Measures of eHealth Literacy: Options for the Malaysian Population

Arina Anis Azlan


Health literacy is an important component to the self-management of one’s health decisions. As information on the Internet becomes more easily accessible, individuals need to be properly equipped to seek and evaluate the health information available to them. Digital health literacy, or eHealth literacy, refers to an array of skills required to properly seek, access, understand and apply health information on the Internet. To date, a number of different models and instruments have been developed to measure eHealth literacy, including the eHealth Literacy Scale (eHEALS), the eHealth Literacy Framework (eHLF), the Digital Health Literacy Instrument (DHLI), the eHealth Literacy Questionnaire (eHLQ), the eHealth Literacy Assessment Toolkit (eHLA) and the Transactional eHealth Literacy Instrument (TeHLI). While some of these instruments rely on the individual’s self-assessment of eHealth literacy, others also test for functional information, communication and technological competencies. This paper presents these different eHealth literacy instruments and how they have been applied in current research. The similarities and differences between the instruments are examined. The discussion concludes with a summary of the measures and potential ways forward in developing an eHealth Literacy instrument for the Malaysian population. It is hoped that this paper may benefit researchers, health care providers, practitioners, ministries and governing bodies interested in understanding eHealth literacy and its measures.


Keywords: Health information seeking, information and communication competencies, conceptual definitions, literature review, digital health literacy.

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Bakker, M. M., Putrik, P., Aaby, A., Debussche, X., Morrissey, J., Borge, C. R. … Maindal, H. T. (2019). Acting together - WHO National Health Literacy Demonstration Projects (NHJDPs) address health literacy needs in the European Region. Public Health Panorama, 5(2-3), 123–329.

Briones, R. (2015). Harnessing the web: how e-Health and e-Health literacy impact young adults’ perceptions of online health information. Medicine 2.0, 4(2), e5. doi: 10.2196/med20.4327

Chen, Y. Y., Li, C. M., Liang, J. C., & Tsai, C. C. (2018). Health information obtained from the Internet and changes in medical decision making: Questionnaire development and cross-sectional survey. Journal of Medical Internet Research, 20(2), e47. doi: 10.2196/jmir.9370

Cho, A. H., Arar, N. H., Edelman, D. E., Hartwell, P. H., Oddone, E. Z., & Yancy, W. S. (2010). Do diabetic veterans use the Internet? Self-reported usage, skills, and interest in using My HealtheVet Web portal. Telemedicine Journal and E-Health, 16(5), 595-602. doi: 10.1089/tmj.2009.0164

Chung, S. Y., & Nahm, E. S. (2015). Testing reliability and validity of the eHealth Literacy Scale (eHEALS) for older adults recruited online. Computers, Informatics, Nursing: CIN, 33(4), 150-156.

Diviani, N., van den Putte, B., Giani, S., & van Weert, J. C. (2015). Low health literacy and evaluation of online health information: A systematic review of the literature. Journal of Medical Internet Research, 17(5), e112. doi: 10.2196/jmir.4018

Eysenbach, G., & Köhler, C. (2002). How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ (Clinical Research ed.), 324(7337), 573–577. doi: 10.1136/bmj.324.7337.573

Fox, S., & Duggan, M. (2013). Health online 2013. Retrieved on June 8, 2019, from

Furstrand, D., & Kayser, L. (2015). Development of the eHealth Literacy Assessment Toolkit, eHLA. Studies in Health Technology and Informatics, 216, 971.

Gilstad, H. (2014). Toward a comprehensive model of eHealth literacy. Proceedings of the 2nd European Workshop on Practical Aspects of Health Information (pp.19-20). Trondheim, Norway: 2nd European Workshop on Practical Aspects of Health Information. Retrieved from

Griebel, L., Enwald, H., Gilstad, H., Pohl, A-L., Moreland, J., & Sedlmayr, M. (2017). eHealth literacy research - Que vaids?. Informatics for Health and Social Care, 1-16. doi: 10.1080/17538157.2017.1364247

Hargittai, E. (2008). An update on survey measures of web-oriented digital literacy. Social Science Computer Review, 27(1), 130-137.

Holt, K. A., Karnoe, A., Overgaard, D., Nielsen, S. E., Kayser, L., & Røder, M. E. (2019). Differences in the level of electronic health literacy between users and nonusers of digital health services: An exploratory survey of a group of medical outpatients. Interactive Journal of Medical Research, 8(2), e8423. doi: 10.2196/ijmr.8423

Karnoe, K. A., & Kayser, L. (2016). Validation of the eHealth Literacy Assessment tool (eHLA). International Journal of Integrated Care, 16(6), a349. doi: 10.5334/ijic.2897

Karnoe, A., Furstrand, D., Christensen, K. B., Norgaard, O., & Kayser, L. (2018). Assessing competencies needed to engage with digital health service: Development of the eHealth Literacy Assessment Toolkit. Journal of Medical Internet Research, 20(5), e178. doi: 10.2196/jmir.8347

Kayser, L., Karnoe, A. Furstrand, D., Batterham, R., Christensen, K. B., Elsworth, G., & Osborne, R. H. (2018). A multidimensional tool based on the eHealth Literacy Framework: development and initial validity testing of the eHealth Literacy Questionnaire (eHLQ). Journal of Medical Internet Research, 20(2), e36. doi: 10.2196/jmir.8371

Kayser, L., Rossen, S., Karnoe, A., Elsworth, G., Vibe-Petersen, J., Christensen, J. F., Ried-Larsen, M., & Osborne, R. H. (2019). Development of the multidimensional Readiness and Enablement Index for Health Technology (READHY) tool to measure individuals’ health technology readiness: Initial testing in a cancer rehabilitation setting. Journal of Medical Internet Research, 21(2), e10377. doi: 10.2196/10377

Koo, M., Norman, C., & Chang, H. M. (2012). Psychometric evaluation of a Chinese version of the eHealth Literacy Scale (eHEALS) in school age children. International Electronic Journal of Health Education, 15, 29-36.

Lam, M. K., & Lam, L.T. (2012). Health information-seeking behaviour on the Internet and health literacy among older Australians. Electronic Journal of Health Informatics, 7(2), e15.

Laugksch, R. C. (2000). Scientific literacy: A conceptual overview. Science Education, 84, 71-94.

McCarthy, D. M., Scott, G. N., Courtney, D. M., Czerniak, A., Aldeen, A. Z., Gravenor, S., & Dresden, S. M. (2017). What did you Google? Describing online health information search patterns of ED patients and their relationship with final diagnoses. The Western Journal of Emergency Medicine, 18(5), 928–936. doi: 10.5811/westjem.2017.5.34108

Mitsutake, S., Shibata, A., Ishii, K., Okazaki, K., & Oka, K. (2011). Developing Japanese version of the eHealth Literacy Scale (eHEALS). Nihon Koshu Eisei Zasshi, 58(5), 361-371.

Nguyen, J., Moorhouse, M., Curbow, B., Cristie, J., Walsh-Childers, K. & Islam, S. (2016). Construct validity of the eHealth Literacy Scale (eHEALS) among two adult populations: A Rasch analysis. JMIR Public Health Surveillance, 2(1), e24.

Norgaard, O., Furstrand, D., Klokker, L., Karnoe, A., Batterham, R. W., Kayser, L., & Osborne, R. H. (2015). The e-health literacy framework: A conceptual framework for characterizing e-health users and their interaction with e-health systems. Knowledge Management & E-Learning, 7(4), 522-540.

Norman, C. D., & Skinner, H. A. (2006a). eHealth Literacy: Essential skills for consumer health in a networked world. Journal of Medical Internet Research, 8(2), e9. doi: 10.2196/jmir.8.2.e9

Norman, C. D., & Skinner, H. A. (2006b). eHEALS: The eHealth literacy scale. Journal of Medical Internet Research, 8(4), e27. doi: 10.2196/jmir.8.4.e27

Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259-267.

Osborne, R. (2016). Digital health literacy for 23 million: A breakthrough in systems design to ensure no one is left behind?. Retrieved from

Paige, S. R., Krieger, J. L., Stellefson, M., & Alber, J. M. (2017). eHealth literacy in chronic disease patients: An item response theory analysis of the eHealth literacy scale (eHEALS). Patient Education and Counseling, 100(2), 320–326. doi: 10.1016/j.pec.2016.09.008

Paige, S. R., Stellefson, M., Krieger, J. L., Anderson-Lewis, C., Cheong, J., & Stopka, C. (2018). Proposing a transactional model of eHealth Literacy: concept analysis. Journal of Medical Internet Research, 20(10), e10175. doi: 10.2196/10175

Paige, S. R., Stellefson, M., Krieger, J. L., Miller, M. D., Cheong, J., & Anderson-Lewis, C. (2019). Transactional eHealth literacy: Developing and testing a multi-dimensional instrument. Journal of Health Communication, 24(10), 737-748. doi: 10.1080/10810730.2019.1666940

Parker, R. M., Baker, D. W., Williams, M. V., & Nurss, J. R. (1995). The test of functional health literacy in adults: A new instrument for measuring patients' literacy skills. Journal of General Internal Medicine, 10(10), 537-541.

Peterson, G., Aslani, P., & Williams, K. A. (2003). How do consumers search for and appraise information on medicines on the Internet? A qualitative study using focus groups. Journal of Medical Internet Research, 5(4), e33. doi: 10.2196/jmir.5.4.e33

Peterson, P. N., Shetterly, S. M., Clarke, C. L., Allen, L. A., Matlock, D. D., Magid, D. J., & Masoudi, F. A. (2009). Low health literacy is associated with increased risk of mortality in patients with heart failure. Circulation, 120(18), S749-S749.

Quinn, S., Bond, R., & Nugent, C. (2017). Quantifying health literacy and eHealth literacy using existing instruments and browser- based software for tracking online health information seeking behavior. Computers in Human Behavior, 69, 256–267. doi: 10.1016/j.chb.2016.12.032

Richtering, S. S., Morris, R., Soh, S. E., Barker, A., Bampi, F., Neubeck, L., … Redfern, J. (2017). Examination of an eHealth literacy scale and a health literacy scale in a population with moderate to high cardiovascular risk: Rasch analyses. PLoS ONE, 12(4), e0175372. doi: 10.1371/journal.pone.0175372

Seçkin, G., Yeatts, D., Hughes, S., Hudson, C., & Bell, V. (2016). Being an informed consumer of health information and assessment of electronic health literacy in a national sample of Internet users: validity and reliability of the e-HLS instrument. Journal of Medical Internet Research, 18(7), e161. doi: 10.2196/jmir.5496

Soellner, R., Huber, S., & Reder, M. (2014). The concept of eHealth literacy and its measurement: German translation of the eHEALS. Journal of Media Psychology: Theories, Methods, and Applications, 26(1), 29–38. doi: 10.1027/1864-1105/a000104

Srivastava, S., Pant, M., Abraham, A., & Agrawal, N. (2015). The technological growth in eHealth services. Computational and Mathematical Methods in Medicine, 894171.

Sun, Y., Zhang, Y., Gwizdka, J., & Trace, C. B. (2019). Consumer evaluation of the quality of online health information: Systematic literature review of relevant criteria and indicators. Journal of Medical Internet Research, 21(5), e12522. doi: 10.2196/12522

Suri, V. R., Majid, S., Chang, Y. K., & Foo, S. (2016). Assessing the influence of health literacy on health information behaviors: A multi-domain skills-based approach. Patient Education Counselling, 99(6), 1038-1045.

van der Vaart, R., van Deursen, A. J., Drossaert, C. H., Taal, E., van Dijk, J. A., & van de Laar, M. A. (2011). Does the eHealth Literacy Scale (eHEALS) measure what it intends to measure? Validation of a Dutch version of the eHEALS in two adult populations. Journal of Medical Internet Research, 13(4), e86. doi: 10.2196/jmir.1840

van der Vaart, R., Drossaert, C. H., de Heus, H. M., Taal, E., van de Laar, M. A. (2013). Measuring actual eHealth literacy among patients with rheumatic diseases: A qualitative analysis of problems encountered using Health 1.0 and Health 2.0 applications. Journal of Medical Internet Research, 15(2), e27. doi: 10.2196/jmir.2428

van der Vaart, R., van Driel, D., Pronk, K., Paulussen, S., te Boekhorst, S., Rosmalen, J. G. M., Evers, A. W. M. (2019). The role of age, education, and digital health literacy in the usability of Internet-based cognitive behavioral therapy for chronic pain: Mixed methods study. JMIR Formative Research, 3(4), e12883. doi: 10.2196/12883

Wangdahl, J. M., Dahlberg, K., Jaensson, M., & Nilsson, U. (2019). Psychometric validation of Swedish and Arabic versions of two health literacy questionnaires, eHEALS and HLS-EU-Q16, for use in a Swedish context: A study protocol. BMJ Open, 9, e029668. doi: 10.1136/bmjopen-2019-029668

Zrubka, Z., Hajdu, O., Rencz, F., Baji, P., Gulacsi, L. & Pentek, M. (2019). Psychometric properties of the Hungarian version of the eHealth Literacy Scale. European Journal of Health Economics, 20(Suppl 1), 57. doi: 10.1007/s10198-019-01062-1


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