Measuring actual eHealth literacy among patients with rheumatic diseases: a qualitative analysis of problems encountered using Health 1.0 and Health 2.0 applications

Meta-analysis: eHealth literacy and attitudes towards internet/computer technology

OBJECTIVE

To explore the relationship between eHealth literacy and attitudes towards internet/computer (I/C) technology use in healthcare.

METHODS

Analysis of data from 16 cross-sectional studies, involving literature search from databases like PubMed, EBSCO, JMIR, up to April 2023. Studies were selected based on a quantitative cross-sectional design, with no restrictions on participant characteristics.

RESULTS

A significant positive correlation (0.36; 95% CI 0.37-0.38, p < 0.05) was found between eHealth literacy and positive attitudes towards I/C technology use. Age and regional differences, especially in participants over 50 and from Asian and Middle Eastern countries, were notable.

CONCLUSION

Lower eHealth literacy is associated with more negative attitudes towards I/C technology in healthcare. This trend is consistent across diverse demographics and regions.

Psychometric validation of the Chinese digital health literacy instrument among Chinese older adults who have internet use experience

INTRODUCTION

In this digital age, the Internet has become a major source of health information, and electronic health (eHealth) literacy becomes increasingly important for older individuals to properly use the extensive eHealth resources for self-care. A valid and reliable tool for assessing older people's eHealth literacy would help healthcare workers identify those disadvantaged groups in digital health and provide relevant health education.

OBJECTIVES

This study aimed to evaluate the psychometric properties of the Chinese version of DHLI in assessing eHealth literacy among older adults in China.

METHODS

A web-based, cross-sectional study was conducted among 277 Chinese older adults from September to November 2021. Two weeks after the first completion, 62 of them answered the C-DHLI again. The reliability (e.g. internal consistency and test-retest reliability), factorial structure and validity (i.e. content validity and convergent validity) of the C-DHLI were evaluated based on the survey data.

RESULTS

The results demonstrated good internal consistency (Cronbach's alpha: 0.94) and test-retest reliability (total intraclass correlation coefficient [ICC]: 0.94) of the C-DHLI. Principal component analysis revealed that the 18 items of C-DHLI loaded on three factors, accounting for 74.69% of the total variance; CFA supported its three-factor structure with good model fits. Convergent validity was examined by the significant associations between C-DHLI and C-eHEALS (r = 0.61), health literacy (r = 0.56), and whether having used the Internet for health information (ρ = 0.43) (ps <.001). A cut-off score of 45 was recommended for determining higher and lower literacy using the C-DHLI, with the area under curve of 0.82 (95% CI = 0.77-0.88).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The C-DHLI showed good psychometric performance in assessing eHealth literacy among Chinese older adults. The findings can support healthcare professionals to effectively measure eHealth literacy among older adults and conduct tailored eHealth interventions or training.

The perspective of Polish patients with rheumatoid arthritis - treatment expectations, patient-reported outcomes, and digital literacy (the SENSE study)

Introduction

A widely accepted treat-to-target strategy for rheumatoid arthritis (RA) requires the patient's perspective in making treatment decisions. However, data on treatment preferences and expectations of Polish patients with RA are scarce. The aim of the study was to determine the satisfaction with treatment and the nature of therapeutic preferences and expectations of Polish patients with moderate to severe RA.

Material and methods

Fifty-two adult Polish patients with moderately to highly active RA were asked to complete patient-reported outcomes and patient-provided information questionnaires. Additionally, patient sociodemographic and clinical data and information on patient current and planned treatment strategies were collected.

Results

The mean global assessment of patient satisfaction with treatment was 64.1 ±24.6, below the level of indicating satisfaction. Rheumatoid arthritis negatively impacted patients' lives, resulting in a 37.8% impairment of work efficiency and 45% impairment of total activity. Primary treatment expectations for patients were lasting relief of RA symptoms, reduced pain and swelling in joints, increased flexibility of joints, and general improvement of arthritis. The most acceptable potential side effect was weight gain and the least acceptable were increases in the risk of cardiovascular disease, infection, and malignancies. The rapid onset of the drug effect (up to 1 week) was a preference of 48.1% of patients. Access to internet health resources was important for 44.2% of patients, but the median total eHealth literacy score in the study population was 24.0 (interquartile range: 20.5-28.0, range 8-37), which means low digital health literacy (DHL).

Conclusions

Understanding these treatment preferences and expectations of patients with RA is essential for clinical practitioners to facilitate shared treatment decision-making. Digital health literacy data suggest the need of further improvement.

Childhood environmental harshness and unpredictability negatively predict eHealth literacy through fast life-history strategy

Background

eHealth literacy-the ability to obtain, understand, evaluate, and use health information from the Internet-is important to maintaining and improving personal health. Prior research found that people differ notably in the levels of eHealth literacy, and this study tests a theoretical account of some of those individual differences. Drawing on life history theory, we propose that low eHealth literacy is partly the outcome of people adopting a resource-allocation strategy emphasizing early and fast reproduction, namely, a fast life-history strategy.

Methods

We conducted a cross-sectional survey study (N = 1,036) that measured Chinese adult respondents' eHealth literacy, childhood environmental harshness and unpredictability, and fast life-history strategy. Covariates included health-information seeking online, self-rated health, sex, age, education level, and monthly income.

Results

Supporting a life-history explanation of eHealth literacy, childhood environmental harshness and unpredictability negatively predicted eHealth literacy through fast life-history strategy and mainly the insight-planning-control dimension of it. Harshness, not unpredictability, also directly and negatively predicted eHealth literacy after fast life-history strategy was controlled for.

Conclusion

Our findings suggest that the psychological mechanisms associated with human life-history strategies produce at least some of the individual differences in levels of eHealth literacy, including those related to neuroticism, socioeconomic status, self-rated health and social capital. Thus, a possible way to increase future generation's eHealth literacy and thereby their health is to reduce the harshness and unpredictability of the environment in which they grow up, thereby making them more likely to adopt a relatively slow life-history in their adulthood.

Assessing eHealth Literacy and Identifying Factors Influencing Its Adoption Among Cancer Inpatients: A Cross-Sectional Study in Guangdong Population

Purpose

The purpose of this study was to investigate the current state of eHealth literacy among cancer patients in a grade A tertiary hospital in Guangzhou, Guangdong Province, and to identify the factors that influence it, in order to provide a basis for improving the eHealth literacy of cancer patients.

Patients and Methods

From September to November 2021, a convenience sampling method was employed to survey cancer patients in the oncology department of a grade A tertiary hospital in Guangzhou, using a self-administered general information questionnaire and the eHealth literacy scale (eHEALS). A total of 130 questionnaires were distributed, and 117 valid questionnaires were returned.

Results

The mean total score of eHealth literacy among cancer patients was 21.32±8.35. Multiple linear regression analysis revealed that the frequency of searching for health information and education level were significant factors influencing eHealth literacy (p<0.05). Specifically, the education level (junior high school vs primary school or below) was found to have a significant association with eHealth literacy (beta=0.26, p=0.039).

Conclusion

The results of this study suggest that the eHealth literacy of cancer patients is relatively low, with low scores on the dimensions of judgment and decision-making ability. The government and relevant regulatory authorities should focus on strengthening the reliability of online health information and implementing targeted e-interventions to enhance the eHealth literacy of cancer patients.

Comparison of eHealth Literacy Scale (eHEALS) and Digital Health Literacy Instrument (DHLI) in Assessing Electronic Health Literacy in Chinese Older Adults: A Mixed-Methods Approach

This study compared the reliability, construct validity, and respondents' preference of the Chinese version of 8-item eHEALS (C-eHEALS) and 21-item DHLI (C-DHLI) in assessing older adults' electronic health (eHealth) literacy using a mixed-methods approach. A web-based, cross-sectional survey was conducted among 277 Chinese older adults from September to October 2021, and 15 respondents were subsequently interviewed to understand their preference of scale to use in practice. Results showed that the internal consistency and test-retest reliability of both scales were satisfactory. For the construct validity, the C-DHLI score showed stronger positive correlations with having Internet use for health information and higher educational attainments, occupational skill levels, self-rated Internet skills, and health literacy than the C-eHEALS score. In addition, younger age, higher household income, urban residence, and longer Internet use history were only positively correlated with C-DHLI score. Qualitative data suggested that most interviewees perceived the C-DHLI as more readable than C-eHEALS for its clear structure, specific description, short sentence length, and less semantic complexity. Findings revealed that both scales are reliable tools to measure eHealth literacy among Chinese older adults, and the C-DHLI seemed to be a more valid and favored instrument for the general Chinese older population based on the quantitative and qualitative results.

Development and psychometric evaluation of a new brief scale to measure eHealth literacy in people with type 2 diabetes

Background

The internet has become a major source of health information, and obtaining appropriate information requires various abilities and skills, labeled as electronic health literacy (eHealth literacy). The existing instruments for measuring eHealth literacy are outdated because they were developed during the Web 1.0 era, or not sufficiently sensitive for people with a specific condition or disease because they were designed to assess eHealth literacy over a broad range for a general population. Approximately one in ten adults worldwide live with diabetes. Health professionals have a responsibility to identify patients with low eHealth literacy to prevent them from obtaining misleading internet diabetes information.

Aims

The aims were to develop a condition-specific eHealth literacy scale for diabetes and to evaluate its psychometric properties among people with type 2 diabetes.

Methods

An instrument development design was used. This study recruited 453 people diagnosed with type 2 diabetes at the outpatient clinics of hospitals in 2021. Psychometric properties (internal consistency, measurement invariance, and content, structural, convergent, and known-groups validities) were analyzed.

Results

An expert panel assessed content validity. Exploratory factor analysis, exploratory graph analysis, and confirmatory factor analysis (CFA) for structural validity yielded a two-factor solution (CFI = 0.977, SRMR = 0.029, RMSEA = 0.077). Cronbach’s alpha and omega values were excellent for each factor (0.87–0.94). Multigroup CFA yielded configural and metric measurement invariance across the gender, age, and glycemic control status groups. Convergent validity with a comparator instrument to measure health literacy was supported by a moderate correlation, and known-groups validity determined using groups with different internet-use frequencies was satisfied with a high effect size.

Conclusion

A new condition-specific eHealth literacy scale for people with type 2 diabetes was developed, comprising 10 items. The scale exhibited good psychometric properties; however, test–retest reliability must be determined for the stability of the scale and cross-cultural validity is required among different languages. The brief scale has the merits of being feasible to use in busy clinical practice and being less burdensome to respondents. The scale can be applied in clinical trials of internet-based diabetes interventions for assessing the eHealth literacy of respondents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01062-2.

COVID-19-Related Health Literacy of School Leaders in Hong Kong: A Cross-Sectional Study

To date, we know little about COVID-19-related health literacy among school leaders, particularly in East Asia. The present study aimed to assess the level of COVID-19-related health literacy and associated factors (vaccine hesitancy, self-endangering behaviour, and work satisfaction) among school leaders in Hong Kong. A cross-sectional study of 259 school leaders was carried out during the COVID-19 pandemic between April 2021 and February 2022. COVID-19-related health literacy using HLS-COVID-Q22, three subscales of self-endangering work behaviour scales (i.e., "extensification of work", "intensification of work" and "quality reduction"), and two dimensions of Burnout Assessment Tool (BAT) (i.e., psychosomatic complaints and exhaustion) were used. The study employed independent sample t-test, ANOVA, and multilinear regression models. The findings show that more than half (53.7%) of school leaders had insufficient health literacy. Participants with insufficient health literacy scored significantly higher in the following factors: exhaustion related to work situation (p = 0.029), psychosomatic complaints (p < 0.001), attitude about vaccination (i.e., less agree with vaccination) (p < 0.001), level of informing on COVID-19 related information (i.e., felt less informed) (p < 0.001), and level of confusion about COVID-19-related information (i.e., felt more confused) (p < 0.001). In a linear regression model predicting attitude about coronavirus vaccination, age (β, -0.188, 95% CI, -0.024, -0.005, p = 0.002) and health literacy (β, -0.395, 95% CI, -0.716, -0.361, p < 0.001) were the negative predictors, F(5, 214) = 11.859, p < 0.001. For the linear regression model adjusted for sex and age for predicting health literacy, the model was insignificant. Despite being a highly educated group, this study reveals that one in two Hong Kong school leaders have insufficient health literacy. Inadequate health literacy was strongly associated with a negative attitude about vaccination, low information, and confusion about COVID-19-related information. Additionally, insufficient health literacy was associated with the two secondary symptoms of burnouts. The study highlights an urgent need to develop intervention programmes to promote the COVID-19-specific as well as overall health literacy of the school leaders.

Factor Structure of the eHEALS

Abstract. The dimensionality of the eHEALS has been the subject of some controversy. Sample populations and language versions vary widely, as do the employed statistical methods to assess dimensionality. In previous research, we assessed the factor structure in two different samples testing 1 vs. 2 and 1 vs. 2 vs. 3 correlated factors. The objective of this reanalysis was to assess whether the 3-factor model fitted better than the 2- and 1-factor models. We analyzed data from a 2009 cross-sectional survey on health literacy in grade 12 ( n = 327) using CFA. All factor models of the eHEALS showed unsatisfactory model fit. A subsequent exploratory bifactor analysis confirmed multidimensionality and indicated that Item 2 was problematic. When this item was excluded from the correlated factor models, model fit improved, and the 3-factor model showed the best fit. The results in our sample of 12th-grade students offer some support to the German eHEALS having a 3-factor structure similar to the results from our previous research in women aged 50. The replicability of the fit pattern in a different sample and setting was limited by diverging results on Item 2.

eHealth literacy measurement tools: a systematic review protocol

BACKGROUND

Improving eHealth literacy (eHL) is one of the biggest challenges currently facing the global healthcare community. Indeed the use of digital services has the potential to engage patients in care as well as improve the effectiveness of chronic disease self-management, it remains highly dependent on a patient's specific skills and experiences in the health care systems. Although eHealth literacy has gained momentum in the past decade, it remains an underresearched area, particularly eHealth literacy measurement. The aim of the review is to identify patient-reported outcome measures (PROMs) of eHealth literacy for adult populations and to summarize the evidence on their psychometric properties.

METHODS

We will conduct a systematic literature review of the tools used to measure eHealth literacy for adult population. The search strategy aims to find published studies. A three-step search strategy will be used in this review. Published studies will be searched in CINAHL, PubMed, PsycINFO, and Web of Science from inception until end. Grey literature will be searched to find theses. Database search strategies will be formulated and tested with the assistance of an expert Health Sciences Librarian. The selection of studies will be done by two independent reviewers. Disagreements will be resolved through consensus, and a third reviewer will solve discrepancies. Furthermore, two reviewers will independently evaluate the methodological rigor of the instruments development and testing and assign a grade using the standardized Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Disagreements will be discussed with a third reviewer, expert in psychometrics. Extracted data will be aggregated and analyzed to produce a set of synthesized findings that will be used to develop evidence-informed recommendations in regard of eHL instruments. We will present a synthesis of all instruments, their psychometric properties, and make recommendations for eHL instrument selection in practice. Reporting will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and a PRISMA flow diagram.

DISCUSSION

This systematic review will summarize the evidence on the psychometric properties of PROMs instruments used to measure eHL and will help clinicians, managers, and policy-makers to select an appropriate instrument.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021232765.

eHealth Literacy in a Sample of South Asian Adults in Edmonton, Alberta, Canada: Subanalysis of a 2014 Community-Based Survey

BACKGROUND

Digital health interventions are efficient and flexible methods for enhancing the prevention and management of cardiovascular disease and type 2 diabetes. However, little is known about the characteristics associated with eHealth literacy in the Canadian South Asian population.

OBJECTIVE

The aim of this study is to describe perceived eHealth literacy and explore the extent to which it is associated with sociodemographic, health status, and technology use variables in a subset of South Asian Canadians.

METHODS

We analyzed data from the e-Patient Project survey, a mixed-mode cross-sectional survey that occurred in 2014. The eHealth Literacy Scale (eHEALS) was used to measure eHealth literacy in a convenience sample of 511 English- or Punjabi-speaking South Asian adults recruited from a community pharmacy, a family physician office, and community events in Edmonton, Alberta. Multivariable quantile regression was used to explore variables associated with eHealth literacy.

RESULTS

The analysis was restricted to 301 internet users (mean age 39.9, SD 14.8 years; 166/301, 55.1% female) who provided responses to all 8 eHEALS questions and complete demographic information. The mean overall eHEALS score was 29.3 (SD 6.8) out of 40, and 71.4% (215/301) agreed to at least 5 out of the 8 eHEALS items. The eHEALS item with the lowest level of agreement was "I can tell high-quality health resources from low-quality health resources on the internet" (182/301, 60.5%). Although there were statistically significant differences in eHEALS scores according to age, educational achievement, language preference, and the presence of chronic medical conditions, multivariable regression analysis indicated that language preference was the only variable independently associated with eHealth literacy (coefficient -6.0, 95% CI -9.61 to -2.39).

CONCLUSIONS

In our sample of South Asian Canadian internet users, preference for written health information in languages other than English was associated with lower eHealth literacy. Opportunities exist to improve eHealth literacy using culturally and linguistically tailored interventions.

Predictors of eHealth Literacy and Its Associations with Preventive Behaviors, Fear of COVID-19, Anxiety, and Depression among Undergraduate Nursing Students: A Cross-Sectional Survey

Background: The infodemic has been co-existing with the COVID-19 pandemic with an influx of misinformation and conspiracy theories. These affect people’s psychological health and adherence to preventive measures. eHealth literacy (eHEALS) may help with alleviating the negative effects of the infodemic. As nursing students are future healthcare professionals, having adequate eHEALS skills is critically important in their clinical practice, safety, and health. This study aimed to (1) explore the eHEALS level and its associated factors, and (2) examine the associations of eHEALS with preventive behaviors, fear of COVID-19 (FCV-19S), anxiety, and depression among nursing students. Methods: We surveyed 1851 nursing students from 7 April to 31 May 2020 from eight universities across Vietnam. Data were collected, including demographic characteristics, eHEALS, adherence to preventive behaviors (handwashing, mask-wearing, physical distancing), FCV-19S, anxiety, and depression. Linear and logistic regression analyses were performed appropriately to examine associations. Results: The mean score of eHEALS was 31.4 ± 4.4. The eHEALS score was significantly higher in males (unstandardized regression coefficient, B, 0.94; 95% confidence interval, 95% CI, 0.15 to 1.73; p = 0.019), and students with a better ability to pay for medication (B, 0.79; 95% CI, 0.39 to 1.19; p < 0.001), as compared to their counterparts. Nursing students with a higher eHEALS score had a higher likelihood of adhering to hand-washing (odds ratio, OR, 1.18; 95% CI, 1.15 to 1.22; p < 0.001), mask-wearing (OR, 1.15; 95% CI, 1.12 to 1.19; p < 0.001), keeping a safe physical distance (OR, 1.20; 95% CI, 1.15 to 1.25; p < 0.001), and had a lower anxiety likelihood (OR, 0.95; 95% CI, 0.92 to 0.99; p = 0.011). Conclusions: Nursing students who were men and with better ability to pay for medication had higher eHEALS scores. Those with higher eHEALS scores had better adherence to preventive measures, and better psychological health. The development of strategies to improve eHEALS of nursing students may contribute to COVID-19 containment and improve their psychological health.

Patients’ willingness and ability to identify and respond to errors in their personal health records: a mixed methods analysis of cross-sectional survey data (Preprint)

Background

Errors in electronic health records are known to contribute to patient safety incidents; however, systems for checking the accuracy of patient records are almost nonexistent. Personal health records (PHRs) enabling patient access to and interaction with the clinical records offer a valuable opportunity for patients to actively participate in error surveillance.

Objective

This study aims to evaluate patients’ willingness and ability to identify and respond to errors in their PHRs.

Methods

A cross-sectional survey was conducted using a web-based questionnaire. Patient sociodemographic data were collected, including age, sex, ethnicity, educational level, health status, geographical location, motivation to self-manage, and digital health literacy (measured using the eHealth Literacy Scale tool). Patients with experience of using the Care Information Exchange (CIE) portal, who specified both age and sex, were included in these analyses. The patients’ responses to 4 relevant survey items (closed-ended questions, some with space for free-text comments) were examined to understand their willingness and ability to identify and respond to errors in their PHRs. Multinomial logistic regression was used to identify patients’ characteristics that predict the ability to understand information in the CIE and willingness to respond to errors in their records. The framework method was used to derive themes from patients’ free-text responses.

Results

Of 445 patients, 181 (40.7%) “definitely” understood the CIE information and approximately half (220/445, 49.4%) understood the CIE information “to some extent.” Patients with high digital health literacy (eHealth Literacy Scale score ≥26) were more confident in their ability to understand their records compared with patients with low digital health literacy (odds ratio [OR] 7.85, 95% CI 3.04-20.29; P<.001). Information-related barriers (medical terminology and lack of medical guidance or contextual information) and system-related barriers (functionality or usability and information communicated or displayed poorly) were described. Of 445 patients, 79 (17.8%) had noticed errors in their PHRs, which were related to patient demographic details, diagnoses, medical history, results, medications, letters or correspondence, and appointments. Most patients (272/445, 61.1%) wanted to be able to flag up errors to their health professionals for correction; 20.4% (91/445) of the patients were willing to correct errors themselves. Native English speakers were more likely to be willing to flag up errors to health professionals (OR 3.45, 95% CI 1.11-10.78; P=.03) or correct errors themselves (OR 5.65, 95% CI 1.33-24.03; P=.02).

Conclusions

A large proportion of patients were able and willing to identify and respond to errors in their PHRs. However, some barriers persist that disproportionately affect the underserved groups. Further development of PHR systems, including incorporating channels for patient feedback on the accuracy of their records, should address the needs of nonnative English speakers and patients with lower digital health literacy.

Assessing eHealth literacy among internet users in Lebanon: A cross-sectional study

Objective

Assessing the level of eHealth literacy in a population is essential to designing appropriate public health interventions. This study aimed to assess eHealth literacy among adult internet users in Lebanon, recruited through social media and printed materials. The study examined the relationship between internet use, perceived eHealth literacy, and sociodemographic characteristics.

Methods

A cross-sectional study based on a web-based questionnaire was conducted between January and May 2020. The survey assessed internet use and eHealth literacy using the homonymous scale (eHEALS) in English and Arabic. Cronbach's alpha and factor analyses were used to evaluate eHEALS’ psychometric properties. A generalized linear model was used to identify factors predicting the eHEALS.

Results

A total of 2715 respondents were recruited mostly through Facebook (78%) and printed materials (17%). Most respondents completed the survey in English (82%), were aged 30 ± 11 years, female (60%), Lebanese (84%), unmarried (62%), employed (54%), and with a graduate-level education (53%). Those who completed the eHEALS questionnaire (n = 2336) had a moderate eHealth literacy (M = 28.7, SD = 5.5). eHEALS was significantly higher among older females with a high education level, recruited from Facebook, Instagram, or ResearchGate, and perceived the Internet as a useful and important source of information.

Conclusions

Future internet-delivered public health campaigns in Lebanon should account for moderate-to-low levels of eHealth literacy and find ways to engage older males with low education levels representing neglected segments (e.g. Syrians). To be more inclusive, campaigns should reach neglected population segments through non-digital, community-based outreach activities.

eHealth Literacy Instruments: Systematic Review of Measurement Properties

Background

The internet is now a major source of health information. With the growth of internet users, eHealth literacy has emerged as a new concept for digital health care. Therefore, health professionals need to consider the eHealth literacy of consumers when providing care utilizing digital health technologies.

Objective

This study aimed to identify currently available eHealth literacy instruments and evaluate their measurement properties to provide robust evidence to researchers and clinicians who are selecting an eHealth literacy instrument.

Methods

We conducted a systematic review and meta-analysis of self-reported eHealth literacy instruments by applying the updated COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) methodology.

Results

This study included 7 instruments from 41 articles describing 57 psychometric studies, as identified in 4 databases (PubMed, CINAHL, Embase, and PsycInfo). No eHealth literacy instrument provided evidence for all measurement properties. The eHealth literacy scale (eHEALS) was originally developed with a single-factor structure under the definition of eHealth literacy before the rise of social media and the mobile web. That instrument was evaluated in 18 different languages and 26 countries, involving diverse populations. However, various other factor structures were exhibited: 7 types of two-factor structures, 3 types of three-factor structures, and 1 bifactor structure. The transactional eHealth literacy instrument (TeHLI) was developed to reflect the broader concept of eHealth literacy and was demonstrated to have a sufficient low-quality and very low-quality evidence for content validity (relevance, comprehensiveness, and comprehensibility) and sufficient high-quality evidence for structural validity and internal consistency; however, that instrument has rarely been evaluated.

Conclusions

The eHealth literacy scale was the most frequently investigated instrument. However, it is strongly recommended that the instrument's content be updated to reflect recent advancements in digital health technologies. In addition, the transactional eHealth literacy instrument needs improvements in content validity and further psychometric studies to increase the credibility of its synthesized evidence.

Digital Approaches for a Reliable Early Diagnosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that develops in up to 30% of patients with psoriasis. In the vast majority of cases, cutaneous symptoms precede musculoskeletal complaints. Progression from psoriasis to PsA is characterized by subclinical synovio-entheseal inflammation and often non-specific musculoskeletal symptoms that are frequently unreported or overlooked. With the development of increasingly effective therapies and a broad drug armamentarium, prevention of arthritis development through careful clinical monitoring has become priority. Identifying high-risk psoriasis patients before PsA onset would ensure early diagnosis, increased treatment efficacy, and ultimately better outcomes; ideally, PsA development could even be averted. However, the current model of care for PsA offers only limited possibilities of early intervention. This is attributable to the large pool of patients to be monitored and the limited resources of the health care system in comparison. The use of digital technologies for health (eHealth) could help close this gap in care by enabling faster, more targeted and more streamlined access to rheumatological care for patients with psoriasis. eHealth solutions particularly include telemedicine, mobile technologies, and symptom checkers. Telemedicine enables rheumatological visits and consultations at a distance while mobile technologies can improve monitoring by allowing patients to self-report symptoms and disease-related parameters continuously. Symptom checkers have the potential to direct patients to medical attention at an earlier point of their disease and therefore minimizing diagnostic delay. Overall, these interventions could lead to earlier diagnoses of arthritis, improved monitoring, and better disease control while simultaneously increasing the capacity of referral centers.

Patients With Cancer Searching for Cancer- or Health-Specific Web-Based Information: Performance Test Analysis

Background

Searching the internet for cancer-related information helps patients with cancer satisfy their unmet information needs and empowers them to play a more active role in the management of their disease. However, to benefit from the search, patients need a sufficient level of skill to search, select, appraise, and apply web-based health information.

Objective

We aim to study the operational, navigational, information, and evaluation skills and problems of patients with cancer performing cancer-related search tasks using the internet.

Methods

A total of 21 patients with cancer were recruited during their stay at the rehabilitation clinic for oncological rehabilitation. Participants performed eight cancer-related search tasks using the internet. The participants were asked to think aloud while performing the tasks, and the screen activities were recorded. The types and frequencies of performance problems were identified and coded into categories following an inductive coding process. In addition, the performance and strategic characteristics of task execution were summarized descriptively.

Results

All participants experienced problems or difficulties in executing the tasks, and a substantial percentage of tasks (57/142, 40.1%) could not be completed successfully. The participants’ performance problems were coded into four categories, namely operating the computer and web browser, navigating and orientating, using search strategies, and evaluating the relevance and reliability of web-based information. The most frequent problems occurred in the third and fourth categories. A total of 90% (19/21) of participants used nontask-related search terms or nonspecific search terms. A total of 95% (20/21) of participants did not control for the source or topicality of the information found. In addition, none of the participants verified the information on 1 website with that on another website for each task.

Conclusions

A substantial group of patients with cancer did not have the necessary skills to benefit from cancer-related internet searches. Future interventions are needed to support patients in the development of sufficient internet-searching skills, focusing particularly on information and evaluation skills.

COVID-19 and Health Information Seeking Behavior: Digital Health Literacy Survey amongst University Students in Pakistan

Amid the COVID-19 pandemic, digital health literacy (DHL) has become a significant public health concern. This research aims to assess information seeking behavior, as well as the ability to find relevant information and deal with DHL among university students in Pakistan. An online-based cross-sectional survey, using a web-based interviewing technique, was conducted to collect data on DHL. Simple bivariate and multivariate linear regression was performed to assess the association of key characteristics with DHL. The results show a high DHL related to COVID-19 in 54.3% of students. Most of the Pakistani students demonstrated ~50% DHL in all dimensions, except for reliability. Multivariate findings showed that gender, sense of coherence and importance of information were found to be significantly associated with DHL. However, a negative association was observed with students' satisfaction with information. This led to the conclusion that critical operational and navigations skills are essential to achieve COVID-19 DHL and cope with stress, particularly to promote both personal and community health. Focused interventions and strategies should be designed to enhance DHL amongst university students to combat the pandemic.

A Smartphone App for Engaging Patients With Catheter-Associated Urinary Tract Infections: Protocol for an Interrupted Time-Series Analysis

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the main cause of health care-associated infections, and they increase the disease burden, antibiotic usage, and hospital stay. Inappropriate placement and unnecessarily prolonged usage of a catheter lead to an elevated and preventable risk of infection. The smartphone app Participatient has been developed to involve hospitalized patients in communication and decision-making related to catheter use and to control unnecessary (long-term) catheter use to prevent CAUTIs. Sustained behavioral changes for infection prevention can be promoted by empowering patients through Participatient.

OBJECTIVE

The primary aim of our multicenter prospective interrupted time-series analysis is to reduce inappropriate catheter usage by 15%. We will evaluate the efficacy of Participatient in this quality improvement study in clinical wards. Our secondary endpoints are to reduce CAUTIs and to increase patient satisfaction, involvement, and trust with health care services.

METHODS

We will conduct a multicenter interrupted time-series analysis-a strong study design when randomization is not feasible-consisting of a pre- and postintervention point-prevalence survey distributed among participating wards to investigate the efficacy of Participatient in reducing the inappropriate usage of catheters. After customizing Participatient to the wards' requirements, it will be implemented with a catheter indication checklist among clinical wards in 4 large hospitals in the Netherlands. We will collect clinical data every 2 weeks for 6 months in the pre- and postintervention periods. Simultaneously, we will assess the impact of Participatient on patient satisfaction with health care services and providers and the patients' perceived involvement in health care through questionnaires, and the barriers and facilitators of eHealth implementation through interviews with health care workers.

RESULTS

To reduce the inappropriate use of approximately 40% of catheters (currently in use) by 15%, we aim to collect 9-12 data points from 70-100 patients per survey date per hospital. Thereafter, we will conduct an interrupted time-series analysis and present the difference between the unadjusted and adjusted rate ratios with a corresponding 95% CI. Differences will be considered significant when P<.05.

CONCLUSIONS

Our protocol may help reduce the inappropriate use of catheters and subsequent CAUTIs. By sharing reliable information and daily checklists with hospitalized patients via an app, we aim to provide them a tool to be involved in health care-related decision-making and to increase the quality of care.

TRIAL REGISTRATION

Netherlands Trial Register NL7178; https://www.trialregister.nl/trial/7178.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28314.

Testing the Digital Health Literacy Instrument for Adolescents: Cognitive Interviews

Background

Despite the increasing number of youth seeking health information on the internet, few studies have been conducted to measure digital health literacy in this population. The digital health literacy instrument (DHLI) is defined as a scale that measures the ability to operate digital devices and read and write in web-based modes, and it assesses seven subconstructs: operational skills, navigation skills, information searching, evaluating reliability, determining relevance, adding self-generated content to a web-based app, and protecting privacy. Currently, there is no validation process of this instrument among adolescents.

Objective

This study aims to explore the usability and content validity of DHLI.

Methods

Upon the approval of institutional review board protocol, cognitive interviews were conducted. A total of 34 adolescents aged 10-18 years (n=17, 50% female) participated in individual cognitive interviews. Two rounds of concurrent cognitive interviews were conducted to assess the content validity of DHLI using the thinking aloud method and probing questions.

Results

Clarity related to unclear wording, undefined technical terms, vague terms, and difficult vocabularies was a major issue identified. Problems related to potentially inappropriate assumptions were also identified. In addition, concerns related to recall bias and socially sensitive phenomena were raised. No issues regarding response options or instrument instructions were noted.

Conclusions

The initial round of interviews provided a potential resolution to the problems identified with comprehension and communication, whereas the second round prompted improvement in content validity. Dual rounds of cognitive interviews provided substantial insights into survey interpretation when introduced to US adolescents. This study examined the validity of the DHLI and suggests revision points for assessing adolescent digital health literacy.

Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study

BACKGROUND

Patients' needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients' perspectives can help identify unmet needs and enhance the understanding of treatment benefits.

OBJECTIVE

The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management.

METHODS

SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed.

RESULTS

A total of 1624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were "general improvement of arthritis" and "less joint pain". Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). "Increased risk for malignancies" and "increased risk for cardiovascular disease" were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients.

CONCLUSION

Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA.

Do Brief Educational Sessions Increase Electronic Health Literacy of Low-Income Persons Living With HIV/AIDS?

This research explored whether participating in a brief educational intervention using the National Library of Medicine video, Evaluating Health Information: A Tutorial From the National Library of Medicine, would increase electronic health literacy. A quasi-experimental longitudinal design was used in two randomly selected settings of a treatment program for low-income persons living with HIV/acquired immune deficiency syndrome (N = 100). Individuals in both intervention groups watched the video and completed an at-home assignment brought to the second session 1 week later; one group received an additional 15 minutes with an HIV nurse clinician who reinforced video content. Generalized linear models were used in order to account for the longitudinal nature of the data; a full model was fitted first that included age, gender, race, ethnicity, education, acquired immune deficiency syndrome diagnosis, time, group, and the interaction of time by intervention group with electronic health literacy as the dependent variable. Group means were not significantly different, and the overall group pattern were the same; the only significant variable was older age, which is consistent with the findings of other literature. Electronic health literacy can be increased by viewing a free video; making this video available in a variety of settings and encouraging clients to use the Internet as a source of health information may improve self-management strategies of persons living with chronic illnesses.

Mobile Health Usage, Preferences, Barriers, and eHealth Literacy in Rheumatology: Patient Survey Study

Background

Mobile health (mHealth) defines the support and practice of health care using mobile devices and promises to improve the current treatment situation of patients with chronic diseases. Little is known about mHealth usage and digital preferences of patients with chronic rheumatic diseases.

Objective

The aim of the study was to explore mHealth usage, preferences, barriers, and eHealth literacy reported by German patients with rheumatic diseases.

Methods

Between December 2018 and January 2019, patients (recruited consecutively) with rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis were asked to complete a paper-based survey. The survey included questions on sociodemographics, health characteristics, mHealth usage, eHealth literacy using eHealth Literacy Scale (eHEALS), and communication and information preferences.

Results

Of the patients (N=193) who completed the survey, 176 patients (91.2%) regularly used a smartphone, and 89 patients (46.1%) regularly used social media. Patients (132/193, 68.4%) believed that using medical apps could be beneficial for their own health. Out of 193 patients, only 8 (4.1%) were currently using medical apps, and only 22 patients (11.4%) stated that they knew useful rheumatology websites/mobile apps. Nearly all patients (188/193, 97.4%) would agree to share their mobile app data for research purposes. Out of 193 patients, 129 (66.8%) would regularly enter data using an app, and 146 patients (75.6%) would welcome official mobile app recommendations from the national rheumatology society. The preferred duration for data entry was not more than 15 minutes (110/193, 57.0%), and the preferred frequency was weekly (59/193, 30.6%). Medication information was the most desired app feature (150/193, 77.7%). Internet was the most frequently utilized source of information (144/193, 74.6%). The mean eHealth literacy was low (26.3/40) and was positively correlated with younger age, app use, belief in benefit of using medical apps, and current internet use to obtain health information.

Conclusions

Patients with rheumatic diseases are very eager to use mHealth technologies to better understand their chronic diseases. This open-mindedness is counterbalanced by low mHealth usage and competency. Personalized mHealth solutions and clear implementation recommendations are needed to realize the full potential of mHealth in rheumatology.

How Caregivers of People With Dementia Search for Dementia-Specific Information on the Internet: Survey Study

BACKGROUND

During the last decade, more research has focused on web-based interventions delivered to support caregivers of people with dementia. However, little information is available in relation to internet use among caregivers in general, especially those caring for people with dementia.

OBJECTIVE

The aim of this study was to evaluate the dementia-related internet use and factors that may be associated with its use among caregivers of people with dementia in Greece.

METHODS

Secondary data from the Greek Dementia Survey of the Athens Association of Alzheimer's Disease and Related Disorders were collected from April to June 2017. A total of 580 caregivers of people with dementia participated in the study.

RESULTS

The majority of the caregivers reported that they had used the internet in the previous 3 months (84.1%, 488/580). Nearly half of the caregivers (47.5%, 276/580) reported that they had received dementia services online. Bivariate analysis showed that a dementia-specific search of information was associated with age, education, kinship, and years of care. Age (odds ratio [OR] 2.362, 95% CI 1.05-5.33) and education (OR 2.228, 95% CI 1.01-4.94) were confirmed as predictors, with younger caregivers and those with higher educational attainment being more likely to search for dementia-specific information. Use of the internet to search for dementia information was only related to hours of care. The internet use by caregivers within the previous 3 months was associated with variables such as age, education, occupation, kinship, years of care, and self-reported impact on physical and social health.

CONCLUSIONS

Caregivers of people with dementia in Greece, as in the other southern European countries, are essential agents of the national health system. The existing short- and long-term respite care services are limited or nonexistent. Currently, caregivers receive mostly support and education from memory clinics and municipality consultation centers, which are mainly based in central cities in Greece. Despite the dementia awareness movement in Greece, there is still space to integrate the role of technology in the support and education of caregivers. Development of training programs for enhancing electronic health literacy skills as well as web-based services provision could support Greek caregivers in their everyday caring tasks.

Associations of eHealth Literacy with Obtaining Knowledge about Colorectal Cancer among Internet Users Accessing a Reputable Cancer Website: Internet-Based Survey Study

Examining the associations of eHealth literacy (eHL) with obtaining health knowledge from websites would help to clarify the causal pathway between eHL and health knowledge. This study aimed to compare the results obtained from Internet users with high or low eHL in accessing a reputable cancer website to obtain colorectal cancer (CRC) knowledge. A total of 105 participants with high eHL and 103 participants with low eHL accessed a reputable CRC website managed by the National Cancer Center and responded to Internet-based surveys before and after accessing a website in 2012. Twelve responses to knowledge statements regarding CRC were selected based on item response theory, and the differences in correct responses of pre- and post-surveys by each eHL group were compared. Two statements showed a significant increase in correct responses in the high eHL group only: "Red meat intake is a risk factor" (p = 0.002), and "Obesity is a risk factor" (p = 0.029), whereas only one response did so in the low eHL group: "Bloody stools are a symptom" (p = 0.004). Low eHL Internet users appeared less capable of obtaining knowledge of CRC by accessing information from a reputable cancer website than high eHL Internet users.

Determinants of eHealth Literacy among Adults in China

eHealth can empower patients to make informed health decisions. However, inaccurate and misleading health information is not uncommon on the Internet, which requires users' competencies to both utilize eHealth technologies and evaluate eHealth credibilities. Therefore, this study investigates the determinants of both self-efficacy in utilizing eHealth and frequency of eHealth information evaluation. An Internet-based survey of 923 Chinese adults who are residing in China aged from 21 to 55 years old was conducted. Path analysis was adopted to examine sociodemographic variables, Internet literacy, and health information evaluation as determinants of eHealth literacy variables. Findings demonstrated that Internet literacy positively predicted only self-efficacy in utilizing eHealth. In contrast, health information orientation positively predicted both self-efficacy in utilizing eHealth and frequency of eHealth information evaluation. In addition, Internet literacy and health information orientation mediated the predicted effects of sociodemographic factors on the two eHealth variables. The findings imply that Internet literacy is no longer the primary determinant of eHealth competencies for adults who are tech-savvy users. Instead, interests in health information play a crucial role in improving eHealth competencies.

The Role of Age, Education, and Digital Health Literacy in the Usability of Internet-Based Cognitive Behavioral Therapy for Chronic Pain: Mixed Methods Study

Background

Internet-based cognitive behavior therapy (iCBT) can be effective in mental and somatic health care. Research on the feasibility of internet interventions in clinical practice is, however, still scarce. Studies with a focus on the patient regarding usability of interventions and digital health literacy skills are especially lacking.

Objective

The goal of this study was to assess the usability of an iCBT for chronic pain, Master Your Pain, and the relationship between its usability outcomes and the factors age, educational level, and digital health literacy skills. The aims were to determine what changes were needed in the program for sufficient usability and which individual characteristics were related to the usability of the program.

Methods

Patients were recruited from two mental health care practices. A mixed methods approach was used in this study. A qualitative observational study comprising performance tasks in the iCBT program was used to test usability. A quantitative questionnaire was used to measure possible related constructs. Usability was operationalized as the number of tasks that could be completed and the type and number of problems that occurred while doing so. Performance tasks were set up to measure 6 digital skills: (1) operating the computer and internet browser, (2) navigation and orientation, (3) using search strategies, (4) evaluating relevance of content, (5) adding personal content, and (6) protecting and respecting privacy. Participants were asked to think aloud while performing the tasks, and screen activities and webcam recordings were captured. The qualitative observational data was coded using inductive analysis by two independent researchers. Correlational analyses were performed to test how usability relates to sociodemographics and digital health literacy.

Results

A total of 32 patients participated, with a mean age of 49.9 years and 84% (27/32) being female. All performance tasks except one (fill in a diary registration) could be completed independently by more than 50% of the participants. On operational, navigation, and search levels, participants struggled most with logging in, logging out, and finding specific parts of the intervention. Half of the sample experienced problems evaluating the relevance and adding content to the program to some extent. Usability correlated moderately negatively with age and moderately positively with digital health literacy skills but not with educational level.

Conclusions

The results provide insight into what is essential for proper usability regarding the design of an iCBT program considering variations in age, educational level, and digital health literacy. Furthermore, the results provide insight into what type of support is needed by patients to properly use the intervention. Tailoring support among the needs of certain age groups or skill levels could be beneficial and could range from no extra support (only online feedback, as intended) to practical support (an additional usability introduction session) to blended care (combined face-to-face sessions throughout the therapy).

Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies

Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.

Examining the Interaction Between Medical Information Seeking Online and Understanding: Exploratory Study

BACKGROUND

Online information seeking on medical topics by patients can have beneficial effects by helping them decide on treatment options and fostering better relationships with doctors. The quality of websites and processes of seeking information online have mostly been studied, with a focus on the accuracy and reliability of websites; however, few studies have examined the relationship between other aspects of quality and the processes of seeking medical information online.

OBJECTIVE

This exploratory study aimed to shed light on the quality of websites used for information seeking from the perspective of understanding medical information in combination with seeking it online.

METHODS

The study participants were 15 Japanese university students with no problem using the internet. A questionnaire survey about health literacy (47 items on a 4-point Likert scale) and information navigation skills on the internet (8 items on a 5-point Likert scale) was conducted before participants engaged in online information seeking and qualitative interviews. The students searched for information on a disease and its treatment. The websites viewed were gathered from search behavior recorded by software and browser logs. Follow-up interviews were conducted to elicit explanations from the participants about the assignments and their views of online information seeking. The explanations were evaluated by 55 health care professionals on a 3-point Likert scale and then assessed based on their comments and the participant interviews.

RESULTS

The mean age of the participants was 20.6 years (median 21; SD 1.06). All participants were able to access reliable websites with information relevant to the assignments. The mean ratings of the students' explanations were 108.6 (median 109; range=83-134) for the disease and 105.6 (median 104; range=87-117) for its treatment. The inter-rater reliability were 0.84 (95% CI 0.77-0.90) and 0.95 (95% CI 0.93-0.97), indicating good and excellent, respectively. The mean of the sum of the health literacy skills was 115.1 (median 115; range=80-166) and the mean for information navigation skills was 25.9 (median 26; range=17-36), respectively. Health literacy and information navigation skills were moderately correlated (r=0.54; 95% CI 0.033-0.822; P=.04). Among the four stages of health literacy, understanding and appraising (r=0.53; 95% CI 0.025-0.820; P=.04) were moderately correlated with information navigation skills (r=0.52; 95% CI 0.013-0.816; P=.046). The participants had no difficulties operating and browsing the internet and considered medical and public institution websites to be reliable; however, due to unfamiliarity with medical terms, they had difficulties choosing a site from the results obtained and comparing and synthesizing information provided by different sites. They also looked for sites providing orderly information in plain language but provided explanations from sites that gave inadequate interpretations of information.

CONCLUSIONS

This study revealed interactions between searching the internet for, and understanding, medical information by analyzing the processes of information seeking online, physicians' evaluations and comments about the participants' explanations, and the participants' perceptions.

Factors Influencing eHealth Literacy of Middle School Students in Korea: A Descriptive Cross-Sectional Study

Objectives

The aim of this study is to identify eHealth literacy level and to analyze the factors influencing eHealth literacy among middle school students in Korea.

Methods

This descriptive cross-sectional study involved the administration of a self-report questionnaire. The participants were 799 middle school students. Descriptive statistics were analyzed via an independent t-test, Mann-Whitney U-test, and one-way ANOVA. Pearson correlation coefficients were used to test the correlations among variables. Multiple linear regression analysis was conducted to identify the factors influencing eHealth literacy.

Results

eHealth literacy was substantially lower in students in their first year than in students in their third year of middle school. Participants with asthma, herniated disc, and atopic dermatitis had significantly lower eHealth literacy than those without the diseases. The major finding was that eHealth literacy of middle school students was influenced by their grade and number of diseases diagnosed. eHealth literacy was higher among students in their second and third years of middle school and among those who had fewer diagnosed diseases.

Conclusions

eHealth literacy among adolescents is important for better health outcomes; however, middle school students with diseases had lower eHealth literacy than healthy students. Therefore, efforts to enhance eHealth literacy should focus on adolescents with diseases; moreover, health education in schools and healthcare settings for adolescents should include critical analytical skill development for better eHealth literacy.

Usability and Usefulness of a Mobile Health App for Pregnancy-Related Work Advice: Mixed-Methods Approach

Background

Pregnant women are often unaware of the potential risks that working conditions can cause to them and their unborn child. A mobile health (mHealth) app, the Pregnancy and Work (P and W) app, developed by a multidisciplinary team and based on an evidence-based guideline for occupational physicians, aims to provide advice on work adjustment during pregnancy.

Objective

This study evaluates the usability of the mHealth P and W app and the perceived usefulness of the work advice, the main goal of the app, by potential end users.

Methods

A total of 12 working pregnant women participated in think aloud usability sessions and performed 9 tasks. All think aloud sessions were recorded, transcribed, and coanalyzed. The usability problems were rated for their severity in accordance with Nielsen severity scale. The completion rates and time taken for completion of tasks were registered. In addition, participants were questioned on demographics and user characteristics and were asked to evaluate the value of the app by filling in the Intrinsic Motivation Inventory (IMI) score and the System Usability Scale (SUS) questionnaire.

Results

In total, 82 usability problems with a severity ≥1 were identified, of which 40 had severity ≥3. The main usability problems concerned the interpretation of terminology used in the app’s questionnaires and difficulties in finding and understanding the work advice. Furthermore, 10 out of 12 participants were able to open the work advice page in the app. Only 7 out of these 10 participants understood and intended to follow the work advice. The overall mean IMI score was relatively high (5 out of 7), indicating that the participants did indeed value the use of the app. This IMI score corresponded to the overall mean SUS score (68 out of 100) and the mean grade given to the P and W app (7 out of 10).

Conclusions

This think aloud usability study showed that the information provided in the P and W app was considered valuable by the end users, working pregnant women, and it meets their needs; however, usability issues severely impacted the perceived usefulness of the work advice given in the app.

Differences in the Level of Electronic Health Literacy Between Users and Nonusers of Digital Health Services: An Exploratory Survey of a Group of Medical Outpatients

BACKGROUND

Digitalization of health services ensures greater availability of services and improved contact to health professionals. To ensure high user adoption rates, we need to understand the indicators of use and nonuse. Traditionally, these have included classic sociodemographic variables such as age, sex, and educational level. Electronic health literacy (eHL) describes knowledge, skills, and experiences in the interaction with digital health services and technology. With our recent introduction of 2 new multidimensional instruments to measure eHL, the eHL questionnaire (eHLQ) and the eHL assessment (eHLA) toolkit, eHL provides a multifaceted approach to understand use and nonuse of digital health solutions in detail.

OBJECTIVE

The aim of this study was to investigate how users and nonusers of digital services differ with respect to eHL, in a group of patients with regular contact to a hospital outpatient clinic. Furthermore, to examine how usage and nonusage, and eHL levels are associated with factors such as age, sex, educational level, and self-rated health.

METHODS

Outpatients were asked to fill out a survey comprising items about usage of digital services, including digital contact to general practitioner (GP) and communication via the national health portal sundhed.dk, the eHLQ, and the eHLA toolkit, as well as items on age, sex, education, and self-rated health. In total, 246 patients completed the survey. A Mann-Whitney test was used to test for differences between users and nonusers of digital services. Correlation tests described correlations between eHL scales (eHEALSs) and age, education, and self-rated health. A significance level of .0071 was used to reject the null hypothesis in relation to the eHEALSs and usage of digital services.

RESULTS

In total, 95.1% (234/246) of the participants used their personal digital ID (NemID), 57.7% (142/246) were in contact with their GPs electronically, and 54.0% (133/246) had used the national health portal (sundhed.dk) within the last 3 months. There were no differences between users and nonusers of sundhed.dk with respect to age, sex, educational level, and self-rated health. Users of NemID scored higher than nonusers in 6 of the 7 dimensions of eHLQ, the only one which did not differ was dimension 2: Understanding of health concepts and language. Sundhed.dk users had a higher score in all of the 7 dimensions except for dimension 4: Feel safe and in control. The eHLA toolkit showed that users of sundhed.dk and NemID had higher levels of eHL with regard to tools 2, 5, 6, and 7. Furthermore, users of sundhed.dk had higher levels of eHL with regard to tools 3 and 4.

CONCLUSIONS

Information about patients' eHL may provide clinicians an understanding of patients' reasons for not using digital health services, better than sociodemographic data or self-rated health.

Health Literacy in Web-Based Health Information Environments: Systematic Review of Concepts, Definitions, and Operationalization for Measurement

Background

Health literacy research seems to lack a consensus on what aspects to include into literacy in the context of health and on how to operationalize these concepts for measurement purposes. In addition to health literacy, several other concepts, such as electronic health (eHealth) literacy and mental health literacy, have been developed across disciplines. This study examines how these different concepts are used when studying health-related competencies in Web contexts.

Objective

This study systematically reviews health literacy concepts and definitions and their operationalization in studies focused on Web-based health information environments.

Methods

A systematic literature search was conducted in April 2016 in 6 electronic databases with a limitation to articles in English published between January 2011 and April 2016. Altogether, 1289 unique records were identified and screened according to the predefined inclusion criteria: (1) original, peer-reviewed research articles written in English; (2) the topic of the article concerned literacy in the context of health; (3) informants of the study were lay people, not health professionals or students of the field; and (4) the focus of the study was placed on an Web-based information environment. In total, 180 full texts were screened, of which 68 were included in the review. The studies were analyzed with an emphasis on the used health literacy concepts and measures.

Results

On the basis of the included studies, several concepts are in use when studying health-related literacy in Web environments, eHealth literacy and health literacy being the most common ones. The reviewed studies represent a variety of disciplines, but mostly medical sciences. Typically, quantitative research methods are used. On the basis of the definitions for health literacy, 3 thematic categories were identified: general and skill-based, multidimensional, and domain-specific health literacy. Most studies adopted a domain-specific concept, followed by the ones that used a general and skill-based concept. Multidimensional concepts occurred least frequently. The general health literacy concepts were usually operationalized with reading comprehension measures, the domain-specific concepts with self-efficacy measures, and multidimensional concepts with several types of measures. However, inconsistencies in operationalization were identified.

Conclusions

The results show that in studies conducted in Web-based information environments, several different health literacy concepts are in use, and there is no clear consensus on the definitions for these concepts. Future studies should place emphasis on the conceptual development of health literacy in Web contexts to gain better results on operationalization for measurement. Researchers are encouraged to provide clear operational definitions for the concepts they use to ensure transparency in reporting.

Assessing the Needs and Perspectives of Patients With Asthma and Chronic Obstructive Pulmonary Disease on Patient Web Portals: Focus Group Study

BACKGROUND

As accessibility to the internet has increased in society, many health care organizations have developed patient Web portals (PWPs), which can provide a range of self-management options to improve patient access. However, the available evidence suggests that they are used inefficiently and do not benefit patients with low health literacy. Asthma and chronic obstructive pulmonary disease (COPD) are common chronic diseases that require ongoing self-management. Moreover, patients with COPD are typically older and have lower health literacy.

OBJECTIVE

This study aimed to obtain and present an overview of patients' perspectives of PWPs to facilitate the development of a portal that better meets the needs of patients with asthma and COPD.

METHODS

We performed a focus group study using semistructured interviews in 3 patient groups from the north of the Netherlands who were recruited through the Dutch Lung Foundation. Each group met 3 times for 2 hours each at a 1-week interval. Data were analyzed with coding software, and patient descriptors were analyzed with nonparametric tests. The consolidated criteria for reporting qualitative research were followed when conducting the study.

RESULTS

We included 29 patients (16/29, 55% male; mean age 65 [SD 10] years) with COPD (n=14), asthma-COPD overlap (n=4), asthma (n=10), or other respiratory disease (n=1). There was a large variation in the internet experience; some patients hardly used the internet (4/29, 14%), whereas others used internet >3 times a week (23/29, 79%). In general, patients were positive about having access to a PWP, considering access to personal medical records as the most important option, though only after discussion with their physician. A medication overview was considered a useful option. We found that communication between health care professionals could be improved if patients could use the PWP to share information with their health care professionals. However, as participants were worried about the language and usability of portals, it was recommended that language should be adapted to the patient level. Another concern was that disease monitoring through Web-based questionnaire use would only be useful if the results were discussed with health care professionals.

CONCLUSIONS

Participants were positive about PWPs and considered them a logical step. Today, most patients tend to be better educated and have internet access, while also being more assertive and better informed about their disease. A PWP could support these patients. Our participants also provided practical suggestions for implementation in current and future PWP developments. The next step will be to develop a portal based on these recommendations and assess whether it meets the needs of patients and health care providers.

Proposing a Transactional Model of eHealth Literacy: Concept Analysis

Background

Electronic health (eHealth) literacy was conceptualized in 2006 as the ability of internet users to locate, evaluate, and act upon web-based health information. Now, advances in eHealth technology have cultivated transactional opportunities for patients to access, share, and monitor health information. However, empirical evidence shows that existing models and measures of eHealth literacy have limited theoretical underpinnings that reflect the transactional capabilities of eHealth. This paper describes a conceptual model based on the Transactional Model of Communication (TMC), in which eHealth literacy is described as an intrapersonal skillset hypothesized as being dynamic; reciprocal; and shaped by social, relational, and cultural contexts.

Objective

The objective of our study was to systematically examine eHealth literacy definitions, models, and measures to propose a refined conceptual and operational definition based on the TMC.

Methods

Walker and Avant’s concept analysis method was used to guide the systematic review of eHealth literacy definitions (n=10), rating scales (n=6), models (n=4), and peer-reviewed model applications (n=16). Subsequent cluster analyses showed salient themes across definitions. Dimensions, antecedents, and consequences reflected in models and measures were extracted and deductively analyzed based on codes consistent with the TMC.

Results

Systematic review evidence revealed incongruity between operational eHealth literacy included in definitions compared with literacies included within models and measures. Theoretical underpinnings of eHealth literacy also remain dismal. Despite the transactional capabilities of eHealth, the role of “communication” in eHealth literacy remains underdeveloped and does not account for physical and cognitive processing abilities necessary for multiway transactions.

Conclusions

The Transactional Model of eHealth Literacy and a corresponding definition are proposed. In this novel model, eHealth literacy comprises a hierarchical intrapersonal skillset that mediates the reciprocal effect of contextual factors (ie, user oriented and task oriented) on patient engagement in health care. More specifically, the intrapersonal skillset counteracts the negative effect of “noise” (or impediments) produced by social and relational contexts. Cutting across health and technology literacies, the intrapersonal skillset of eHealth literacy is operationalized through four literacies that correspond with discrete operative skills: (1) functional (ie, locate and understand); (2) communicative (ie, exchange); (3) critical (ie, evaluate); and (4) translational (ie, apply).

Experiences and Opinions of Adults with Type 2 Diabetes Regarding a Self-Regulation-Based eHealth Intervention Targeting Physical Activity and Sedentary Behaviour

Background: Online interventions targeting a healthy lifestyle in adults with type 2 diabetes are more effective when informed by behaviour change theories. Although these theories provide guidance in developing the content of an intervention, information regarding how to present this content in an engaging way is often lacking. Consequently, incorporating users’ views in the creation of eHealth interventions has become an important target. Methods: Via a qualitative interview study with 21 adults with type 2 diabetes who had completed an online self-regulation-based intervention (‘MyPlan 2.0’), we assessed participants’ opinions regarding the usefulness of the implemented self-regulation techniques, the design of the programme as well as their knowledge regarding physical activity and sedentary behaviour. A directed content analysis was performed to synthesize the interview data. Results: Participants experienced difficulties completing the coping planning component. The simple design of the website was considered helpful, and most participants were aware of the beneficial effects of an active lifestyle. Conclusions: ‘MyPlan 2.0’ was well-accepted by the majority of participants. However, the coping planning component will need to be adapted. Based on these findings, recommendations on how to tailor eHealth interventions to the population of adults with type 2 diabetes have been formulated.

Development of Saudi e-health literacy scale for chronic diseases in Saudi Arabia: using integrated health literacy dimensions

OBJECTIVE

Health literacy has become a global issue, and it is important that patients and individuals are able to use information technology to access health information and educational services. The research objective is to develop a Saudi e-health literacy scale (SeHL) for measuring e-health literacy among Saudis suffering from non-communicable diseases (NCD).

METHODS

Overall, 14 relevant papers in related interdisciplinary fields were reviewed to select the most useful literacy dimensions. From these articles, we extracted the most common dimensions used to measure e-health literacy across the disciplines. Multiple workshops with multidisciplinary team members reviewed and evaluated items for SeHL.

RESULTS

Four key aspects of e-health literacy-use of technology/media, information-seeking, usefulness and confidence-were identified and integrated as e-health literacy dimensions. These will be used to measure e-health literacy among Saudi patients with NCDs. A translation from Arabic to English was performed in order to ensure that translation process was accurate. A SeHL scale was developed to measure e-health literacy among Saudi patients. By understanding e-health literacy levels, we will be able to create a patient-education system to be used by patients in Saudi Arabia.

CONCLUSIONS

As information technology is increasingly used by people of all ages all over the world, e-health literacy has been identified as a key factor in determining health outcomes. To date, no comprehensive scale exists to assess e-health literacy levels among speakers of Arabic, particularly among people with NCD such as diabetes, cardiovascular diseases and hypertension.

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.

eHealth literacy research-Quo vadis?

The concept of electronic health (eHealth) literacy evolved from the social and information sciences and describes competencies necessary to use electronic health services. As it is a rather new topic, and as there is no current overview of the state of the art in research, it is not possible to identify research gaps. Therefore, the objective of this viewpoint article is to increase knowledge on the current state of the art of research in eHealth literacy and to identify gaps in scientific research which should be focused on by the research community in the future. The article provides a current viewpoint of the concept of eHealth literacy and related research. Gaps can be found in terms of a missing "gold standard" regarding both the definition and the measurement of eHealth literacy. Furthermore, there is a need for identifying the implications on eHealth developers, which evolve from the measurement of eHealth literacy in eHealth users. Finally, a stronger inclusion of health professionals, both in the evolving concept and in the measurement of eHealth literacy, is needed in the future.

Health literacy in the eHealth era: A systematic review of the literature

OBJECTIVES

This study aimed to identify studies on online health service use by people with limited health literacy, as the findings could provide insights into how health literacy has been, and should be, addressed in the eHealth era.

METHODS

To identify the relevant literature published since 2010, we performed four rounds of selection-database selection, keyword search, screening of the titles and abstracts, and screening of full texts. This process produced a final of 74 publications.

RESULTS

The themes addressed in the 74 publications fell into five categories: evaluation of health-related content, development and evaluation of eHealth services, development and evaluation of health literacy measurement tools, interventions to improve health literacy, and online health information seeking behavior.

CONCLUSION

Barriers to access to and use of online health information can result from the readability of content and poor usability of eHealth services. We need new health literacy screening tools to identify skills for adequate use of eHealth services. Mobile apps hold great potential for eHealth and mHealth services tailored to people with low health literacy.

PRACTICE IMPLICATIONS

Efforts should be made to make eHealth services easily accessible to low-literacy individuals and to enhance individual health literacy through educational programs.

Exploring the Measurement Properties of the eHealth Literacy Scale (eHEALS) Among Baby Boomers: A Multinational Test of Measurement Invariance

BACKGROUND

The eHealth Literacy Scale (eHEALS) is one of only a few available measurement scales to assess eHealth literacy. Perhaps due to the relative paucity of such measures and the rising importance of eHealth literacy, the eHEALS is increasingly a choice for inclusion in a range of studies across different groups, cultures, and nations. However, despite its growing popularity, questions have been raised over its theoretical foundations, and the factorial validity and multigroup measurement properties of the scale are yet to be investigated fully.

OBJECTIVE

The objective of our study was to examine the factorial validity and measurement invariance of the eHEALS among baby boomers (born between 1946 and 1964) in the United States, United Kingdom, and New Zealand who had used the Internet to search for health information in the last 6 months.

METHODS

Online questionnaires collected data from a random sample of baby boomers from the 3 countries of interest. The theoretical underpinning to eHEALS comprises social cognitive theory and self-efficacy theory. Close scrutiny of eHEALS with analysis of these theories suggests a 3-factor structure to be worth investigating, which has never before been explored. Structural equation modeling tested a 3-factor structure based on the theoretical underpinning to eHEALS and investigated multinational measurement invariance of the eHEALS.

RESULTS

We collected responses (N=996) to the questionnaires using random samples from the 3 countries. Results suggest that the eHEALS comprises a 3-factor structure with a measurement model that falls within all relevant fit indices (root mean square error of approximation, RMSEA=.041, comparative fit index, CFI=.986). Additionally, the scale demonstrates metric invariance (RMSEA=.040, CFI=.984, ΔCFI=.002) and even scalar invariance (RMSEA=.042, CFI=.978, ΔCFI=.008).

CONCLUSIONS

To our knowledge, this is the first study to demonstrate multigroup factorial equivalence of the eHEALS, and did so based on data from 3 diverse nations and random samples drawn from an increasingly important cohort. The results give increased confidence to researchers using the scale in a range of eHealth assessment applications from primary care to health promotions.

Development of the Digital Health Literacy Instrument: Measuring a Broad Spectrum of Health 1.0 and Health 2.0 Skills

Background

With the digitization of health care and the wide availability of Web-based applications, a broad set of skills is essential to properly use such facilities; these skills are called digital health literacy or eHealth literacy. Current instruments to measure digital health literacy focus only on information gathering (Health 1.0 skills) and do not pay attention to interactivity on the Web (Health 2.0). To measure the complete spectrum of Health 1.0 and Health 2.0 skills, including actual competencies, we developed a new instrument. The Digital Health Literacy Instrument (DHLI) measures operational skills, navigation skills, information searching, evaluating reliability, determining relevance, adding self-generated content, and protecting privacy.

Objective

Our objective was to study the distributional properties, reliability, content validity, and construct validity of the DHLI’s self-report scale (21 items) and to explore the feasibility of an additional set of performance-based items (7 items).

Methods

We used a paper-and-pencil survey among a sample of the general Dutch population, stratified by age, sex, and educational level (T1; N=200). The survey consisted of the DHLI, sociodemographics, Internet use, health status, health literacy and the eHealth Literacy Scale (eHEALS). After 2 weeks, we asked participants to complete the DHLI again (T2; n=67). Cronbach alpha and intraclass correlation analysis between T1 and T2 were used to investigate reliability. Principal component analysis was performed to determine content validity. Correlation analyses were used to determine the construct validity.

Results

Respondents (107 female and 93 male) ranged in age from 18 to 84 years (mean 46.4, SD 19.0); 23.0% (46/200) had a lower educational level. Internal consistencies of the total scale (alpha=.87) and the subscales (alpha range .70-.89) were satisfactory, except for protecting privacy (alpha=.57). Distributional properties showed an approximately normal distribution. Test-retest analysis was satisfactory overall (total scale intraclass correlation coefficient=.77; subscale intraclass correlation coefficient range .49-.81). The performance-based items did not together form a single construct (alpha=.47) and should be interpreted individually. Results showed that more complex skills were reflected in a lower number of correct responses. Principal component analysis confirmed the theoretical structure of the self-report scale (76% explained variance). Correlations were as expected, showing significant relations with age (ρ=–.41, P<.001), education (ρ=.14, P=.047), Internet use (ρ=.39, P<.001), health-related Internet use (ρ=.27, P<.001), health status (ρ range .17-.27, P<.001), health literacy (ρ=.31, P<.001), and the eHEALS (ρ=.51, P<.001).

Conclusions

This instrument can be accepted as a new self-report measure to assess digital health literacy, using multiple subscales. Its performance-based items provide an indication of actual skills but should be studied and adapted further. Future research should examine the acceptability of this instrument in other languages and among different populations.

Perceived and Performed eHealth Literacy: Survey and Simulated Performance Test

BACKGROUND

Electronic health (eHealth) literacy of consumers is essential in order to improve information and communication technology (ICT) use for health purposes by ordinary citizens. However, performed eHealth literacy is seldom studied. Therefore, the present study assessed perceived and performed eHealth literacy using the recent conceptualization of health literacy skills.

OBJECTIVE

The aim of this paper was to examine the association between perceived and performed eHealth literacies.

METHODS

In total, 82 Israeli adults participated in the study, all 50 years and older, with a mean age of 67 (SD 11). Of the participants, 60% (49/82) were women and 72% (59/82) had a post-secondary education. The participants were first surveyed and then tested in a computer simulation of health-related Internet tasks. Performed, perceived (eHealth Literacy Scale, eHEALS), and evaluated eHealth literacy were assessed, and performed eHealth literacy was also recorded and re-evaluated later. Performance was scored for successful completion of tasks, and was also assessed by two researchers for motivation, confidence, and amount of help provided.

RESULTS

The skills of accessing, understanding, appraising, applying, and generating new information had decreasing successful completion rates. Generating new information was least correlated with other skills. Perceived and performed eHealth literacies were moderately correlated (r=.34, P=.01) while facets of performance (ie, digital literacy and eHealth literacy) were highly correlated (r=.82, P<.001). Participants low and high in performed eHealth literacy were significantly different: low performers were older and had used the Internet for less time, required more assistance, and were less confident in their conduct than high performers.

CONCLUSIONS

The moderate association between perceived and performed eHealth literacy indicates that the latter should be assessed separately. In as much, the assessment of performed eHealth literacy in clinical settings should entail the structuring of tasks as well as shortening and automatizing the assessment.

Identifying Health Consumers' eHealth Literacy to Decrease Disparities in Accessing eHealth Information

The increasing amount of health information available on the Internet highlights the importance of eHealth literacy skills for health consumers. Low eHealth literacy results in disparities in health consumers' ability to access and use eHealth information. The purpose of this study was to assess the perceived eHealth literacy 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. Participants were recruited from three public library branches in a Northeast Florida community. The eHealth Literacy Scale was used. The majority of participants (n = 108) reported they knew how and where to find health information and how to use it to make health decisions; knowledge of what health resources were available and confidence in the ability to distinguish high- from low-quality information were considerably less. The findings suggest the need for eHealth education and support to health consumers from healthcare professionals, in particular, how to access and evaluate the quality of health information.

Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 2: Six-Month Outcomes of a Randomized Controlled Trial and Qualitative Feedback From Participants

BACKGROUND

Despite empirical evidence supporting the use of Web-based interventions for problem drinking, much remains unknown about factors that influence their effectiveness.

OBJECTIVE

We evaluated the performance of 2 resources for people who want to achieve and maintain abstinence: SMART Recovery (SR) and Overcoming Addictions (OA). OA is a Web application based on SR. We also examined participant and intervention-related factors hypothesized to impact clinical outcomes of Web-based interventions.

METHODS

We recruited 189 heavy drinkers through SR's website and in-person meetings throughout the United States. We began by randomly assigning participants to (1) SR meetings alone, (2) OA alone, and (3) OA and SR (OA+SR). Recruitment challenges compelled us to assign participants only to SR (n=86) or OA+SR (n=102). The experimental hypotheses were as follows: (1) Both groups will reduce their drinking and alcohol-related consequences at follow-up compared with their baseline levels, and (2) The OA+SR condition will reduce their drinking and alcohol or drug-related consequences more than the SR only condition. Additionally, we derived 3 groups empirically (SR, OA, and OA+SR) based on the participants' actual use of each intervention and conducted analyses by comparing them. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol or drug-related consequences. Postbaseline assessments were conducted by phone at 3 and 6 months. Secondary analyses explored whether clinical issues (eg, severity of alcohol problems, level of distress, readiness to change) or intervention-related factors (eg, Internet fluency, satisfaction with site) affected outcomes.

RESULTS

Both intent-to-treat analyses and the actual-use analyses showed highly significant improvement from baseline to follow-ups for all 3 groups. Mean within-subject effect sizes were large (d>0.8) overall. There was no significant difference between groups in the amount of improvement from baseline to the average of the follow-ups. We found that participants who stopped drinking before joining the clinical trial had significantly better outcomes than participants who were still drinking when they joined the study. Neither Internet fluency nor participants' reported ease of navigating the site had an impact on outcomes.

CONCLUSIONS

These results support our first experimental hypothesis but not the second. On average, participants improved on all dependent measures. Both SR and OA helped participants recover from their problem drinking. Web-based interventions can help even those individuals with lengthy histories of heavy drinking to make clinically significant reductions in their consumption and related problems. These interventions work well for individuals in the action stage of change.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01389297; https://clinicaltrials.gov/ct2/show/NCT01389297 (Archived by WebCite at http://www.webcitation.org/6kLNUNDcc).

Making Quality Health Websites a National Public Health Priority: Toward Quality Standards

Background

Most US adults have limited health literacy skills. They struggle to understand complex health information and services and to make informed health decisions. The Internet has quickly become one of the most popular places for people to search for information about their health, thereby making access to quality information on the Web a priority. However, there are no standardized criteria for evaluating Web-based health information. Every 10 years, the US Department of Health and Human Services' Office of Disease Prevention and Health Promotion (ODPHP) develops a set of measurable objectives for improving the health of the nation over the coming decade, known as Healthy People. There are two objectives in Healthy People 2020 related to website quality. The first is objective Health Communication and Health Information Technology (HC/HIT) 8.1: increase the proportion of health-related websites that meet 3 or more evaluation criteria for disclosing information that can be used to assess information reliability. The second is objective HC/HIT-8.2: increase the proportion of health-related websites that follow established usability principles.

Objective

The ODPHP conducted a nationwide assessment of the quality of Web-based health information using the Healthy People 2020 objectives. The ODPHP aimed to establish (1) a standardized approach to defining and measuring the quality of health websites; (2) benchmarks for measurement; (3) baseline data points to capture the current status of website quality; and (4) targets to drive improvement.

Methods

The ODPHP developed the National Quality Health Website Survey instrument to assess the quality of health-related websites. The ODPHP used this survey to review 100 top-ranked health-related websites in order to set baseline data points for these two objectives. The ODPHP then set targets to drive improvement by 2020.

Results

This study reviewed 100 health-related websites. For objective HC/HIT-8.1, a total of 58 out of 100 (58.0%) websites met 3 or more out of 6 reliability criteria. For objective HC/HIT-8.2, a total of 42 out of 100 (42.0%) websites followed 10 or more out of 19 established usability principles. On the basis of these baseline data points, ODPHP set targets for the year 2020 that meet the minimal statistical significance—increasing objective HC/HIT-8.1 data point to 70.5% and objective HC/HIT-8.2 data point to 55.7%.

Conclusions

This research is a critical first step in evaluating the quality of Web-based health information. The criteria proposed by ODPHP provide methods to assess website quality for professionals designing, developing, and managing health-related websites. The criteria, baseline data, and targets are valuable tools for driving quality improvement.

Associations of eHealth Literacy With Health Behavior Among Adult Internet Users

Background

In the rapidly developing use of the Internet in society, eHealth literacy—having the skills to utilize health information on the Internet—has become an important prerequisite for promoting healthy behavior. However, little is known about whether eHealth literacy is associated with health behavior in a representative sample of adult Internet users.

Objective

The aim of this study was to examine the association between eHealth literacy and general health behavior (cigarette smoking, physical exercise, alcohol consumption, sleeping hours, eating breakfast, eating between meals, and balanced nutrition) among adult Internet users in Japan.

Methods

The participants were recruited among registrants of a Japanese Internet research service company and asked to answer a cross-sectional Internet-based survey in 2012. The potential respondents (N=10,178) were randomly and blindly invited via email from the registrants in accordance with the set sample size and other attributes. eHealth literacy was assessed using the Japanese version of the eHealth Literacy Scale. The self-reported health behaviors investigated included never smoking cigarettes, physical exercise, alcohol consumption, sleeping hours, eating breakfast, not eating between meals, and balanced nutrition. We obtained details of sociodemographic attributes (sex, age, marital status, educational attainment, and household income level) and frequency of conducting Internet searches. To determine the association of each health behavior with eHealth literacy, we performed a logistic regression analysis; we adjusted for sociodemographic attributes and frequency of Internet searching as well as for other health behaviors that were statistically significant with respect to eHealth literacy in univariate analyses.

Results

We analyzed the data of 2115 adults (response rate: 24.04%, 2142/10,178; male: 49.74%, 1052/2115; age: mean 39.7, SD 10.9 years) who responded to the survey. Logistic regression analysis showed that individuals with high eHealth literacy were significantly more likely to exhibit the good health behaviors of physical exercise (adjusted odds ratio [AOR] 1.377, 95% CI 1.131-1.678) and eating a balanced diet (AOR 1.572, 95% CI 1.274-1.940) than individuals with low eHealth literacy.

Conclusions

We found that some health behaviors, including exercise and balanced nutrition, were independently associated with eHealth literacy among Japanese adult Internet users.