eHealth Literacy

According to Pew Research Centerexternal icon, approximately 52% of American adults in 2000 said they used the Internet compared to 89% in early 2018; a trend that is likely to continue rising.

Yet individuals are not the only ones using the Internet more. Organizations have also mobilized the Internet to deliver health services. The World Health Organizationpdf iconexternal icon (WHO) reports 58% of Member States surveyed reported they have an eHealth strategy, signaling a global movement. WHO defines electronic health (eHealth) services as the cost-effective and secure use of information communication technologies to support health and health-related fields. Examples include electronic communication between patients and providers, electronic medical records, patient portals, and personal health records. A category of eHealth is mobile health (mHealth) including phones, tablets, and computers to use applications (apps), wearable tracking devices, and texting services. The research referenced on this page may include mHealth when referring to eHealth.

Defining health literacy and eHealth literacy

In Healthy People 2030, the U.S. Department of Health and Human Services (HHS) updated the definition of health literacy to include personal health literacy as well as organizational health literacy. HHS provides the following definitions:

• Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
• Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others

Norman and Skinner (2006)external icon define eHealth literacy as the ability to appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.

Readers are cautioned not to substitute eHealth literacy for health literacy as noted by Monkman and colleagues (2017)external icon. The authors analyzed participant responses (N=36) on the Newest Vital Sign to measure health literacy, and used the eHealth Literacy Scale (eHEALS) to assess eHealth literacy. Their findings suggest assessing health literacy and eHealth literacy separately.

Assessing health literacy in eHealth studies

In 2021, Sanders and colleagues published the results of a randomized controlled trial in which they examined the impact of a six-week, peer-led intervention on eHealth literacy, general health literacy, HIV-related health literacy, and numeracy among people living with HIV (PLWH). The investigators used the Electronic Health Literacy Scale to measure eHealth literacy, the Rapid Estimate of Adult Literacy to measure general health literacy, the Brief Estimate of Health Knowledge and Action-HIV to measure HIV-related health literacy, and the Newest Vital Sign to measure numeracy. At the end of the intervention and six months later, the intervention group had statistically significant improvements in eHealth literacy and HIV-related health literacy compared to the control group. Neither the control group nor the intervention group showed any statistically significant improvement in general health literacy or numeracy.

(For more on numeracy, see Numeracy Research Summaries and Understanding Literacy & Numeracy. Read more about health literacy and PLWH too.)

Kim & Xie (2017)external icon conducted a literature review (N=74) to assess how people with limited health literacy use online health services. Only nine studies reported interventions focused on improving health literacy. The review indicates that six of those nine reported positive effects on knowledge, skills, and confidence using eHealth. Measures: Thirty-three studies reported measuring participants’ health literacy level. Five studies used the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and four studies used the Rapid Estimate of Adult Literacy in Medicine (REALM). Eight of the 33 studies used the eHealth Literacy Scale (eHEALS), which as noted previously may not accurately capture health literacy but rather a sub-category—eHealth literacy. Recommendations: When designing websites, the authors suggest improving readability in web-based apps and mobile apps (sixth grade reading level or below), increasing content available for people with limited English proficiency, using plain language strategies such as shorter sentences, use of bullets, and incorporating more consistent design with icons and pictures.

Most studies in this review reported a mean participant age between 46-66 years. However, in an intervention study by Horvath & Bauermeister (2017) that focused on a population of men self-identifying as having sex with men, the mean age of participants was of 21 years. Researchers assessed participants’ eHealth literacy and randomized them into tailored and non-tailored message groups for an HIV/STI (sexually transmitted infection) online intervention. Participants with low eHealth literacy in the non-tailored group were less likely to educate others about HIV/STIs and less likely to report deciding to get tested at 30-day follow-up. Findings from this study suggest that tailoring and eHealth literacy may influence behavior change.

Visit Health Literacy Onlineexternal icon to access research-based guidance for better web and digital tool design.

Factors associated with use of eHealth

Wearable digital devices (also known as fitness trackers) have become popular tools for providing users with information about their health. However, a variety of barriers to their use lead to disparities among populations. Holko and colleagues (2022) identified those barriers by surveying more than 1,000 adult patients in six Federally Qualified Health Centers (FQHCs) across the United States. FQHCs are community-based health care providers that receive federal funds to deliver primary care services in areas with limited access to medical care.

Of the five hindering factors to device ownership, three were related to health literacy: language barriers, lack of access to devices due to cost, and the need for information on how to use the devices. Of the six helping factors to ownership, three were related to health literacy: the belief that the devices could provide relevant health information, the desire to learn how the devices could provide health information, and the desire to have access to the devices (thus making the information they provide accessible). The authors also noted the importance of using culturally appropriate language when referring to these devices. When the researchers used the term “fitness tracker,” some Spanish-speaking participants were concerned that the devices could track their movements. The authors also provide recommendations for overcoming barriers to the use of wearable digital health devices.

As more people use the internet and social media platforms to access health information, more organizations are using these digital channels to share their health information. A study published in 2022 by Arshanapally et al indicated that a paid digital marketing campaign increased the rate at which parents of newborns through preschoolers downloaded a mobile health app that tracks childhood milestones. The authors found that messages—in English and Spanish—that included animated GIFs and simple, direct calls to action prompted more readers to click through to the app. The authors also discuss the features and limitations of the digital marketing platforms they used.

A cross-sectional study published in 2021 assessed whether health literacy, access to technology, and sociodemographic factors are associated with online health information-seeking behavior. Questions from the Health Information National Trends Survey were used to measure health-related information seeking. Health literacy was assessed using three health literacy items from the 2016 Behavioral Risk Factor Surveillance System Questionnaire. The data showed that people with higher health literacy scores and greater access to technology devices were more likely to use the internet for health information compared to people with lower health literacy scores or less access to technology.

The authors also found that

• Health-related internet use among adults increased with age until about 38 years, decreased between 38 and 71 years, and increased again after 71 years.
• People who reported poor or fair health status had higher health-related internet use scores than people who reported good, very good, or excellent health status.
• Nearly half of respondents used the internet to communicate with their health care provider.
• More than half of respondents searched for online information about diet, weight, and physical activity.
• More than half of respondents went online to search for health-related information about someone else.

In a survey conducted by Escoffery’s (2017)external icon, more than 70% of the 400 participants reported they owned laptops and smartphones, and nearly half reported using the Internet several times a day. Female participants reported higher use of health apps and were more likely to have apps related to exercise and diet compared to males. However, males were more likely to report looking for information for themselves the last time they searched the Internet compared to females.

Spooner and colleagues (2016)external icon surveyed adults (N=3677) and found that Hispanic people, people the authors categorized as non-Hispanic others, and people from higher income households were more likely to have communicated with a provider via text, phone app, or social media. Those who preferred non-Internet sources of information such as books, primary care provider, or brochures were more likely to be people over 65 years, Hispanic people, and people with less than a high school education.

Understanding use of eHealth: Tailoring for success

Trust and confidence

In addition to socio-demographics, we must also consider the possible association between eHealth literacy and perceived trust in source, self-efficacy (confidence), and other factors. Paige and colleagues (2017)external icon surveyed participants (N=402) to assess use of internet health resources in the last 12 months. While 75% of respondents said they had skills to evaluate online health resources, only 60% reported confidence in evaluating the quality or these resources and making health decisions based on that information. Females with lower eHealth literacy reported higher trust in online sources compared to men with low eHealth literacy and compared to females with higher eHealth literacy. Researchers also learned that older adults with low eHealth literacy were more likely to trust online channels compared to younger adults. Compared to Caucasian (White) participants with high eHealth literacy, Black/African American participants with high eHealth literacy were more likely to report higher trust in online information from government, charitable, and religious organizations.

A growing number of studies are exploring the use of eHealth resources and self-management of chronic conditions. Stellefson and colleagues (2017)external icon surveyed (N=1270) patients with chronic obstructive pulmonary disease (COPD). Higher eHealth literacy was associated with higher COPD knowledge and use of web-based resources. Most participants were laptop and desktop users, and 25% reported use of wireless devices including phones. Greater COPD self-efficacy was significantly associated with finding helpful resources online, knowing how to use them to make health decisions, and feeling able to distinguish quality of materials. Escoffery (2017)external icon, referenced earlier, also reported similar findings related to self-efficacy. Participants in that study reported high trust in doctors, the Internet, and government agencies.

Other factors

As a follow-up to a failed attempt to enroll participants for a trial, Thies and colleagues (2017)external icon conducted interviews (N=22) and learned about the various aspects of readiness to use eHealth resources among patients and health professionals. The authors suggest a health team needs to assess patients’ eHealth literacy including proficiency with technology and whether patients have phones that support apps. It is equally important to assess patients’ motivation for behavior change and the degree to which their health condition is under control. The authors learned that barriers that prevented health professionals from adopting the app in this trial included: not having enough time in a twenty-minute visit to explain and download the app, lack of integration to an electronic health record, and no dedicated staff to support the trial.

In the Spooner and colleagues (2016)external icon study described earlier, 65%-85% of participants reported interest in exchanging information with providers electronically, but 68% said they had no online patient-provider communication. Researchers posited that access offered by the provider and the individual’s personal health information online access behavior predict occurrence of patient-provider communication.

An important role for health and communication professionals

From these few studies we know adults use eHealth resources. We also know that health literacy and eHealth literacy are influential factors in successful use of eHealth resources. What we are still learning is how greater emphasis on eHealth may disproportionately affect groups with limited health literacy. In light of what is known,

Health professionals can

• Assess how confident a person feels about managing their own health.
• Identify a patient’s knowledge or skill gaps and together create a plan that is understandable.
• Identify a health team member who can teach patients how to evaluate web contentexternal icon and who can suggest top web sourcesexternal icon for patient health information.
• Ask patients about their preferred and available communication options, e.g., telephone, teleconference, email, apps, patient portal, or another preference.

Communication professionals can

• Use plain language strategiesexternal icon – shorter sentences, bulleted lists.
• Assess readability of all materials.
• Use Health Literacy Onlineexternal icon recommendations.
• Incorporate images and graphics that complement and reinforce text.
• Design materials for populations with limited English skills.
• Consider demographic characteristics when determining the channel and source for different audience segments.