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

https://doi.org/10.1016/j.pec.2017.01.015Get rights and content

Highlights

  • It is necessary to promote sufficient skills in using ICTs.

  • Online services should offer functionalities tailored to low-literate individuals.

  • New health literacy screening tools are necessary to identify skills for adequate use of eHealth services.

Abstract

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.

Introduction

Information and communication technologies (ICTs) are now used widely to support and deliver health care for patients and the general public. Electronic Health (eHealth) refers to “health services and information delivered or enhanced through the Internet and related technologies” [1]. Internet-based health services include electronic communication between patients and providers, electronic medical records, personal health records, health education programs, patient portals, and Web-based applications for patients [2]. Mobile Health (mHealth) represents a subset of eHealth and can be defined as “the use of mobile computing and communication technologies in health care and public health” [3]. It features a wide variety of services provided through mobile networks, including patient education, remote monitoring, communication and training, disease and outbreak tracking, and diagnostic and treatment decisional support [4], [5], [6].

With the increasing adoption of eHealth services, individuals are increasingly expected to engage in appropriate self-care and self-management of their conditions through eHealth [7]. Health consumers must therefore have sufficient health literacy within the context of eHealth. Health literacy can be defined as “people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion” [8]. eHealth literacy comprises “a set of skills and knowledge that are essential for productive interactions with technology-based health tools” [9].

Unfortunately, over 90 million Americans have low health literacy [10]. Individuals with limited health literacy experience disparities in their health and access to health care resources [11]. Individuals with low health literacy tend to use fewer preventive services and less eHealth, which are associated with poor health outcomes [12]. Low health literacy is related to delayed diagnoses, poor adherence to treatment regimens, increased morbidity and mortality [13], and increased rates of hospitalization and poor health outcomes [14]. Individuals with low health literacy have difficulties in effectively utilizing and interacting with eHealth [15], [16].

Although ICTs are providing new opportunities for accessing health information and self-management of health conditions, no comprehensive reviews have focused on the relationship between patients’ health literacy and their use of Internet-based health services. We conducted a systematic review of the literature to address this gap. The study aim was to examine whether or not existing studies have addressed health literacy within the context of Internet-based services, and if so, how they have done so, including whether or not they have considered both web-based and mobile applications (apps). The findings could provide insights into how health literacy has been, and should be, addressed in the eHealth era.

Section snippets

Method

Between February–March of 2014, we performed four rounds of searches to identify relevant publications published since 2010.

Results

Forty five (61%) studies investigated a variety of special populations (e.g., older adults with heart failure, low-literacy patients with diabetes, and low-income parents whose children have special health care needs). Target groups with low health literacy varied according to demographics (age, race, and economic status) and health conditions. Individuals with limited health literacy were prevalent among those of age 65 years or older, African Americans or Hispanics, non-English speakers, and

Discussion

Based on the review of 74 empirical studies, we have identified five key themes and suggest future directions for research and practice related to health literacy in the eHealth era.

Conflict of interest

The authors have no potential conflicts of interests to declare, including relevant financial interests, activities, relationships, and affiliations.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (141)

  • J. Choi et al.

    Web-based education for low-literate parents in neonatal intensive care unit: development of a website and heuristic evaluation and usability testing

    Int. J. Med. Inform.

    (2010)
  • J.L. Welch et al.

    Merging health literacy with computer technology: self-managing diet and fluid intake among adult hemodialysis patients

    Patient Educ. Couns.

    (2010)
  • A.R. Tait et al.

    Using animated computer-generated text and graphics to depict the risks and benefits of medical treatment

    Am. J. Med.

    (2012)
  • B. Xie

    Improving older adults’ e-health literacy through computer training using NIH online resources

    Libr. Inf. Sci. Res.

    (2012)
  • W. Chen et al.

    More than search? Informational and participatory eHealth behaviors

    Comput. Hum. Behav.

    (2014)
  • G. Eysenbach

    What is e-health?

    J. Med. Internet Res.

    (2001)
  • P. Neupert et al.

    Personal health management systems: applying the full power of software to improve the quality and efficiency of care

    Health Aff.

    (2009)
  • C. Free et al.

    The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis

    PLoS Med.

    (2013)
  • A.S.M. Mosa et al.

    A systematic review of healthcare applications for smartphones

    BMC Med. Inform. Decis. Mak.

    (2012)
  • M. Nacinovich

    Defining mHealth

    J. Commun Healthc.

    (2011)
  • M. Tomlinson et al.

    Scaling up mHealth: where is the evidence?

    PLoS Med.

    (2013)
  • M. Fagnano et al.

    Health literacy and sources of health information for caregivers of urban children with asthma

    Clin. Pediatr.

    (2012)
  • K. Sørensen et al.

    Health literacy and public health: a systematic review and integration of definitions and models

    BMC Public Health

    (2012)
  • C.V. Chan et al.

    A framework for characterizing eHealth literacy demands and barriers

    J. Med. Internet Res.

    (2011)
  • M. Kutner et al.

    A First Look at the Literacy of America’s Adults in the 21st Century

    (2005)
  • R.L. Sudore et al.

    Limited literacy in older people and disparities in health and healthcare access

    J. Am. Geriatr. Soc.

    (2006)
  • M.K. Paasche-Orlow et al.

    The causal pathways linking health literacy to health outcomes

    Am. J. Health Behav.

    (2007)
  • N.D. Berkman et al.

    Low health literacy and health outcomes: an updated systematic review

    Ann. Intern. Med.

    (2011)
  • J.D. Jensen et al.

    Utilization of internet technology by low-income adults: the role of health literacy, health numeracy, and computer assistance

    J. Aging Health

    (2010)
  • C.D. Norman et al.

    eHEALS: The eHealth literacy scale

    J. Med. Internet Res.

    (2006)
  • R.M. Parker et al.

    The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills

    J. Gen. Intern. Med.

    (1995)
  • T.C. Davis et al.

    Rapid estimate of adult literacy in medicine: a shortened screening instrument

    Fam. Med.

    (1993)
  • B.D. Weiss et al.

    Quick assessment of literacy in primary care: the newest vital sign

    Ann. Fam. Med.

    (2005)
  • Australian Institute of Health and Welfare (AIHW). The Active Australia Survey: a guide and manual for implementation,...
  • H. Ishikawa et al.

    Measuring functional communicative, and critical health literacy among diabetic patients

    Diabetes Care

    (2008)
  • K.A. Rawson et al.

    The METER: a brief self-administered measure of health literacy

    J. Gen. Intern. Med.

    (2009)
  • N.S. Morris et al.

    The single item literacy screener: evaluation of a brief instrument to identify limited reading ability

    BMC Fam. Pract.

    (2006)
  • U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, National...
  • L.D. Chew et al.

    Brief questions to identify patients with inadequate health literacy

    Fam. Med.

    (2004)
  • O. Aliu et al.

    Readability of ASPS and ASAPS educational websites: an analysis of consumer impact

    Plast. Reconstr. Surg.

    (2010)
  • D.H. Charbonneau

    Readability of menopause web sites: a cross-sectional study

    J. Women Aging

    (2012)
  • D.V. Cherla et al.

    Readability assessment of internet-based patient education materials related to endoscopic sinus surgery

    Laryngoscope

    (2012)
  • J.A. Eloy et al.

    Readability assessment of patient education materials on major otolaryngology association websites

    Otolaryngol. Head Neck Surg.

    (2012)
  • S. Sanghvi et al.

    Readability assessment of internet-based patient education materials related to facial fractures

    Laryngoscope

    (2012)
  • T. Hove et al.

    Using adolescent eHealth literacy to weigh trust in commercial web sites: the more children know the tougher they are to persuade

    J. Advert. Res.

    (2011)
  • M.R. Edmunds et al.

    Readability assessment of online ophthalmic patient information

    JAMA Ophthalmol.

    (2013)
  • M.R. Edmunds et al.

    Patient information in graves' disease and thyroid-associated ophthalmopathy: readability assessment of online resources

    Thyroid

    (2014)
  • D.R. Hansberry et al.

    Analysis of the readability of patient education materials from surgical subspecialties

    Laryngoscope

    (2014)
  • D.R. Hansberry et al.

    Health literacy in vascular and interventional radiology: a comparative analysis of online patient education resources

    Cardiovasc. Intervent. Radiol.

    (2014)
  • P.R. Fitzsimmons et al.

    A readability assessment of online Parkinson's disease information

    J. R. Coll. Phys. Edinb.

    (2010)
  • Cited by (244)

    View all citing articles on Scopus
    View full text