Nicola Diviani

Mapping mHealth research: a decade of evolution.

Background For the last decade, mHealth has constantly expanded as a part of eHealth. Mobile applications for health have the potential to target heterogeneous audiences and address specific needs in different situations, with diverse outcomes, and to complement highly developed health care technologies. The market is rapidly evolving, making countless new mobile technologies potentially available to the health care system; however, systematic research on the impact of these technologies on health outcomes remains scarce. Objective To provide a comprehensive view of the field of mHealth research to date and to understand whether and how the new generation of smartphones has triggered research, since their introduction 5 years ago. Specifically, we focused on studies aiming to evaluate the impact of mobile phones on health, and we sought to identify the main areas of health care delivery where mobile technologies can have an impact. Methods A systematic literature review was conducted on the impact of mobile phones and smartphones in health care. Abstracts and articles were categorized using typologies that were partly adapted from existing literature and partly created inductively from publications included in the review. Results The final sample consisted of 117 articles published between 2002 and 2012. The majority of them were published in the second half of our observation period, with a clear upsurge between 2007 and 2008, when the number of articles almost doubled. The articles were published in 77 different journals, mostly from the field of medicine or technology and medicine. Although the range of health conditions addressed was very wide, a clear focus on chronic conditions was noted. The research methodology of these studies was mostly clinical trials and pilot studies, but new designs were introduced in the second half of our observation period. The size of the samples drawn to test mobile health applications also increased over time. The majority of the studies tested basic mobile phone features (eg, text messaging), while only a few assessed the impact of smartphone apps. Regarding the investigated outcomes, we observed a shift from assessment of the technology itself to assessment of its impact. The outcome measures used in the studies were mostly clinical, including both self-reported and objective measures. Conclusions Research interest in mHealth is growing, together with an increasing complexity in research designs and aim specifications, as well as a diversification of the impact areas. However, new opportunities offered by new mobile technologies do not seem to have been explored thus far. Mapping the evolution of the field allows a better understanding of its strengths and weaknesses and can inform future developments.

Low Health Literacy and Evaluation of Online Health Information: A Systematic Review of the Literature

Background Recent years have witnessed a dramatic increase in consumer online health information seeking. The quality of online health information, however, remains questionable. The issue of information evaluation has become a hot topic, leading to the development of guidelines and checklists to design high-quality online health information. However, little attention has been devoted to how consumers, in particular people with low health literacy, evaluate online health information. Objective The main aim of this study was to review existing evidence on the association between low health literacy and (1) people’s ability to evaluate online health information, (2) perceived quality of online health information, (3) trust in online health information, and (4) use of evaluation criteria for online health information. Methods Five academic databases (MEDLINE, PsycINFO, Web of Science, CINAHL, and Communication and Mass-media Complete) were systematically searched. We included peer-reviewed publications investigating differences in the evaluation of online information between people with different health literacy levels. Results After abstract and full-text screening, 38 articles were included in the review. Only four studies investigated the specific role of low health literacy in the evaluation of online health information. The other studies examined the association between educational level or other skills-based proxies for health literacy, such as general literacy, and outcomes. Results indicate that low health literacy (and related skills) are negatively related to the ability to evaluate online health information and trust in online health information. Evidence on the association with perceived quality of online health information and use of evaluation criteria is inconclusive. Conclusions The findings indicate that low health literacy (and related skills) play a role in the evaluation of online health information. This topic is therefore worth more scholarly attention. Based on the results of this review, future research in this field should (1) specifically focus on health literacy, (2) devote more attention to the identification of the different criteria people use to evaluate online health information, (3) develop shared definitions and measures for the most commonly used outcomes in the field of evaluation of online health information, and (4) assess the relationship between the different evaluative dimensions and the role played by health literacy in shaping their interplay.

Defining and measuring health literacy: how can we profit from other literacy domains?

When the antecedents of health-promoting behavior are explored, the concept of health literacy is deemed a factor of major influence. Originally defined as reading, writing and numeracy skills in the health domain, health literacy is now considered a multidimensional concept. The ongoing discussion on health literacy reveals that no agreement exists about which dimensions to include in the concept. To contribute to the development of a consistent and parsimonious concept of health literacy, we conducted a critical review of concepts in other literacy domains. Our review was guided by two research questions: (i) Which dimensions are included in the concepts of other literacy domains? (ii) How can health literacy research profit from other literacy domains? Based on articles collected from PubMed, PsycINFO, Communication & Mass Media Complete, CINAHL, SAGE Full-Text Collection, Cochrane Library and Google Scholar as well as selected monographs and editions, we identified seven distinct dimensions. Some of the dimensions recur across all reviewed literacy domains and first attempts have been made to operationalize the dimensions. Expanding upon these dimensions, the paper discusses how they can prove useful for elaborating a consistent and parsimonious concept of health literacy and foster the development of a more holistic measure.

Exploring the role of health literacy in the evaluation of online health information: Insights from a mixed-methods study

OBJECTIVE To gain new insights into the relationship between health literacy and evaluation of online health information. METHODS Using a mixed-methods approach, forty-four semi-structured interviews were conducted followed by a short questionnaire on health literacy and eHealth literacy. Qualitative and quantitative data were merged to explore differences and similarities among respondents with different health literacy levels. RESULTS Thematic analysis showed that most respondents did not question the quality of online health information and relied on evaluation criteria not recognized by existing web quality guidelines. Individuals with low health literacy, despite presenting higher eHealth literacy scores, appeared to use less established criteria and to rely more heavily on non-established ones compared to those with high health literacy. CONCLUSION Disparities in evaluation ability among people with different health literacy might be related to differences in awareness of the issue and to the use of different evaluation criteria. Future research should quantitatively investigate the interplay between health literacy, use of established and non-established criteria, and ability to evaluate online health information. PRACTICE IMPLICATIONS Communication and patient education efforts should aim to raise awareness on online health information quality and to promote use of established evaluation criteria, especially among low health literate citizens.

Comparing the quality of pro- and anti-vaccination online information: a content analysis of vaccination-related webpages

BackgroundThe exponential increase in health-related online platforms has made the Internet one of the main sources of health information globally. The quality of health contents disseminated on the Internet has been a central focus for many researchers. To date, however, few comparative content analyses of pro- and anti-vaccination websites have been conducted, and none of them compared the quality of information. The main objective of this study was therefore to bring new evidence on this aspect by comparing the quality of pro- and anti-vaccination online sources.MethodsBased on past literature and health information quality evaluation initiatives, a 40-categories assessment tool (Online Vaccination Information Quality Codebook) was developed and used to code a sample of 1093 webpages retrieved via Google and two filtered versions of the same search engine. The categories investigated were grouped into four main quality dimensions: web-related design quality criteria (10 categories), health-specific design quality criteria (3 categories), health related content attributes (12 categories) and vaccination-specific content attributes (15 categories). Data analysis comprised frequency counts, cross tabulations, Pearson’s chi-square, and other inferential indicators.ResultsThe final sample included 514 webpages in favor of vaccination, 471 against, and 108 neutral. Generally, webpages holding a favorable view toward vaccination presented more quality indicators compared to both neutral and anti-vaccination pages. However, some notable exceptions to this rule were observed. In particular, no differences were found between pro- and anti-vaccination webpages as regards vaccination-specific content attributes.ConclusionsOur analyses showed that the overall quality of pro-vaccination webpages is superior to anti-vaccination online sources. The developed coding scheme was proven to be a helpful and reliable tool to judge the quality of vaccination-related webpages. Based on the results, we advance recommendations for online health information providers as well as directions for future research in this field.

What should laypersons know about cancer? Towards an operational definition of cancer literacy

OBJECTIVE To operationally define cancer literacy, understanding which aspects of cancer are important to be known by a layperson to be considered cancer literate. METHODS A Delphi study in three consecutive rounds was conducted among a panel of Swiss cancer experts (oncologists, GPs, nurses from oncology wards, social workers, public health experts). RESULTS The result of the Delphi process is a first operational definition of the concept of cancer literacy, a list of the aspects of cancer that, in the experts view, laypeople should know to be considered cancer literate. CONCLUSIONS We have now an idea of what should be known about cancer. The study also provides us with some useful hints about what should be communicated about cancer, e.g. via public communication campaigns, school education, or media. PRACTICE IMPLICATIONS The operational definition of the concept can be used for the development and the validation of a measure of cancer literacy, not anymore limited to basic literacy and numeracy skills.

A Psychometric Analysis of the Italian Version of the eHealth Literacy Scale Using Item Response and Classical Test Theory Methods

Background The eHealth Literacy Scale (eHEALS) is a tool to assess consumers’ comfort and skills in using information technologies for health. Although evidence exists of reliability and construct validity of the scale, less agreement exists on structural validity. Objective The aim of this study was to validate the Italian version of the eHealth Literacy Scale (I-eHEALS) in a community sample with a focus on its structural validity, by applying psychometric techniques that account for item difficulty. Methods Two Web-based surveys were conducted among a total of 296 people living in the Italian-speaking region of Switzerland (Ticino). After examining the latent variables underlying the observed variables of the Italian scale via principal component analysis (PCA), fit indices for two alternative models were calculated using confirmatory factor analysis (CFA). The scale structure was examined via parametric and nonparametric item response theory (IRT) analyses accounting for differences between items regarding the proportion of answers indicating high ability. Convergent validity was assessed by correlations with theoretically related constructs. Results CFA showed a suboptimal model fit for both models. IRT analyses confirmed all items measure a single dimension as intended. Reliability and construct validity of the final scale were also confirmed. The contrasting results of factor analysis (FA) and IRT analyses highlight the importance of considering differences in item difficulty when examining health literacy scales. Conclusions The findings support the reliability and validity of the translated scale and its use for assessing Italian-speaking consumers’ eHealth literacy.

First insights on the validity of the concept of Cancer Literacy: A test in a sample of Ticino (Switzerland) residents

OBJECTIVE To develop a measure of Cancer Literacy and have a first insight into the validity of the concept. METHODS A measure of Cancer Literacy was developed and administered to a sample of Ticino (Switzerland) residents (N=639). Internal consistency, test-retest reliability and construct validity of the measure were assessed. RESULTS The Cancer Literacy Score (CLS) showed acceptable internal consistency and 4-week test-retest reliability. Independent-samples t-tests and one-way ANOVAs confirmed that women, Swiss citizens, people with higher educational levels, people with a medical qualification, and people who had played an active role in the cancer experience of a family member or a friend presented significantly higher CLS. Correlational analyses indicated a more positive attitude towards screening participation and engagement in health-promoting behaviours in people with higher levels of Cancer Literacy. CONCLUSIONS AND PRACTICE IMPLICATIONS The Cancer Literacy scale provides us with evidence of the validity of our conceptual attempt to go in the direction of a context- and content-specific concept of health literacy. Despite some limitations and the need for further refinement before it can be applied on a larger scale, the scale already offers Ticino researchers and public health workers a comprehensive measure of cancer knowledge.

Health Literacy and Online Health Information Processing: Unraveling the Underlying Mechanisms

The usefulness of the Internet as a health information source largely depends on the receiver’s health literacy. This study investigates the mechanisms through which health literacy affects information recall and website attitudes. Using 2 independent surveys addressing different Dutch health websites (N = 423 and N = 395), we tested the mediating role of cognitive load, imagination ease, and website involvement. The results showed that the influence of health literacy on information recall and website attitudes was mediated by cognitive load and imagination ease but only marginally by website involvement. Thus, to improve recall and attitudes among people with lower health literacy, online health communication should consist of information that is not cognitively demanding and that is easy to imagine.

Association between cancer literacy and cancer-related behaviour: evidence from Ticino, Switzerland

Background This paper details the role of different dimensions of health literacy in the relationship between health literacy and cancer-related health behaviours. In particular, Cancer Literacy is studied as an exemplar of a dimension of health literacy beyond basic reading and writing skills. The link between functional health literacy, Cancer Literacy and cancer-related health behaviours is investigated in a sample of Ticino (Switzerland) residents (n=639). Design and methods Detailed data is collected about respondents’ functional health literacy, Cancer Literacy, cancer information seeking behaviour, engagement in cancer preventive behaviours, participation to cancer screenings, and intention to adhere to current screening recommendations. Results Results confirm the added value of Cancer Literacy – compared to functional health literacy – in explaining people’s cancer information seeking behaviour, their participation to several cancer screenings and their screening intention, underscoring the need to take into account dimensions of health literacy beyond basic functional skills. Conclusions From a public health perspective, findings provide further evidence on the importance of adapting informational and educational communication intervention designed to improve cancer prevention and screening to different audiences. Significance for public health From a public health perspective, our findings underscore the importance of adapting informational and educational communication interventions designed to improve cancer prevention and screening to different audiences, which could differ not only in their functional health literacy, and in particular to put into place strategies to evaluate their success, including the actual transformation of information in relevant knowledge that can be used as a basis for health decision making. Moreover, the cancer literacy score is able to provide researchers and public health officials with detailed information on which are the main gaps in cancer knowledge and to identify the segments of the population that are more at risk. This information could be used to design and develop targeted informational campaigns for low health literate citizens.