E-health literacy and associated factors among chronic patients in a low-income country: a cross-sectional survey

Noncommunicable diseases (NCDs) are “also known as chronic diseases, which tend to be of extended period resulted from a combination of genetic, physiological, environmental and behavioral factors” [1]. According to the world health organization’s (WHO) report in 2018, non-communicable diseases (NCDs) are accounted for the deaths of 41 million people each year, equivalent to 71% of all deaths globally [1]. In Ethiopia, 39% of all deaths are estimated to be due to Non-communicable diseases [2]. Worldwide, Numerous activities and initiatives are undertaking to alleviate this huge number of incidence and death by one third as indicated in United Nations sustainable development goals (SDG) by 2030 [3]. Literatures depicted that patient empowerment and education focused on self-management and health promotion is very important [4, 5]. Enabling patients to ask about their condition, to follow medication instructions, to improve their adherence and to enhance their engagement in the healthcare process is not an easy task. But, helping patients to help themselves is a key step in improving the overall health status and even in reducing the patient load in hospitals specially in low-income countries [6‐8].

The development in internet access and the improvements in performance due to the new technologies makes the internet to be the focus of many new healthcare improvements [9, 10]. Systematic reviews conducted in different chronic disease cases have steadily stated that eHealth interventions for people with chronic diseases have considerable impact on enhancing self-management and patient engagement for their healthcare [11‐14]. Despite of the limited number of studies from the perspective of chronic patients in middle and low-income countries, eHealth literacy is pointed in several literatures as one of the major skill required to be acquired by patients with chronic diseases if eHealth interventions are tailored to improve patient’s self-management and facilitating patient’s engagement in the care service [11, 15, 16]. In addition to the low internet penetration in Ethiopia (15%), the gap in skill to find and evaluate online resources is another challenge. E-Health literacy is defined as “one’s ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained for addressing or solving a health problem.” [17]. As the concept of eHealth literacy is a function of different set of skills, it is highly affected by multidimensional factors including sociocultural, economical and behavioral factors [18]. According to the Lily model, eHealth literacy is a congregate set of six basic skills (traditional literacy, health literacy, information literacy, scientific literacy, media literacy and computer literacy) [19]. The details of each components are available in the attached table as Additional file.

Although it is not mandatory to have a mastery in all the six literacy skills, the gap in any of these could be a constraint to benefit from eHealth merits. As a result, one has to have at least a moderate level of skills in all the literacies to make an effective use of the outrageous eHealth resources. To explore the eHealth literacy level and its associated factors in a population with chronic disease is more urgent and important now than ever. The lesson from COVID-19 thought the world that eHealth is not optional and luxurious approach to healthcare rather it is necessary, safer and effective way of providing healthcare service for both patients with underlying conditions and others during such times. The escalating number of internet users, information needs and smartphone penetration in African countries are the most important driving reasons ringing the relevance of assessing eHealth literacy & factors thereof among patients to harness eHealth merits. Given the gap in literatures regarding chronic patients’ eHealth literacy skill in Africa, conducting this study will contribute to the scientific knowledge in addressing the research question in this region. Hence, the aim of this study was to assess eHealth literacy level and associated factors among internet user chronic patients in University of Gondar comprehensive specialized hospital, North West Ethiopia.

In total, 423 study subjects were approached and included in the study from March 02 to May 17, 2019. The response rate was 95.3%. The majority of respondents 268 (66.3%) were males and the mean age participants was 35.58 ± 14.8 years. A large number of respondents were diploma holders and above 208 (51.5%). Most of the study participants were urban residents352 (87.1%). About 150 (37.1%) of the respondents were governmental employees. See (Table 1) for detail descriptive statistics.

The purpose of this study was to determine the level of eHealth literacy skill and associated factors among internet user chronic patients in University of Gondar Comprehensive Specialized Hospital. The result showed that eHealth literacy skill was relatively low with 188 (46.5%) of the participants reporting high eHealth literacy skill. The result also shows 353 (87.3%) use of daily and several days a week internet use of participants with more than three fourth of them using it for browsing social medias like Facebook. Younger, educated and peoples from urban residence were more frequent users of internet. Educational status, occupation type, residence, self-reported health status, monthly salary, frequency of internet use, knowledge about the availability and importance of online resources, attitude toward using online resources and computer literacy level were statistically significant factors associated with eHealth literacy skill among internet user chronic patients in this study. This study also found that, the majority of respondents 268 (66.3%) were males and there was no significant chi square difference among the groups which is different from a study which revealed that males are superior internet users [41]. This could be due to the fact that the participants in this study are all internet users. The mean age was 35.58 ± 14.8 years and when compared to elders, youngsters were more frequent internet users. This could be due to the internet penetration rate among youngsters which is related with internet using habit [42].

when compared to studies conducted in other countries, the mean eHealth literacy score of chronic patients in this study was relatively lower and this could be due to the less internet penetration and economic berries in low-income countries like Ethiopia [43‐45]. The univariate analysis indicated that patient’s educational status, occupation type, permanent residence, self-reported health status, monthly salary, frequency of internet use, knowledge about the availability and importance of online health information resources, attitude towards using online sources and computer literacy level of participants were significantly associated with eHealth literacy skill with 95% confidence interval, (p-value< 0.05). After adjustment for the covariates, except for two variables (residence and frequency of internet use) all the other predictor variables were significantly associated with eHealth literacy skill with p-value< 0.05. See Table 2 for detail. Patients with diploma and above education level were 3.48 (CI: 1.54, 7.87) times more likely to have high eHealth literacy skill compared with those with primary and below education level (p-value< 0.05). This finding is similar with other studies in different populations which underlined the need for capacity building and continuous educational support for chronic patients with lower educational status [15, 46, 47]. Participants who works in governmental organizations were more likely to possess high eHealth literacy when compared to unemployed chronic patients with AOR: 1.73, 95%CI: (1.11, 2.68). This study also indicated that chronic patients living in urban setting are COR: 3.77 (95%CI: (1.88, 7.57) times more likely to possess high eHealth literacy skill compared to patients residing on rural setting. The finding seems obvious in most cases [48, 49] but it is different in developed countries in which majority of rural patients have computer and internet connection in their home preferring internet for health information [50‐52]. Income was the other significant factor associated with eHealth literacy skill among chronic patients in which patients those who have a monthly income > 5500 ETB are more likely to have higher eHealth literacy skill compared with those who earn monthly income < 800 ETB with AOR:4.44, (95%CI, 1.32, 14.86), P-value< 0.05. Higher income is highly associated with higher eHealth literacy skill in different studies [53, 54]. In this study, patients who perceived their health status as good were 3.97 times more likely to have higher eHealth literacy skill with 95% CI: (1.38, 11.38) and p-value< 0.05 compared to those who perceive their health status as bad. This finding is similar with other studies done elsewhere which argues the more likely possession of eHealth literacy skill by patients who perceive their health status as good [30, 55, 56]. This could be due to the fact that peoples with perceived good health condition are more likely to be looking for possible medical treatment and preventive actions before their health get worse. Frequency of internet use was also the predictive variable with p-value< 0.05 where chronic patients those who use internet on a daily basis are almost 3 (AOR: 2.96) times more likely to have high eHealth literacy skill when compared to those who use internet 1 day and less than 1 day a week with 95%CI: (1.08, 6.76). This finding is similar with different studies confirming that frequent internet users possess higher eHealth literacy skill [15, 30, 57, 58]. In addition, higher computer literacy was also highly associated with higher eHealth literacy skill which is similar with studies done elsewhere [59‐61]. Knowledge regarding the availability and importance of health information and attitude toward using online resources were significant factors associated with eHealth literacy skill where patients with good knowledge and favorable attitude toward online resources are more likely to possess high eHealth literacy skill with AOR: 3.12, 95% CI: (1.61, 5.3) and AOR: 2.94, 95%CI: (1.07, 3.52) respectively. This finding was also in line with other studies [62‐65].

This study found that educational status, perceived health status, income and frequency of internet use have significant impact on consumers eHealth literacy skill confirming with several studies. It also suggested other factors like knowledge about availability and importance of online sources, attitude and computer literacy are important variables associated with eHealth literacy level in this population. Internet use and eHealth literacy level of chronic patients in this setting is relatively low. This clearly implicate the need to fill the skill gap in eHealth literacy among chronic patients which may help them in building their capacity to find and evaluate relevant online sources for their health-related decisions.