The increasing amount of high-quality health information available on the Internet represents an important source of health information for health consumers. According to a recent survey by Pew Research Center,1 87% of American adults used the Internet, and 72% of Internet users looked online for health information within the past year. Other Pew Research Center studies report 75% of Internet users state their last health search significantly affected their health decisions,2 and 39% indicated the information they found changed their health-coping behaviors for chronic diseases.3
Concurrent with the emergence of consumer-directed eHealth resources, health consumers are increasingly responsible for accessing and evaluating electronic health information resources. Consumer engagement in health-related decision making has also increased in health service delivery.4 Because online health information can affect health consumers’ health decisions and health outcomes, it is important for them to possess eHealth literacy, defined as “the ability to seek, find, understand, appraise online health information, and apply the knowledge to make a health decision.”5
The Internet provides a portal for everyone to access available health knowledge, but disparities exist in consumers’ ability to parse the health information they read. The low level of eHealth literacy of some consumers makes it more difficult for them to retrieve and comprehend online health information. Moreover, the quality of online health information varies with some sources of health information being of very low quality.6 Hence, an ability to distinguish between high- and low-quality online health information sites is a critical skill for health consumers, in particular, those health consumers seeking specific, valid, and reliable high-quality online health information.5–7
Many health consumers report they have limited eHealth literacy skills to engage online health resources effectively.8,9 This means there is often a gap between the online health information available and consumers’ ability to find and use the information. Norman and Skinner5 argue that the mismatch between what online health information is provided and what health consumers are able to access should be determined and remedied. An understanding of the deficits in current consumers’ eHealth literacy skills is needed to enable heath care providers to effectively address and remedy skills gaps in the context of eHealth service delivery.10 To date, most of the literature on literacy and health has focused on health literacy in relation to paper-based resources, as opposed to literacy in electronic-based environments.5,11 Only a few studies have specifically assessed eHealth literacy, focusing on discrete populations such as college students,12 older adults,13 and parents of children with special healthcare needs.14 The purpose of this study was to assess the eHealth literacy skills of a general health consumer population so that healthcare professionals can effectively address skills gaps in health consumers’ ability to access and use high- quality online health information. The specific aims were (1) to assess participants’ eHealth literacy and (2) determine if there are relationships between eHealth literacy skills and individual characteristics of participants.
Sample, Recruitment, and Ethics
This descriptive study used convenience sampling to recruit participants. After receiving approval from the institutional review board at the researcher’s institution, permission was obtained from library directors in three public library branches in a Northeast Florida community. The researchers visited the public libraries weekly to recruit participants and collect data for 2 months. The purpose of the study was explained to participants before obtaining consent from those willing to fill out the questionnaires. A total of 111 questionnaires were returned at three public libraries; three were incomplete. The remaining 108 questionnaires were analyzed for this study. Participants included men and women older than 18 years, of all ethnic groups, with the ability to read and write English.
Questionnaire: eHealth Literacy Scale
Participants’ eHealth literacy was measured using the eHealth Literacy Scale (eHEALS).5 This eight-item self-report questionnaire focuses on knowledge and understanding of what health information is available on the Internet, where one can find helpful health resources, how to access this information, how to use the Internet to answer questions about health, skills to evaluate online health information, and ability to discern high- from low-quality health resources on the Internet. Each item is rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores of the eHEALS are summed to range from 8 to 40, with higher scores representing higher self-perceived eHealth literacy. A score of 24 or higher on the eHEALS denotes high eHealth literacy.15 An internal consistency reliability of Cronbach’s α = .89 to .97 with good test-retest reliability has previously been reported for this scale. In this study, two supplemental items recommended by the authors of eHEALS5 were included in order to assess perceived usefulness of the Internet for making health decisions (a five-point-Likert scale ranging from 1 = not useful at all to 5 = very useful) and perceived importance of being able to access health resources on the Internet (also a five-point Likert scale ranging from 1 = not important at all to 5 = very important).
Descriptive statistics were computed to summarize demographic characteristics, total score on the eHEALS, individual eHEALS scale items, and Internet usage and perceived usefulness/importance. In order to identify differences in eHealth literacy related to demographic characteristics (age, gender, race, educational level, marital status, income, employment status, health status, hours per day of Internet use, and years of Internet use), analysis of variance (ANOVA) methods were utilized in conjunction with pairwise comparison procedures where appropriate. Once it was determined which demographic variables yielded significant relationships with the overall eHealth literacy score, individual eHEALS items were compared with those demographic variables using the χ 2 test of independence (Pearson χ 2).
Participant demographic characteristics and associated eHealth literacy scores are presented in Table 1. Of the 108 library users who participated, 51.9% (n = 56) were female, and 48.1% (n = 52) were male. This is consistent with the gender distribution in Leon County, FL, of 93 males for every 100 females.16 More than half (n = 71 [65.7%]) of the respondents were older than 50 years, with the youngest age group (18-29 years) being the least represented (n = 4 [3.7%]). Approximately half were white (n = 56 [51.9%]); slightly more than one-third were black or African American (n = 40 [37.0%]). Approximately half of the participants (n = 53 [49.1%]) were married, with the remaining participants either single, never married (n = 28 [25.9%]), or divorced/widowed/separated (n = 27 [25.0%]). The majority had at least some college education (n = 25 [21%]), followed by a BA/BS (n = 18 [16.7%]) or master’s degree (n = 18 [16.7%]), a high school diploma or GED (n = 16 [14.8%]), and a doctorate (n = 13 [12.0%]). Reported annual household income was predominantly below the county median income of $44 824, with 34 (31.5%) and 33 respondents (30%) reporting less than $25 000 per year and between $25 000 and $50 000 per year, respectively. Of note, the percentage of participants who reported earning more than $50 000 per year was equal to the percentage with a bachelor’s degree or higher, 37.9% (n = 41). Almost half of the respondents (45.6%) reported that they were either not working (n = 23 [21.3%]) or retired (n = 26 [24.1%]); 40.7% (n = 44) reported that they were employed full time. The majority of participants reported their health status was very good (n = 46 [42.6%]).
eHealth Literacy Skills and Internet use
As shown in Table 1, mean eHealth literacy score for participants in this study was 29.27 (SD, 5.89). The sample mean was not statistically different from the eHEALS benchmark score of 24,15 but can be interpreted as slightly higher than average eHealth literacy. Most of the respondents reported that they knew what health-related resources were available on the Internet (n = 62 [57.4%]), where to find them (n = 75 [69.4%]), how to find helpful health resources (n = 81 [75%]), how to use the Internet to answer questions about health (n = 78 [72.3%]), and how to use the health information they find on the Internet to help themselves (n = 73 [77%]). However, whereas 69.5% (n = 75) indicated that they had the skills needed to evaluate health resources found on the Internet and 60% (n = 66) reported they felt confident in using this information to make health decisions, only 54.9% (n = 59) reported they could distinguish high-quality health resources from low-quality resources.
Table 2 summarizes the Internet usage of the participants and eHealth literacy scores. The majority reported they had been using the Internet for more than 10 years (n = 47 [43.5%]) and used it from 1 to 4 hours per day (n = 79 [73.1%]). With regard to health information, a large percentage indicated that accessing health resources on the Internet was important or very important (n = 85 [78.7%]) and useful or very useful in helping them to make decisions regarding their health (n = 84 [77.8%]).
Differences in Overall eHealth Literacy
In relation to demographic characteristics, eHealth literacy was significantly associated with gender (P = .01), employment status (P = .005), hours per day of Internet use (P < .001), and years of Internet use (P = .002). Women perceived they had higher levels of eHealth literacy than did men. Participants who were employed full time also reported higher eHealth literacy than all other groups, in particular, those who were not employed (P = .026). Participants who spend 3 to 4 hours per day on the Internet reported higher eHealth literacy than all other subgroups; eHealth literacy levels were lower for those who spend no time on the Internet relative to participants who spend 1 to 2 hours per day (P < .001), 3 to 4 hours per day (P < .001), or 5 to 10 hours per day on the Internet (P < .001). Although not statistically significant, it is worth noting that non–Internet users’ eHealth literacy scores were 7.5 (SD, 2.9) points lower than those who spend 11 or more hours per day on the Internet. The lack of statistical significance here is likely due to the small number of participants in the cohort who indicated they spent 11 or more hours on the Internet (n = 5).
When examining the pairwise differences among participants’ years of Internet usage, the assumption of constant variance across groups was violated. As a result, Dunnett T3 was used to test for pairwise comparisons on this variable. Although the differences were not statistically significant, on average, participants with no history of Internet usage had eHealth literacy scores that were between 6.7 and 8.7 points lower than did all other groups. The same violation in the assumption of constant variance across groups occurred when appraising the relationship between health status and eHealth literacy. Although the overall ANOVA P value was not significant, the researchers determined that examination of the pairwise comparisons using Dunnett T3 was justified because it accounts for the unequal variances across groups. Participants who perceived their health status as excellent demonstrated significantly higher eHealth literacy levels than did those who described their health status as poor (P = .024).
Relationship Between eHealth Literacy Scale Items and Demographic Variables
Only demographic variables that yielded a significant association with overall eHealth literacy were included in the analysis of individual eHEALS items using the χ 2 test. These included gender, employment status, health status, hours per day of Internet use, and years of Internet use. Knowledge of what health resources are available (P = .031) and where to find health resources on the Internet (P = .002) was positively associated with the hours per day spent on the Internet.
Knowledge of how to find helpful health resources on the Internet was significantly associated with gender (P = .049), employment status (P = .018), hours per day spent on the Internet (P = .001), and years of Internet use (P = .026). Participants who were female, were employed full time, had been using the Internet for longer than a year, and spent 1 to 2 hours or more per day on the Internet were most likely to report that they know how to find helpful health resources on the Internet.
Knowledge of how to use the Internet to answer questions about health was significantly associated with participant health status (P = .010), hours per day spent on the Internet (P < .001), and years of Internet use (P = .005). Similarly, knowledge of how to use the information they found on the Internet to help resolve a health issue was associated with the hours per day spent on the Internet (P = .001) and years of Internet use (P = .014) and confidence in the ability to evaluate health resources was significantly associated with health status (P = .017) and hours per day spent on the Internet (P = .047). Ability to discriminate high-quality from low-quality health resources on the Internet was also associated with employment status (P < .001) and confidence in using this information to make health decisions was associated with both employment status (P = .013) and health status (P = .004). As would be expected, participants who claimed they had fair or poor health status, were not employed, never spent time on the Internet, and had been using the Internet for less than 1 year were least likely to report that they know how to use the Internet to pursue queries about their health, evaluate the quality of Internet health information, and use that information to make important health decisions.
The present study assessed the perceived eHealth literacy of health consumers using the eHEALS. eHealth literacy scores of adult participants in this study were on average higher than those reported in previous studies.15,17,18 The participants’ high eHealth literacy is likely a function of population characteristics, the setting, and other factors that would require further study to fully understand. Consistent with the findings of other studies, the vast majority of participants perceived the Internet as a valuable resource in helping them make decisions about their health.12,17 eHealth literacy skills in relation to how to use the Internet and where and how to access health information were reportedly high, but knowledge of what health resources are available on the Internet was considerably less. This suggests that how to find health information and how to use Internet are related to Internet skills, whereas what health resources are available and where to find them are situated in specific knowledge about online health information Web sites. Even though many people have search skills, associated with computer literacy, they do not know what useful online health information exists and where they can find that information in a Web-based environment. For example, a Google search for “common cold” in February 2015 yielded 37 600 000 results.19 It can be difficult to sort through so much information. Pew Internet and American Life Project20 found that the amount of information provided on the Internet can be overwhelming to consumers. Many health information seekers are unable to decipher which Web sites are most useful and reliable for them.
A majority of participants in this study indicated they did not feel confident in their ability to differentiate between high- and low-quality health-related Web sites on the Internet. This self-perception suggests a potential limitation in health consumers’ ability to identify key criteria that could help them discern which health information Web sites on the Internet can be trusted. Previous studies of health literacy confirm that of those who have access to health information online in the US report that they have difficulty evaluating whether that information is credible.12,21,22 If health consumers are using the Internet to access health related information, health professionals have an obligation to raise their awareness and help them identify credible Web sites. Contents of the Web sites on health topics should be evaluated to determine whether they provide any misinformation. Professionals also should be involved in developing and promoting high-quality health information Web sites so that health consumers are able to access qualified online information to make health decisions.
In addition to not feeling confident about their ability to assess health resource quality, a majority of participants reported they did not feel confident using the information from the Internet to make health decisions. This uncertainty is consistent with findings of previous studies, in which participants scored the lowest on confidence in using information from the Internet to make health decisions.17,23 In keeping with Robb and Shellenbarger23 and Brown and Dickson,17 these findings suggest even though health consumers can retrieve online health information, they might not be secure enough about their knowledge to make good decisions about their health options.
In this study, eHealth literacy skills were significantly associated with gender, employment status, health status, hours per day of Internet use, and years of Internet use, whereas others, such as age, race, education level, marital status, and income level, were not. This is not surprising because eHealth literacy skills are connected to operational Internet usage skills, which co-occur with Internet use experience. Hargittai24 also reported people who have been Internet users for longer periods are presumed to be better at finding information online because they have more experience to draw on. Women in this study reported higher eHealth literacy than did men. Several researchers have noted that women are the primary health information seekers for their families, which may explain their drive and predisposition to seek health information on the Internet.17,25–27
The importance of employment status in this study in relation to eHealth literacy skills is not unexpected. It is likely that full-time employees have more opportunity to be exposed to or are required to have computer skills than others. Perceived health status was associated with eHealth literacy in the study sample. One might assume that if people perceive that they have excellent health they would be more likely to search for health information online to prevent illnesses and manage their health status, and as they gain experience searching for online information, their eHealth literacy would improve in kind. Neter and Brainin’s28 study, however, reported no significant difference between the high and low eHealth literacy groups in perceived health. It may be that those with excellent health may obtain their health information from other resources such as printed Internet pages, friends/family, and healthcare providers. Indeed, according to studies reported by Pew Research Center,29 70% of adults obtain their health information from healthcare professionals, 60% from friends and family, and 24% from others who have the same health condition.
Although a significant relationship between eHealth literacy and age was not identified in this study, other studies30,31 have reported higher eHealth literacy levels among younger health consumers. A likely explanation for the lack of significance in this study is that participants were on average 50 years or older, with only four participants younger than 29 years. Educational level in this study was not associated with eHealth literacy. This finding is consistent with other studies in which education was not a significant contributor to operational Internet skills and greater eHealth literacy.28,31 A recent study,30 however, reported that patients with rheumatoid arthritis with higher education and higher Internet skills followed through on assignments and managed their health condition better. Further consideration of this variable in future research is clearly warranted.
The analysis revealed several positive relationships between individual eHEALS items and demographic characteristics of participants. Being female was associated with better skills in accessing helpful health resources, and participants who were employed were more likely to report they could discern high- and low-quality information and use that health information. Several eHEALS items were associated with years of Internet use and hours of Internet use per day, but discriminating high- from low-quality information and confidence in using health information to manage health problems was not. These findings suggest the need for eHealth education and support to health consumers from healthcare professionals. Healthcare providers can recommend credible Web sites to patients and help them learn how to conduct effective searches and evaluate the quality of health information.
Several limitations of the study should be noted. First, consumers’ eHealth literacy was measured using a self-report measure. Perceived skills are not necessarily a reflection of actual skills. Second, the sample size was small and circumscribed, such that associations between age and perceived health status and eHealth literacy were difficult to detect.
A central goal of Healthy People 2020 is to decrease health disparities and to improve health literacy.32 eHealth literacy is an important component of health literacy because online health information is gradually increasing in the technology era. Identifying and assessing health consumers’ eHealth literacy level are an essential first step to inform strategies for improving their eHealth literacy.
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