Informatics in Medicine Unlocked 18 (2020) 100273

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Informatics in Medicine Unlocked

journal homepage: http://www.elsevier.com/locate/imu

eHealth literacy and internet use among undergraduate nursing students in

a resource limited country: A cross-sectional study
Kirubel Biruk Shiferaw a, *, Eden Abetu Mehari b, Tewodros Eshete a
a
Debre Markos University, College of Medicine and Health Science, Department of Health Informatics, Ethiopia
b
University of Gondar, College of Medicine and Health Science, School of Pharmacy, Department of Clinical Pharmacy, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: eHealth literacy empowers caregivers and patients to actively engage in healthcare decisions. Most
Nursing students prior studies regarding eHealth literacy have been done in developed countries, and the perspective of nursing
eHealth literacy students in a resource-constrained environment is not well documented. The aim of this study was to assess
Internet use
Internet use and eHealth literacy skill among nursing students at the University of Gondar, North West Ethiopia.
Methods: An institutional based cross-sectional study was conducted to assess the pattern of Internet use and
eHealth literacy among nursing students at the University of Gondar, College of Medicine and Health Science,
from November 15 to January 28, 2018. The total sample size was 236. A stratified random sampling design with
a proportional allocation technique was performed to select study participants from each batch. eHealth literacy
was measured using the widely used and validated eHealth literacy scale (eHEALS). After data collection was
done, it was checked, cleaned, and analyzed by using SPSS Version 20. Descriptive statistics were utilized to
identify socio-demographic characteristics and Internet use of participants, and the total sum of eHealth literacy
scale was used as a dependent variable with linear regression done to identify predictors.
Result: From the total of 236 approached participants, 229 participants were included in the study, and thus the
response rate was 97.3%. The mean age of participants was 20.66 � 1.45 years and the average cumulative GPA
was 3.07 � 0.40. Overall, 89.1% of nursing students reported that they have access to the Internet, of which
60.7% of the participants use it daily. Only 22.7% of survey respondents said that they use Internet for
educational purposes, while a majority of the users (52.8%) stated that they use Internet for social media and
chat rooms. The mean eHealth literacy level was 25.23 with a 7.29 standard deviation. The linear regression
result depicted that 72.6% of the variation in eHealth literacy is explained with an adjusted R2 ¼ 0.726 in this
model. Gender, enrollment year, and place of residence were significantly associated with participants’ eHealth
literacy skill (p < 0.01).
Conclusion: Nursing students from rural residence and first-year students demonstrated relatively low access and
use of the Internet. Gender, residence, and enrollment year were predictive variables of eHealth literacy among
nursing students in this setting.

1. Introduction
The Internet is one of the main sources of multidisciplinary infor­
mation that enables users to have access to a larger volume of infor­
mation in different sectors. Studies show that majority of Internet users
have utilized it to search for health information [1–4]. The Internet has
the potential to influence both administrative and clinical tasks, and it
can be harnessed into integrated delivery systems for education and
health service provision [5]. A massive volume of eHealth resources are
available on the Internet to help those who have access to it [6].
However, the ability to find and use the information from the
Internet is an important skill. “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” is defined
as E-Health literacy [7]. E-health literacy is considered essential for
improving healthcare delivery and quality of care as well [8–10].
Studies show that eHealth literacy empowers caregivers and patients to
influence control care decisions [11–13].
The eHEALS is an eight-item scale used to assess the self-reported
skill of eHealth consumers to find, appraise, and use health related

* Corresponding author.
E-mail address: birukkirubel@gmail.com (K.B. Shiferaw).

https://doi.org/10.1016/j.imu.2019.100273
Received 16 May 2019; Received in revised form 13 November 2019; Accepted 20 November 2019
Available online 22 November 2019
2352-9148/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
K.B. Shiferaw et al. Informatics in Medicine Unlocked 18 (2020) 100273

information from the Internet to answer their health related queries Table 1
[14]. According to Norman and Skinner, the eHealth Literacy Scale Characteristics of participants.
(eHEALS) is a promising tool to evaluate users’ ease and skills to use the Variables Frequency Percentages %
Internet in order to obtain health related information [14,15]. The scale
Gender
has been used in various studies in different populations exhibiting Male 111 48.5
considerable reliability and validity of items [2,10,16–21]. The eHealth Female 118 51.5
literacy scale consists of six basic skills (traditional literacy, health lit­ Enrollment year
eracy, information literacy, scientific literacy, media literacy and com­ First year 69 30.1
Second year 54 23.6
puter literacy) [22]. As the eHEALS aims to assess a wide-ranging Third year 47 20.5
summary of literacy skills, it is a potential instrument to evaluate the Fourth year 59 25.8
comprehensive literacy skill of eHealth consumers. The eHEALS have Place of residence
demonstrated significant reliability and validity in its original English Rural based 129 56.3
Urban based 100 43.7
version [14]. The reliability and validity of eHEALS has also been sup­
ported by different studies in different settings [14,23–25]. eHEALS has
been translated and validated in different language versions, for formula with finite population correction [38], 95% confidence level,
instance Korean [26], Iranian [27], Dutch [24], Hebrew [28], German proportion of eHealth literate 50% [39] since there were no previous
[29], Japanese [25], Spanish [30], Chinese [31], and Italian [32]. study done in the same domain, relative precision of 5%, and 10%
Apparently, all of these diverse linguistic versions of the eHEALS non-response rate. The total sample size was 236. Stratified random
demonstrated greater internal consistency with (>0.7) Cronbach alpha sampling design with the proportional allocation technique was per­
coefficient, which is perceived as a key indicator for the reliability of the formed to select study participants from each batch of students from first
eHEALS in these dissimilar demographics. On the other hand, Van der year to fourth year.
Vaart et al. suggested the need for further research to ensure the validity
of eHEALS [33]. According to Van der Vaart et al., the eHealth literacy
2.3. Instruments and data analysis
scale coined by Norman and Skinner was unable to distinguish the dif­
ference in literacy level, and no correlation between eHealth literacy
A self-administered structured questionnaire was designed and pre­
skill and Internet use was observed. As a result, the authors suggested
tested after reviewing relevant the literature [9,17,24,40–43] on 30
the incorporation of important aspects of eHealth literacy, including
midwifery students for its consistency and reliability. The questionnaire
operational, strategic, formal, and information related aspects [33].
has three major segments. The first segment contains items on
As health science students are future health professional candidates,
socio-demographic information of participants. The second segment is
their efficacy to conduct advanced eHealth searches is a key concern
related to Internet use, and the third segment contains items to evaluate
[17]. Nursing is a major health profession in most health facilities, even
eHealth literacy skill of participants. Each item in the third segment was
in developed countries like the USA [34]. Altogether with the migration
valued on a Likert scale of 1–5 (1 is strongly disagree and 5 is strongly
and limited number of physicians, nurses are the primary health work­
agree). The eHEALS scale was used as a measuring tool for eHealth lit­
force in most underdeveloped countries [35,36]. Nursing professionals
eracy skill, as it has high internal consistency with an alpha coefficient of
need to be equipped with the ability to find, understand, and use health
0.88 [14]. One can score a minimum of 8 and a maximum of 40 in this
information from electronic sources, and apply the knowledge gained to
section [25,26,44,45].
address or solve a health problem [37]. In addition to the low Internet
After the data collection was done, it was checked, cleaned, and
penetration in Ethiopia (15%), the gap in skill to find and evaluate on­
analyzed by using SPSS Version 20. Descriptive statistics were used to
line resources is another challenge. To have this skill is critically crucial
identify socio-demographic characteristics and Internet use of partici­
for nursing and medical students and professionals as well, due to the
pants, and the total sum of eHealth literacy scale was used as a depen­
dynamic nature of scientific outputs.
dent variable for linear regression analysis to identify predictors.
Most of the studies regarding eHealth literacy were done in devel­
oped countries, and the perspective in resource-constrained environ­
ments is not well documented. The purpose of this study was to assess 2.4. Ethical consideration
Internet use and eHealth literacy skill among nursing students at the
University of Gondar, North West Ethiopia. In conducting the study, ethical clearance was secured from the
Debre Markos University ethical review board. Additional permissions
2. Method to access participants were also attained. Written informed consent was
also gained from all participants.
2.1. Study design
3. Result
An institutional based cross-sectional study was conducted to assess
pattern of Internet use and eHealth literacy among nursing students at From the total of 236 approached participants, 229 participants were
the University of Gondar, College of Medicine and Health Science, from included in the study, because five students were unable to take part and
November 15 to January 28, 2018. During the study period, the medical other two participants returned incomplete responses. Accordingly, the
college had 443 nursing students including all enrolled students from response rate was 97.3%. The mean age of participants was 20.66 � 1.45
first year to graduating class. years and the average cumulative GPA was 3.07 � 0.40. See Table 1 for
more detail.
2.2. Sample and setting Overall, 89.1% of nursing students reported that they have access to
the Internet of which 68.1% of the participants use it daily. Only 22.7%
The University has a computer lab for medical and health science of survey respondents said that they use the Internet for educational
students, and also a digital library on several campuses. In addition, purposes while majority of the users (59.3%) stated that they use the
computer related courses like “Introduction to Health Informatics” is Internet for social media and chat rooms. The result from this study
delivered to first-year medical and health science students during their revealed that students from rural-based residence have relatively low
first-year enrollment, at the beginning of the academic year. The sample Internet access and frequency of use. First-year students are also found
for this study was calculated by using a single population proportion to be lesser users of the Internet. See Table 2 for detail.

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K.B. Shiferaw et al. Informatics in Medicine Unlocked 18 (2020) 100273

Table 2
Internet use and participants characteristics.
Independent variables Internet use items

Do you have If you use the Internet, how frequently do you use it? For what purpose you mostly use Internet?
Internet
access?

Yes No daily Several days a week One day a week <1 day a week Social media Email Educational purpose entertainment

Gender
Male 101 10 81 7 11 2 64 11 19 7
female 103 15 49 23 19 12 50 12 26 15
Enrollment year
First year 50 19 12 9 18 11 20 2 12 16
Second year 49 5 36 9 3 1 31 3 11 4
Third year 47 0 34 11 2 0 29 5 12 1
Fourth year 58 1 42 9 7 0 35 12 8 3
Place of residence
Rural 104 25 38 26 30 10 40 14 33 17
urban 100 0 94 6 0 0 77 7 15 1

done in Taiwan [52]. This could be because of socio-cultural issues that

Table 3
are still the problem of most developing countries.
Linear regression, Dependent variable: (sum of eHEALS).
In this study, age and cumulative GPA were not significant variables,
Variables Coefficient(B) p-value Confidence level (95%) which is confirmatory with respect to other relevant studies [53],
Lower bound upper bound meaning that eHealth literacy is likely not related to academic score and
Gender 8.064 <.01* 9.307 6.821 participant age.
age -.185 .296 -.533 .163 Stakeholders should consider a specific and targeted intervention to
CGPA .418 .519 -.857 1.693 bridge the skill gap of eHealth literacy among nursing students at the
Enrollment year 2.246 <.01* 1.793 2.700 University of Gondar. As first-year and students from rural residence
place of residence 4.241 2.921 5.500
possess relatively lower access and use of Internet, focused intervention
<.01*

*significant. could be appropriate.

The mean eHealth literacy level was 25.2 with a 7.3 standard devi­
ation. The linear regression result depicted that 72.6% of the variation in
eHealth literacy is explained with an adjusted R2 ¼ 0.726 in this model.
Gender, enrollment year, and place of residence were significantly
associated with participants’ eHealth literacy skill (p < 0.01). Female
students were 8.06% lower in eHealth literacy level as compared to
males, and a year increase in student enrollment year increased their
eHealth literacy level by 2.25% (p < 0.01). Students from urban resi­
dents were 4.24% higher in eHealth literacy skill as compared to those
from rural-based residence. See Table 3 for more detail.
5. Conclusion
Besides the growing indication of efficacy, the present data
confirmed that Internet use and eHealth literacy skill of nursing students
are relatively low, which clearly implies that there is a need to address
efficient Internet use and eHealth literacy. Gender, residence, and
enrollment year were predictive variables of eHealth literacy among
nursing students in this setting.
Declaration of competing interest

4. Discussion The authors declare that they have no competing interests.

Although the access and use of Internet by nursing students was Acknowledgement
reasonably fair, their eHealth literacy level was limited. Specifically,
females and all students from rural residence demonstrated relatively The authors of this study would like to thank all nursing students for
low Internet use and eHealth literacy skill. their time and collaboration during our data collection.
This study indicated that Internet access was 89.1%, and the majority
of the users browse daily, mainly for the purpose of using social media
Appendix A. Supplementary data
and chat rooms, which is similar to other relevant studies [43,46–48].
The results also showed that as the year of enrollment increases, the
Supplementary data to this article can be found online at https://doi.
students’ access and use of Internet increases, and this could be because
org/10.1016/j.imu.2019.100273.
of computer-related courses they received during their stay in college. In
this study, students from rural provinces demonstrated relatively low
Funding
Internet access and frequency of use, and this could be due to infra­
structural inequalities and economic factors. This finding confirms what
Not applicable.
studies conducted elsewhere have stated, i.e., that residence has a sig­
nificant effect on Internet use [49,50].
Availability of data and material
Overall, the average eHealth literacy skill among nursing students in
this setting is by far lower than for other medical and health science
All data generated or analyzed during this study are included in this
students from different countries [17,51]. Although there is no signifi­
article.
cant difference in Internet access and use among gender, female students
inveterate relatively low eHealth literacy as compared to males. Gender
was considered as a significant predictor of eHealth literacy among Authors’ contributions
undergraduate nursing students, and this result was similar to a study
All authors contributed equally.

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K.B. Shiferaw et al. Informatics in Medicine Unlocked 18 (2020) 100273

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