Citation: Robb, M. & Shellenbarger, T. (2014). Influential factors and perceptions of eHealth literacy among undergraduate college students. Available in the Online Journal of Nursing Informatics (OJNI), 18 (3).
College students are embracing technology and using the Internet to search for information yet little is known about their ability to find and appraise electronic health information. The eHealth Literacy Scale (eHEALS) was used to examine the perceptions of eHealth literacy of undergraduate college students who recently completed an introductory health and wellness course. The influence of personal and demographics factors, and the relationship between technology use and eHealth literacy was also explored. Findings indicated that participants (N = 59) perceived they knew how to use the Internet to answer questions about health, but scored the lowest on confidence in using this information to make health decisions. Results suggest nursing faculty should consider incorporating learning activities that help students to develop the skills, knowledge, and confidence to locate and evaluate information on the Internet. Providing structured activities may improve eHealth literacy, positively influence health practices of college students, and ultimately advance patient health.
The rapid development of communication technology has impacted every aspect of society. With the growth of the Internet, and more recently mobile technology, information is available for instant access anytime, anywhere. The rapid proliferation of smartphones and other mobile devices makes information retrieval via the Internet easier than ever before. Young adults are embracing this technology and represent the largest group of Internet users. According to Pew Research, 95% of 18-29 year olds are using the Internet (Fox & Duggan, 2013) and are searching the web for a variety of things including healthcare information. Additional literature suggeststhat the Internet is a preferred source of health information for the millennial generation of college students (Heuberger & Ivanitskaya, 2011).
During the past year, 76% of Internet users searched online for health-related information (Fox & Duggan, 2013). That number may continue to grow as health-related information on the Internet becomes even more pervasive. As a result of The American Recovery Reinvestment Act of 2009, the US government will spend more than $37 million to support health information technology sharing during the next 10 years, making health information even more readily available to Internet users (Lustria, Smith, & Hinnant, 2011). This explosion of online information has created the potential for Internet resources and mobile applications to become a low-cost and effective source of health promotion interventions (Evers, 2006; Larkin, 2011).
College students are already using the Internet to search for health information on topics such as physical fitness/exercise and diet/nutrition information (Baxter, Eghert, & Ho, 2008; Escoffery, Miner, Adame, et al., 2005; Nsuangani & Pérez, 2006). While the Internet offers college students an abundance of health-related materials they still need essential skills to critically analyze the information effectively. This ability to seek, find, understand, and appraise health information from electronic resources and apply such knowledge to addressing or solving health problems is known as eHealth literacy (Stellefson, Hanik, Chaney, et al., 2011). eHealth literacy is especially important since college students are developing lifelong health habits that may be impacted by the information that they review. Therefore, ensuring that this generation of students has the necessary skills to find, critique, and apply eHealth information is an important responsibility for nursing faculty teaching health- and wellness-related courses on college campuses.
Additionally, health communication and health information technology competencies are considered essential attributes of an informed consumer and have been identified as critical for improving population health outcomes and healthcare quality. Healthy People 2020 goals strive to increase health literacy skills and recognize the influence this can have on improving healthcare quality and safety, support care, facilitate healthcare decision-making and build health skills and knowledge (US Department of Health and Human Services, 2012).
Therefore, eHealth literacy is an important student learning outcome that requires careful consideration by nurse educators to ensure that students develop skills beyond Internet searching and reading Internet information and are able to sort reputable and credible information from the disreputable and unsubstantiated. Furthermore, they must be able to work with technology, think critically about issues of media and science, and navigate through a vast array of information tools and sources to acquire the information necessary to make appropriate and informed decisions (Norman & Skinner, 2006).
Even though health information is readily available through mobile sources, studies indicate that many college students may lack the fundamental eHealth literacy skills of seeking and finding that health information and then being able to evaluate what they have found. In a survey conducted by Escoffery, Miner, and Adame (2005), 89% (n = 743) of college students did not always locate the desired eHealth information they were seeking. Among those, only 11% reported always finding the appropriate eHealth resources. However, Buhi, Daley, Fuhrmann and Smith (2009) found that when asked questions about sexual health at least 71% (n = 34) of students answered the question correctly based upon information they retrieved online. Holman (2011) noted that many college students are rather unsophisticated eHealth information seekers. Through observations it was determined that college students (n = 21) typically used Google (72%) to find health information, and struggled with troubleshooting search terms and syntax.
Despite extensive use of the Internet and mobile applications, the ability of college students to determine the credibility of eHealth resources is uncertain. Through an online eHealth literacy assessment, Ivanitskaya, Brookins-Fisher , O'Boyle, et al. (2010)concluded that college students were unable to critically evaluate health information retrieved from the Internet. In their study only 31% (n = 1914) of respondents gave a low rating to an untrustworthy online resource. Other research has illuminated a discrepancy between college students' perceived ability and actual ability to evaluate eHealth information. Ivanitskaya, O'Boyle, and Casey (2006) measured eHealth information competency of undergraduate college students (n = 308). Participants completed the Readiness Self-Assessment Health Scale developed by Ivanitskaya, Laus, & Casey (2004). Results revealed while the majority of students (84%) rated their research skills as good or excellent, two thirds were unable to conduct advanced information searchers. In addition, only 50% of the respondents were able to judge the trustworthiness of health related websites. Similarly, Hanik & Stellefson (2011) investigated both perceived and actual abilities of undergraduate college students (n = 77) to find and evaluate eHealth information. The researchers also used the Readiness Self-Assessment Health Scale. The study concluded actual mean eHealth literacy test scores (39.3% - 50.4%) were distinctly inferior to mean ratings of perceived eHealth literacy (75.3% - 78.5%). A similar discrepancy between confidence in accessing online information and applying the information to care situations was true for the 75 occupational therapy students studied by Brown and Dickson (2010).
Health information training, including exposure to websites such as Medline Plus® was linked positively to high school students reported levels of eHealth literacy skills and confidence in searching for health information (Ghaddar, Valerio, Garcia, & Hansen, 2012). No such studies are available for college students and further study is needed given the use of the Internet by college students.
Evidence from previous research suggests that undergraduate college students have difficulty locating and evaluating electronic health information and may potentially benefit from structured experiences that will encourage their development of eHealth literacy skills. Therefore, it is essential for nursing faculty to evaluate, understand, and appropriately address eHealth literacy proficiencies of this student population. To best develop these skills, nurse educators require a better understanding of students' perceptions of and personal factors that may impact their eHealth literacy. An improved understanding of what influences an undergraduate college student's perception of eHealth literacy can help nurse educators recognize and identify methods and strategies for encouraging students to develop such skills which then may ultimately improve health decision making of college students. It may also help nursing faculty to identify methods that educators can implement to produce informed consumers of health information. Therefore, this study sought to answer the following questions:
- What is the perceived eHealth literacy of undergraduate college students who have completed a required introductory college health and wellness course?
- What personal and demographic factors influence perceived eHealth literacy in undergraduate college students?
- What is the relationship between technology use and perceived eHealth literacy in undergraduate college students?
A web-based survey program, Qualtrics©, was used to answer the research questions and assess undergraduate college students' perceived eHealth literacy levels, technology use, and personal and demographic factors that may influence eHealth literacy skills. The study population consisted of a convenience sample of undergraduate college students who recently completed an introductory health and wellness course taught by nursing faculty at a moderate- size state university in western Pennsylvania. An invitation e-mail was sent to the students' academic e-mail accounts inviting them to participate in an electronic survey. A brief overview of the study and a link to the informed consent form was included in the e-mail. Once the participant provided his/her informed consent, the online survey questions appeared. No identifying information about the participant was linked to the collected data. Participation was strictly voluntary and no compensation was provided. Before beginning the research, the study was approved by the university Institutional Review Board.
Perceived eHealth Literacy Among College Students Survey
The participants' perceptions of their eHealth literacy were assessed using the eHealth literacy scale (eHEALS). The eHEALS is an eight-item self-reported measure of perceived eHealth literacy. The tool provides a general estimate of an individual's combined knowledge, comfort, and perceived skills at finding, evaluating, and applying electronic health information to health problems. Participants indicate their level of agreement with eHealth statements on a five-point Likert type scale (1 = strongly disagree, 5 = strongly agree). Score totals range from 8 to 40. Higher scores reflect higher perceived levels of eHealth literacy. Reported Cronbach's alpha coefficient of the tool is 0.88 (Norman & Skinner, 2006). The tool has been used with adolescent and adult populations to aid in determining the fit between eHealth programs and consumers perceived technology abilities (Norman & Skinner, 2006). For this study, the calculated Cronbach's alpha coefficient was 0.89. This result resembles previously published literature, which support good internal consistency of the tool. Permission to use this tool from the author was provided via email. Additionally, the eHEALS is available via an open source journal thereby suggesting open use of this tool.
Additional questions that are not part of the eHEALS were also included to explore personal and demographic factors that may influence eHealth literacy. The questions included a six-item measure of personal characteristics that emerged from the literature, and four items that sought to understand Internet use among the sample. Survey completion took approximately 10 minutes.
The collected data was coded for computer analysis with the use of the Statistical Package for the Social Sciences software, SPSS ® version 20. Descriptive statistics were completed and used to report the demographics of the participants. Ranges, mean score, and standard deviation were calculated for the perceived eHealth literacy levels, as measured by eHEALS. The difference between perceived levels of eHealth literacy among gender was examined through the Mann-Whitney U Test. This statistical test is the non-parametric alternative to the t-test for independent groups (Polit & Beck, 2012). Additionally, the difference between perceived levels of eHealth literacy among race, age, class standing, college major, final course grades, use of the Internet, time spent on the Internet, and perceived usefulness and importance of the Internet for making health decisions was examined through analysis of variance (ANOVA). A priori level was set at .05 to establish significance.
Fifty-nine respondents completed the survey. Most of the participants were female (80%). The majority of participants (85%) were White non-Hispanic. Participants' ages were classified into three categories. The sample was predominately younger with 81% (n = 48) between the ages of 18 - 20 years, while 14% (n = 8) of the respondents were between 21 - 23 years of age, and 5% (n = 3) were 24 years of age and older. The majority of respondents 56% (n = 33) were freshman, followed by 32% (n = 19) sophomores; 7% (n = 4) juniors; and 5% (n = 3) seniors. Since the study involved health topics, participants' majors were classified as allied health (e.g., nursing or allied health), not a related allied health major, and undecided. Non-allied health majors constituted 86% (n = 51) of the respondents. Final course grades ranged from an "A" to a "C". The majority of respondents 70% (n = 41) reported earning an "A". While, 24% (n = 14) reported earning a "B" and 7% (n = 4) reported a final course grade of a "C".
Respondents were fairly evenly split between their use of the Internet for communication 24% (n = 14); entertainment 37% (n = 22); and school related work 27% (n = 16). The majority of respondents 63% (n = 37) spent greater than two hours a day on the Internet, whereas, 25% (n = 15) spent 1 - 2 hours per day and only 12% (n = 7) spent less than one hour per day on the Internet. In terms of perceived importance of being able to access health resources on the Internet, 75% (n = 44) thought it was important; 17% (n = 10) were unsure; and 9% (n = 5) did not think it was important. When asked about the usefulness of the Internet in helping to make health decisions, 78% (n = 46) thought it was useful; 17% (n = 10) were unsure; and 5% (n = 3) did not think it was useful.
The perceived eHealth literacy scores as measured by the eHEALS ranged from a low score of 24 to a high score of 40 (M = 34.8, SD = 4.5): the higher the score, the higher the perceived level of eHealth literacy. When examining individual items on the eHEALS (see Table 1), participants scored the lowest on confidence in using information from the Internet to make health decisions (M = 3.9).
The Mann-Whitney U Test was used to determine if males and females differed in terms of their perceived eHealth literacy levels. The results revealed no significant difference in scores for males (Md = 32, n = 12) and females (Md = 35, n = 47), U = 215, z = -1.28, p = .202. Differences between levels of eHealth literacy among race, age, class standing, college major, final course grades, use of the Internet, time spent on the Internet, and perceived usefulness and perceived importance of the Internet for making health decisions was examined through ANOVA. Results indicated there was a statistically significant (F (2, 56) = 4.3, p = .018) difference in eHealth scores for participants who rated the Internet as useful (M = 35.7) and those who were unsure (M = 31.7). There was no statistically significant differences, at the p<.05 level, between perceived eHealth literacy scores and the other stated variables.
In this study, the perceived eHealth literacy levels of undergraduate college students would be considered relatively high (M = 34.59). The students in the present study overall scored higher than the eHealth literacy scores found in prior research with high school students and occupational health college student (Brown & Dickson, 2010; Ghaddar et al., 2012). The participants in the current study believe they have the necessary skill sets to seek, find, understand, and appraise health information from electronic sources. Prior research suggests that younger Caucasian college females are more likely to use the Internet to search for health information. Given the demographics of this sample, it is not surprising that the eHealth literacy scores are high since they represent the demographics of those who frequently seek out health information on the Internet.
Consistent with the findings of Brown & Dickson (2010) the participants scored the lowest on confidence in using information from the Internet to make health decisions. This finding suggests that although the participants are able to retrieve health information on their own they may not be confident enough about their knowledge to make decisions about health options independently. As nurse educators, it is important to assist students to develop these skills and enhance their confidence in using health related information in their personal and professional lives.
Although no difference was noted in eHealth literacy scores between men and women, a small sample of men participated in this study. Further research with a larger sample of males may provide additional information about the influence of this demographic on eHealth literacy. Other personal and demographics variables were explored to determine their impact on eHealth literacy scores. Those who evaluated the usefulness of the Internet also had higher eHealth literacy scores. This finding is not surprising, since the students who found the Internet useful would probably be using the Internet more, know what information is available, and have the ability to find health resources. Other personal and demographic variables did not significantly impact eHealth literacy scores in this study, which is contrary to what is reported in the research literature. Other studies report differences in eHealth literacy for race, age, educational background, and motivation (Lustria et al., 2011; Norman & Skinner, 2006) but these did not emerge in this study. Further research, using a larger and more diverse sample, may help to provide more data about these variables.
This study provides useful information to help nursing faculty understand eHealth literacy among undergraduate college students; however, there are some limitations associated with this study that raise concerns about generalizability. The research used a small convenience sample of individuals from one institution. These students who were willing to complete the survey may not represent college students in other locations, from other institutions, or from diverse majors and backgrounds. Although the sample size was small the data generated in this study stimulates further investigation and offers new information about the college student's ability to find and appraise electronic health information. The tools used, while reported as valid and reliable, provided limited data because of the small number of items on the tool and the self-reported nature of the items. Further research with more diverse student populations would contribute additional understanding of eHealth literacy.
This research provides a beginning understanding of eHealth literacy, an essential skill, of college students. It suggests that the Internet is a valuable tool used by students providing them with important information about health-related topics and thus may ultimately impact health practices of college students. For nursing and allied health students this skill may influence future professional practice. Internet use is expected to continue to grow as cell phone technology expands and people use these mobile communication devices for immediate access of information. College students, already digital natives, will continue to use the Internet to meet their needs and may use these electronic resources for accessing health related information. Nursing faculty need to realize that students see Internet access as an important resource for accessing information about a variety of topics including health-related issues; however, students may lack some confidence in using this information to make health decisions. Nursing faculty should consider ways to incorporate teaching-learning strategies that will help to develop the skills and knowledge to locate and evaluate information found on the Internet. For example, introducing students to trustable websites and providing exposure to databases like MEDLINE® may assist students in identifying reputable information.
Including learning opportunities that introduce the search strategies of controlled vocabulary, truncation, and Boolean operators may help students effectively narrow or expand their searches of databases and websites. Incorporating a discussion regarding strategies for reviewing and critiquing digital sources will provide students with the foundational skills needed for eHealth literacy. Having students complete an assignment that requires critical analysis of a website through answering questions such as 1) Who created the message? 2) When was the information produced? and 3) What evidence is cited?, may assist students in determining the credibility of health information presented on the Internet.
Introducing reputable Internet sources and providing guided practice learning activities may ultimately help students become confident and knowledgeable consumers of electronic health information. In addition, providing students with feedback during learning activities that require analysis of electronic health information may facilitate the development of students' confidence with these skills. Further research is needed to better develop our understanding of eHealth literacy among college students, the factors that facilitate these skills, and what nursing faculty can do to enhance this learning.
Younger adults are one of the most likely groups to turn to the Internet for eHealth information. Ensuring that undergraduate college students have the necessary skills to find, critique, and apply eHealth information is an important responsibility for nursing faculty. The results from this study revealed that students perceived that they knew how to use the Internet to answer questions about health but scored the lowest on confidence in using this information to make health decisions. These findings suggest that nursing faculty should consider ways to develop student eHealth literacy skills that will assist students in becoming confident informed consumers of eHealth information.
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Dr. Meigan Robb is an assistant professor of nursing at Chatham University. She has experience with teaching a variety of courses at the baccalaureate, master and doctoral levels. Her professional focus is directed towards exploring innovative methods for engaging students in the learning process. Dr. Robb has presented and published widely on a variety of topics focusing on nursing faculty, technology, mentoring, classroom management techniques, and educational strategies.
Teresa Shellenbarger, PhD, RN, CNE, ANEF
Dr. Teresa Shellenbarger is currently Professor of Nursing at Indiana University of Pennsylvania and teaches nursing courses at the undergraduate and graduate levels. Dr. Shellenbarger is an experienced educator and has widely published and presented in nursing education on topics such as innovative teaching strategies, faculty role development, scholarly writing, and the use of technology in nursing education. She is a certified nurse educator, a Fellow in the Academy of Nursing Education, and serves as a board member for the National League for Nursing.