Digital Health Literacy: Comparing Factor Structures of the Portuguese eHEALS Using Confirmatory Factor Analysis

Document Type : Original Article

Authors

Department of Physiotherapy, Escola Superior de Saúde do Alcoitão / Alcoitão School of Health Sciences, Alcoitão, Portugal.

Abstract

Background and Objectives: Digital health literacy is essential for navigating digital health environments safely, particularly for future health professionals. Validated assessment tools are crucial for understanding competency levels and guiding educational interventions. This study evaluated the construct validity and internal consistency of the Portuguese version of the eHealth Literacy Scale (eHEALS) among health sciences students. Two models were tested using Confirmatory Factor Analysis (CFA): a unidimensional model and a second-order bidimensional model.

Materials and Methods: A total of 375 undergraduate and postgraduate health sciences students (75.2% female, 23.2% male, 1.6% undisclosed) participated. CFA was performed to assess model fit using Chi-square divided by degrees of freedom (CMIN/DF), Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Goodness-of-Fit Index (GFI), Root Mean Square Residual (RMR), and Akaike Information Criterion (AIC). Internal consistency was assessed via Cronbach’s alpha.

Results: Both models demonstrated very good fit. The bidimensional model showed slightly better fit (CMIN/DF=1.704, RMSEA=0.043, CFI=0.991, TLI=0.985, RMR=0.015, GFI=0.983, AIC=67.261) than the unidimensional model (CMIN/DF=1.767, RMSEA=0.045, CFI=0.990, TLI=0.983, RMR=0.017, GFI=0.980, AIC=68.047). The chi-square difference test (Δχ²=2.786, Δdf =1, p=0.095) indicated that both models were statistically comparable. Internal consistency was high (α=0.868 total, 0.850 Factor 1, 0.743 Factor 2).

Conclusion: The Portuguese version of eHEALS demonstrates good construct validity and internal consistency for assessing digital health literacy in higher education students. The bidimensional model, distinguishing between "Ability to Search for Online Health Information" and "Ability to Evaluate and Apply Health Information," provides a more detailed understanding of competency areas, helping to identify specific aspects for improvement and inform targeted educational interventions.

Keywords

Acknowledgments: The authors would like to thank the participants and the supporting institution for their collaboration in this study.


Availability of data and materials: The dataset analyzed in this study is available from the corresponding author upon reasonable request.


Conflicts of interest: The authors declare no conflicts of interest related to this manuscript.


Consent for publication: Not applicable.


Ethics approval and consent to participate: The study was approved by the Ethics Committee of the higher education institution where it was conducted, ensuring compliance with applicable ethical and legal principles for scientific research. This study adhered to the ethical principles outlined in the Declaration of Helsinki, ensuring that all participants provided informed consent, understood the study objectives, and were assured of data protection and confidentiality, in full compliance with the General Data Protection Regulation (GDPR).


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


Authors’ contribution: AAL, VHA, FFL, LVR, and TMD contributed to the study design, data collection, analysis, and manuscript preparation. CRS was responsible for data processing and manuscript submission. All authors read and approved the final version of the manuscript.

 

Open Access Policy: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/

References

  1. Norman CD, Skinner HA. eHEALS: The eHealth Literacy Scale. J Med Internet Res. 2006;8(4):e27. https://doi.org/10.2196/jmir.8.4.e27 PMid:17213046 PMCid:PMC1794004
  2. Neter E, Brainin E. eHealth literacy: Extending the digital divide to the realm of health information. J Med Internet Res. 2012;14(1):e19. https://doi.org/10.2196/jmir.1619 PMid:22357448 PMCid:PMC3374546
  3. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12(1):80. https://doi.org/10.1186/1471-2458-12-80 PMid:22276600 PMCid:PMC3292515
  4. Kayser L, Kushniruk A, Osborne RH, Norgaard O, Turner P. Enhancing the effectiveness of consumer-focused health information technology systems through eHealth literacy: A framework for understanding users' needs. JMIR Hum Factors. 2015;2(1):e9. https://doi.org/10.2196/humanfactors.3696 PMid:27025228 PMCid:PMC4797661
  5. Diviani N, van den Putte B, Giani S, van Weert JCM. Low health literacy and evaluation of online health information: A systematic review of the literature. J Med Internet Res. 2015;17(5):e112. https://doi.org/10.2196/jmir.4018 PMid:25953147 PMCid:PMC4468598
  6. Oscalices MIL, Okuno MFP, Lopes MCBT, Batista REA, Campanharo CRV. Health literacy and adherence to treatment of patients with heart failure. Rev Esc Enferm USP. 2019 Jul 15;53:e03447. English, Portuguese. doi: 10.1590/S1980-220X2017039803447. PMID: 31314864. https://doi.org/10.1590/s1980-220x2017039803447 PMid:31314864
  7. Kim K, Shin S, Kim S, Lee E. The Relation Between eHealth Literacy and Health-Related Behaviors: Systematic Review and Meta-analysis. J Med Internet Res. 2023;25:e40778. Published 2023 Jan 30. doi:10.2196/40778 https://doi.org/10.2196/40778 PMid:36716080 PMCid:PMC9926349
  8. Le LTT, Tran LT, Dang CS, et al. Testing reliability and validity of the Vietnamese version of the eHealth literacy scale (eHEALS) among medical students in Vietnam. Int J Med Inform. 2023;170:104962. https://doi.org/10.1016/j.ijmedinf.2022.104962 PMid:36542903
  9. Wijaya MC, Kloping YP. Validity and reliability testing of the Indonesian version of the eHealth Literacy Scale during the COVID-19 pandemic. Health Informatics J. 2021;27(1):1460458220975466. https://doi.org/10.1177/1460458220975466 PMid:33446030
  10. Chung S, Park BK, Nahm ES. The Korean eHealth Literacy Scale (K-eHEALS): Reliability and Validity Testing in Younger Adults Recruited Online. J Med Internet Res. 2018;20(4):e138. Published 2018 Apr 20. doi:10.2196/jmir.8759 https://doi.org/10.2196/jmir.8759 PMid:29678800 PMCid:PMC5935806
  11. Lee J, Lee EH, Chae D. eHealth Literacy Instruments: Systematic Review of Measurement Properties. J Med Internet Res. 2021;23(11):e30644. https://doi.org/10.2196/30644 PMid:34779781 PMCid:PMC8663713
  12. Tomás CC, Queirós PJP, Ferreira T, Lopes MJ. Adaptation and validation of the Portuguese version of eHEALS in adolescents. J Med Internet Res. 2014;16(3):e65.
  13. Oliveira L, et al. From validation to assessment of e-health literacy: A study among higher education students in Portugal. Healthcare. 2024;12:1626. https://doi.org/10.3390/healthcare12161626 PMid:39201184 PMCid:PMC11353653
  14. Maroco J. Structural Equation Analysis: Theoretical Foundations, Software & Applications. 3rd ed. ReportNumber; 2021
  15. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. McGraw-Hill; 1994.
  16. Neter, E., & Brainin, E. (2012). eHealth literacy: Extending the digital divide to the realm of health information. Journal of Medical Internet Research, 14(1), e19. https://doi.org/10.2196/jmir.1619 PMid:22357448 PMCid:PMC3374546
  17. Tennant, B., Stellefson, M., Dodd, V., Chaney, B., Chaney, D., Paige, S., & Alber, J. (2015). eHealth literacy and Web 2.0 health information seeking behaviors among baby boomers and older adults. Journal of Medical Internet Research, 17(3), e70. https://doi.org/10.2196/jmir.3992 PMid:25783036 PMCid:PMC4381816
  18. Barros GAF, Ramos DO, Machado MH, Oliveira AL, Sá EM. Cultural adaptation and validation of eHEALS in Brazil. JMIR Mhealth Uhealth. 2022;10(4):e31807.
  19. Huhta AM, Hirvonen N, Huotari ML. Health Literacy in Web-Based Health Information Environments: Systematic Review of Concepts, Definitions, and Operationalization for Measurement. J Med Internet Res. 2018;20(12):e10273. https://doi.org/10.2196/10273 PMid:30567690 PMCid:PMC6315258
  20. Mohamed, A. S., Massoud, R., & Wong, C. P. (2024). An integrative systematic review on interventions to improve layperson's ability to identify trustworthy digital health information. PLOS Digital Health, 3(1), e0000638. https://doi.org/10.1371/journal.pdig.0000638 PMid:39453891 PMCid:PMC11508166
  21. Domingues JP, Fronteira I, Sousa P. Validation of the European Health Literacy Survey Questionnaire (HLS-EU-Q) for the Portuguese population. Acta Med Port. 2020;33(12):781-789. doi:10.20344/amp.14236.
  22. Domingos R, Araújo D, Pinho L, Ribeiro O, Paúl C. Adaptação e validação do European Health Literacy Survey Questionnaire (HLS-EU-Q) para a população portuguesa. Revista de Enfermagem Referência. 2021;5(10):e21050. doi:10.12707/RV21050

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