The eHealth literacy scale (eHEALS): is it suitable for health education nursing officers in Sri Lanka?

Abstract

Effective use of electronic health tools requires a specific set of skills. These skills can be assessed using valid eHealth literacy measurement tools. This study aimed to validate the widely used eHEALS scale among Health Education Nursing officers (HENOs) working in government hospitals in Sri Lanka. We sent eHEALS questionnaires to all hospitals in the country where HENOs were present. The sample size used in the validation study was 80. Exploratory Factor Analysis (EFA) and reliability analyses were performed. The results of the EFA fit into a unidimensional model (60.97% of the variance explained). The Cronbach’s alpha for the scale was 0.90. Our study found that the original version of the eHEALS was unidimensional, as reported by the original authors. It is sufficiently valid and reliable for health education nursing officers in Sri Lanka.

SUMMARY

eHealth literacy refers to how well people seek, find, understand, and use the Internet, websites, and social media to address their health problems. eHEALS is an eHealth literacy measurement questionnaire used in many countries to gauge how well-informed different groups are about electronic health information. In Sri Lanka, health education nurses are responsible for helping patients and staff understand health information. However, their health information literacy has not yet been assessed. This study validated the widely used eHEALS questionnaire and found it to be suitable for measuring eHealth literacy among health education nurses in Sri Lanka, who work in government hospitals.

Keywords:

• e-health literacy
• eHEALS
• Health Education
• Nursing officers

Introduction

eHealth literacy (also known as digital health literacy) is the “ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” (Ortiz, 2017). This is considered to be a key area of the eHealth ecosystem.

According to the “Liley Model,” eHealth literacy is categorized into two main types. The “analytic type” includes traditional, media and information literacy. The “context-specific” type includes health, computer, and scientific literacy. The former involves skills that are relevant to a broad range of information sources, whereas the latter involves more situation-specific skills (Norman & Skinner, 2006b).

There are many tools for measuring eHealth literacy, namely, the eHealth Literacy Scale (eHEALS) (Norman & Skinner, 2006a), eHealth Literacy Scale - E (eHEALS-E) (Petrič et al., 2017), electronic Health Literacy Scale (e-HLS) (Seçkin et al., 2016), Digital Health Literacy Instrument (DHLI) (Van Der Vaart & Drossaert, 2017), eHealth Literacy Assessment Toolkit (eHLA) (Karnoe et al., 2018), eHealth Literacy Questionnaire (eHLQ) (Kayser et al., 2018), and transactional eHealth Literacy Instrument (Paige et al., 2018). Among these tools, the eHEALS (Norman & Skinner, 2006a) is the most widely used scale, which has been translated into 18 languages in 26 countries involving diverse populations (Lee et al., 2021).

eHealth literacy varies among populations, groups, and job categories. Understanding what shapes eHealth is important for policy makers of a country because it provides important information to tailor targeted interventions (Xesfingi & Vozikis, 2016). Although very few studies have been conducted to measure and validate the measuring tools of e-health literacy in the Sri Lankan population (Gunasekara & Fernando, 2020; Rathnayake & Senevirathna, 2019; Tissera & Silva, 2017), no validation studies have been conducted among health education staff at the forefront of hospital patient education. There is very limited research evidence available from Sri Lanka on eHealth literacy among nurses. In addition, it is important to explore nurses’ general understanding of health literacy because they are considered the single largest group of healthcare providers (Macabasco-O'Connell & Fry-Bowers, 2011). Furthermore, nurses’ health literacy skills can be considered the foundation of patient-centered care (Yang, 2022). Therefore, this study aimed to validate eHEALS among HENOs working in government hospitals in Sri Lanka.

Materials and method

We conducted a descriptive cross-sectional study on a sample of eligible HENOs working in government hospitals in Sri Lanka. Nursing officers in Sri Lanka are involved in the provision of routine care to patients and in preventing illness. ‘Nursing officer’ is the term used in Sri Lanka for nurses (similar to ‘medical officer’ for doctors). In Sri Lanka, to become a government nursing officer, one must pass the General Certificate Examination of Advanced Level in Biology. They are then trained in Nursing Training colleges attached to the hospitals, and the Diploma in Nursing is awarded, following completion of the training for three years with a practical exam. Nursing officers can apply to become a Health Education Nursing Officer (HENO). Once appointed, HENOs received special training on health education provided by the Ministry of Health. HENOs in Sri Lanka are special cadres that play an important role in health promotion and education for both patients and staff in many government hospitals.

Furthermore, in Sri Lanka, government healthcare delivery is conducted by teaching hospitals, provincial general hospitals, district general hospitals, base hospitals, divisional hospitals, and primary medical care units. However, consultant-level care is mainly available at the base-hospital level. Because there is a staff shortage in many hospitals, HENOs are appointed to base hospitals and above. At the time of data collection, the country had 116 institutions in the following categories: teaching hospitals, provincial general hospitals, district general hospitals, and base hospitals. We collected data on age, marital status, ethnicity, and level of education as sociodemographic variables. Work experience as a nursing officer and work experience as a HENO were collected as data related to their profession. We used the widely used eHEALS scale with permission from the original authors (Norman & Skinner, 2006a). The scale consisted of eight items scored on a five-point Likert scale. This instrument was translated into Sinhala and Tamil by two qualified language specialists who ensured that the questions maintained their conceptual meaning. Once translated, it was reviewed by subject experts. The translated tool was again back-translated by an independent language specialist who was blinded to the original English terms and phrases. All differences were resolved by the entire team (language specialists and subject experts) to arrive at the final translation. We used the guidelines published by the World Health Organization for this purpose for WHODAS 2.0 (World Health Organization, n.d.).

The content validity of the instrument was assessed by two consultant community physicians, five medical officers, and a health education officer. Pre-testing of the scale was performed with ten nursing officers in a teaching hospital. Pre-testing was performed to identify the problems with the questions in the tool in terms of their understandability, wording, and whether the questions were being filled properly. The required sample size for the main analysis was ten per variable because we decided to use the N:p ratio, assuming that the strength of item loadings is higher and numerous pieces of evidence suggest a single-factor structure with uniformity of communalities (Kyriazos, 2018). As eight items were included in the eHEALS scale, the minimum sample size was 80. Convenience sampling was performed. Relevant information sheets, consent forms, and the pretested eHEALS scale were posted to HENOs working in 116 government hospitals by registered posts. A copy of all the documents with instructions was also given to the heads of each institution. An exploratory factor analysis was conducted to assess construct validity. Internal consistency of the scale was assessed using Cronbach’s alpha. The eHEALS scale consists of eight items, and each item is measured on a five-point Likert scale (strongly disagree (1) to strongly agree (5)). The lowest score for any person was eight, and the highest score was 40. Higher scores indicate higher eHealth literacy skills. Ethical approval for the study was obtained from the Ethics Review Committee of the Postgraduate Institute of Medicine, University of Colombo (ERC/PGIM/2021/054).

Results

Sample characteristics

The sample consisted of 76 health-education nursing officers working in government hospitals in Sri Lanka. Table 1 shows the sociodemographic characteristics of the participants.

Table 1. Sociodemographic characteristics of the sample.

Characteristic	Value
	Mean (SD)
Age	40.13 (7.33)
Marital status	Number (%)
Single	8 (10.5)
Married	67 (88.2)
Widowed	1 (1.3)
Ethnicity
Sinhalese	46 (60.5)
Tamil	19 (25.0)
Moor	11 (14.5)
Education level
Up to GCE A/L*	7 (9.2)
Having a diploma	47 (61.8)
Having a degree	19 (25.0)
Having a postgraduate degree	3 (3.9)
Working experience as Nursing Officer
1–3 years	8 (10.5)
4–6 years	4 (5.3)
6–10 years	11 (14.5)
>10 years	53 (69.7)
Working experience as a HENO
<1	21 (27.6)
1–3 years	28 (36.8)
4–6 years	14 (18.4)
7–10 years	6 (7.9)
>10 years	7 (9.2)

* General Certificate of Education Advanced Level – which is similar to British Advanced Level, an exam conducted by Department of Examinations of the Ministry of Education. It is usually taken during their final two years of collegiate level (usual ages 18–19 years).

The total score of the eHEALS was moderately normally distributed with a skewness of -0.55 and kurtosis of 3.23, according to Curran’s criteria (Curran et al., 1996). The total mean eHEALS score was 31.34 (SD, 4.3), out of a maximum of 40. We did not find any significant correlations between eHEALS scores and age (Pearson’s r = -0.075, p = 0.518). In addition, there was no statistically significant correlation between the eHEALS score and educational level (Kendall’s tau-b = 0.094, p = 0.325) or work experience as a nursing officer (Kendall’s tau-b =-0.027, p = 0.775). However, there was a statistically significant correlation between the eHEALS score and work experience as an HENO (Kendall’s tau-b = 0.224, p = 0.014). This difference may be because more senior HENOs have better skills in accessing and using information via electronic sources.

EFA and reliability of eHEALS literacy scale

Table 2 presents the eHealth Literacy Scale mean item scores, standard deviations, factor loadings, communalities and reliability statistics. The internal consistency of the eHEALS was satisfactory. The Cronbach’s alpha for the total scale was 0.90. The EFA supported the scale’s unidimensionality with Principal Axis Factoring (eigenvalue = 4.8, 60.97% of the variance explained). The factor loadings ranged from 0.658 to 0.821, and communalities ranged from 0.433 to 0.674.

Table 2. eHealth literacy scale mean item scores, SD, factor loadings, communalities and reliability values.

Item	Mean	SD	Factor loading	Communalities	Item-total correlation	Cronbach’s alpha if item deleted
I know how to find helpful health resources on the Internet	4.01	0.622	0.742	0.550	0.685	0.887
I know how to use the Internet to answer my questions about health	4.08	0.536	0.821	0.674	0.777	0.882
I know what health resources are available on the Internet	4.05	0.539	0.746	0.556	0.712	0.887
I know where to find helpful health resources on the Internet	3.96	0.662	0.776	0.602	0.719	0.884
I know how to use the health information I find on the Internet to help me	4.00	0.653	0.698	0.487	0.673	0.888
I have the skills I need to evaluate the health resources I find on the Internet	3.79	0.822	0.735	0.540	0.692	0.887
I can tell high-quality health resources from low-quality health resources on the Internet	3.66	0.809	0.773	0.598	0.728	0.883
I feel confident in using information from the Internet to make health decisions	3.79	0.869	0.658	0.433	0.627	0.896

The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.897, indicating that the sampling was adequate and had a substantial correlation. Bartlett’s test of sphericity was highly significant (p < 0.000), indicating the suitability of the data for factor analysis.

Discussion

The aim of this study was to validate the eHEALS among Health Education Nursing Officers (HENOs) working in government hospitals in Sri Lanka. In our sample of 76 HENOs, we found that the original version of the eHEALS scale was unidimensional, as reported by the original authors. The eHEALS was found to be sufficiently valid and reliable for use for HENOs working in government hospitals in Sri Lanka.

The scale’s unidimensionality was also reported among other study populations in the country, such as the study by Rathnayake and Liyanage, who validated it among a sample of health science students and also reported a single-factor solution (Rathnayake & Liyanage, 2022). However, a validation study by Gunasekara and Fernando (2020) conducted on managers and senior working-age employees in Sri Lanka reported a two-factor solution for the scale. This variation in the dimensionality of the eHEALS scale has been demonstrated in many other studies on different population groups. A systematic review of the measurement properties of all eHealth literacy instruments performed by Lee et al. (2021) stated that 62.1% of the results in their review supported a single-factor structure, with the second-most frequent two-factor structure reported in eight studies and a three-factor structure from four studies. The authors further stated that a two-factor structure is better; however, the tool must be updated to match the social media era (Web 2.0).

The factor loadings, communalities, and reliability found in our study were within the ranges described by the original authors (Norman & Skinner, 2006a, 2006b). The mean eHEALS score in this study was 31.34 (SD 4.3). This finding is compatible with studies conducted by Tissera and Silva (2017) (mean =30.8, SD 3.5) and Rathnayake and Senevirathna (2019) (mean =28.02, SD 4.6) in Sri Lanka among nursing school students and health science students. Our findings on the mean eHEALS score are also compatible with other international studies conducted among in-service nurses (mean =31.72, SD = 5.5) (Isazadeh et al., 2020).

Our findings have many implications for health practice and research. This study shows the importance of routine monitoring of eHealth literacy among the health service categories in Sri Lanka. This validated tool can be used for this purpose. It also highlights the need for special in-service training on eHealth literacy to narrow the gap between junior and senior HENOs working in government sector hospitals. Further research should be conducted to determine the causes of the difference in eHealth literacy among junior and senior HENOs.

This study has several limitations. First, most nurses in the sample had more than ten years of work experience, which may have affected the generalizability of the results. Second, the sample size was too small to obtain an accurate estimate of mean eHEALS scores. However, it is worth noting that there were only 116 base and high-level institutions in the country at the time of the study in the HENO category. Third, this was a cross-sectional survey; hence, we did not conduct a test-retest reliability. Fourth, we did not calculate the content validity index or ratio for content validation. In addition, although we translated the tool into two languages, Cronbach’s alpha was calculated and the validity was checked for both languages together. Fifth, the eHEALS tool is a subjective health literacy measure that focuses on self-reporting of a person’s perception of how easy or difficult it is for them to engage with health material. However, it is worth noting that there is no gold-standard eHealth literacy measure (Politi et al., 2020).

Conclusions

Our study concluded that the original version of the eHEALS scale was unidimensional, as reported by the original authors, in relation to HENOs working in government hospitals in Sri Lanka. Thus, this tool is sufficiently valid and reliable.

Author contribution

Study conception and design SJB, MSDW, RB, PK: Data collection, Data analysis and interpretation: BMIR, WMPCW, RMNUR, PSN, DKI, EJ Drafting of the article, Critical revision of the article: MSDW, SJB, RB, PK.

Acknowledgements

The authors would like to thank the translators and the staff at the Health Promotion Bureau, Colombo, Sri Lanka.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data supporting the findings of this study are available from the corresponding author, BMIG, upon reasonable request.