Assessment of eHealth behaviors in national surveys: a systematic review of instruments

Abstract

Objectives

To conduct a systematic review of instruments used in national surveys of eHealth behaviors.

Materials and Methods

Major databases and websites of federal agencies were searched with pre-determined inclusion and exclusion criteria. National surveys with measures of eHealth behaviors were identified. The survey instruments were retrieved, and their measures of eHealth behaviors were categorized and critiqued.

Results

We located 13 national surveys containing eHealth behavior assessment questions that were administered from 1999 to 2017. Most surveys were conducted annually or biennially and typically covered topics on searching health information, obtaining social support, communicating with healthcare providers, and buying medicine online; recent surveys included items related to personal health management and use of mobile tools. There were redundant measures of searching health information online but insufficient measures of use of mobile apps, social media, and wearable devices.

Discussion

Future assessment of eHealth behaviors should reflect the growing varieties of behaviors enabled by technology development and reflect the current mobile ownership patterns in diverse social groups. More studies also need to include longitudinal surveys, integrative and standardized measures, and better designs to allow data linkage and comparison.

Conclusion

The existing survey instruments covering eHealth behaviors are rather limited compared to fast technological progress. We call for more national surveys on eHealth behaviors that are more responsive to technology development; we also advocate for more analysis and dissemination of existing national data on eHealth behaviors for evidence-based health policies.

INTRODUCTION

The past two decades have witnessed significant changes in how people access and share information. The percentage of U.S. adults who use the Internet increased from 52% in 1997 to 89% in 2016;¹ ownership of cell phones has increased from 62% of U.S. adults in 2002 to 95% in 2016.² Health behaviors have changed profoundly because of high penetration rates of the Internet and cell phones. People have used mobile tools to seek health information, buy medicines or health products, communicate with healthcare providers or peers, and manage personal health records.³ Meanwhile, the HI-TECH legislation has promoted adoption and mandated “meaningful use” of health information technology, suggesting more health resources will be delivered electronically.⁴

Coupled with widely accessible eHealth resources is the persistent digital divide.^5–8 Literature documents the association of digital divide and health disparities.^5,6,9,10 Individual and community social economic status (SES) predicts digital divide, which limits access to eHealth resources, potentially aggravating health disparities, which in turn reinforces SES.^11–13 As advocated by the American Medical Informatics Association, “broadband access is or will soon become a social determinant of health.”¹⁴

In recent years, the assessment of digital divide has shifted from access to usage, as most Americans have already accessed the Internet, including people of low SES.¹⁵ However, people of low SES are more likely to be smartphone dependent;¹⁶ they are also more likely to use smartphones for social reasons and entertainment but less likely for health-related purposes.¹⁷ These people also have a lower level of health literacy,¹⁸ an important mediator to realize the benefits of widely available eHealth resources.^19,20 Some experts argue that the benefits of eHealth resources have not been uniformly distributed across social groups, and thus the eHealth movement has exacerbated health disparities.^21–23

Meanwhile, consumer information technology has moved from desktop computers to smartphones and to wearable devices supported by artificial intelligence. In spite of a surge of technologic capability, the corresponding research and evaluation methodologies have not kept up with the rapid evolution and proliferation of health information and communication technologies.^24,25

Within such a dynamic context of ubiquitous access to the Internet and mobile tools, rapid development of digital technologies, and persistent digital divide and health disparities, understanding American eHealth behaviors is an important first step in formulating evidence-based strategies to bridge the digital divide with the goal of addressing health disparities.

Since the late 1990s and early 2000s, a series of national surveys has been administered to understand U.S. eHealth behaviors. For example, in 1999, the Center for Digital Future at the University of Southern California began its first Digital Future Survey (DFS) among youths.²⁶ In 2000, the Pew Internet Project released the first report on eHealth behaviors based on a national survey among American adults completed in the same year. This report, titled “The Online health care revolution: How the web helps Americans take better care of themselves,” described how Americans searched for health information online and their attitudes towards online privacy.²⁷ In 2003, the National Cancer Institute (NCI) began its biennial survey of Health Information National Trends Survey (HINTS) and included a variety of questions about how people used the Internet for health purposes, marking a milestone of studying American eHealth behaviors.²⁴ Since then, more organizations have joined the endeavor by either administering independent surveys or adding eHealth-related questions into existing national surveys.

Nearly two decades have passed since the first national study of eHealth behaviors in the United States, and the literature on this new topic has grown substantially.^25,28 A lack of consistent definitions, tools, and instruments would hinder knowledge development of a new field, as we have seen in the research on health literacy.²⁹ To enhance reproducibility of eHealth behavior survey research and to promote healthy development of this new field, it is of timely importance to conduct a systematic review of the instruments used in national surveys on eHealth behaviors. Such a review may facilitate more generalizable research regarding eHealth behavior. Accordingly, we conduct this study with the following research objectives: 1) to identify the available national surveys with assessment of eHealth behaviors and report the key characteristics of these national surveys, 2) to summarize the instruments used for eHealth behaviors assessment and map the major domains covered in the existing instruments, and 3) to make recommendations on future design of national surveys on eHealth behaviors.

METHODS

Conduct of systematic review

In this study, eHealth behavior was defined as using mobile tools (eg, Internet, cellphone, wearable devices) for health purposes, such as seeking health information online, using patient portals, communicating with providers online, and use of health apps, or use of wearable fitness devices. To accomplish the above research objectives, the systematic review was carried out in 3 phases, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.³⁰ The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO).

Search strategy and selection criteria

The first phase of this review was searching the literature. The two researchers independently searched major databases based on predetermined inclusion and exclusion criteria. The results were compared; any discrepancy was addressed after discussion or consultation with experts.

Our search of national surveys of eHealth behaviors consisted of two parts. As illustrated in Figure 1, the first part involved searching the databases of peer-reviewed articles and identifyng the articles that reported results from national surveys of eHealth behaviors. From June to August 2017, we searched PubMed, EMBASE, Web of Knowledge, and Google Scholar using the following key words, alone or in combination: national survey, Internet, online, cell phone, mobile, app, wearable device, eHealth, and mHealth.

Figure 1.

Flowchart of searching and selecting national surveys on eHealth behaviors.

We applied the following inclusion and exclusion criteria in selecting articles for further review. The inclusion criteria were 1) empirical studies based on national surveys in the United States, 2) report of any eHealth behaviors, and 3) peer-reviewed studies. The exclusion criteria were 1) studies not based on nationally representative samples, eg, state- or community-level surveys, 2) studies not focused on eHealth behaviors, eg, some studies asked only questions related to Internet use (but not health related), 3) studies not focused on patients or general public, eg, studies on adoption of electronic health records in clinics or healthcare providers’ use of mobile tools, and 4) review studies, theoretical studies, or commentaries.

A total of 2994 articles were identified initially; after applying inclusion and exclusion criteria and removing duplicates, 131 articles were kept for further analysis. We identified 11 national surveys on eHealth behaviors from these articles.

The second part of the search involved reviewing the websites of federal agencies of CDC, NIH, and AHRQ for existing national surveys; we also Googled the keywords listed above to identify the national surveys that may not have led to any peer-reviewed publications. Nine national surveys containing questions on eHealth behaviors were identified. After combining the surveys identified from 2 parts of the search and removing the duplicates, a total of 13 national surveys on eHealth behaviors were included in this review.

Data extraction

The second phase of the review focused on eHealth behavior measures in the identified national surveys. Two researchers independently extracted data by completing a predesigned summary table that included the following information: name of the survey, administration agency, years of survey that include the relevant questions, target population and sample size, data collection mode, and all the eHealth behavior questions included in the survey. The intercoder reliability was .90; discrepancies were discussed until a consensus was reached.

After all the eHealth behavior questions were retrieved, the two researchers independently synthesized these questions and categorized them into independent but related domains. The categorization was based on the types of eHealth behaviors assessed in the surveys. Disagreements were addressed through thorough discussion and consultation with experts.

Identification of gaps

The final phase of the review was identifying the gaps in the existing eHealth behavior measures and making recommendations for future research. Based on the characteristics of the eHealth behavior measures synthesized in the previous step, the research team collaboratively discussed the gaps by comparing the existing measures with the current status of eHealth technologies and the blueprint of applying these tehcnologies for better population health,³¹ and made recommendations thereafter.

RESULTS

Figure 2 is a timeline illustrating when the 13 national surveys of eHealth behaviors were initiated. The first national survey of this kind, the DFS was initiated in 1999 among 2000 youths and has been administered annually since then.³² In 2000, the Pew Internet Project (Pew) administered a survey to 12,751 American adults, and the first report of American eHealth behavior was released in the same year based on this survey.²⁷ After that, Pew conducted more surveys in 2002, 2006, 2010, and 2012 with varying samples. The General Social Survey (GSS), Health Retirement Study (HRS), and Knowledge Network Panel (KNP) began to include eHealth behavior questions from 2000 to 2002.^33–35 In 2003, the biennial survey of HINTS was initiated by NCI,²⁴ followed by 3 one-time surveys, eHealth and Elderly, DECISIONS,³⁶ and California Health Information Technology Survey (CHITS) in 2004, 2006, and 2010, respectively. From 2010 to 2011, 4 more recurring national surveys began to include relevant questions: National Survey on Drug Use and Health (NSDUH),³⁷ National Health Interview Survey (NHIS),³⁸ Youth Risk Behavior Surveillance Survey (YRBSS),³⁸ and National Health and Aging Trends Study (NHATS).³⁹

Figure 2.

Timeline of initiation of eHealth behavior national surveys.

Table 1 lists the titles, administration agencies, years of data available, target populations and sample sizes, data collection modes, and domains of topics covered in the 13 national surveys. Six of the 13 surveys were administered by federal agencies at NIH and CDC, 4 were administered by private foundations, and the remaining 3 were administered by universities. All of the federally administered surveys recur annually or biennially. Out of the 13 surveys, 8 focused on general adults, 3 targeted older adults, and 2 included youth samples. The sample size varied from 1450 to 67,500 with a median of 6000. The most frequently used survey method was random digital dialing with computer-assisted personal interviewing. Some surveys also included mailed questionnaires. Most (10 out of 13) of the survey data were publically available through the links listed under Table 1. Most surveys led to peer-reviewed journal publications, and the 2 surveys without publications made their summary reports available online.

Table 1.

National Surveys on eHealth Behaviors

Survey	Administration agency	Years of survey w. relevant questions	Target population and sample Size	Data collection mode	Topics covered
Digital Future Survey (DFS)a	Center of Digital Future at Univ.of Southern California	Annually since 1999	Youth and adults (≥ 12 yrs) N ≈ 2000	Random digit dial telephone survey	- Seek health info online - Online risksn
Pew Internet and American Life Project (Pew)b	Pew Research Center	Since 2000, interval varies	Adults (≥ 18yrs) N ≈ 12 750 (first wave), varies after	Random digit dial telephone survey	- Seek health info online - Social support online - Communicate w. providers - Health service managemento
General Social Survey (GSS)c	NORC at University of Chicago	Biennially since 2000	Adults (≥ 18yrs ) N ≈ 2800	Computer-assisted personal interview	- Seek health info online
Knowledge Network Panel (KNP)d	National Institute of Aging, Dept of Veteran Affairs, and Stanford University	2001-2002	Adults (≥ 21yrs ) N ≈ 8900.	Internet survey after recruiting through Random digit dial telephone survey	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online
Health & Retirement Study (HRS)e	National Institute of Aging	Biennially since 2002	Older adults (≥ 50yrs) N ≈ 20 000	Face-to-face interview+ random digit dial phone survey	- Seek health info online - Social support online - Communicate w. providers - Apps/Devices usage
Health Information National Trends Survey (HINTS)f	National Cancer Institute	Biennially since 2003	Adults (≥ 18yrs) N ≈ 6000+	Random digit dial computer-assisted telephone survey and mailed survey	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online - Health service management - Apps/Devices usage
eHealth and Elderlyg	Kaiser Permanente Foundation	2004	Older adults (≥ 50yrs) N=1450	Random digit dial telephone survey	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online
National Survey of Medical Decisions (DECISIONS) studyh	Foundation for Informed Medical Decision Making	2006-2007	Adults (≥ 40 yrs) N=3010	Random digit dial telephone survey	- Seek health info online
Consumer and Health Information Technology Survey (CHITS)i	California Health Care Foundation	2009-2010	Adults (≥ 18 yrs) N=1849	Random digit dial telephone survey	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online
National Survey on Drug Use and Health (NSDUH)j	Substance Abuse & Mental Health Service Admin.	Annually since 2010	Adults (≥ 12yrs ) N ≈ 67 500	Computer-assisted personal interviewing	- Social support online - Buy medicine online - Health service management
Youth Risk Behavior Surveillance Survey (YRBSS)k	Centers for Disease Control and Prevention	Biennially since 2011	Youth (9th-12th grades) N ≈ 15 000	Self-administered paper questionnaire survey	- Online risksn
National Health Interview Survey (NHIS)l	Centers for Disease Control and Prevention	Annually since 2011	Adults (≥ 18 yrs) N ≈ 33 000	Computer-assisted personal interviewing	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online
National Health and Aging Trends Study (NHATS)m	National Institute of Aging	Annually since 2011	Older adults(≥ 65yrs) N ≈ 8500	Computer-assisted personal interviewing	- Seek health info online - Social support online - Communicate w. providers - Buy medicine online - Health service managemento

^ahttp://www.digitalcenter.org/digital-future-project/.

^bhttp://www.pewinternet.org/.

^chttp://gss.norc.org/.

^dThe data were not publically available. The sampling and method report is available: https://www.cdc.gov/pcd/issues/2004/oct/pdf/04_0004_01.pdf.

^ehttp://hrsonline.isr.umich.edu/.

^fhttp://hints.cancer.gov.

^gThe data were not publically available; no peer-reviewed publications were found. The summary report and survey instruments are available: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/e-health-and-the-elderly-how-seniors-use-the-internet-for-health-information-key-findings-from-a-national-survey-of-older-americans-survey-report.pdf.

^hhttp://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/25983.

ⁱThe data were not publically available; no peer-reviewed publications were found. The summary report is available http://www.chcf.org/publications/2010/04/consumers-and-health-information-technology-a-national-survey.

^jhttps://nsduhweb.rti.org/respweb/homepage.cfm.

^khttps://www.cdc.gov/healthyyouth/data/yrbs/.

^lhttps://www.cdc.gov/nchs/nhis/index.htm.

^mhttps://www.nhats.org/.

ⁿOnline risks: online bullying, unwanted sexual attention online.

^oHealth service management: access personal health records or health insurance online.

The early studies, roughly 1999 to 2002, of eHealth behaviors were typically limited to questions on Internet use and seeking health information online. For example, DFS, GSS, KNP, and Pew from 1999 to 2001 asked the similar question of, “Have you used the Internet to search health information?” This pattern changed in 2003 when NCI started HINTS; 6 questions on health-related Internet use were included: searching health information, communicating with healthcare provider online, obtaining social support online, and buying medicine or health products online.²⁴ In recent years, HINTS has included more questions related to personal health records management, social media use, and use of mobile tools for healthcare management;^21,40,41 and HINTS has become a rich resource to provide information on eHealth behaviors and communication.⁴²

Table 2 lists examples of questions from each survey organized by domains. The existing national surveys on eHealth behaviors have covered the following domains, by the order of frequency: seeking health information, obtaining social support, communicating with healthcare providers, buying medicine, health service and management (eg, personal health records tracking, manage health insurance), and app or devices use; the last two domains appeared after 2011.^21,40,41 Most eHealth behavior measures in the national surveys were about positive or beneficial effects of mobile tools except 2 surveys of YRBSS and DFS, which included questions related to online risks. They probed adolescents and youths about their risky online behaviors such as texting while driving, online bullying, unwanted sexual attention, and buying tobacco products via the Internet.^32,39,42,43

Table 2.

Exemplary Questions by Domains in Existing National Surveys of eHealth Behaviors

Survey	Topics	Example questions
DFSa	Seek health info online	− Have you used the Internet to search health information?
	Online risks	− Have you been bullied or harassed online (9 questions)?
		− Have you received unwanted sexual attention online (4 questions)?
GSS	Seek health info online	− In the past 12 months, have you used the Web to look for information about a health concern or medical problem?
KNP	Seek health info online	− Have you used the Internet to search health-related information?
	Communicate with providers online	− Have you used the Internet or email to communicate with your healthcare provider?
	Social support online	− Have you used I the nternet or email to communicate with family or friends about your health?
		− Have you used the Internet or email to communicate with people of similar health concerns?
	Buy medicine online	Have you ever used E-mail or the Internet in past year
		− To purchase prescription drugs?
		− To learn more about a drug?
		− To search for the cheapest place to buy prescription drugs?
HRSa	Seek health info online	− Do you regularly use the World Wide Web, or the Internet, for finding medical and health information?
		− In the past month, have you used the Internet to search for information relating to your health?
		− In the past month, have you sent or received e-mails related to your health? (other similar questions on using video chats, posting information, visiting websites).
	Social support online	− Did you seek health-related advice or support from others using emails/using video chats/using social media/visiting websites/using apps?
	Communicate with providers online	− Did you share information about your health with a health care professional using emails/using video chats/using social media/visiting websites/using apps?
	Apps/Devices usage	− Do you use an online wellness or health monitoring program?
		− In the past month, have you used any downloaded health-related mobile applications or “apps” on a smartphone or tablet computer such as an iPad, Android, or Kindle Fire (other related questions on purpose, topics, recipients, frequency)?
		− In the past month, have you used any computerized or online brain games or brain training programs designed to keep your memory and thinking sharp?
Pewa	Seek health info online	− In the last 12 months, have you looked health information online (12 questions)?
	Social support online	− In the last 12 months, have you posted a health-related question online or shared your own personal health experience online in any way?
	Communicate with providers online	− Do you receive any updates or alerts (on your phone or email) about health or medical issues, such as from your doctors or pharmacists (6 questions)?
		− Do you share these health tracking records or notes with anyone, either online or offline?
	Healthcare service management	− In the last 12 months, have you downloaded forms online or applied for health insurance online, including private insurance, Medicare, or Medicaid
HINTSa	Seek health info online	− In the past 12 months, have you looked for health or medical information for yourself while using the Internet?
		− In the last 12 months, have you used the Internet to help you with your diet, weight, or physical activity?
	Social support online	− In the last 12 months, have you used the Internet to exchange support about health concerns with family or friends?
		− In the last 12 months, have you used the Internet to participate in an on-line support group for people with a similar health or medical issue?
	Communicate with providers online	− In the last 12 months, have you used the Internet to look for a health care provider?
		− In the last 12 months, have you used the Internet or e-mail to communicate with a doctor or doctor’s office?
	Buy medicine online	− In the last 12 months, have you used the Internet to buy medicine or vitamins on-line?
	Healthcare service management	− In the last 12 months, have you used the Internet to keep track of personal health information such as care received, test results, or upcoming medical appointments?
	App/Devices usage	− On your tablet or smartphone, do you have any software applications or “apps” related to health?
eHealth and Elderly	Seek health info online	− Please tell me how much information about these kinds of issues you generally get from the Internet.
		− Please tell me if you’ve ever used the Internet to look for information about health problems or medical conditions.
	Social support online	− Have you ever participated in a chat room, online support group, or e-mail list for people concerned about a particular health or medical issue?
	Communicate with providers online	− Have you ever communicated with a doctor or other health care provider through e-mail?
	Buy medicine	− Have you ever used the Internet to purchase prescription drugs?
	online	− Have you ever used the Internet to purchase any other medical products such as hearing aids or walkers?
DECISIONS	Seek health info online	− Did you, or someone else for you, use the Internet to find information on screening tests (9 questions for 9 conditions)?
CHITS	Seek health info online	Have you ever done any of these things online?
		− Searched online for info about a disease or medical problem
		− Entered info on a website about your weight, nutrition, or exercise
		− Entered info on a website about a chronic illness?
	Social support online	Have you ever done any of these things online?
		− Posted online about your health or health care
		− Joined an online group about a health issue
	Communicate with providers online	Have you ever sent/received email from doctor?
	Buy medicine online	Have you renewed prescription online?
	Healthcare service management	Have you ever done any of these things online?
		− Used a personal health records
		− Looked at test results online
		− Used a health-related application for a cell phone
NSDUHa	Social support online	− Have you used the Internet for social support?
	Buy medicine online	− Have you used the Internet for medication/drug purchase?
	Healthcare service Management	− Have you used the Internet for counseling services?
YRBSSa	Online risks	− During the past 30 days, how did you usually get your own cigarettes/electronic vapor products (response options include online purchase)?
NHISa	Seek health info online	− Did you look up health information on the Internet in the past 12 months?
	Social support online	− Did you use online chat groups to learn about health topics in the past 12 months?
	Communicate with providers online	− Did you schedule an appointment with a health care provider using the Internet in the past 12 months?
		− Did you communicate with a health care provider over e-mail in the past 12 months?
	Buy medicine online	− Did you refill a prescription on the Internet in the past 12 months?
NHATSa	Seek health info online	− In the last year, have you gone on the Internet or online to get information about your or family’s health conditions?
	Social support online	− In the last month, have you gone on the Internet or online to visit social network sites?
	Communicate with providers online	− In the last year, have you gone on the Internet or online to contact any of your medical providers?
	Buy medicine online	− In the last month, have you gone on the Internet or online to order or refill prescriptions?
	Healthcare service management	− In the last year, have you gone on the Internet or online to handle Medicare or other health insurance matters?

Note: For the purpose of brevity, most questions listed in the column of example questions were truncated or revised. For the original questions used in these surveys, please go the website listed under Table 1.

^aExample questions were retrieved from surveys across multiple waves.

DISCUSSION

The 13 surveys described above have provided valuable datasets for examining American eHealth behaviors in the digital era. In the past 2 decades, our understanding of eHealth behaviors has progressed from how people seek health information online to how they use various mobile tools for myriad health purposes. The publications generated from these surveys have informed us on patterns and trends of how Americans use eHealth resources and exchange health information as well as the relationship between eHealth behaviors and other health outcomes, allowing program developers and policymakers to design evidence-based programs and policies.^44–46 Despite the extensive amount of data collected so far, the existing surveys and instruments are limited compared to fast technological progress and explosive resources online. We therefore suggest the following recommendations on future design and application of national surveys of eHealth behaviors.

First, the measurement of eHealth behaviors needs to reflect the growing varieties of behaviors enabled by technology development. Survey questions regarding use of social media and mobile apps appeared only in recent years.^42,47 Digital tools have penetrated our daily lives and also the healthcare system. Gaming, virtual reality, and use of wearable devices or interactive smart devices have not yet been covered in existing surveys.

Second, the data collection methods and sampling strategy need to reflect the current mobile ownership patterns. About 10% of Americans, mostly younger, low-income, and minority population, are smartphone dependent.¹⁶ Traditional phone surveys may not reach these people.⁴⁸ New survey methods are being explored, including re-application of mailed surveys.^48,49 Innovative survey modes and tailored design for target populations are needed to achieve more representative samples.

Third, we need more longitudinal surveys to track the patterns of eHealth behaviors of individuals and populations. Some national surveys are administered annually or biennially, which allows trends analysis; but most of them are open-cohort, limiting causal relationship analysis. Small scale longitudinal surveys as addendums to existing surveys maybe an option to track changes over time and among groups.

Fourth, as eHealth behaviors vary significantly across social groups, especially in the underserved communities, we recommend more targeted and smaller-scale surveys. Some existing surveys are focused on certain age groups such as older adults or youths, but further segmentation or subgroup studies are needed. NCI has used supplement grants to national cancer centers to collect such data.⁴⁴ Given that it typically takes more than two years from data collection to data publication, we especially recommend shorter surveys with targeted populations for quicker data update.

Fifth, agencies need to communicate better to reduce redundancies in the development of survey questions. We discourage developing new questions for well-covered topics. Searching health information online has been asked in all national surveys, resulting in duplication of this measure. In contrast, there has been insufficient measurement of other eHealth behaviors.

Sixth, an urgent need exists for standardizing or reusing some measures to promote comparability across studies and among populations. For instance, the domains of searching health information online and obtaining social support online were measured differently in the existing surveys. We especially call for reusing the instruments with good validity and reliability, so that efforts to conceptualize additional measures can be focused on the eHealth behaviors not well covered in existing surveys.

Seventh, we call for better methods in using, linking, and analyzing multiple datasets. As adoption of eHealth behaviors will become more prevalent and broadband access is a social determinant of health,¹⁴ more interdisciplinary research is needed to understand how SES determines eHealth behaviors, and how eHealth behaviors shape health outcomes. We anticipate the data from national surveys of eHealth behaviors can be linked with not only other national and state-level data but also electronic health records and social media data.

Eighth, we call for more collaborations among agencies to extend the influence a single survey. For example, NCI has recently collaborated with the Food and Drug Administration to launch HINTS-FDA, which oversampled smokers.⁵⁰ NCI has also collaborated with China Ministry of Health to launch HINTS-China.⁵¹ Such multi-organization and international collaboration will facilitate the progress of eHealth behavior research.

Ninth, in studying eHealth behaviors, we need to expand our understanding of potential harms. For example, some surveys have included measures of information overload for online information seekers.⁵² YRBSS and DFS have included questions related to online risks.^32,39,42,43 More data are needed on privacy endangerment, misinformation, information overload, and increased health disparities due to digital divide. Only when we understand both sides of the advances of the digital era can we best harness the technological capacities to improve population health.

Finally, we call for more scientific research on eHealth behavior and more dissemination of research findings.⁴⁴ In our search of peer-reviewed articles, we identified only 131 peer-reviewed articles based on national surveys of eHealth behaviors, and 87 articles were based on HINTS; some national surveys did not lead to any peer-reviewed publication. We call for more use of the enormous assets of existing eHealth datasets, so as to inform more data-driven public health programs and evidence-based policies.

Limitations

This brief review is limited in the following aspects. First, as a systematic review of instruments, the focus of this work was not to report outcomes of eHealth behaviors. Some studies have made such attempts,^22,53,54 and we anticipate more such studies will emerge as we are entering the third decade of studying eHealth behaviors. Second, all national surveys included in the review were of the general population; national surveys of eHealth use by healthcare providers, organizations, or specific populations such as veterans were not included. Third, we did not include any state-level data, as most state-level surveys are designed for disease surveillance and very limited state-level data on eHealth behaviors were available.⁵⁵ Fourth, this short paper does not provide a detailed description of the surveys and instruments. We anticipate that the 7 domains of eHealth behaviors we identified in national survey instruments will be expanded as research on eHealth behavior continues. Each domain deserves in-depth analysis in future studies. We hope this review will foster more research on eHealth behavior measurement.

CONCLUSION

Despite these limitations, to the best of our knowledge, our review is the first to identify and examine existing national surveys of eHealth behaviors and synthesize the major domains of measurement and example survey questions. We call for more rapid, relevant, and responsive surveys on eHealth behaviors with more standardized measures and longitudinal design. Such surveys should reflect the current U.S. demographic profile, technology development, and digital divide, so as to provide up-to-date data on eHealth behaviors for evidence-based policymaking.

CONTRIBUTIORS

YAH conceptualized and designed the study, YAH and JC searched the literature, extracted data, and analyzed the data. YAH drafted the manuscript, and JC revised the manuscript.

Conflict of interest statement. Authors declare no competing interests.