A systematic review of eHealth interventions to improve health literacy

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    http://jhi.sagepub.com/content/early/2014/06/08/1460458214534092The online version of this article can be found at:

    DOI: 10.1177/1460458214534092

    published online 10 June 2014Health Informatics JournalRobin J Jacobs, Jennie Q Lou, Raymond L Ownby and Joshua Caballero

    A systematic review of eHealth interventions to improve health literacy

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    A systematic review of eHealth interventions to improve health literacy

    Robin J Jacobs, Jennie Q Lou, Raymond L Ownby and Joshua CaballeroNova Southeastern University, USA

    AbstractImplementation of eHealth is now considered an effective way to address concerns about the health status of health care consumers. The purpose of this study was to review empirically based eHealth intervention strategies designed to improve health literacy among consumers in a variety of settings. A computerized search of 16 databases of abstracts (e.g. Biomedical Reference Collection, Cochrane Central Register of Controlled Trials, Computers & Applied Sciences Complete, Health Technology Assessments, MEDLINE) were explored in a systematic fashion to assess the presence of eHealth applications targeting health literacy. Compared to control interventions, the interventions using technology reported significant outcomes or showed promise for future positive outcomes regarding health literacy in a variety of settings, for different diseases, and with diverse samples. This review has indicated that it is feasible to deliver eHealth interventions specifically designed to improve health literacy skills for people with different health conditions, risk factors, and socioeconomic backgrounds.

    Keywordscomputer, eHealth, health literacy, Internet, systematic review


    Patients with limited health literacy may not have the requisite skills to effectively interact with the health system and engage in appropriate self-care, such as know-how to take their medica-tions and to understand labels and other health information. Literacy for health information is emerging as a key factor related to health status.1,2 There are many definitions of health literacy, but for the purpose of discussing the role of eHealth applications, the working definition of health literacy is the following: The degree to which individuals have the capacity to obtain,

    Corresponding author:Robin J Jacobs, Biomedical Informatics/Preventive Medicine/Public Health/Psychiatry and Behavioral Medicine/International Medicine, College of Osteopathic Medicine, Nova Southeastern University, 3200 S. University Drive, Terry Bldg 1421, Fort Lauderdale, FL 33328, USA.Email: rjacobs@nova.edu

    534092 JHI0010.1177/1460458214534092Health Informatics JournalJacobs et al.research-article2014


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    process and understand basic health information and services needed to make appropriate health decisions.3 This definition focuses on individual capability and does imply needed skills.4

    Low health literacy has been linked to poorer health status, increased hospitalization rates, and non-adherence to medications across a number of diseases.1,5,6 It has been related to self-reported poor health,7 risk for hospital admission,8,9 reduced participation in cervical cancer screening,10 poor self-management in patients with diabetes,11 and unstable hemoglobin A1C concentrations in patients with diabetes.12 Low levels of health literacy are associated with greater use of health services7,13 and with higher health costs14 in Medicare enrollees. Elderly persons with low health literacy report that they have more chronic health conditions, worse physical functioning, and poorer mental health,15,16 and minority elderly persons with lower health literacy report more chronic health conditions than whites with similar health literacy levels.15,17 Additional studies have linked limited health literacy to medication dosing errors and increased mortality.18

    While there is evidence to suggest that low levels of health literacy are associated with inferior health outcomes, increased hospitalization rates, and non-adherence to medications across a num-ber of diseases, relatively few effective interventions have been developed to address low literacy and even less have been developed that target ethnic minority populations prone to lower health literacy rates. The interventions that exist, however, rely primarily on communication and educa-tion alone and have mostly failed to achieve substantial and sustainable behavioral change.19 Increased interest in health literacy has emerged in part due to continuing changes in the delivery of health care services. These changes create new responsibilities for patients and their caregivers, which include finding and evaluating information, self-monitoring of health status, and under-standing financial constraints and obligations. Thus, a persons health depends more and more on his or her ability and willingness to carry out a complex set of related behaviors. This set of behav-iors is essential for patients who often must make decisions about treatment with complex combi-nations of medications.

    The task of obtaining optimal care is likely to be difficult for individuals with low levels of health literacy. As the US health care system becomes more complex, this problem is likely to increase further.20 One possible approach to addressing low health literacy is to create interventions that can be easily understood, are acceptable, easily deployed, cost-effective, and readily accessi-ble on the Internet. Yet few studies have systematically reviewed the current information technol-ogy (IT)-based interventions related to improving health literacy.

    eHealth applications

    eHealth is the application of information communication technologies across all range of func-tions involved in the practice and delivery of health care.21,22 IT-based interventions used to pro-mote health literacy have the potential for being readily available over the Internet and on handheld devices such as smartphones and tablets. The field of eHealth is promising in that it can support and enable health behavior change and aid in the prevention and management of dis-ease.23 Once created, these interventions can be easily sustained as costs for their continued main-tenance and deployment are relatively low. One study suggested that new advances in multimedia could be used to better disseminate patient education25. Technology-enabled health research and care has emerged in the past decade as a dynamic field that may offer great potential to help pro-duce better outcomes in key risk patients. This alternate strategy for increasing patients knowl-edge of pertinent health care related information has been to provide it through computers and mobile devices.

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    Trends in eHealth applications and health literacy

    Strategies to promote health literacy at the individual patient level have relied heavily on paper materials such as pamphlets and brochures. Some recommend emphasizing the need for drawing upon communication and social science theories of information behavior, using a range of tradi-tional and novel formats, gaining better understanding of the publics health information needs, and developing medical informatics solutions for tailoring applications to patients needs and abilities.25 However, some studies have shown that the effectiveness and patient satisfaction with web-based health education materials are greater than if presented in a traditional format.26 For individuals who have learned to rely upon oral forms of communication or who have low literacy levels, written information sources may be of little or no use. Current trends indicate eHealth technology will con-tinue to expand. Due to the multiple variables involved with health care, any health literacy applica-tion will need to be multi-faceted, comprehensive, and culturally and linguistically appropriate. As a result, it is important to understand patients individual health decision-making abilities.

    Regarding technology use, a survey conducted in Harlem27 found that 77 percent of the 646 adult residents aged 18 years and older said they had used a computer and 87 percent reported hav-ing friends or family who use the Internet. This is useful information for understanding diffusion of and normative support for technology use. The survey also found that 68 percent of respondents had one or more computers at home and 57 percent used the Internet at home. For those who did not have a computer at home, 76 percent said they knew where a computer was publicly available. Of the respondents, 60 percent said that the most important problem in accessing the computer is overcrowding. Other problems in access were cost (2%), equipment problems (4%), location or transportation (8%), and hours of operation (13%). Such data show an interest exists in using tech-nology in low-income minority communities.

    The Harlem study also revealed that native English speakers are more likely to use the Internet, African-Americans are more likely to be Internet users than Hispanics/Latinos, and Internet users are more likely to have higher educational attainment, be employed, and have higher incomes than those who do not use the Internet. Little is known about the extent to which certain racial/ethnic minority groups have access to, or interest in, using the Internet for health-related activities. More research is needed to gain information about how health consumers from racial/ethnic minority communities use technology and seek health information.

    The goal of this article was to review empirically based eHealth intervention strategies designed to improve health literacy among health care consumers. Specifically, this review aimed to (1) identify and summarize types of eHealth applications and technologies being used to improve health literacy; (2) discuss effectiveness of eHealth applications to improve health literacy based on reports of attributes; and (3) assess the gaps in knowledge and make recommendations for future research in eHealth applications to improve health literacy. This literature review also strives to add to the biomedical informatics knowledge base and demonstrates how existing health literacy strategies might be used with various populations.

    Rationale for the research question

    The challenge facing biomedical informatics researchers is to disseminate knowledge and enrich the perspective of both health practitioners and consumers to ensure the highest quality of care possible. One common, but incorrect, assumption is that all health consumers understand medical and health information related to their illness and are thus able to make informed decisions about their treatment protocols and health care options. In fact, physicians often overestimate patients literacy levels.28

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    Creating eHealth interventions to improve health literacy will aid in extended duration and quality of life for patients. Traditional methods (i.e. pamphlets, talking) may not be as effective as delivering information through alternate venues. In order to promote continued research on the impact of eHealth applications that improve health literacy in patients, it is important to continually and empirically evaluate the research literature to better understand what is known, what remains unknown, and any future trends in the field. To address this gap in knowledge, we sought to iden-tify and review the most current technology-based applications designed to improve health liter-acy. Observations and implications for future study in the area will also be explicated.


    A review of the current state of the science regarding types of eHealth technology for health liter-acy interventions was conducted. We used the US Department of Health and Human Services18 Healthy People 2010 definition of health literacy, the capacity to obtain, process and understand basic health information and services needed to make appropriate health. The study selection criteria flowed directly from the review question (i.e. What are the current eHealth interventions to improve health literacy?) and were specified a priori. Interventions had to include at least one eHealth delivery component (e.g. touchscreen computer, handheld electronic device, Internet delivered, and one measure of (or components related to) health literacy to promote positive change in lifestyle behaviors for improved health outcomes). Studies also had to have been completed with outcome reports; interventions not yet implemented were excluded.

    Search strategy

    Inclusion and exclusion criteria. Inclusion and exclusion criteria were established in advance. Studies were included when their authors (1) were published in scholarly (peer reviewed) journals, (2) discussed eHealth interventions that included at least one health literacy component or measure, (3) evaluated eHealth applications addressing health literacy likely to be accessed by consumers, and (4) provided quantitative and/or qualitative results or information on the effectiveness of the applications.

    Identification of studies. A computerized search of 16 databases of scientific abstracts were explored in a systematic fashion to assess the presence of eHealth applications to improve health literacy...


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