Research paper
eHealth literacy in chronic disease patients: An item response theory analysis of the eHealth literacy scale (eHEALS)

https://doi.org/10.1016/j.pec.2016.09.008Get rights and content

Highlights

  • A 1-factor structure of eHEALS was confirmed.

  • Analyses produced acceptable reliability estimates (ω = 0.94; α = 0.90).

  • Assumptions of the Partial Credit Model were met.

  • Item threshold values revealed the possible need for additional response options.

  • Findings provide reliability evidence for eHEALS use with chronic disease patients.

Abstract

Background

Chronic disease patients are affected by low computer and health literacy, which negatively affects their ability to benefit from access to online health information.

Objective

To estimate reliability and confirm model specifications for eHealth Literacy Scale (eHEALS) scores among chronic disease patients using Classical Test (CTT) and Item Response Theory techniques.

Methods

A stratified sample of Black/African American (N = 341) and Caucasian (N = 343) adults with chronic disease completed an online survey including the eHEALS. Item discrimination was explored using bi-variate correlations and Cronbach’s alpha for internal consistency. A categorical confirmatory factor analysis tested a one-factor structure of eHEALS scores. Item characteristic curves, in-fit/outfit statistics, omega coefficient, and item reliability and separation estimates were computed.

Results

A 1-factor structure of eHEALS was confirmed by statistically significant standardized item loadings, acceptable model fit indices (CFI/TLI > 0.90), and 70% variance explained by the model. Item response categories increased with higher theta levels, and there was evidence of acceptable reliability (ω = 0.94; item reliability = 89; item separation = 8.54).

Conclusion

eHEALS scores are a valid and reliable measure of self-reported eHealth literacy among Internet-using chronic disease patients.

Practice implications

Providers can use eHEALS to help identify patients’ eHealth literacy skills.

Introduction

In the evolving technological era, patients now have online access to personal healthcare information, as well as the ability to communicate with peers and providers through the Internet and mobile devices. Although a rising number of patients living with chronic disease are accessing online health information [1], research suggests many of these patients lack the skills to effectively navigate and identify relevant health information [2]. Individuals who live with chronic disease are considered unique online health information seekers, because they are searching for specialized and sometimes sophisticated health information that will help them to learn as much as possible about their condition [3]. Chronic disease patients tend to be older [4], disproportionately affected by low socioeconomic status [5], experience poor health-related outcomes [6], and report both low computer and health literacy [7]. As such, it is critical to understand the knowledge and self-efficacy that chronic disease patients with diverse backgrounds have in their ability to access online health information.

eHealth literacy is defined as an individual’s capability to locate, comprehend, and evaluate online health information to make informed health decisions [8]. Chronic disease patients who lack adequate eHealth literacy skills often feel overwhelmed, confused, and frightened when searching for health information online [9], which can lead to resisting the use of the Internet as a source of health information. Healthcare providers who are aware of their patients’ eHealth literacy skillsets can better recommend relevant health information resource or train them to use technology-based resource [9]. Improving patients’ skills using Internet-based health resources, such as interactive discussion forums and secure messaging platforms [10], may enhance patients’ health-related knowledge and self-efficacy and self-manage their chronic condition(s).

A central theoretical construct of eHealth literacy is self-efficacy, which is an estimate of an individual’s belief in his or her own ability to succeed in specific situations or to accomplish a specified task [11]. High self-efficacy and eHealth literacy predict engagement in health promoting behaviors, such as chronic disease self-management [8], [12]. Measuring health seekers’ self-efficacy to successfully locate, understand, and act on web-based health information is particularly important for patients living with chronic disease, because these patient populations experience barriers to healthcare access, cognitive declines attributable to advanced age, and physical immobility [13], [14].

Currently, the only instrument specifically designed to measure eHealth literacy is the eHealth Literacy Scale (eHEALS). eHEALS was developed to measure an individual’s confidence in their ability to locate and evaluate health information from static webpages, as well as to inform the development and recommendation of health programs that align with a patient’s perceived eHealth literacy skill level [15]. While eHEALS has been used to assess eHealth literacy among patients living with chronic disease [16], [17]; there is limited evidence about the reliability and validity of eHealth literacy scores within this population.

van der Vaart and colleagues [18] adapted the original English version of eHEALS to the Dutch language and reported adequate validity and reliability evidence of eHEALS scores earned by patients with rheumatic arthritis (N = 189). However, weak correlations between eHEALS scores and Internet use brought into question the validity of eHEALS to measure eHealth literacy among English-speaking patients living with chronic disease [19]. Moreover, the sample was limited to patients living with only one chronic disease and the size of the sample did not meet sampling recommendations for CFA [20]. Given the limitations in previous research administering the eHEALS in chronic disease populations, the purpose of this study was to explore the one-factor structure and reliability of eHEALS scores among a diverse sample of US chronic disease patients who report using the Internet to find health information. This study goes beyond classical measurement approaches [21], [22] by applying a higher-level Item Response Theory (IRT) technique to explore the reliability and internal structure of responses to eHEALS items.

Section snippets

Sample and procedures

Participants were recruited to complete a web-based survey through an opt-in Qualtrics Panel. Participants who completed the survey received a cash value reward credited to their Qualtrics account. Institutional Review Board approval was obtained to prior to data collection. Participants were included in the main analyses if they reported: (1) using the Internet or e-mail at least once in the past 12 months, and (2) currently living with at least one chronic disease.

eHealth literacy

eHealth literacy was

Sample and eHealth literacy description

Of the 811 participants who completed the survey, 648 (79.9%) met inclusion criteria. Participants reported being diagnosed with cardiovascular disease (n = 311; 47.9%), arthritis (n = 131; 20.2%), mental health disorder (n = 181; 27.9%), chronic lung disease (n = 52; 8.1%), and cancer (n = 31; 4.5%). A large proportion reported being diagnosed with another chronic disease not listed (n = 269; 41.5%).

The final sample consisted of mostly females (n = 493; 72.1%) and almost equal representation from

Discussion and conclusion

Findings of this study support the intended use of eHEALS to measure self-reported eHealth literacy among chronic disease patients. Similar to other studies exploring the validity of eHEALS scores in other populations [15], [18], [33], eHEALS is a 1-factor measure of eHealth literacy. Overall, results from CTT, CFA, and PCM procedures in this study support the internal structure and reliability of eHEALS among adults who use the Internet who live with at least one chronic disease. Chronic

Funding

This work was supported by the STEM Translational Communication Center and the Graduate Division of the University of Florida’s College of Journalism and Communications, Gainesville, FL.

References (37)

  • A.T. McCray

    Promoting health literacy

    J. Am. Med. Inf. Assoc.

    (2005)
  • Pew Internet & American Life Project, Chronic disease and the Internet....
  • K. Lee et al.

    Consumer use of Dr. Google: a survey on health information-seeking behaviors and navigational needs

    J. Med. Internet Res.

    (2015)
  • Office of Disease Prevention and Health Promotion, Older adults....
  • A. Mielck et al.

    Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease

    Health Qual. Life Outcomes

    (2014)
  • A.K. Parekh et al.

    Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life

    Publ. Health Rep.

    (2011)
  • N. Egbert et al.

    Health literacy: challenges and strategies

    Online J. Issues Nurs.

    (2009)
  • C.D. Norman et al.

    eHealth literacy: essential skills for consumer health in a networked world

    J. Med. Internet. Res.

    (2006)
  • S. Fox, E-patients with a disability or chronic disease...
  • J.N. Haun et al.

    Large-scale survey findings inform patients’ experiences in using secure messaging to engage in patient-provider communication and self-care management: a qualitative assessment

    J. Med. Internet. Res.

    (2015)
  • A. Bandura, Self-efficacy, V. S. Ramachuaudran (Ed.) New York,...
  • N.M. Clark et al.

    Exploring self-efficacy as a predictor of disease management health

    Educ. Behav.

    (1999)
  • B.L. Chang et al.

    Bridging the digital divide: reaching vulnerable populations

    J. Med. Inf. Assoc.

    (2014)
  • E. Neter et al.

    eHealth literacy: extending the digital divide to the realm of health information

    J. Med. Internet Res.

    (2012)
  • C.D. Norman et al.

    eHEALS: the eHealth literacy scale

    J. Med. Internet Res.

    (2006)
  • R.A. Marrie et al.

    Health literacy association with behaviors and healthcare utilization in multiple sclerosis: a cross-sectional study

    Interact. J. Med. Res.

    (2014)
  • B. Tennant et al.

    eHealth literacy and web 2.0 health information seeking behaviors among baby boomers and older adults

    J. Med. Internet Res.

    (2015)
  • R. van der Vaart et al.

    Does the eHealth literacy scale (eHEALS) measure what it intends to measure? Validation of a dutch version of the eHEALS in two adult populations

    J. Med. Internet Res.

    (2011)
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