnaires, participants with insufficient reading and writing skills (which in the Netherlands is one in six persons of 16 years and older \[43\]) are either excluded intentionally by researchers or unintentionally as a result of low literacy patients choosing not to participate because they do not want to put themselves in such a demanding situation \[35\]. A systematic review of Valderas et al. \[44\] showed that clinicians are more dependent on the usability of questionnaires than researchers are, because researchers exclude participants who are not up to the task and they have the time and the means to create the optimal circumstances for participants to correctly complete the questionnaire(s) of interest. In addition, researchers have the time and the means to select the most appropriate questionnaires to meet their measurement goals and to deepen their knowledge of the questionnaires they use, which enables them to interpret the outcomes correctly and use them in a justifiable way to guide diagnostic and treatment decisions, treatment planning and/or treatment evaluation \[44\]. This is all much more difficult for clinical therapists who have very limited time and means to get all of this done within the complex and demanding context of clinical practice \[45\], in which an ever-growing amount of questionnaires are available for their use \[46\]. Results of research exploring the perspectives of patients on patient burden and added value of the use of PROMs in clinical practice are not all that positive \[28-31\], especially for patients with low health literacy \[27\]. Clinicians are less eager to incorporate the use of PROMs in their practice than researchers and policy makers are \[44\]. In fact, in a qualitative study on the use and usefulness of the most-used PROM in Dutch physical therapy practice, all participating physical therapists admitted that their main reason for using this PROM was to meet external obligations from health insurance companies and quality audits \[42\]. The results presented in Chapter 2 and 4 of this current PhD thesis give some insight into why patients and clinicians lack enthusiasm when it comes to the use of PROMs in clinical practice. In Chapter 2, it is shown how difficult it is for patients 194