Background: The internet and social media have become an important source for health information. In 2017, the State of Kuwait ranked first in mobile subscription penetration in the Arab world; nearly 90% of its population uses the internet. Electronic health (eHealth) literacy is important in populations that have easy and affordable access to internet resources to more effectively manage health conditions as well as improve general population health.
Objective: The aim of this study was to assess eHealth literacy levels across internet users in Kuwait and identify demographic characteristics that influence eHealth literacy. Furthermore, the study aimed to identify the reasons and type of information that people seek online. Finally, this study examined the utilization of various social media channels for accessing online health information. The social media platforms considered were as follows: WhatsApp, Twitter, Instagram, YouTube, Facebook, and Snapchat.
Methods: A cross-sectional anonymous Web-based survey was used to collect data about eHealth literacy and related information. The eHealth literacy scale (eHEALS), originally developed by Norman and Skinner, is measured using 8 Likert-type scales. A linear regression model estimates the effect of demographic variables such as age, gender, and education on eHealth literacy while controlling for participants’ perceived usefulness and importance of the internet. Participants were also surveyed about their frequency in using social media platforms for seeking health information.
Results: Kuwait’s composite eHEALS, based on a sample of 386 participants, was 28.63, which is very similar to eHEALS observed among adult populations in other developed countries. Females in Kuwait demonstrated a higher average eHEALS compared with males. Among the social media platforms, the survey results indicated that YouTube is the most frequently used to seek health information, with Facebook being the least frequently used.
Conclusions: Internet users in Kuwait appear confident in their ability to search for health-related information online compared with other populations, as indicated by aggregate eHEALS scores. Considering this finding, government and health care organizations should shift more efforts from traditional media toward online health information, focusing on the social media outlets that people in Kuwait find more useful for seeking health information.
Nearly 4.1 billion individuals have access to the internet worldwide . Among its many purposes, the internet has become a popular destination for individuals seeking information about health, diet, and lifestyle [ - ]. Accordingly, there has been an uptick in the propagation of electronic health (eHealth) apps that support health care delivery [ ], and the topic has received increased attention from health care institutions and health informatics researchers [ ].
Online Health Information as a Health Care Resource for Patients
Internet searches for health-related information online have been increasing exponentially, catalyzed by affordable access to the World Wide Web and the proliferation of mobile phones, including smartphones . However, despite this large supply of health-related information online, many individuals are not able to use this information to make informed health decisions [ ]. Seeking health information online requires eHealth literacy, which is defined as the ability to read, use computers, search for information, understand health information, and put it into context [ ]. A prerequisite for one’s health management is an adequate level of knowledge about how to manage his or her diseases, conditions, and lifestyle[ - ]. Therefore, eHealth literacy becomes important for patients to be in charge of their health. Norman and Skinner [ ] developed the eHealth Literacy Scale (eHEALS) to measure an individual’s skills in finding, evaluating, and applying online health information. This scale has since been widely adopted and tested in numerous contexts [ - ].
Combating Noncommunicable Diseases With Information
Noncommunicable diseases (NCDs), such as diabetes and hypertension, have a great toll on health care systems [, ]. Patients with NCDs must manage their conditions and adapt their lifestyles to gradually reduce the need for constant supervision of a health care professional [ ]. Online health information is especially valuable for patients living with NCDs, who must eventually transition to self-management of their condition by seeking health information independently [ ]. Providing patient-centered information resources to people with NCDs can save lives, improve quality of life, and ultimately reduce the burden on the health care system [ , ]. Therefore, it is essential that patients are able to independently identify, locate, process, and use the necessary information that can help them manage these diseases [ , ].
Examining Electronic Health Literacy in an Internet-Savvy and Disease-Prone Population
The accessibility and widespread use of the internet and social media in the Middle East region can be a cost-effective mechanism for delivering health information to masses and creating support communities . In this study, we consider the case of the State of Kuwait and the prevalence of eHealth literacy in Kuwait. This context is interesting because some of the population’s characteristics create great potential for eHealth literacy to augment traditional health care delivery channels. Kuwait is an oil-rich country with a high per capita gross domestic product and an affluent population that ranked first in mobile subscription penetration in the Arab world with nearly 90% of its population having access to the internet [ ].
The World Health Organization reports that 72% of all deaths in Kuwait are attributed to NCDs . The population in Kuwait struggles with numerous health issues such as high rates of obesity and other NCDs across most demographics such as diabetes (14.6% of the population), hypertension (15.7% of the population), and osteoarthritis (16%) [ ]. Recent research reports that almost 40% of Kuwaiti citizens had prediabetes or diabetes [ ].
The combination of internet, affluence, and high rate of NCDs provides a lucrative opportunity to empower patients and reduce health care system costs through the dissemination of online health information. For example, through the use of social media, patients, as well as their caregivers, can share personal information relevant to the disease, ask for help, and seek disease-specific emotional support [, ].
This study targets the internet users in Kuwait and aims to (1) assess eHealth literacy rates, (2) gauge perceptions about the utility and importance of the internet as a source of health information, (3) determine demographic characteristics (such as age, internet usage, gender, and education) that influence eHealth literacy rates, (4) identify reasons for seeking health information online, and (5) examine the frequency of using social media channels to seek health information.
This cross-sectional study  was initiated after obtaining the necessary ethical approvals from the Research Ethics Committee at Kuwait University, and it was conducted in full accordance with the World Medical Association Declaration of Helsinki. A convenience sampling approach was followed to recruit participants from the general population in Kuwait between September and October 2017 based on 3 inclusion criteria: respondents were aged 18 years or older, resided in Kuwait, and agreed to voluntarily participate in this anonymous study.
The Web-based, self-administered, voluntary, and anonymous questionnaire consisted of the following 5 parts:
First, it involved collecting demographic information including age, gender, education, and internet use.
Second, respondents were asked about the reasons for seeking online health information and the types of health information sought online. Under each of these categories, participants provided binary, yes or no, answers to choices related to that category.
Third, the 8 items of the eHEALS were included . Respondents rated their level of agreement with each of the 8 items on a scale of 1 to 5, with 1 being the lowest and 5 being the highest. Therefore, the theoretical range of the composite score is between 8 and 40. Furthermore, 2 supplemental eHEALS questions measuring perceived usefulness and importance of accessing health information online, used in similar studies [ ], were also included. These questions were also measured on a scale of 1 to 5.
Fourth, following previous studies, 2 additional questions related to the reasons for and types of information sought online were included [, ].
Finally, participants rated, on a scale of 1 to 5 (1=Never, 5=Always), their frequency in using social media platforms as a venue for seeking health information. Participants rated the following 6 social media platforms: WhatsApp, Twitter, YouTube, Snapchat, Instagram, and Facebook.
Bilingual faculty members in the Information Science and the Health Informatics disciplines translated the survey instrument from English to Arabic. Initially, the Information Science faculty member translated the survey from English to Arabic and then a Health Informatics faculty member checked this translation. A graduate student back-translated the survey from Arabic to English. The back-translated survey was checked for accuracy and clarity and approved by the researchers. Moreover, 10 individuals, who were colleagues of 1 of the researchers, were contacted to pilot the survey with the researcher face to face. In addition, 5 individuals tested the English version of the survey, and the other 5 individuals tested the translated Arabic version. Feedback from the pilot survey provided valuable insights to clarify concepts, questions, design, and the structure of the final survey instrument.
The survey was published online using LimeSurvey hosted on the researchers’ server. The online survey was made available in both the Arabic and English languages.
A broad combination of strategies similar to those used by other studies was used to identify the convenience sample . In addition to disseminating the survey to the researchers’ contacts and to capitalize on the heavy traffic around universities and shopping centers, open invitations to participate were circulated via printed posters at these locations. The posters were strategically displayed at the front entrance of 8 shopping centers distributed across Kuwait’s 6 governorates. The posters were also displayed on student boards across 11 colleges in Kuwait’s state university. The recruitment posters at universities allowed inviting a mixed group of students, faculty, and staff who were likely to use the internet given the nature of higher education. The recruitment posters at shopping centers allowed to expand the sampling pool to include a diverse set of the general population in Kuwait who regularly visit the cooperative store but may not currently attend a university or have graduated from a university.
The researchers also circulated electronic invitations through various mediums including emails, short message service (SMS) text messages, and social media. Initially, the researchers sent email invitations to their network of family, friends, and colleagues, inviting them to participate and help pass on the invitation to others. SMS text messages were sent via WhatsApp to an expanded network of the researchers’ contacts, especially as some potential participants may not use or check emails. To recruit participants via social media, the researchers mainly used Twitter to announce the study. The researchers approached major Twitter accounts followed by people in Kuwait to help voluntarily tweet or retweet about the study and how to participate.
The survey data were analyzed using the R software (version 3.5) developed by R Core Team . The eHEALS score was analyzed, and its distribution was examined. Ordinary least squares regression was utilized to assess how demographics and perceptions can influence the eHEALS. Factors of interest were collected via the survey to examine their correlation with eHEALS. Factors included in the analysis were age, gender, education, and internet usage. We controlled for the perceived usefulness and perceived importance of the internet because these 2 measures were significant correlates to the eHEALS.
P values for all statistical tests were reported, and we considered an alpha of .05 when reporting that a test statistic is significant. In other words, we consider statistical tests to be significant when they show a P value of less than .05.
Participant demographic information is shown in. In total, 615 people attempted the survey, and 386 fully completed it (completion rate of 62.7%, 386/615). Of the respondents, 63% (243/386) were females, and 37% (143/386) were males. Furthermore, 63% of participants (244/386) accessed the internet for 3 hours or more per day. Compared with the general population in Kuwait, more females participated in the survey than males. In terms of age, our sample was more skewed toward older participants compared with the general population in Kuwait.
Electronic Health Literacy
The eHealth literacy score, which was calculated as the composite of the 8 items, had a mean of 28.63, median of 29, and SD of 5.6. The dispersion of the observations appears normally distributed with a range between 8 and 40.
We ran a confirmatory factor analysis for a single factor model where all 8 items load onto 1-factor and a 3-factor model. The 3-factor model is based on recent studies that parse the eHEALS items into subgroups [, ]. The fit statistics of the 2 models are presented in . We found that the 3-factor model demonstrated a better fit based on the global fit indices. However, the correlations between the 3 factors were statistically significant, indicating that they are subscales to an overarching unidimensional structure.
|Demographic||Statistics, n (%)||Kuwait population, %a|
|Primary school or lower||8 (2.1)||—c|
|High school||69 (17.9)||—|
|Bachelor’s degree||185 (47.9)||—|
|Master\'s degree||48 (12.4)||—|
|Doctorate degree||33 (8.5)||—|
|Less than 1 hour per day||32 (8.3)||—|
|1-3 hours per day||110 (28.5)||—|
|3-5 hours per day||99 (25.6)||—|
|5+ hours per day||145 (37.6)||—|
aKuwait population statistics are from the Kuwait Central Bureau of Statistics estimate for January 1, 2018.
bRespondents in this group were either 18 or 19 years old.
cData not available.
|Goodness of fit statistics||1-Factor model||3-Factor model|
|Comparative fit index||.899||.931|
|Root mean square error of approximation||.142||.128|
|Standardized root mean square residual||.053||.045|
In response to the item How useful do you feel the internet (including social media) is in helping you in making decisions about your health?, 81% (312/386) of the participants considered the internet useful or very useful. In response to How important is it for you to be able to access health resources on the internet (including social media)?, 77% (296/386) of the participants expressed that it was important (or very important) to be able to access health resources on the internet.
The 2 items are correlated with one another with a correlation coefficient of .52. In addition, both perceived usefulness and perceived importance of the internet correlate highly with the eHealth literacy score, at .426 and .431, respectively.
Factors Related to Electronic Health Literacy
Demographic characteristics were considered when investigating the study’s third aim of determining any factors that contribute to eHealth literacy rates. The results of the regression model are presented in. The model was statistically significant, explaining 28% of the variance in eHEALS observations (F11,374=12.29, P<.001).
Age (as measured by year of birth) was not a significant predictor of eHEALS after controlling for other factors. With regard to gender, the model predicts that males have a lower eHEALS score than females (β=−.23, P<.05) after controlling for other factors.
In terms of education, individuals with a Doctorate degree are expected to have a higher eHEALS score compared with bachelor’s degree holders by an average of 3.5 points, controlling for all other factors. Finally, individuals who used the internet more than 5 hours a day on average are expected to have a higher eHEALS compared with individuals who used the internet an average of 1 to 3 hours daily.
Types and Reasons for Seeking Health Information Online
In addition to measuring the eHEALS score, the study aimed to identify the type of health information sought via the internet and social media, as well as the reasons that the participants sought them. The top health information sought online by participants included information about a disease or medical problem and medical treatment or procedure. The least common types were online support group and search for a particular physician or hospital (refer to).
In terms of reasons for seeking health information online, most participants cited reasons related to having a general curiosity about a topic (ie, to be more informed and just out of interest). On the other hand, the least common reasons for seeking health information online were limited time with health professional and disagree with health professional's opinion (refer to).
|Variablea||B (SE)||β||t (df)||P value|
|Intercept||25.93 (46.97)||−.17||−1.72 (374)||.087|
|Usefulness||2.06 (0.39)||.28||5.34 (374)||<.001|
|Importance||1.87 (0.36)||.28||5.18 (374)||<.001|
|Gender (Male=1, Female=0)||−1.29 (0.53)||−.23||−2.42 (374)||.016|
|Age||−0.01 (0.02)||−.02||−0.30 (374)||.766|
|Primary school||0.41 (1.78)||.07||0.23 (374)||.816|
|High school||0.73 (0.75)||.13||0.98 (374)||.329|
|Diploma||0.40 (0.84)||.07||0.47 (374)||.639|
|Master’s degree||1.24 (0.80)||.22||1.55 (374)||.122|
|Doctorate degree||3.52 (0.97)||.62||3.64 (374)||<.001|
|Less than 1 hour||0.25 (1.01)||.04||0.25 (374)||.801|
|3-5 hours||0.87 (0.70)||.15||1.24 (374)||.217|
|More than 5 hours||1.42 (0.67)||.25||2.13 (374)||.034|
aR2=0.28. F=12.29 on 12 and 374 degrees of freedom (P<.001).
bEducation variables are binary variables that compare with bachelor’s degree holders.
cInternet usage variables are binary variables that compare with the 1- to 3-hour usage group.
|Types of health information sought onlinea||n (%)b|
|A disease or medical problem||284 (73.6)|
|Medical treatment or procedure||237 (61.4)|
|Diet, nutrition, and vitamins||219 (52.3)|
|Sports and exercise||196 (50.8)|
|A particular physician or hospital||137 (35.5)|
|Online support groups||35 (9.1)|
aFor each item, participants were requested to answer yes or no.
bPercentages represent the proportion of participants (out of the 386) who answered yes.
|Reasons for seeking health information onlinea||n (%)b|
|To be more informed||224 (58.0)|
|Just out of interest||203 (47.2)|
|Help manage my own condition||182 (36.0)|
|Look for alternative or additional treatment options||146 (52.6)|
|Clarify information that has been given to me by a health professional||139 (31.6)|
|Check information discussed during a consultation with a health professional||122 (37.8)|
|Have information to read||107 (27.7)|
|Insufficient information from a health professional||79 (14.8)|
|Limited time with a health professional||57 (20.5)|
|Disagree with a health professional’s opinion||52 (13.5)|
aFor each item, participants were requested to answer yes or no.
bPercentages represent the proportion of participants (out of the 386) who answered yes.
Social Media Channels for Health Information
Participants indicated their frequency of using various social media platforms for seeking health information online.provides the means and SDs of participant responses, as well as the prevalence of these platforms among the general population in Kuwait. All these platforms demonstrate a relatively high level of market penetration in Kuwait led by WhatsApp and Facebook with 84% and 75% penetration, respectively [ ].
Participants generally conveyed that they Never or Rarely use these social media platforms for seeking health information. The exception was YouTube, where about 50% of the participants indicated that they use the platform Always or Sometimes compared with 28% who indicated Never or Rarely. Facebook was the least desirable social media platform for seeking health information, with 71% of the respondents indicating that they never use this platform for seeking health information. This was followed by Snapchat with 45% unfavorable opinions (Never or Rarely). Twitter was also not deemed a reliable source of health information. WhatsApp and Instagram showed a relatively uniform number of responses across the 1 to 5 scale.
|Social media platform||Mean (SD)a||Platform penetration in Kuwait, 2015, %b|
aThe mean is based on a 1 to 5 scale (1=Never, 5=Always).
bSource: Arab Social Media Report 
To date, a limited number of studies have investigated eHealth literacy in the Middle East . To our knowledge, no previous research has studied eHealth literacy rates in Kuwait, as well as the types of health information people seek and reasons why people seek health information online. The importance of eHealth literacy will continue to grow as more people gain access to the World Wide Web and as patients increasingly expect to be active consumers of health care services [ ].
When the eHEALS scale was first developed in 2006, it was initially validated as a unidimensional scale . This scale has since been measured and revalidated across many populations and demographics. More recent studies have shown that the 8 items reflect a 3-factor scale [ , ]. The 3 factor–scale measures awareness (2 items), skill (3 items), and evaluation (3 items). Nonetheless, researchers who have observed the multidimensional scale note a significant correlation among all 3 factors, which is indicative of an overarching unidimensional structure [ ].
Despite some evidence that several subscales preside within eHEALS, we follow Hyde’s  recommendation to analyze the eHEALS as a unidimensional factor. Therefore, our analysis considers the full eHEALS, which also allows us to compare our results with that of other studies. The reported eHEALS score in this study is similar to the eHEALS scores observed in other developed countries (see ). The majority of the participants indicated that the internet is a valuable source for health-related information.
Furthermore, 2 of the most important factors in predicting a participant’s eHealth literacy were the perceived importance of accessing health information through the internet and the perceived usefulness of the internet in guiding health-related decisions. This finding is consistent with previous studies and commonly associated with eHEALS .
The results revealed that females, on average, demonstrate higher eHEALS than males. After controlling for factors such as education, internet usage, and age, gender’s effect on eHEALS was statistically significant in our regression analysis (). In terms of using health services, previous studies observe that females visited physicians more often than males, consumed more diagnostic services, and had more hospitalizations even after excluding pregnancy-related visits [ , ]. When comparing differences in internet use, research has shown that the main drivers for internet usage among females were interpersonal communication and educational use, whereas entertainment and leisure were main drivers for males [ ]. An educational motive combined with higher consumption of health services provides some logic as to why females may demonstrate higher eHealth literacy over males.
Our results indicate limited perceived value from accessing health information through social media, as demonstrated by low reliance on social media platforms (with YouTube being a slight exception). This finding corroborates previous studies, which find that evidence related to the efficacy and effectiveness of social media is currently limited . Although the use of social media may have a promising future, there is a present need to engage and educate consumers about accessing health information via social media [ , ].
Many of the participants in this study indicated that they searched YouTube the most for health information but did not place high value on other social media platforms such as Twitter, Snapchat, and Facebook. In a classroom setting, online videos [are] by far the most common type of social media used…with 80% of faculty reporting some form of class use of online video . This in-classroom finding may be extended to a general context as well, making online videos an effective medium for consuming information. Alternatively, it may be the ease of searchability of YouTube, which is a content-centric platform as compared with the other user-centric platforms.
|Study (N)||Country||Yeara||Electronic Health Literacy Scale||SD||Group|
|Britt et al  (422)||United States||2017||31.92b||5.68||College students|
|Sudbury-Riley et al  (313)||United States||2017||30.48b||6.40||Baby boomers|
|Sudbury-Riley et al  (407)||United Kingdom||2017||29.28b||6.32||Baby boomers|
|Sudbury-Riley et al  (276)||New Zealand||2017||28.72b||6.72||Baby boomers|
|Richtering et al  (453)||Australia||2017||27.2||4.91||Moderate-to-high cardiovascular risk|
|Giudice et al  (868)||Italy||2016||28.20||6.20||Health-literate group versus general public|
|Chung et al  (500)||Korea||2016||28.08b||6.43||Young adults|
|Tubaishat et al  (541)||Jordan||2016||28.96b||4.64||Undergraduate nursing students|
|Tennant et al  (283)||United States||2015||29.05||5.75||Baby boomers|
|Lee et al  (400)||Australia||2015||29.50||4.30||Patients with chronic health conditions|
|Suri et al  (1,062)||Singapore||2015||23.44b||—c||College students|
|James et al  (881)||Florida, United States||2014||30.40||7.80||African American adults|
|Choi et al ; Study 1 (73)||Texas, United States||2013||28.24||6.08||Low-income adults, under 60 years|
|Choi et al ; Study 2 (218)||Texas, United States||2013||25.76b||6.80||Low-income adults over 60 years|
|Mitsutake et al  (2,115)||Japan||2012||23.40||6.40||General population|
|Ghaddar et al  (261)||Texas, United States||2012||30.60||5.90||High school students|
|Van der Vaart et al  Study 1 (189)||Netherlands||2011||28.20||5.90||Patients with rheumatic diseases|
|Van der Vaart et al  Study 2 (88)||Netherlands||2011||27.60||5.90||Stratified sample of the Dutch population|
|Mitsutake et al  (2,970)||Japan||2009||23.50||6.50||Japanese internet users|
aThis refers to the year the study was conducted and not necessarily the year it was published.
bThe indicated studies reported eHEALS as an average of the 8 items. To allow for a direct comparison with the other studies and our own (sum of the 8 items), we converted the average scale into a sum scale by multiplying the mean and SD by 8.
Facebook appears to have the least credibility as a source of health information even though it is the most widely recognized platform in Kuwait  and the most widely used platform for news [ ]. Furthermore, an explanation for this may be a general lack of reliability of information that spreads on that platform. In fact, the spreading of fake news and rumors on Facebook has become so widespread that the company has attempted to take direct action [ ]. Rumors and fake information that circulate via Twitter have also been criticized and researched in recent years [ , ]. This drives us to hypothesize that it is perhaps the perceived quality of information on a platform that drives preference for health information sources or perhaps it is the type of content; quality online videos generally take more effort to produce than news articles or blog posts and are, therefore, less likely to be authored by rumor peddlers. More research is needed to confirm or refute these observations.
In this study, most participants believed that online health information helped them make decisions about their health. This presents an opportunity for health care organizations, professionals, and government agencies providing health care services to play a more active role in monitoring, evaluating, and curating health information online . It can be useful to establish policies and guidelines that ensure the credibility and quality of information similar to the HealthOnNet or DISCERN certification efforts of online health-related resources [ - ].
Comparison With Other Electronic Health Literacy Scale Studies
In this study, we report a mean for eHEALS of 28.63 and an SD of 5.69. These findings are similar to other studies that evaluate eHEALS (refer to). Although our results are comparable with other countries, it is notable that studies conducted in some Asian countries such as Japan and Singapore report lower eHEALS scores. We acknowledge that it can be difficult to compare eHEALS because of the heterogeneity of the populations being studied. We hypothesize that the geographic location, cultural and language barriers could affect eHEALS [ ] because of the lesser availability of health-related information in languages other than English. This may not be the case for the State of Kuwait as English is a secondary official language and is taught at all levels of its educational system.
Several limitations of this study need to be considered. Given the lack of previous research about eHEALS in the region, we started with the survey approach. Although the eHEALS scale is widely used to assess eHealth literacy, we recognize this as a potential limitation as the scale only captures participants' perceptions and not their actual performance . In the future, more experimental studies are required to measure actual eHealth literacy performance and develop a more reliable self-assessment instrument. In addition, the results may have been influenced by the voluntary bias of the participants who were already interested in using the internet to search for information online. It may also be informative in future efforts to ask how often participants sought the health information for themselves versus for others such as a child or an elderly person.
Given our convenience sampling approach, we are not able to accurately report the survey response rates. However, this approach was useful because it provided us with a sizable sample in a reasonable amount of time. Another limitation of the study is that our sample may not accurately represent the population of Kuwait. Although our sampling approach allows for the collection of a large sample, it introduces the potential for sample selection bias. As shown in, the sample’s age distribution does not accurately reflect Kuwait’s population. Furthermore, university graduates are overrepresented in the sample. The 20- to 29-year old demographic and those with a university degree are also overrepresented in our sample, likely because 1 of the survey’s distribution channels was university colleges. Given that younger people are generally more tech-savvy and computer-literate, this sample bias may have inflated the eHEALS results. Therefore, we caution readers about the generalizability of the study and call for future research in the region to validate or update our study’s results.
This study reports on eHealth literacy rates among internet users in Kuwait, as well as their perceptions about the utility and importance of the internet as a source of health information. The findings reveal high eHEALS score among the participants, suggesting that many internet users in Kuwait are confident in their ability to search for health-related information online. This high confidence and the high frequency of accessing the internet reported by the participants presents a myriad of opportunities to better engage patients digitally and conveniently. Our exploration of social media platforms as outlets for eHealth may provide guidance about how to best reach the intended audiences and stimulate further research. YouTube appears to be the most effective platform for delivering health information. Health care organizations, professionals, and government agencies providing health care services need to play a more active role in monitoring, evaluating, and curating online health information. There is a need to establish policies and guidelines that ensure the credibility and quality of information.
The authors wish to acknowledge Dr Sana BuHamra for her support in reviewing the manuscript and verifying the results.
Conflicts of Interest
- Internet World Stats. 2018. Internet Usage Statistics URL: https://www.internetworldstats.com/stats.htm [accessed 2019-05-10] [WebCite Cache]
- Bidmon S, Terlutter R. Gender differences in searching for health information on the internet and the virtual patient-physician relationship in Germany: exploratory results on how men and women differ and why. J Med Internet Res 2015 Jun 22;17(6):e156 [FREE Full text] [CrossRef] [Medline]
- Reid P, Borycki EM. Emergence of a new consumer health informatics framework: introducing the healthcare organization. Stud Health Technol Inform 2011;164:353-357. [Medline]
- Lee C, Gray SW, Lewis N. Internet use leads cancer patients to be active health care consumers. Patient Educ Couns 2010 Dec;81(Suppl):S63-S69 [FREE Full text] [CrossRef] [Medline]
- Chesser A, Burke A, Reyes J, Rohrberg T. Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States. Inform Health Soc Care 2016;41(1):1-19. [CrossRef] [Medline]
- Alqudsi-ghabra T, Al-Bannai T, Al-Bahrani M. The Internet in the Arab Gulf Cooperation Council (AGCC): Vehicle of Change. Int J Internet Sci 2011;6(1):44-67 [FREE Full text]
- Ranallo PA, Kilbourne AM, Whatley AS, Pincus HA. Behavioral health information technology: from chaos to clarity. Health Aff (Millwood) 2016 Jun 1;35(6):1106-1113. [CrossRef] [Medline]
- Neter E, Brainin E. eHealth literacy: extending the digital divide to the realm of health information. J Med Internet Res 2012 Jan 27;14(1):e19 [FREE Full text] [CrossRef] [Medline]
- van der Vaart R, van Deursen AJ, Drossaert CH, Taal E, van Dijk JA, van de Laar MA. Does the eHealth Literacy Scale (eHEALS) measure what it intends to measure? Validation of a Dutch version of the eHEALS in two adult populations. J Med Internet Res 2011 Nov 9;13(4):e86 [FREE Full text] [CrossRef] [Medline]
- Bo A, Friis K, Osborne RH, Maindal HT. National indicators of health literacy: ability to understand health information and to engage actively with healthcare providers - a population-based survey among Danish adults. BMC Public Health 2014 Oct 22;14:1095 [FREE Full text] [CrossRef] [Medline]
- Watkins I, Xie B. eHealth literacy interventions for older adults: a systematic review of the literature. J Med Internet Res 2014 Nov 10;16(11):e225 [FREE Full text] [CrossRef] [Medline]
- Richtering SS, Morris R, Soh S, Barker A, Bampi F, Neubeck L, et al. Examination of an eHealth literacy scale and a health literacy scale in a population with moderate to high cardiovascular risk: Rasch analyses. PLoS One 2017;12(4):e0175372 [FREE Full text] [CrossRef] [Medline]
- Norman CD, Skinner HA. eHEALS: the eHealth Literacy Scale. J Med Internet Res 2006 Nov 14;8(4):e27 [FREE Full text] [CrossRef] [Medline]
- Schulz PJ, Nakamoto K. Health literacy and patient empowerment in health communication: the importance of separating conjoined twins. Patient Educ Couns 2013 Jan;90(1):4-11. [CrossRef] [Medline]
- Lee K, Hoti K, Hughes JD, Emmerton LM. Consumer Use of. J Med Internet Res 2015 Dec 29;17(12):e288 [FREE Full text] [CrossRef] [Medline]
- Sudbury-Riley L, FitzPatrick M, Schulz PJ. Exploring the measurement properties of the eHealth literacy scale (eHEALS) among baby boomers: a multinational test of measurement invariance. J Med Internet Res 2017 Dec 27;19(2):e53 [FREE Full text] [CrossRef] [Medline]
- Tubaishat A, Habiballah L. eHealth literacy among undergraduate nursing students. Nurse Educ Today 2016 Jul;42:47-52. [CrossRef] [Medline]
- Mitsutake S, Shibata A, Ishii K, Oka K. Associations of eHealth literacy with health behavior among adult internet users. J Med Internet Res 2016 Dec 18;18(7):e192 [FREE Full text] [CrossRef] [Medline]
- Tennant B, Stellefson M, Dodd V, Chaney B, Chaney D, Paige S, et al. eHealth literacy and Web 2.0 health information seeking behaviors among baby boomers and older adults. J Med Internet Res 2015 Mar 17;17(3):e70 [FREE Full text] [CrossRef] [Medline]
- Suri VR, Majid S, Chang Y, Foo S. Assessing the influence of health literacy on health information behaviors: a multi-domain skills-based approach. Patient Educ Couns 2016 Dec;99(6):1038-1045. [CrossRef] [Medline]
- Choi NG, Dinitto DM. The digital divide among low-income homebound older adults: internet use patterns, eHealth literacy, and attitudes toward computer/internet use. J Med Internet Res 2013 May 2;15(5):e93 [FREE Full text] [CrossRef] [Medline]
- Ghaddar SF, Valerio MA, Garcia CM, Hansen L. Adolescent health literacy: the importance of credible sources for online health information. J Sch Health 2012 Jan;82(1):28-36. [CrossRef] [Medline]
- Mitsutake S, Shibata A, Ishii K, Oka K. Association of eHealth literacy with colorectal cancer knowledge and screening practice among internet users in Japan. J Med Internet Res 2012 Nov 13;14(6):e153 [FREE Full text] [CrossRef] [Medline]
- Chaker L, Falla A, van der Lee SJ, Muka T, Imo D, Jaspers L, et al. The global impact of non-communicable diseases on macro-economic productivity: a systematic review. Eur J Epidemiol 2015 May;30(5):357-395 [FREE Full text] [CrossRef] [Medline]
- Gostin LO. Non-communicable diseases: healthy living needs global governance. Nature 2014 Jul 10;511(7508):147-149. [Medline]
- Xiao Y. The. Chronic Dis Transl Med 2015 Sep;1(3):145-151 [FREE Full text] [CrossRef] [Medline]
- Zakaria N, AlFakhry O, Matbuli A, Alzahrani A, Arab NS, Madani A, et al. Development of Saudi e-health literacy scale for chronic diseases in Saudi Arabia: using integrated health literacy dimensions. Int J Qual Health Care 2018 May 1;30(4):321-328. [CrossRef] [Medline]
- Hussein SH, Almajran A, Albatineh AN. Prevalence of health literacy and its correlates among patients with type II diabetes in Kuwait: a population based study. Diabetes Res Clin Pract 2018 Jul;141:118-125. [CrossRef] [Medline]
- Ahn S, Basu R, Smith ML, Jiang L, Lorig K, Whitelaw N, et al. The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health 2013 Dec 6;13:1141 [FREE Full text] [CrossRef] [Medline]
- Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011 Jul 19;155(2):97-107. [CrossRef] [Medline]
- Alanzi T. Role of social media in diabetes management in the Middle East region: systematic review. J Med Internet Res 2018 Dec 13;20(2):e58 [FREE Full text] [CrossRef] [Medline]
- Salem F. The Arab World Online 2017: Digital Transformations and Societal Trends in the Age of the 4th Industrial Revolution (Vol. 3). Dubai: MBR School of Government; 2017.
- World Health Organization. Noncommunicable Diseases (NCD) Country Profiles 2018, Kuwait. Geneva, Switzerland; 2018.
- World Health Survey in Kuwait: Summary Report 2013. Sulaibikhat, Kuwait: Ministry of Health, Kuwait; 2015.
- Alkandari A, Longenecker JC, Barengo NC, Alkhatib A, Weiderpass E, Al-Wotayan R, et al. The prevalence of pre-diabetes and diabetes in the Kuwaiti adult population in 2014. Diabetes Res Clin Pract 2018 Oct;144:213-223. [CrossRef] [Medline]
- Patel R, Chang T, Greysen SR, Chopra V. Social media use in chronic disease: a systematic review and novel taxonomy. Am J Med 2015 Dec;128(12):1335-1350. [CrossRef] [Medline]
- AlQarni ZA, Yunus F, Househ MS. Health information sharing on Facebook: an exploratory study on diabetes mellitus. J Infect Public Health 2016;9(6):708-712 [FREE Full text] [CrossRef] [Medline]
- Levin KA. Study design III: cross-sectional studies. Evid Based Dent 2006;7(1):24-25. [CrossRef] [Medline]
- Chung S, Park BK, Nahm E. The Korean eHealth Literacy Scale (K-eHEALS): reliability and validity testing in younger adults recruited online. J Med Internet Res 2018 Dec 20;20(4):e138 [FREE Full text] [CrossRef] [Medline]
- Jamal A, Khan SA, AlHumud A, Al-Duhyyim A, Alrashed M, Bin Shabr F, et al. Association of online health information–seeking behavior and self-care activities among type 2 diabetic patients in Saudi Arabia. J Med Internet Res 2015 Aug 12;17(8):e196 [FREE Full text] [CrossRef] [Medline]
- James DC, Harville C. eHealth literacy, online help-seeking behavior, and willingness to participate in mHealth chronic disease research among African Americans, Florida, 2014–2015. Prev Chronic Dis 2016 Dec 17;13:E156 [FREE Full text] [CrossRef] [Medline]
- R Core Team. The R Project for Statistical Computing. URL: https://www.r-project.org/ [accessed 2019-05-13] [WebCite Cache]
- Hyde LL, Boyes AW, Evans T, Mackenzie LJ, Sanson-Fisher R. Three-factor structure of the ehealth literacy scale among magnetic resonance imaging and computed tomography outpatients: a confirmatory factor analysis. JMIR Hum Factors 2018 Feb 19;5(1):e6 [FREE Full text] [CrossRef] [Medline]
- Stellefson M, Paige SR, Tennant B, Alber JM, Chaney BH, Chaney D, et al. Reliability and validity of the telephone-based eHealth literacy scale among older adults: cross-sectional survey. J Med Internet Res 2017 Dec 26;19(10):e362 [FREE Full text] [CrossRef] [Medline]
- TNS. Arab Social Media Report. Dubai, UAE: Arab Social Media Influencers Summit; 2015:1-64.
- Britt RK, Collins WB, Wilson K, Linnemeier G, Englebert AM. eHealth literacy and health behaviors affecting modern college students: a pilot study of issues identified by the American College Health Association. J Med Internet Res 2017 Dec 19;19(12):e392 [FREE Full text] [CrossRef] [Medline]
- Richtering SS, Hyun K, Neubeck L, Coorey G, Chalmers J, Usherwood T, et al. eHealth literacy: predictors in a population with moderate-to-high cardiovascular risk. JMIR Hum Factors 2017 Jan 27;4(1):e4 [FREE Full text] [CrossRef] [Medline]
- Del Giudice P, Bravo G, Poletto M, De Odorico A, Conte A, Brunelli L, et al. Correlation between eHealth literacy and health literacy using the eHealth literacy scale and real-life experiences in the health sector as a proxy measure of functional health literacy: cross-sectional web-based survey. J Med Internet Res 2018 Oct 31;20(10):e281 [FREE Full text] [CrossRef] [Medline]
- Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract 2000 Feb;49(2):147-152. [Medline]
- Rosenstock IM. Why people use health services. Milbank Mem Fund Q 1966 Jul;44(3):Suppl:94-Suppl127. [Medline]
- Weiser EB. Gender differences in internet use patterns and internet application preferences: a two-sample comparison. Cyberpsychol Behav 2000 Apr;3(2):167-178. [CrossRef]
- Househ M, Borycki E, Kushniruk A. Empowering patients through social media: the benefits and challenges. Health Informatics J 2014 Mar;20(1):50-58. [CrossRef] [Medline]
- Lupton D. Health promotion in the digital era: a critical commentary. Health Promot Int 2015 Mar;30(1):174-183. [CrossRef] [Medline]
- Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res 2013 Apr 23;15(4):e85 [FREE Full text] [CrossRef] [Medline]
- Moran M, Seaman J, Tinti-Kane H. ERIC - Education Resources Information Center. 2011. Teaching, Learning, and Sharing: How Today's Higher Education Faculty Use Social Media Internet URL: https://eric.ed.gov/?id=ED535130 [accessed 2019-01-02] [WebCite Cache]
- Moon A. Reuters. 2017 Sep 08. Two-thirds of American adults get news from social media: survey Internet URL: https://www.reuters.com/article/us-usa-internet-socialmedia/two-thirds-of-american-adults-get-news-from-social-media-survey-idUSKCN1BJ2A8 [accessed 2019-05-10] [WebCite Cache]
- Wingfield N, Isaac M, Benner K. The New York Times. 2016 Nov 14. Google and Facebook Take Aim at Fake News Sites URL: https://www.nytimes.com/2016/11/15/technology/google-will-ban-websites-that-host-fake-news-from-using-its-ad-service.html [WebCite Cache]
- Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science 2018 Dec 9;359(6380):1146-1151. [CrossRef] [Medline]
- Oh O, Agrawal M, Rao H. Community intelligence and social media services: a rumor theoretic analysis of tweets during social crises. MIS Q 2013;37(2):407-426 [FREE Full text]
- Bianco A, Zucco R, Nobile CG, Pileggi C, Pavia M. Parents seeking health-related information on the internet: cross-sectional study. J Med Internet Res 2013 Sep 18;15(9):e204 [FREE Full text] [CrossRef] [Medline]
- Boyer C, Dolamic L. Automated detection of HONcode website conformity compared to manual detection: an evaluation. J Med Internet Res 2015 Jun 2;17(6):e135 [FREE Full text] [CrossRef] [Medline]
- Charnock D, Shepperd S, Needham G, Gann R. DISCERN: an instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999 Feb;53(2):105-111 [FREE Full text] [CrossRef] [Medline]
- Khazaal Y, Chatton A, Zullino D, Khan R. HON label and DISCERN as content quality indicators of health-related websites. Psychiatr Q 2012 Mar;83(1):15-27. [CrossRef] [Medline]
- Schyve PM. Language differences as a barrier to quality and safety in health care: the Joint Commission perspective. J Gen Intern Med 2007 Nov;22(Suppl 2):360-361 [FREE Full text] [CrossRef] [Medline]
|eHEALS: Electronic Health Literacy Scale|
|eHealth: electronic health|
|NCDs: noncommunicable diseases|
|SMS: short message service|
Edited by G Eysenbach; submitted 30.05.18; peer-reviewed by M Stellefson, K Schroeder, JR Bautista, C Bakker; comments to author 30.09.18; revised version received 14.01.19; accepted 10.04.19; published 24.05.19Copyright
©Dari Alhuwail, Yousef Abdulsalam. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.05.2019.
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