How do we determine whether individuals have the capacity to engage with eHealth programs and interventions? Health practitioners, eHealth developers, and researchers alike need to know if electronic health tools are suitable methods for effectively promoting population health and aiding health care. An often unmentioned assumption underlying the deployment of eHealth resources intended for public consumption is that consumers have the skills to use such resources to their optimal level. Yet, with over 40% of US and Canadian adults having basic (or prose) literacy levels below what is considered necessary to optimally participate in civil society [1
], it is unlikely that eHealth will provide population-level benefits as it requires much more than just prose literacy. Consumer-directed eHealth requires the ability to seek out, find, evaluate and appraise, integrate, and apply what is gained in electronic environments toward solving a health problem, or eHealth literacy
]. This composite skill requires that people are able to work with technology, critically think about issues of media and science, and navigate through a vast array of information tools and sources to acquire the information necessary to make decisions.
Informed decision making requires that people can adequately access, understand, and process health information to meet their needs. Access refers both to the literal ability to access information resources like health websites, but also the quality of this access. This includes the quality of the technology (eg, Internet connection speed, hardware, software) and the conditions of use, such as whether people have the privacy or time to properly engage eHealth resources. Access in the Internet age also requires an ability to derive meaning from text. As basic literacy skills rise, so does the ability to use computers effectively to solve problems, regardless of age, income, or education [4
Given issues of access and literacy, health practitioners in clinical and public health settings require an understanding of what abilities their patients/clients have before recommending eHealth resources. This article describes the development and psychometric evaluation of a measure of eHealth literacy designed for broad use in supporting consumer eHealth in public health and clinical care.
Health and Literacy in an Electronic Context
Health literacy has been identified as a public health goal for the 21st century and a significant challenge facing health care globally [5
]. The recent Institute of Medicine report [8
] on health literacy highlights the need to look at the different contexts where health information is obtained and used as part of a strategy of addressing health literacy. More than ever, this health information context includes electronic resources such as the World Wide Web and other technologies that now play an increasing role in consumer health [9
]. Electronic health information introduces challenges pertaining to both the medium and the message that differ substantially from other media forms. Issues of access to information, retrieval, evaluation and appraisal, and other quality markers fundamentally differ in unregulated environments such as the Web, where new information is added every minute of every day. Being health literate in an electronic world requires a different or at least expanded set of skills to engage in health care and promotion, or eHealth literacy.
eHealth literacy is comprised of six core skills, or literacies: (1) traditional literacy, (2) health literacy, (3) information literacy, (4) scientific literacy, (5) media literacy, and (6) computer literacy [3
]. The foundations of the eHealth literacy concept are based in part on social cognitive theory and self-efficacy theory [11
], which promote competencies and confidence as precursors to behavior change and skill development and are described in detail elsewhere [3
]. The challenge is developing the means to assess this skill in order to provide strategies to assist consumers in using eHealth to its fullest potential.
The eHealth Literacy Scale (eHEALS) has been developed to address the need to assess eHealth literacy for a wide range of populations and contexts. The eHEALS is a self-report tool that can be administered by a health professional and is based on an individual’s perception of her or his own skills and knowledge within each measured domain. The instrument is designed to provide a general estimate of consumer eHealth-related skills that can be used to inform clinical decision making and health promotion planning with individuals or specific populations.
It is not unreasonable to assume a link between eHealth literacy and technology use in general. The more an individual uses technology, the more likely they are to develop skills in using that technology as a tool. For that reason, youth can serve as an ideal group to test a measure of eHealth literacy given this population’s high familiarity with technology. In Canada, 99% of adolescents have access to the Internet, and the majority of Canadian teens report using the Internet for health in some capacity [12
]. Although questions remain about the quality of this Internet access [13
], this group is most likely to be familiar with information technology tools and is more likely to use eHealth than most other populations[13
]. Despite having relative familiarity with eHealth, many adolescents are unable to derive the full benefit from it. Gray and colleagues looked at the issue of health literacy and technology in adolescents and found many teens experienced difficulty engaging with eHealth and understanding or using health information online, despite frequently using information technologies [15
Regardless of the population of interest, the need to navigate the Internet with confidence is particularly important for health issues in which the consequences for using low quality, misleading, or false information are great [16
]. By providing tools and resources to evaluate health information online and critically appraise eHealth resources, we offer an opportunity to both protect consumers from harm and empower them at the same time [17
]. In order to provide relevant tools to aid consumers in navigating through eHealth, an understanding of what skills consumers possess at the outset, or their eHealth literacy, is required. This study’s objective is to develop and test a functional method of assessing perceived eHealth literacy skills to aid consumers and health practitioners alike in assessing a fit with eHealth to support clinical care and promote population health.
A review of the literature was undertaken on each of the six key literacies that comprise Norman and Skinner’s eHealth literacy model [3
] in the Medline, PsycInfo, ERIC, Sociological Abstracts, and Web of Science databases to identify existing literacy measures. Although some measures were found, few had been rigorously psychometrically evaluated, and some were designed for specific projects that were not relevant to how the literacy concept was conceived of in relation to the eHealth literacy model. Given these constraints, it was decided that creating items from scratch was appropriate. Based on the theoretical model, an initial item pool was established and an iterative process of item reduction was used to create an instrument that could be easily deployed within a variety of settings and contexts as intended. The initial battery was circulated by the investigator to colleagues working in the area of eHealth for comment and review. After this initial review, the eHEALS was given to youth involved with TeenNet Research [19
] to test general readability, item wording, and relevance. Youth are a consumer group with developing literacy skills and thus were expected to reflect the reading needs of a lower literacy population. These youth ranged in age from 12 to 19, came from many different social, ethnic, and educational backgrounds, and represented diverse interests among the adolescent population. Reviews were conducted in small groups over the course of 3 months. Further readability tests were conducted during the pilot phase of the project described below. Revisions were made as necessary before being pilot tested with a larger number of participants.
A total of 89 youth (ages 14-24) completed the initial, larger version of the eHEALS as part of a pilot test and provided comments on the readability and item wording in focus groups immediately following completion of the instrument in paper form. The eHEALS was subsequently reviewed and modified to create the final battery of 8 items based on the qualitative and response feedback from participants, theoretical fit, and comprehensiveness. This study represents its first full psychometric assessment.