Review article

Digital Health
Volume 8: 1–13
COVID-19 infodemic and digital health literacy in © The Author(s) 2022
Article reuse guidelines:
vulnerable populations: A scoping review sagepub.com/journals-permissions
DOI: 10.1177/20552076221076927
journals.sagepub.com/home/dhj

Mohamed-Amine Choukou1,2,3 , Diana C Sanchez-Ramirez4 ,

Margriet Pol5,6, Mohy Uddin7, Caroline Monnin8 and Shabbir Syed-Abdul9,10

Abstract

Background: People from lower and middle socioeconomic classes and vulnerable populations are among the worst affected
by the COVID-19 pandemic, thus exacerbating disparities and the digital divide.
Objective: To draw a portrait of e-services as a digital approach to support digital health literacy in vulnerable populations
amid the COVID-19 infodemic, and identify the barriers and facilitators for their implementation.
Methods: A scoping review was performed to gather published literature with a broad range of study designs and grey lit-
erature without exclusions based on country of publication. A search was created in Medline (Ovid) in March 2021 and trans-
lated to Medline, PsycINFO, Scopus and CINAHL with Full Text (EBSCOhost). The combined literature search generated 819
manuscripts. To be included, manuscripts had to be written in English, and present information on digital intervention(s)
(e.g. social media) used to enable or increase digital health literacy among vulnerable populations during the COVID-19
pandemic (e.g. older adults, Indigenous people living on reserve).
Results: Five articles were included in the study. Various digital health literacy-enabling e-services have been implemented
in different vulnerable populations. Identified e-services aimed to increase disease knowledge, digital health literacy and
social media usage, help in coping with changes in routines and practices, decrease fear and anxiety, increase digital knowl-
edge and skills, decrease health literacy barriers and increase technology acceptance in specific groups. Many facilitators of
digital health literacy-enabling e-services implementation were identified in expectant mothers and their families, older
adults and people with low-income. Barriers such as low literacy limited to no knowledge about the viruses, medium of
contamination, treatment options played an important role in distracting and believing in misinformation and disinforma-
tion. Poor health literacy was the only barrier found, which may hinder the understanding of individual health needs, illness
processes and treatments for people with HIV/AIDS.
Conclusions: The literature on the topic is scarce, sparse and immature. We did not find any literature on digital health lit-
eracy in Indigenous people, though we targeted this vulnerable population. Although only a few papers were included, two

1
Department of Occupational Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, Canada
2
Centre on Aging, University of Manitoba, Canada
3
Riverview Health Centre, Canada
4
Department of Respiratory Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, Canada
5
Department of Occupational Therapy, Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, The Netherlands
6
Department of Medicine for Older People, Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, The Netherlands
7
Research Quality Management Section, King Abdullah International Medical Research Center, King Saud bin Abdul-Aziz University for Health Sciences,
Ministry of National Guard - Health Affairs, Kingdom of Saudi Arabia
8
Neil John Maclean Health Sciences Library, University of Manitoba, Canada
9
Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taiwan
10
International Center for Health Information Technology (ICHIT), College of Medical Science and Technology, Taipei Medical University, Taiwan
Corresponding authors:
Mohamed-Amine Choukou, Department of Occupational Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba,
R111 - 771 McDermot Ave, Winnipeg, MB, Canada R3E 0T6.
Email: Amine.choukou@umanitoba.ca
Shabbir Syed-Abdul, Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, 15F., No. 172-1,
Sec. 2, Keelung Rd., Da'an Dist., Taipei, Taiwan.
Email: drshabbir@tmu.edu.tw

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial
4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work
without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/
open-access-at-sage).
2 DIGITAL HEALTH

types of health conditions were covered by the literature on digital health literacy-enabling e-services, namely chronic con-
ditions and conditions that are new to the patients. Digital health literacy can help improve prevention and adherence to a
healthy lifestyle, improve capacity building and enable users to take the best advantage of the options available, thus
strengthening the patient’s involvement in health decisions and empowerment, and finally improving health outcomes.
Therefore, there is an urgent need to pursue research on digital health literacy and develop digital platforms to help
solve current and future COVID-19-related health needs.

Keywords

Digital health, literacy, vulnerable, COVID-19, misinformation, digital divide

Submission date: 9 July 2021; Acceptance date: 12 January 2022

Introduction
The COVID-19 pandemic has imposed various restrictions, surge in COVID-19 cases around the world, there is an
such as lockdown and social distancing, affecting the abundance of COVID-19-related information available on
quality of life and inter-individual social interactions. A various online platforms and social media tools that
survey conducted with 256 college students in the United people commonly used for different information-seeking
States showed that, on average, student discussed purposes. For example, people use digital platform to find
pandemic-related health topics with 4–5 people, which health information such as COVID statistics and research,
did not vary by health literacy or digital health literacy protective approaches, preventive measures, treatment
(DHL) measures.1 Information and Communication guidelines, vaccine deployment and lifestyle recommenda-
Technologies (ICTs) have always played a pivotal role in tions.4 This sea of online information related to COVID-19
enabling communication and information exchange can contain accurate and incorrect information, which has
among people and digital health is one of its prominent brought in the concept of ‘infodemic’ in this context.5 An
applications in healthcare as communicating health infor- infodemic is defined by the WHO as ‘too much information
mation matters.2 The need for natural interpersonal commu- including false or misleading information in digital and
nication has been disrupted by the COVID-19 lockdown; physical environments during a disease outbreak’.6
however, technology is playing a major role in maintaining Accessibility to the correct information, at the right time,
social interaction. Digital health and technologies have pro- in the right place, and in the right way is crucial in the pan-
vided many online e-services to address the social chal- demic; therefore, proper tackling and management of info-
lenges of the pandemic like communication gaps, demic is imperative. The Internet encompasses various
information provision and remote work. The pandemic information channels and tools, for example, online
has extensively increased the reliance of the people on search engines, video sharing platforms, social media chan-
digital media platforms and social media (e.g. Quora, nels and article indexing and abstracting services used to
Facebook, YouTube, Instagram, Reddit, TikTok). Social disseminate information or misinformation. Although
media are undoubtedly one of the major means of accessing these are some of the key information sources that people
to information. For example, a study exploring the satisfac- usually rely on for seeking health-related information,
tion level of the online information related to COVID-19 in most of these sources are vulnerable to the spread of mis-
more than 4000 persons with and without chronic diseases leading pandemic-related information. Misinformation can
has revealed that the majority of people with chronic dis- negatively affect and endanger human health and lives.7,8
eases sought online information related to COVID-19 To deal with complex health information, one needs
from social media.3 The level of information satisfaction health literacy to understand, assimilate and use health
of the online information related to COVID-19 was signifi- information and be able to communicate effectively with
cantly lower in people with chronic diseases as compared to their care provider. Health literacy is defined as ‘the
people without chronic diseases.3 degree to which individuals can obtain, process, understand
E-services focused on health literacy have emerged and communicate about health-related information needed
extremely quickly to cover the population’s need for infor- to make informed health decisions’.9,10 Looking it in the
mation about the progress of the pandemic and its implica- digital context, the DHL, which is also often used inter-
tions in terms of health management, such as continuing the changeably as eHealth Literacy, is ‘the ability to seek,
management of chronic conditions. Due to the widespread find, understand and appraise health information from
Choukou et al. 3

electronic sources and apply the knowledge gained to and anxiety among 266 older adults.17 Leung et al.17
addressing or solving a health problem’.11 DHL is of parti- reported that 43.2% expressed anxiety about the future
cular interest in the current historical context where the and concluded that SOC had direct negative effect on
COVID-19 pandemic has forced lockdown, and access to anxiety and mediated the relationships between anxiety
health information through traditional means (e.g. informa- and DHL and financial satisfaction. According to Leung
tion sheets, pamphlets in medical offices) has become obso- et al.17, actions should be taken to enhance SOC and
lete. As reflected from its name, DHL is more linked with DHL among older adults, as these capacities may help to
the ability to use digital technologies for online information, manage anxiety during the pandemic. This review paper
interaction and activities related to the online environments, extends the negative effects of loss of SOC beyond older
and an individual’s ability to understand and judge the adults to cover a wider range of vulnerable populations.
information for appropriate decision making.12 Higher Vulnerable populations commonly show diversity from dif-
DHL is associated with better health, positive behaviour ferent perspectives, such as age, gender, ethnicity, race, and
and increased health knowledge.13 A cross-sectional socioeconomic status, and represent the population’s cat-
survey14 conducted with more than 1000 Vietnamese stu- egory that usually gets fewer healthcare services than the
dents has explored the association between the importance requirements of their healthcare issues.18 In the literature,
of online information search and subjective well-being many papers have discussed the concept of vulnerability
through their ability to find, understand, appraise and use in healthcare,19–22 and several definitions exist for the vul-
online health-related information during lockdown through- nerable populations,21,23–28 as it is utilized in different con-
out the first COVID-19 pandemic wave. According to texts and might change over time. In general, the vulnerable
the same survey, 87.2% of students reported sufficient populations are already on the low level of health literacy
well-being, while almost 13% reported low or very low and have health disparities in a social, economic or environ-
well-being.14 Another study1 explored whether COVID-19- mental context, so it might be difficult for vulnerable popu-
related information access, attitudes, and behaviours were lations to cope and rely on complex technologies for
associated with health literacy and DHL among 256 information seeking.12 The information gap among the
college students in the United States. Half of the cohort people who have access to ICTs compared to those who
(49%) reported adequate health literacy, and 57% found do not have – or have less – access to ICTs brings the
DHL tasks easy overall.1 Patil et al.1 showed that DHL digital divide issue.29 Therefore, vulnerable populations
did not vary by health literacy level, and both health literacy must adopt the current and emerging ICTs to address the
and DHL were independently associated with overall com- digital divide and improve their quality of life. Various
pliance with basic COVID-19-related preventive practices. online information resources have emerged during the
The authors also reported that higher DHL, but not HL, was COVID-19 pandemic to close this digital divide by indu-
significantly associated with greater willingness to get a cing online patient education, a key element of quality
COVID-19 vaccine and the belief that acquiring the virtual patient care. For example, online education tools,
disease would negatively affect their life. Ease of access to including dedicated search engines, online classes and
information and the reliability of the retrieved health infor- digital education stations, are valuable resources that can
mation remains questionable. A cross-sectional survey15 help patients with low health literacy find reliable patient
conducted with 3621 students in Slovenia showed that, education materials.30
although the level of DHL among students is sufficient, Similarly, virtual education practices, such as video
assessing the reliability of information remains problematic tutorials, one-on-one trainings, and regular group trainings,
among half of the participants to the study. Approximately can provide an opportunity for community healthcare
one third of the students reported having problems in workers to interact, guide and educate different communi-
finding information of their interest, and about one third ties; particularly, the underprivileged, disadvantaged and
reported having difficulties in selecting the information neglected communities that are increasingly vulnerable to
that is relevant to them. However, literature exploring the multiple health burdens; for example, people who belong
associations between DHL skills and health and wellbeing to high-risk groups. Examples of high-risk groups are the
among vulnerable groups seems very limited. highly conservative and patriarchal families and persons
DHL can be influenced by age, health status, educational living with regressive sociocultural norms.31 On a broader
background, digital literacy skills and motivations for level, governments should take practical steps to provide
seeking information.11,16 COVID-19-related information- access to the technology and implement DHL programs
seeking behaviour might vary between groups of people. in these populations to move forward to the era of an
Sense of coherence (SOC) seems hard to reach by the increasingly digital future.32 There are various studies
times of a pandemic. Data from three Asian countries about DHL, digital divide, and COVID-19 for different
(China, the Philippines and Singapore) extracted from a population categories in multiple healthcare settings in the
larger-scale cross-sectional survey conducted across 41 literature. This paper aims to draw a portrait of the barriers
countries explored the relationship between DHL, SOC and facilitators of implementing e-services as a digital
4 DIGITAL HEALTH

approach to support DHL in vulnerable populations amid ‘digital health literacy’. The librarian utilized the
the COVID-19 pandemic. To the best of our knowledge, Canadian Agency for Drugs and Technologies in Health
this article is one among very scarcely available literature (CADTH) Covid-19 search filter developed and peer-
review that explores the DHL and information-seeking reviewed by CADTH Information Specialists.35 During
behaviour aspects related to the COVID-19 pandemic the search development, we included a search concept for
among vulnerable populations.30 We define the vulnerable Indigenous peoples, comprising of North American,
populations in this paper as the group of persons in need of Australian, New Zealand and Austronesian (including
special support adapted to their socioeconomic status, Taiwanese) Indigenous peoples. However, adding this
health needs or any context that prevents access to digital concept resulted in zero results and was ultimately
health information. As such, we non-exhaustively consider removed. The extraction took place in the following data-
the following profiles as ‘vulnerable’: illiterate, digitally bases in March 2021: Medline, PsycINFO, Scopus and
illiterate, older adults, with visual or hearing impairments, CINAHL with Full Text (EBSCOhost). The original
with mental or cognitive impairments, living in remote or search was created in Medline (Ovid) and translated to
underserved communities, with limited access to the the other databases. The Medline (Ovid) search strategy is
Internet, Indigenous living on reserve, immigrants, having available in Appendix 2. All other search strategies are
language barriers and with low socioeconomic status. The available upon request. To locate grey literature, we
specific objectives of this literature review are: focused on preprint servers. With the rapidly evolving
research on COVID-19, preprint servers have become
1. To profile the users of e-services for DHL documented essential tools to find and disseminate coronavirus informa-
in the literature. tion. We searched the DHL keywords previously men-
2. To depict the needs in terms of health-related informa- tioned on preprint servers, including MedRxiv, SocArXiv
tion among the vulnerable populations. (OSF Preprints), Research Square and SSRN (The
3. To portray e-services that were implemented during the Lancet). All records were exported into EndNote (version
pandemic to support or promote DHL among vulner- x9; Clarivate Analytics, Philadelphia, PA, USA), and dupli-
able individuals. cates were removed.36 All records were screened in Rayyan
4. To explore the effects of DHL on individual behaviours – a free online tool used for initial screening of articles to
and perceptions about the pandemic. support systematic or narrative, or scoping review pro-
5. To draw a portrait of the future of DHL based on the cesses.37 Full-text manuscripts of the included papers
learning from the pandemic. were retrieved, and the data extraction was processed in a
customized Excel table.
Methods
Study design Inclusion and exclusion criteria
Literature corresponding to the topic of DHL in relation to To be included, manuscripts had to be written in English,
the COVID-19 pandemic is expected to be emerging and and present information on digital intervention(s) used to
disparate; therefore, we performed a scoping review to enable or increase DHL among vulnerable populations
gather published literature with a broad range of study during the COVID-19 pandemic. The manuscripts included
designs and grey literature without exclusions based on an e-service focused on health literacy content (e.g.
country of publication.33,34 The ‘Indigenous’ concept was Internet, mobile application, web-based platforms and
primarily focused on North American and Taiwanese social media) related to the COVID-19 pandemic. The
terms (Appendix 1). We performed the scoping review fol- manuscripts specifically focused on vulnerable populations
lowing the recommendation of Arksey and O’Malley33 and (e.g. older adults, Indigenous people living on reserve and
Levac et al.34 people with low socioeconomic status). Two independent
reviewers performed the search and study selection by
reviewing the titles and abstracts relevant to the research
Search strategy question and inclusion criteria. A manuscript had to be
A health sciences librarian (CM) developed and tested the judged relevant by both reviewers to be included. If consen-
search strategy in consultation with the research team. sus could not be reached, a third reviewer was consulted.
The librarian used a combination of controlled vocabulary The disagreement for the inclusion or exclusion of articles
and keywords to create the DHL search concept. As there was resolved through discussions. Only empirical manu-
is no Medical Subject Heading (MeSH) term for DHL, scripts of various formats were screened, namely, journal
the librarian used different keywords to capture the articles, abstracts, MSc and PhD theses and project
concept entirely. Keywords included: ‘patient education’, reports. Literature reviews, methodological papers and
‘digital divide’, ‘e-health literacy’, ‘m-health literacy’ and study protocols were excluded.
Choukou et al. 5

Data analysis and extraction Study characteristics

A data extraction form was developed by MAC and inde- In the selected five manuscripts, four articles were pub-
pendently piloted on three articles by two reviewers (M.P. lished in 2020 and one report in 2021. Manuscripts were
and S.S.A.). All selected manuscripts were read by the published in five different countries: USA (n = 1), UK (n
authors and publication details were extracted accordingly, = 1), China (n = 1), Italy (n = 1) and Turkey (n = 1).
as follows: Regarding the publication channel, all the manuscripts
were peer-reviewed journal articles involving survey data
(n = 4) and one report (n = 1).
• Article details: first author name, publication year, arti-
cle’s title, country of publication and study type.
• DHL-enabling e-service: technology supporting DHL, Vulnerable populations targeted by the DHL
description/modality of use, maturity level (under approaches
testing/already implemented), target users (vulnerable
populations), and population characteristics. Three vulnerability categories were identified in this
• Issues expressed by e-services users. scoping review. The vulnerability was either health-related
• Focus on COVID-19 matters. (diabetes,42 cancer,43 expectant mothers and new fam-
• Knowledge about COVID-19. ilies44), related to aging45 and/or socioeconomic (low-
• Individual-level outcomes: Use of e-service, ability to income persons46). None of the included manuscripts
process information, engagement in own health, ability reported on Indigenous people.
to engage with digital services, feel safe and control,
motivated to engage with digital services and other. Needs for DHL-enabling e-services
• System-level outcomes: access to digital services that
work, digital services that suit individual needs, incen- The thematic analysis focused on clustering the needs for
tives (e.g. discount) and other. DHL-enabling e-services into categories. The included
• Expected long-term shift to digital health services. papers reported on the following needs for e-services to
• Conclusions. support DHL:
• Recommendations for future research.
• To increase the disease knowledge, eHealth literacy and
social media usage.
The extracted information related to DHL-enabling e-ser-
◦ Strong need to increase the public’s awareness for
vices was not consistent across the included studies; there-
fore, we performed a qualitative synthesis38 to classify the health literacy in different disease conditions.46
information according to the emerging themes; for ◦ Usage of aggregated social media and public social
media.46
example, the needs for DHL-enabling e-services along
with the barriers and facilitators for their implementation. • To cope with changes in routines and practices.
Thematic analysis was chosen as a flexible methodological ◦ Restrictions placed on hospital visitors during birth
and postpartum.44
approach that can be tailored to the needs of the current
review to cluster and concise the set of data retrieved in • To overcome fear and anxiety.
the included articles, and provide a rich and detailed portrait ◦ Fear about cancer care disruption by COVID-19.43
of the literature.39,40 ◦ Many clients voiced fear and concerns of
potential exposure to the virus while in the hospital
and had questions about the hospital’s safety
measures.44
Results ◦ Some clients had tested positive for COVID-19 and
The initial search yielded 819 documents, of which 306 were were anxious about separation from their babies and
duplicates, leaving 513 manuscripts that were screened for possible exposure and transmission to their newborns.44
relevance. Of these, 411 were excluded, resulting in 102 • To increase digital knowledge and skills.
manuscripts being considered for a full-text review. From
◦ More male patients stated that their knowledge about
these, 97 were excluded because they were not written in
the COVID-19 was inadequate compared to female
English, or did not include a DHL-enabling e-service, not
patients.43
related to the COVID-19 pandemic, not focused on vulner-
• To decrease health literacy barriers and increase technol-
able populations, or did not provide primary data (validation
ogy acceptance among specific groups (e.g. older adults).
of scale, framework, position articles, reviews or editorials).
Five articles were included in the scoping review. The com- ◦ Problems with cognition, decreased physical abilities,
plete article selection process is described in Figure 1. hearing or visual impairments and lack of motivation
6 DIGITAL HEALTH

Figure 1. PRISMA flow diagram for article selection process.41

could impede the acceptance of technology among framework (eHLF) by Norgaard et al.,47 who describe the
older adults.45 eHLF as a conceptual model that ‘offers a framework for
evaluating an individual’s or a population’s capacity to
understand, use and benefit from e-services to promote
DHL approaches and maintain their health’.47 Therefore, barriers and facili-
tators were categorized to match the seven components of
Table 1 shows the retrieved e-services used to support and the eHLF.47 The information presented in Table 2 reflects
promote DHL and describes their characteristics, modality data from three articles.42,44,46
of use and the vulnerable populations that each e-services
targets (Table 1).

Effects of DHL on individual behaviours and

Facilitators and barriers to DHL-enabling e-services perceptions about the pandemic
implementation The effects of DH-enabling e-services on the behaviours
Table 2 summarizes the barriers and facilitators of the dif- and perception about the pandemic underwent a thematic
ferent DHL approaches as retrieved in the included litera- analysis that helped in characterizing the barriers and facil-
ture. This study is informed by the e-health literacy itators of implementing DHL-enabling e-services.
Choukou et al. 7

Table 1. DHL addressing the needs of vulnerable populations during the COVID-19 pandemic.

e-service supporting Description /modality of Population

DHL Country use Target users characteristics Study type Reference

44
E-class childbirth USA The program uses Expectant and The number of session Report
education program WEBEX for new families participants
and a free online prerecorded classes Increased from 2459
hospital information and Zoom for the to 2616 in the
session virtual tour, support groups and transition to virtual
‘Ready, Set, Baby’. more interactive learning ( + 6.4)
sessions (90min to
2 h) + EMAIL checked
daily 5/7 + FACEBOOK
+ HOTLINE to convey
a breastfeeding
support system. The
virtual sessions are
offered at a 40% to
50% discount from
the in-person class
fees to increase
access to more
families.
42
MyDesmond, an UK The theory-based digital People with Of those who Online survey
online program to program adopts diabetes. Of responded (n =
support people with evidence-based those who 803), the majority
diabetes with their strategies to optimize responded had been
self-management. It is learning and (n = 803), diagnosed with type
accessible on the NHS. engagement while the majority 2 diabetes in the
Apps Library and allowing people with had been last year (55%),
incorporates content diabetes to progress diagnosed 28% had been
from the NICE through the with type 2 living with type 2
endorsed face-to-face educational content diabetes in diabetes for 1-5
DESMOND program. at their own pace. the last years, and 17% for
Other features of year (55%), more than 10 years.
MyDesmond include 28% had Experience of
discussion forums, been living MyDesmond also
booster sessions, goal with type 2 varied with 21%
setting features, diabetes for having used the
monitoring steps, 1 program for <1
‘Ask the Expert,’ step -5 years, month, 51% for 1-6
challenges, health and 17% for months and 28% for
trackers and a buddy more than >6 months.
system to tailor 10 years
self-management
strategies and
promote behaviour
change
43
TV and social media Turkey Common TV and social Cancer 195 patients [20–82 Survey
media use patients year] (Median 59),
57% females. More
than a third of
patients were 65 + .
74.6% under

(continued)
8 DIGITAL HEALTH

Table 1. Continued.
e-service supporting Description /modality of Population
DHL Country use Target users characteristics Study type Reference

palliative treatment
for the
advanced-stage
disease. 23.8%
breast cancer
patients. There
were differences in
the sources of
knowledge among
patients, and a
significant portion
of patients had false
knowledge about
COVID-19.
46
Social media as public China Online General Low-income users National web-based
preventive behaviour population were about 34.7% cross-sectional
in China during the with (n = 802) in this survey
COVID-19 pandemic. low-income paper.
the most frequently Respondents were
used media types also equipped with
were public social high levels of
media and aggregated disease knowledge
social media and and eHealth
professional social literacy.
media, and official
social media
45
mHealth, telecare and Italy Enable constant and Elderly Elderly Workshop Proceedings
telehealth/behaviour effective
monitoring solutions communication
between older adults
and professionals. On
the one hand, the
older adults increase
their autonomy and
awareness in
managing their
health and, on the
other, physicians can
quickly intervene in
case of emergency.

Facilitators of DHL-enabling interventions implementa- • Connecting to a live educator provides a forum for ques-
tion during the COVID-19 pandemic tions and discussion and enhances the educational pro-
gram’s success.44
• COVID-19 has ushered in a new era for delivering patient
education by combining in-person and digital education
• Virtual perinatal education is an alternative format for approaches that can increase access to education, reduce
providing evidence-based guidance and support after disparities, and improve quality of care.42
suspension of all in-person classes and support groups • Medical expert systems, provided with solid AI technol-
due to the COVID-19 pandemic.44 ogies, can promote healthy ageing by providing aid to
• Connection to a live educator can help ease anxiety and older adults to maintain their functional ability and
address concerned families’ emotional needs.44 improve their wellbeing.45
Choukou et al. 9

Table 2. Facilitators and barriers to DHL-enabling e-services .

Outcomes as per
the eHLF47 Facilitators Reference Barriers Reference

44
Systemic Digital services - Inclusion of the updated guidelines
level that suit and evidence-based practice
individual during COVID-19. - Adding content
needs to meet the emotional needs and
challenges families were facing
46
Official social media may be
challenged by different competitive
sources (maybe sources of
misinformation)
44,46
Access to digital Effectiveness in getting patients -
services that questions answered
work

Individual Motivated to - -
level engage with
digital services
44
Feel safe and in Connection to a healthcare -
control professional is key
44 44
Ability to actively Ability to connect despite the Patient-provider cannot replicate
engage with lockdown in-person sessions
digital services
42
Engaging interactively -
42
Engagement in Helping patients understand their -
own health condition: helpful educational
material, for example., helping
patient improving their diet,
becoming more active, better
managing stress
46
Increasing preventive behaviours -
42
Ability to process Ease of use: Content sufficiently -
information detailed, providing clear and
concise information, program that
is easy and enjoyable to use

• There is a definite need for action, both in the short and Expected long-term transformation in DHL-enabling
long terms, to minimize the adverse effects of the digital e-services
divide caused by this pandemic as well as to act to close
the divide in the long term, and the shift to focus on The thematic analysis helped identify and classify the pre-
digital tools can have a successful role in it.46 visions and expectations regarding long-term transforma-
tion in DHL-enabling e-services. The analysis of the
Barriers to DHL-enabling interventions implementation included articles allows us to draw the following general-
during the COVID-19 pandemic ized recommendations and previsions:
• Social media as a practical preventative approach –
• Poor health literacy created barriers in understanding social media is helpful to disseminate pandemic news
individual health, illness, and treatments for people and disease knowledge, which can help the public to
with HIV/AIDS.46 adopt necessary preventive measures for disease
10 DIGITAL HEALTH

control collectively. On the other hand, the predictive e-services, namely the ability of someone to use digital
ability of disease knowledge and DHL literacy provided means (the Internet, social media and mobile apps) to
an endorsement that improving one’s level of health lit- search, understand and use health information relevant to
eracy is essential during a pandemic in the long term.46 a specific health condition.46
• Permanent virtual patient education – Virtual perinatal Adaptive needs – were reflected in the new ways of deli-
education could reasonably become the permanent way vering healthcare amid the pandemic, including important
of providing support for the near future. The increase adjustments supported by digital means. For instance,
in the volume of participants suggests that the delivery remote interventions targeting expectant mothers and their
of information via a virtual modality may be preferable families successfully adapted to the restrictions placed on
with this generation of expectant families.44 hospital visitors during birth and postpartum44 and have
• Digital equipment for the patients who do not have helped expectant families cope with the changes in the
access to them – Some ways for health care organiza- related routines and practices.44 E-services were also
tions to meet the need in marginalized groups might be needed to support self-management in people with type-2
to have electronic tablets accessible in provider practices diabetes during the COVID-19 pandemic42 and to help
preloaded with educational content that the client could patients overcome COVID-19-related fear and anxiety,
view during an office visit. Another option is to provide such as the fear of care disruption amongst chronic patients
or increase telephonic information and support lines for (e.g. cancer care).43 Fear and anxiety were reported in
expectant mothers and new parents.44 expectant mothers about hospital safety measures, potential
• Virtual education for non-English patients – Providing exposure to the virus while in hospital,44 and, if they tested
virtual education to non-English speaking clients and positive, would transmit the virus to their newborns44 or be
gathering and examining survey data to stay abreast of separated from their babies. E-services implemented during
evolving patients’ needs.44 the pandemic to support and promote DHL among vulner-
able individuals include a virtual childbirth education
program together with a free online hospital information
Discussion session virtual tour offered to expectant mothers,44 an
This study aimed to portray the e-services implemented as a online program to support self-management in people
digital approach to support DHL in vulnerable populations with diabetes,42 a virtual behaviour monitoring for
amid the COVID-19 infodemic and identify the barriers and elderly,45 as well as the use of TV and social media to
facilitators for their implementation. The literature on the explore knowledge and concerns in cancer patients43 and
topic is scarce, sparse and immature. We classified the to promote preventive behaviour during the COVID-19
needs in terms of health-related information among the vul- pandemic.46
nerable populations. We have identified three types of Health conditions could be considered the first reason of
needs: informational, transformational and adaptive: concern about someone in the context of a pandemic.
Informational need – was characterized as a need to Although only a few papers were included, we can see
increase public awareness of health literacy in different two types of health conditions, namely chronic conditions
disease conditions.46 Health-related information appears and conditions that are new to the patient. Chronic condi-
to be widely available; however, it is not necessarily access- tions are overwhelming conditions as scheduled follow-up
ible by everyone, in particular, to some vulnerable popula- appointments are needed, sometimes with different health
tions. Health information is one of the very first bases for care professionals. People living with chronic conditions
someone to understand, assimilate and use health prac- would be more concerned about managing their condition
tices,9,10 such as preventative approaches (e.g. hand amid unprecedented times, such as the COVID-19 pan-
washing, face masking, social distancing) or to contribute demic. For example, in ref. 43 cancer patients had a signifi-
to health management, such as understanding the cant degree of fear of disruption of cancer care due to the
institution-related organizational procedures and the clin- COVID-19 restriction, in addition to the population-wide
ical processes as explained by the health professionals. fear of contracting the COVID-19 virus. Another example
Once accessed, the information has to be satisfactory for is the lower level of information satisfaction of the online
the user regardless of their vulnerability level. Satisfaction information related to COVID-19 in people with chronic
level seems proportionate to the level of complexity of diseases as compared to people with an acute disease.3
each case and health condition (e.g. chronic diseases vs Interestingly, a significant number of cancer patients had
an acute disease).3 Transformational needs – included the wrong information about protection necessities and dis-
increasing digital knowledge and skills required to use content about the adequacy of information.43 The role of
any DHL enabling e-service,43 decreasing health literacy DHL-enabling e-services in the context of chronic disease
barriers and increasing technology acceptance among spe- is of the highest necessity, as mismanaging the condition
cific groups.45 Transformational needs appear to be would directly worsen patient outcomes. Older people are
related to digital literacy as enabled by DHL-enabling at double risk during the pandemic from contracting the
Choukou et al. 11

virus per se and the loneliness and boredom induced by the same time, be confident while they are under quarantine
social distancing restrictions. A recent study noted that or home care. Wildenbos et al.52 identified four significant
loneliness among Dutch older people increased during the barriers to technology acceptance by the elderly;52 namely,
COVID-19 pandemic and was influenced by personal cognitive impairments (memory loss and dementia), physi-
losses, pandemic-related worries, and reduced trust in soci- cal abilities, may be bound to hearing or visual impairments
etal organizations.48 Digital media can help people stay and motivation, which could be represented by the lack of
socially connected and positively affect health and quality perceived usefulness or ease of use of the new technologies.
of life. However, subsequent to challenges, such as over- DHL can be useful to mitigate these mentioned concerns
coming deficiencies in digital skills, decreasing health lit- and facilitate elderly to accept and use digital solutions
eracy barriers and increasing technology acceptance,32 whether during the pandemic or beyond. This scoping
once online, older people are susceptible to review also aimed to draw a portrait of the future of DHL
pandemic-related misinformation that negatively affect based on the learning from the COVID-19 pandemic. The
their health. DHL-enabling-e-services are therefore essen- illiterate in this Internet era will not be those who cannot
tial to overcome these challenges to support older people read and write (e.g. a pamphlet distributed in a hospital, a
in improving digital literacy, online safety and adaptive public website, YouTube), but those who cannot distin-
behaviours toward the pandemic-related restrictions. guish between trustworthy and misleading information
Patients faced with a new condition, such as expecting available online.53 Citizens’ DHL is an essential element
childbirth, always live with a certain amount of anxiety for successful eHealth deployment. However, although
related to uncertainty about their health and how the health- they might be digitally literate, vulnerable citizens often
care system manages their healthcare needs. In Pasadino do not have the necessary skills to understand and appraise
et al.44, a virtual perinatal education program has been online health information and apply their knowledge to
reported as a successful way of enabling DHL about preg- make health decisions. DHL can indeed help improve pre-
nancy, labour, delivery and postpartum among expectant vention and adherence to a healthy lifestyle, improve cap-
mothers and as an alternative format for providing acity building and take the best advantage of the available
evidence-based guidance and support when in-person ses- options, thus strengthening the patient’s involvement in
sions are not possible. Connection to a live educator has health decisions and empowerment, and finally improving
been reported as a facilitator to easing anxiety and addressing health outcomes.
the emotional needs of families. Surprisingly, there is no litera-
ture on DHL manuscripts reported on Indigenous people
despite the vulnerability of this population that could be exa- Limitations
cerbated by the pandemic. Choukou et al.49 have reported This scoping review has focused on the studies that reported on
various advantages of using digital technology for empirical research involving data collection. Literature reviews,
Indigenous populations, particularly the Indigenous older editorials, theses and magazines were also excluded from this
adults, and barriers to implementing such technologies in review. Therefore, these exclusion criteria could have limited
Indigenous communities. Implementing DHL-enabling e-ser- the amount of DHL-enabling e-services included in the
vices in Indigenous communities seems an urgent matter, and review. The general scope of the current review may not have
it is recommended according to the literature49 to keep highlighted all the DHL-enabling e-services that could be avail-
Indigenous patient’s acceptance and culture at the forefront able, such as on social media and the Internet in general, without
and to provide appropriate e-services by digital-health-trained being studied. Findings encourage the implementation of
healthcare professionals. DHL-enabling e-services and their use in digital health research
Under the pandemic lockdown, we have seen ICT reports. Due to the limited number of results and heterogeneity
become more readily available as a convenient and effect- of the included articles, the included articles were not critically
ive way of providing primary health guidelines and appraised to identify the strengths and weaknesses of the
care;50 however, the vulnerable population will be deprived research and assess the usefulness and validity of research find-
of such opportunities due to a lack of access to digital infor- ings. As a quality assessment check approach, critical appraisal
mation. The governments, health organizations, health-care of manuscripts will be necessary for future reviews to help
providers and academia should not overestimate patient’s provide solid guidance to developers of DHL-enabling e-ser-
health literacy,51 and should increase awareness about vices based on the most substantial published work.
DHL-enabling e-services as a mean of promoting health lit-
eracy and create best practice guidelines targeting vulner-
able groups to take advantage of ICT tools. COVID-19 Conclusions
pandemic has shown the transition of traditional care to tel- This review revealed that several factors could either facili-
emedicine and home care.45 DHL plays a pivotal role in tate or hinder the implementation of DHL-enabling e-ser-
teaching the elderly how to use ICT tools, thus allowing vices for vulnerable populations. Literature was scarce,
them to maintain their privacy, independence, and at the which prevented us from drawing robust conclusions.
12 DIGITAL HEALTH

However, we pointed out an absence of implementation of 3. Kor PPK, et al. Are people with chronic diseases satisfied with
DHL-enabling e-services in Indigenous communities. We the online health information related to COVID-19 during the
also identified the need for researchers to fill in the knowl- pandemic? J Nurs Scholarsh 2021; 53: 75–86.
edge gap regarding the contribution to developing not only 4. Dadaczynski K, et al. Digital health literacy and web-based
information-seeking behaviors of university students in
effective DHL-enabling e-services but also strategies to
Germany during the COVID-19 pandemic: cross-sectional
support and promote DHL. Strategies should focus on
survey study. J Med Internet Res 2021; 23: e24097.
increasing digital skills, health literacy to combat misinfor- 5. Cinelli M, et al. The COVID-19 social media infodemic. Sci
mation and awareness of DHL-enabling e-services and their Rep 2020; 10: 16598.
benefits in terms of prevention, adherence to health and 6. WHO. Infodemic, https://www.who.int/health-topics/infode-
wellness guidelines and active involvement of the patient mic#tab = tab_1 (2020).
in health decisions. 7. Islam MS, et al. COVID-19-Related infodemic and its impact
on public health: a global social media analysis. Am J Trop
Acknowledgements: MAC and SAS have initiated the study and Med Hyg 2020; 103: 1621–1629.
built the search strategy with CM, DSR, MP, MU and SAS. The 8. Bhattacharya C, et al. The nature, cause and consequence of
authors run the screening, data extraction and materials COVID-19 panic among social media users in India. Soc
preparation. MAC has initiated a first draft of the manuscript. Netw Anal Min 2021; 11: 53–53.
All the authors contributed to the final version of the 9. Berkman ND, Davis TC and McCormack L. Health literacy:
manuscript. The article processing charges for this article are what is it? J Health Commun 2010; 15: 9–19.
supported by the University of Manitoba, College of 10. Patil U, et al. Health literacy, digital health literacy, and
Rehabilitation Sciences. COVID-19 pandemic attitudes and behaviors in U.S.
College students: implications for interventions. Int J
Environ Res Public Health 2021; 18: 3301.
Conflict of interest: The authors declared no potential conflicts of 11. First Meeting of the WHO GCM/NCD Working Group on
interest with respect to the research, authorship and/or publication Health Literacy for NCDs Digital Health Literacy for NCDs
of this article. (Geneva, 27-28 February, 2017).
12. Harris K, Jacobs G and Reeder J. Health systems and
Ethical Approval: Not applicable, because this article does not adult basic education: a critical partnership in supporting
contain any studies with human or animal subjects. digital health literacy. Health Lit Res Pract 2019; 3:
S33–s36.
13. van der Vaart R and Drossaert C. Development of the digital
Funding: The authors disclosed receipt of the following financial health literacy instrument: measuring a broad Spectrum of
support for the research, authorship and/or publication of this health 1.0 and health 2.0 skills. J Med Internet Res 2017;
article: This work was supported by the Gerry McDole 19: 27.
Professorship in Improved Healthcare Delivery to Rural, Remote 14. Nguyen LHT, et al. Digital health literacy about COVID-19 as
and Underserved Populations of Manitoba 2020-2023 Grant. a factor mediating the association between the importance of
online information search and subjective well-being Among
Peer review: Dr. Mitja Vrdelja, National Institute of Public university students in Vietnam. Frontiers Digit Health
Health of the Republic of Slovenia. 2021; 3. Article 739476. doi:10.3389/fdgth.2021.739476
15. Vrdelja M, Vrbovšek S, Klopč ič V, et al. Facing the growing
COVID-19 infodemic: digital health literacy and information-
ORCID iDs: Mohamed-Amine Choukou https://orcid.org/0000- seeking behaviour of university students in Slovenia. Int J
0001-9477-2412 Environ Res Public Health 2021; 18: 8507.
Diana C. Sanchez-Ramirez https://orcid.org/0000-0003-1637- 16. Norman CD and Skinner HA. Ehealth literacy: essential skills
4309 for consumer health in a networked world. J Med Internet Res
Shabbir Syed-Abdul https://orcid.org/0000-0002-0412-767X 2006; 8: e9.
17. Leung AYM, et al. Sense of coherence mediates the relation-
Supplemental material: Supplementary material for this article ship between digital health literacy and anxiety about the
is available online. future in aging population during the COVID-19 pandemic:
a path analysis. Aging Ment Health 2021: 1–10. doi:10.
1080/13607863.2020.1870206
References 18. Chang BL, et al. Bridging the digital divide: reaching vulner-
1. Patil U, et al. Health literacy, digital health literacy, and able populations. J Am Med Inform Assoc 2004; 11: 448–457.
COVID-19 pandemic attitudes and behaviors in U.S. 19. Clark B and Preto N. Exploring the concept of vulnerability in
College students: implications for interventions. Int J health care. CMAJ 2018; 190: E308–E309.
Environ Res Public Health 2021; 3301: 1–14. doi:10.3390/ 20. Bracken-Roche D, Bell E, Macdonald ME, et al. The concept
ijerph18063301 of ‘vulnerability’ in research ethics: an in-depth analysis of
2. Syed Abdul S, et al. The pandemic, infodemic, and people’s policies and guidelines. Health Res Policy Syst 2017; 15: 8.
resilience in India: viewpoint. JMIR Public Health Surveill 21. Aday LA. Health status of vulnerable populations. Annu Rev
2021; 7: e31645: 1–7. doi:10.2196/31645 Public Health 1994; 15: 487–509.
Choukou et al. 13

22. de Groot N, Bonsel GJ, Birnie E, et al. Towards a universal 39. Braun V and Clarke V. Using thematic analysis in psychol-
concept of vulnerability: broadening the evidence from the ogy. Qual Res Psychol 2006; 3: 77–101.
elderly to perinatal health using a Delphi approach. PLoS 40. King N. Using templates in the thematic analysis of text. In:
One 2019; 14: e0212633. Essential guide to qualitative methods in organizational
23. Association WM. Declaration of Helsinki. Ethical principles research. California, United States: Sage Publication Ltd,
for medical research involving human subjects. Jahrbuch 2004, pp.256–270. doi:10.4135/9781446280119.n21
für Wissenschaft und Ethik 2009; 14: 233–238. 41. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting
24. Greenall M, Kunii O, Thomson K, et al. Reaching vulnerable items for systematic reviews and meta-analyses: the
populations: lessons from the global fund to fight AIDS, PRISMA statement. Br Med J 2009; 339: b2535.
Tuberculosis and malaria. Bull World Health Organ 2017; 42. Quinn LM, et al. Use of MyDesmond digital education pro-
95: 159–161. gramme to support self-management in people with type 2
25. Tangcharoensathien V, Mills A and Palu T. Accelerating diabetes during the COVID-19 pandemic. Diabetic Med
health equity: the key role of universal health coverage in 2021; 38: e14469.
the sustainable development goals. BMC Med 2015; 13: 01. 43. Guven DC, et al. Perspectives, knowledge, and fears of
26. Vulnerable populations: who are they? Am J Manag Care cancer patients about COVID-19. Front Oncol 2020; 10:
2006; 12: S348–S352. 1553.
27. Claeson M and Folger P. in International Encyclopedia of 44. Pasadino F, DeMarco K and Lampert E. Connecting with
Public Health (ed Harald Kristian Heggenhougen) 197-204 families through virtual perinatal education during the
(Academic Press, 2008). COVID-19 pandemic. MCN. Am J Maternal Child Nurs
28. Jennings B, Arras JD, Barrett DH, et al. Emergency ethics. 2020; 45: 364–370.
Oxford, United Kingdom; Oxford University Press, 2016. 45. Saibene A, et al. Addressing digital divide and elderly accept-
ISBN-13: 9780190270742. doi:10.1093/med/9780190270742. ance of medical expert systems for healthy ageing. Vol. 2804
001.0001 (CEUR-WS, 2020).
29. Soomro KA, Kale U, Curtis R, et al. Digital divide among 46. Li X and Liu QU. Social Media Use, eHealth literacy, disease
higher education faculty. Int J Educ Technol Higher Educ knowledge, and preventive behaviors in the COVID-19 pan-
2020; 17: 21. demic: cross-sectional study on Chinese netizens. J Med
30. Giuliani M, Papadakos T and Papadakos J. Propelling a New Era Internet Res 2020; 22: e19684.
of patient education into practice-cancer care post-COVID-19. 47. Norgaard O, et al. The e-health literacy framework: a concep-
Int J Radiat Oncol Biol Phys 2020; 108: 404–406. tual framework for characterizing e-health users and their
31. Jafree SR, Bukhari N, Muzamill A, et al. Digital health lit- interaction with ehealth systems. Knowl Manage E-Learn
eracy intervention to support maternal, child and family 2015; 7: 522.
health in primary healthcare settings of Pakistan during the 48. van Tilburg TG, Steinmetz S, Stolte E, et al. Loneliness and
age of coronavirus: study protocol for a randomised con- mental health during the COVID-19 pandemic: a study
trolled trial. BMJ Open 2021; 11: e045163. among Dutch older adults. J Gerontol, Series B 2020; 76:
32. Martins Van Jaarsveld G. The effects of COVID-19 Among e249–e255.
the elderly population: a case for closing the digital divide. 49. Choukou MA, Maddahi A, Polyvyana A, et al. Digital health
Front Psychiatry 2020; 11: 577427–577427. technology for indigenous older adults: a scoping review. Int J
33. Arksey H and O’Malley L. Scoping studies: towards a methodo- Med Inform 2021; 148: 104408.
logical framework. Int J Soc Res Methodol 2005; 8: 19–32. 50. Sixsmith A. COVID-19 and AgeTech. Qual Ageing Older
34. Levac D, Colquhoun H and O’Brien KK. Scoping studies: Adults 2020; 21: 247–252.
advancing the methodology. Implement Sci 2010; 5: 69. 51. Voigt-Barbarowicz M and Brütt AL. The agreement between
35. CADTH. COVID-19 Search Strings. Accessed March 9, 2021. patients’ and healthcare professionals’ assessment of patients’
https://covid.cadth.ca/literature-searching-tools/cadth-covid-19- health literacy – a systematic review. Int J Environ Res Public
search-strings/. Health 2020; 17: 2372. doi:10.3390/ijerph17072372
36. Bramer WM, Giustini D, de Jonge GB, et al. De-duplication 52. Wildenbos GA, Peute L and Jaspers M. Aging barriers influ-
of database search results for systematic reviews in encing mobile health usability for older adults: a literature
EndNote. J Med Libr Assoc 2016; 104: 240–243. based framework (MOLD-US). Int J Med Inform 2018;
37. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan—a web 114: 66–75.
and mobile app for systematic reviews. Syst Rev 2016; 5: 10. 53. Syed-Abdul S, et al. Misleading health-related information
38. Nowell LS, Norris JM, White DE, et al. Thematic analysis. Int J promoted through video-based social media: anorexia on
Qual Methods 2017; 16: 1–13. doi:10.1177/1609406917733847 YouTube. J Med Internet Res 2013; 15: 30.