Electronic health resources are helpful only when people are able to use them, yet there remain few tools available to assess consumers’ capacity for engaging in eHealth. Over 40% of US and Canadian adults have low basic literacy levels, suggesting that eHealth resources are likely to be inaccessible to large segments of the population. Using information technology for health requires eHealth literacy—the ability to read, use computers, search for information, understand health information, and put it into context. The eHealth Literacy Scale (eHEALS) was designed (1) to assess consumers’ perceived skills at using information technology for health and (2) to aid in determining the fit between eHealth programs and consumers.
The eHEALS is an 8-item measure of eHealth literacy developed to measure consumers’ combined knowledge, comfort, and perceived skills at finding, evaluating, and applying electronic health information to health problems. The objective of the study was to psychometrically evaluate the properties of the eHEALS within a population context. A youth population was chosen as the focus for the initial development primarily because they have high levels of eHealth use and familiarity with information technology tools.
Data were collected at baseline, post-intervention, and 3- and 6-month follow-up using control group data as part of a single session, randomized intervention trial evaluating Web-based eHealth programs. Scale reliability was tested using item analysis for internal consistency (coefficient alpha) and test-retest reliability estimates. Principal components factor analysis was used to determine the theoretical fit of the measures with the data.
A total of 664 participants (370 boys; 294 girls) aged 13 to 21 (mean = 14.95; SD = 1.24) completed the eHEALS at four time points over 6 months. Item analysis was performed on the 8-item scale at baseline, producing a tight fitting scale with α = .88. Item-scale correlations ranged from
The eHEALS reliably and consistently captures the eHealth literacy concept in repeated administrations, showing promise as tool for assessing consumer comfort and skill in using information technology for health. Within a clinical environment, the eHEALS has the potential to serve as a means of identifying those who may or may not benefit from referrals to an eHealth intervention or resource. Further research needs to examine the applicability of the eHEALS to other populations and settings while exploring the relationship between eHealth literacy and health care outcomes.
How do we determine whether individuals have the capacity to engage with eHealth programs and interventions? Health practitioners, eHealth developers, and researchers alike need to know if electronic health tools are suitable methods for effectively promoting population health and aiding health care. An often unmentioned assumption underlying the deployment of eHealth resources intended for public consumption is that consumers have the skills to use such resources to their optimal level. Yet, with over 40% of US and Canadian adults having basic (or prose) literacy levels below what is considered necessary to optimally participate in civil society [
Informed decision making requires that people can adequately access, understand, and process health information to meet their needs. Access refers both to the literal ability to access information resources like health websites, but also the quality of this access. This includes the quality of the technology (eg, Internet connection speed, hardware, software) and the conditions of use, such as whether people have the privacy or time to properly engage eHealth resources. Access in the Internet age also requires an ability to derive meaning from text. As basic literacy skills rise, so does the ability to use computers effectively to solve problems, regardless of age, income, or education [
Given issues of access and literacy, health practitioners in clinical and public health settings require an understanding of what abilities their patients/clients have before recommending eHealth resources. This article describes the development and psychometric evaluation of a measure of eHealth literacy designed for broad use in supporting consumer eHealth in public health and clinical care.
Health literacy has been identified as a public health goal for the 21st century and a significant challenge facing health care globally [
eHealth literacy is comprised of six core skills, or literacies: (1) traditional literacy, (2) health literacy, (3) information literacy, (4) scientific literacy, (5) media literacy, and (6) computer literacy [
The eHealth Literacy Scale (eHEALS) has been developed to address the need to assess eHealth literacy for a wide range of populations and contexts. The eHEALS is a self-report tool that can be administered by a health professional and is based on an individual’s perception of her or his own skills and knowledge within each measured domain. The instrument is designed to provide a general estimate of consumer eHealth-related skills that can be used to inform clinical decision making and health promotion planning with individuals or specific populations.
It is not unreasonable to assume a link between eHealth literacy and technology use in general. The more an individual uses technology, the more likely they are to develop skills in using that technology as a tool. For that reason, youth can serve as an ideal group to test a measure of eHealth literacy given this population’s high familiarity with technology. In Canada, 99% of adolescents have access to the Internet, and the majority of Canadian teens report using the Internet for health in some capacity [
Regardless of the population of interest, the need to navigate the Internet with confidence is particularly important for health issues in which the consequences for using low quality, misleading, or false information are great [
A review of the literature was undertaken on each of the six key literacies that comprise Norman and Skinner’s eHealth literacy model [
A total of 89 youth (ages 14-24) completed the initial, larger version of the eHEALS as part of a pilot test and provided comments on the readability and item wording in focus groups immediately following completion of the instrument in paper form. The eHEALS was subsequently reviewed and modified to create the final battery of 8 items based on the qualitative and response feedback from participants, theoretical fit, and comprehensiveness. This study represents its first full psychometric assessment.
This study was conducted as part of another larger evaluation project looking at eHealth smoking prevention and behavior change using a randomized controlled trial. The study described here involved participants from one arm of this trial given that the other arm was intended to promote eHealth literacy, thus potentially confounding the results of the psychometric review. The study recruited 664 adolescents from 14 secondary schools in a large Canadian city. Students in grades 9, 10, and 11 were sampled from a variety of class types encompassing different subject areas (eg, physical education, computer science) and formats (eg, single sex and mixed sex classes). An attempt was made to involve a cross-section of schools in the study through active recruitment directly with school administrators and teachers. Schools were offered a modest stipend for their involvement, but no direct incentives were provided to individual students as the study was considered a part of classroom activities due to a fit with the curriculum. Ethical approval for the study was obtained from the ethical review boards or committees from the University of Toronto, Toronto Public Health (a project partner), and both of the participating school boards.
Age of the participants ranged from 13 to 21 (mean = 14.95; SD = 1.24), which included recent immigrants who may have been older than typical students in a particular grade. Sex was unevenly distributed within the sample due in part to the involvement of many single-sex classes involved in the study (boys N = 370; girls N = 294). The sample reflected the ethno-cultural diversity of the community, with the most commonly identified ethno-cultural groups being of Eastern European (N = 107, 16% of sample), East Asian (N = 103, 16% of sample), and Central Asian origin (N = 78), while 16% (N = 106) of participants did not identify with a particular cultural group. Ethno-cultural identity was determined using categories modified from Statistics Canada [
Participants reported being regular users of various forms of information technologies: 71% of participants (N = 468) reported using email at least once a week, with 37% (N = 544) using it daily; 79% (N = 522) reported using the Web each week, with 35% (N = 232) using it daily; and 71% (N = 473) of participants were regular (weekly) users of text messaging, with 42% (N = 280) reporting using it daily. Most participants reported that their primary access point for the Internet was at home (81%, N = 537); school (42%, N = 276) and friends’ homes (34%, N = 227) were identified as the most common secondary access points for the Internet.
The eHEALS was administered within a larger battery of measures as part of a combined randomized trial evaluation of an eHealth literacy promotion intervention and a Web-based smoking cessation program [
Internal consistency reliability was assessed using SPSS version 11.5[
The internal consistency reliability and factor analysis results are presented in
eHEALS scale reliability and factor analysis
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Q1: I know how to find helpful health resources on the Internet | .77 | .68 |
Q2: I know how to use the Internet to answer my health questions | .79 | .70 |
Q3: I know what health resources are available on the Internet | .77 | .68 |
Q4: I know where to find helpful health resources on the Internet | .84 | .76 |
Q5: I know how to use the health information I find on the Internet to help me | .81 | .73 |
Q6: I have the skills I need to evaluate the health resources I find on the Internet | .72 | .63 |
Q7: I can tell high quality from low quality health resources on the Internet | .65 | .55 |
Q8: I feel confident in using information from the Internet to make health decisions | .60 | .51 |
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Coefficient alpha = .88 |
eHealth literacy scale scores were calculated and test-retest reliability was assessed by Pearson product moment correlation between scores at each interval (time 1 to time 4) using a standard regression model (SPSS REGRESSION) and using the intra-class correlation coefficient (SPSS RELIABILITY ICC MODEL (MIXED)). eHealth literacy scale scores were modestly correlated between administrations of the eHEALS, ranging from
eHEALS test-retest reliability correlations
eHealth Literacy Score Time 1 | eHealth Literacy Score Time 2 | eHealth Literacy Score Time 3 | eHealth Literacy Score Time 4 | |
eHealth Literacy Score Time 1 | - | |||
eHealth Literacy Score Time 2 | .68 | - | ||
eHealth Literacy Score Time 3 | .46 | .49 | - | |
eHealth Literacy Score Time 4 | .40 | .40 | .52 | - |
Baseline levels of eHealth literacy were higher among males (
The eHEALS has shown promise as a measure of the concept of eHealth literacy as defined as a set of skills required to effectively engage information technology for health. The eHEALS’ high levels of internal consistency and modest test-retest reliability suggests that it has utility in examining eHealth literacy over time to both assess natural histories and evaluate eHealth literacy intervention outcomes. While tools exist that enable consumers to critically evaluate eHealth resources [
eHealth literacy promotion takes place within a larger learning context, thus it makes sense to develop partnerships with other groups working within other literacy sectors in validating the eHEALS in relation to other measures of literacy, social functioning, health, and well-being. Two examples of such multi-sectoral partnerships include the National Literacy and Health Program sponsored by the Canadian Public Health Association [
Conducting this study as part of a larger trial did pose problems for test-retest reliability; therefore, these results should be interpreted with caution. The lower than expected test-retest correlations between administrations of the eHEALS is attributed to a rise in eHealth literacy scores from baseline to post-intervention follow-ups, attributed to the smoking prevention intervention used in collecting the data [
Additional studies are required to longitudinally examine the eHEALS in study conditions that are not susceptible to influence of the characteristics of a specific intervention. Testing the eHEALS with a population that has high rates of information technology presents a limitation; however, it also provides an opportunity to understand the robustness of the measure within a specific population. Further research needs to consider the eHEALS’ application to other populations as well as groups with highly variable levels of technology familiarity.
The eHEALS measures consumers’
The need for skills in seeking, appraising, and applying lessons learned through use of eHealth resources is common across ages, genders, and cultural groups, and thus the potential applicability of the eHEALS as a standard assessment tool for gauging eHealth literacy in health care is high. Assessing consumers’ comfort in using eHealth allows for the identification of skill gaps and can better assist those with low comfort levels in taking advantage of the potential benefits that eHealth can afford. Doing so may foster development of tools that can meet these needs and aid in creating appropriate strategies for bridging the digital divide in consumer health care quality. Only by increasing the understanding of the disparities between available eHealth tools and consumers’ abilities to use them can the necessary steps towards eliminating them be taken.
The authors thank Oonagh Maley for her assistance in the planning and delivery of this study. This study was supported by research grants from the Canadian Institutes of Health Research, Ontario Ministry of Health, Health Canada, and the Ontario Tobacco Research Unit.
None declared.
eHealth Literacy Scale
eHealth Literacy Scale