Discussion
The eHEALS has shown promise as a measure of the concept of eHealth literacy as defined as a set of skills required to effectively engage information technology for health. The eHEALS’ high levels of internal consistency and modest test-retest reliability suggests that it has utility in examining eHealth literacy over time to both assess natural histories and evaluate eHealth literacy intervention outcomes. While tools exist that enable consumers to critically evaluate eHealth resources [24], there remains a dearth of instruments that assess consumers’ skills at using eHealth in general. Indeed, relatively few validated measures exist for most of the key literacy conditions within the eHealth literacy model (eg, science literacy, information literacy). Thus, it is imperative that future studies examine the links between perceived skills, eHealth use, and health behavior and health outcomes. Of those literacy tools available, most require significant time resources to administer and analyze. The eHEALS was designed for simple, easy administration and thus can be used on its own or incorporated with other measures of health as part of a standard health assessment battery in primary care or to support health promotion planning.
eHealth literacy promotion takes place within a larger learning context, thus it makes sense to develop partnerships with other groups working within other literacy sectors in validating the eHEALS in relation to other measures of literacy, social functioning, health, and well-being. Two examples of such multi-sectoral partnerships include the National Literacy and Health Program sponsored by the Canadian Public Health Association [25] and the Learners Advisory Network of the Movement for Canadian Literacy [26], which brings literacy groups together to address systemic literacy issues. Such partnerships illuminate the shared challenges in creating capacity for research, development, and policy advocacy around health and literacy issues.
Limitations and Opportunities for Further Research
Conducting this study as part of a larger trial did pose problems for test-retest reliability; therefore, these results should be interpreted with caution. The lower than expected test-retest correlations between administrations of the eHEALS is attributed to a rise in eHealth literacy scores from baseline to post-intervention follow-ups, attributed to the smoking prevention intervention used in collecting the data [20]. Although unanticipated, one potential explanation for this increase is that the control intervention was designed based on the principles advocated by the eHealth literacy intervention itself (eg, user-friendly and audience-specific language, easy to read and navigate), which could have influenced participants’ eHealth literacy scores. This may explain the relatively modest correlations (.68 to .70) compared with what was expected.
Additional studies are required to longitudinally examine the eHEALS in study conditions that are not susceptible to influence of the characteristics of a specific intervention. Testing the eHEALS with a population that has high rates of information technology presents a limitation; however, it also provides an opportunity to understand the robustness of the measure within a specific population. Further research needs to consider the eHEALS’ application to other populations as well as groups with highly variable levels of technology familiarity.
The eHEALS measures consumers’ perceived skills and comfort with eHealth, not the skills directly. The eHealth literacy model includes six types of literacy, and thus each skill would require independent measurement, such as rigorous usability tests of standard computer equipment for computer literacy and reading aloud text passages to assess basic prose literacy. For health practitioners and consumers alike, such detailed assessment would be problematic in practice; however, it is worthwhile considering ways to conduct such measures in the future.
Conclusions
The need for skills in seeking, appraising, and applying lessons learned through use of eHealth resources is common across ages, genders, and cultural groups, and thus the potential applicability of the eHEALS as a standard assessment tool for gauging eHealth literacy in health care is high. Assessing consumers’ comfort in using eHealth allows for the identification of skill gaps and can better assist those with low comfort levels in taking advantage of the potential benefits that eHealth can afford. Doing so may foster development of tools that can meet these needs and aid in creating appropriate strategies for bridging the digital divide in consumer health care quality. Only by increasing the understanding of the disparities between available eHealth tools and consumers’ abilities to use them can the necessary steps towards eliminating them be taken.