Evaluating the Need to Address Digital Literacy Among Hospitalized Patients: Cross-Sectional Observational Study
Authors: Vollbrecht Hanna , Arora Vineet , Otero Sebastian , Carey Kyle , Meltzer David , Press Valerie G 
Published: March 2020

Background
Technology is a potentially powerful tool to assist patients with transitions of care during and after hospitalization. Patients with low health literacy who are predisposed to poor health outcomes are particularly poised to benefit from such interventions. However, this population may lack the ability to effectively engage with technology. Although prior research studied the role of health literacy in technology access/use among outpatients, hospitalized patient populations have not been investigated in this context. Further, with the rapid uptake of technology, access may no longer be pertinent, and differences in technological capabilities may drive the current digital divide. Thus, characterizing the digital literacy of hospitalized patients across health literacy levels is paramount.

Objective
We sought to determine the relationship between health literacy level and technological access, use, and capability among hospitalized patients.

Methods
Adult inpatients completed a technology survey that asked about technology access/use and online capabilities as part of an ongoing quality of care study. Participants’ health literacy level was assessed utilizing the 3-question Brief Health Literacy Screen. Descriptive statistics, bivariate chi-squared analyses, and multivariate logistic regression analyses (adjusting for age, race, gender, and education level) were performed. Using Bonferroni correction for the 18 tests, the threshold P value for significance was <.003.

Results
Among 502 enrolled participants, the mean age was 51 years, 71.3% (358/502) were African American, half (265/502, 52.8%) were female, and half (253/502, 50.4%) had at least some college education. Over one-third (191/502, 38.0%) of participants had low health literacy. The majority of participants owned devices (owned a smartphone: 116/173, 67.1% low health literacy versus 235/300, 78.3% adequate health literacy, P=.007) and had used the Internet previously (143/189, 75.7% low health literacy versus 281/309, 90.9% adequate health literacy, P<.001). Participants with low health literacy were more likely to report needing help performing online tasks (133/189, 70.4% low health literacy versus 135/303, 44.6% adequate health literacy, P<.001). In the multivariate analysis, when adjusting for age, race, gender, and education level, we found that low health literacy was not significantly associated with a lower likelihood of owning smartphones (OR: 0.8, 95% CI 0.5-1.4; P=.52) or using the internet ever (OR: 0.5, 95% CI 0.2-0.9; P=.02). However, low health literacy remained significantly associated with a higher likelihood of needing help performing any online task (OR: 2.2, 95% CI 1.3-3.6; P=.002).

Conclusions
The majority of participants with low health literacy had access to technological devices and had used the internet previously, but they were unable to perform online tasks without assistance. The barriers patients face in using online health information and other health information technology may be more related to online capabilities rather than to technology access. When designing and implementing technological tools for hospitalized patients, it is important to ensure that patients across digital literacy levels can both understand and use them.