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The eHealth Literacy Scale (eHEALS) has been widely adopted by researchers to understand how eHealth literacy can be put into context. eHealth researchers need to know how to promote positive health behavior changes across college students, given the importance of the Internet to acquire and use health information. The American College Health Association identified a set of key health issues that affect college students today. By understanding how eHEALS might be related to college students’ maintenance of their health and their use of online health resources, researchers will be provided with a better understanding of eHealth literacy and its pragmatic implications for health campaigns and future interventions.
The goal of the study was to examine what eHEALS reveals about college student health behaviors identified by the American College Health Association. To understand college student current health maintenance and their intentions to maintain their health and use online resources, the theory of planned behavior was used as the theoretical framework for the study.
Data were collected via a survey of 422 college students that included the eHEALS measure and questions about health issues based on the recommendations of the American College Health Association. These questions asked about college student current health, subsequent use of online health resources, and their intention to maintain their health and make use of such resources in the future.
eHEALS was positively and significantly associated with all 8 areas of health issues identified by the American College Health Association for college student current maintenance of health and use of online health resources and for future intention of health maintenance and use of online resources. Key issues that emerged with eHealth literacy were maintaining safe sex practices and seeking out related information, seeking out information on an exercise regime, information on vaccinations, and maintaining a balanced diet.
These results suggest several areas that may be targeted for future health campaigns toward college students. In addition, eHEALS was found to be a useful instrument for college students in the United States. Lastly, these results point to a need to deliver targeted information to college students, particularly since eHEALS captures literacy based on positively phrased items.
In recent years, Norman and Skinner [
Despite its accolades, eHEALS has only begun to be explored with college students, who are regularly exposed to propaganda and Internet media on health issues and face a number of health issues such as social pressures, maintaining a healthy diet, getting enough sleep, and living with stress from balancing classes, relationships, and work [
The objective of this study was to address eHEALS and its association with college student health behaviors based on past, current, and future behaviors [
TPB was developed by psychologist Icek Ajzen [
TPB has been used in various health contexts to explain an individual’s intent to engage in some future behavior, such as diet and fasting [
eHealth resources allow patients, providers, consumers, and caregivers to make better health-based decisions [
eHEALS is widely used today by researchers to measure eHealth literacy [
eHEALS is one of the earliest scale developments to address a need for eHealth literacy for a wide population. Current research has retested eHEALS, although scholars have stated that there is a continued need to do so [
With growing choices that students can make about their health today—such as getting vaccinated for the human papillomavirus, provided at some universities, or how to balance school and increasing work demands—there is little wonder that many turn to the Internet to seek out information [
eHEALS was used to seek out the relationship between the scale and behaviors across a range of health issues identified by the ACHA. Emerging research has explored eHEALS to examine college student beliefs and behaviors relevant to the health issues that tend to affect them the most [
The current executive summary from the ACHA reports that the 8 most common indexes for college student health include drug use, sleep, sexual health, getting vaccinations, proper diet, maintaining friendships, maintaining an exercise regime, and overall general maintenance of health [
Electronic health literacy focuses on individual capacity to use electronic resources appropriately and as such, we would expect individual patterns of health information-seeking to be related to their overall level of electronic health literacy. Therefore,
Finally, we expect that electronic health literacy will be related to intention to maintain a healthy regime as well as intention to seek out additional Internet resources in these areas. Therefore,
Following institutional review board approval, this study was conducted among a population of college students at a large midwestern university in the United States. An online survey was developed that included the eHEALS measurement [
Participants took a survey that was created to assess students’ use of the Internet to address health concerns or issues. A total of 420 participants participated in the study, ranging in ages from 18 to 35 (mean 20.48, SD 2.14) years, and the majority of participants were undergraduate students (mean 2.76, SD 1.15). Participants reported race/ethnicity of white (330/420, 78.6%), Asian/Pacific Islander (48/420, 11.4%), African American (15/420, 3.8%), Hispanic/Latino (14/420, 3.3%), other (11/420, 2.6%), and 4 missing values.
Participants first answered a series of demographic questions, followed by a question that asked whether or not they have a health condition that requires regular interaction with a physician. Participants were not asked to elaborate on this answer, and no participant chose to elaborate. The majority of participants (380/420, 90.6%) reported not having a major health condition, but 9.4% (39/420) did, with 3 missing values. To understand the level of past behavior, current behavior, and intent to participate in future behaviors, a series of questions were asked relating to each of the major dimensions of health items as identified by the ACHA [
In the online survey, items provided measures of intent, attitudes, subjective norms, perceived behavioral control, and eHEALS. To answer the hypotheses, correlations were used as these best answered the questions at hand [
Electronic health literacy was assessed through the 8-item eHEALS measure through the average of all items measured on a 5-point Likert-scale (mean 3.99, SD .71). The eHEALS items were designed to solicit self-report assessments of knowledge of or comfort in finding, evaluating, or using Internet-based health information resources (eg, “I have the skills I need to evaluate the health resources I find on the Internet” and “I feel confident in using the information from the Internet to make health decisions”). The scale evidenced high internal consistency (Cronbach alpha=.897).
Behavior was measured with a single item for each of the 8 health areas identified from the ACHA, for example: “I have maintained a balanced sleep schedule (approximately 7 to 8 hours per night) so far this semester.” The phrasing of the behavior items was taken directly from Ajzen’s [
Following typical recommendations for TPB research [
Descriptive statistics for self-reported past behavior for 8 areas of health issues.
Mean (SDa) | |
Overall health | 3.98 (0.786) |
Exercise regime (at least 2.5 hours per week) | 3.33 (1.29) |
Maintain lifestyle free of harmful substances | 3.32 (1.32) |
Sleep (approximately 7 to 8 hours per night) | 2.91 (1.20) |
Get necessary vaccinations | 3.68 (1.16) |
Maintain safe sex practices | 4.18 (0.917) |
Maintain balanced diet | 3.48 (1.00) |
Maintain positive social relationships | 4.41 (0.676) |
aSD: standard deviation.
Descriptive statistics for self-reported intention items for the 8 areas of health issues.
Mean (SDa) | |
Overall health | 3.30 (1.01) |
Exercise regime (at least 2.5 hours per week) | 3.96 (1.17) |
Maintain lifestyle free of harmful substances | 3.64 (0.109) |
Sleep (approximately 7 to 8 hours per night) | 3.28 (1.12) |
Get necessary vaccinations | 3.68 (1.12) |
Maintain safe sex practices | 3.90 (0.190) |
Maintain balanced diet | 4.08 (1.13) |
Maintain positive social relationships | 4.44 (0.234) |
aSD: standard deviation.
The first hypothesis predicted that electronic health literacy would be significantly correlated with an individual’s general health, exercise regime, sleep, getting vaccinations, and maintenance of sexual health, a balanced diet, stable friendships, and a lifestyle free of harmful substances. The results of the survey support this as shown in
Because our researchers come from a communication background in the behavioral sciences, correlation interpretation guidelines were based on the typical guidelines of Cohen [
In addressing the first hypothesis, eHEALS was positively and significantly correlated with all 8 areas of health identified by the ACHA. Most notably, self-report of an individual’s current maintenance of positive social relationships (
The second hypothesis predicted that eHEALS would be significantly related to college student current use of Internet health resources in the areas of general health, exercise regime, sleep, getting vaccinations, and maintenance of sexual health, a balanced diet, stable friendships, and a lifestyle free of harmful substances. Out of the 8 areas of health, 7 were significant at the
eHealth Literacy Scale correlated with current maintenance and current use of online health resources.
Current use of online health resources approached a moderate relationship for seeking out information in the following areas: a balanced diet (
Hypothesis 3 predicted that future intention to maintain health would be related to eHEALS. Maintaining positive social relationships (
Finally, the fourth hypothesis predicted that future intention to use online health resources would be significantly related to eHEALS. The strongest relationships were found in this area, with several variables approaching a moderate correlation. Among these, diet (
In this study, we sought out what eHEALS reveals about college student health behaviors, focusing on health issues recommended by the ACHA. With numerous online options available for information-seeking behaviors, it is important to intimately know the audience and the issues that can inform campaign design and evaluation [
We learned that maintaining a balanced diet remains an important issue for college students, particularly as campus food [
In particular, online health campaigns can be designed for specific college campuses that employ the use of technologies. For example, previous research has evaluated the design, usability, and acceptability of social media resources for chronic health conditions [
Next, it is important for researchers to use theory to help create online interventions for college students that use eHEALS in a theory-based context. For example, TPB allowed us to gain a better sense of student intentions to make use of online resources. Results that were consistent in all findings were maintenance of safe sex practices, diet, and positive social relationships. Internet campaigns have an opportunity to reach student populations, particularly as scholarship in JMIR has noted the need to support the effective use of technology for students [
This study had several limitations. First, recruitment occurred through a single university. In order for these results to be more generalizable, researchers at different institutions should examine eHEALS among college students; for instance, rurally located universities in medically underserved areas would benefit from similar studies. In addition, tailored interventions for different colleges require different expectations and carefully crafted messages and multimedia design use, especially since Internet-based campaigns may not be the best mechanism for all institutions. Lastly, it is important to note that in this study, participants were recruited through a liberal arts recruitment system. While participants came from a broad range of academic backgrounds, recruitment from different universities entirely would be helpful in better understanding eHealth literacy, critical health issues for college students, and addressing those in the best manner possible.
This study focused on the relationship between eHealth literacy and health issues that are crucial for many college students. Sexual health emerged as a primary concern, along with diet and maintaining vaccinations. This means that education about safe sex practices are key areas for researchers to target, and the use of online interventions can mitigate possible barriers and unintended effects of traditional face-to-face and mass media campaigns [
American College Health Association
eHealth Literacy Scale
theory of planned behavior
This publication was supported by the Regenstrief Center for Healthcare Engineering, Purdue University. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the university.
None declared.