Data for this report were collected as part of a larger pilot randomized controlled trial—Latino Colorectal Cancer Awareness, Research, Education, and Screening (Latino CARES)—that promoted CRC screening by providing education and a FIT. The pilot study aimed to evaluate the feasibility and impact of a Spanish-language, low-literacy, culturally targeted intervention (ie, a photonovella and DVD) plus FIT compared with a standard Spanish-language booklet developed by the Centers for Disease Control and Prevention plus FIT. Of note, recruitment took place at two participating clinic sites that are part of a Federally Qualified Health Center (FQHC) in Southwest Florida. The FQHC sites are centrally located in agricultural farmworker communities and annually serve a large number (ie, approximately 5000) of medically underserved patients aged 50 to 75 years, a majority of whom are of Latino origin from diverse nationalities and include farmworker populations [30]. Detailed methods are provided in prior publications that communicate the results of the main outcomes of the Latino CARES study [29-31].

Participant consent was obtained prior to baseline interview and randomization. Eligible participants (1) were receiving care at two participating FQHC clinic locations; (2) were between the ages of 50 and 75 years; (3) self-identified as Latino; (4) were able to read, speak, and understand Spanish; (5) preferred to receive health information in Spanish; (6) were currently not up to date per CRC screening guidelines (ie, had never screened or previously screened but were now overdue); and (7) were at average risk for CRC.

The University of South Florida Institutional Review Board approved the study (approval No. MCC-17665) prior to participant enrollment. Study procedures were conducted in accordance with the Declaration of Helsinki. During enrollment, participants provided informed consent to be included in the study.

Study assessments consisted of validated measures that were translated into Spanish and refined for cultural relevance using the following established procedures. Our study team included three bilingual (ie, fluent in English and Spanish) researchers and a bilingual (ie, fluent in English and Spanish) community advisory board. Applying the Brislin method [32], measures were first translated into Spanish by a bilingual study coordinator and then back-translated by a second bilingual study team member. Any discrepancies were arbitrated by a third bilingual study team member. Items were pretested among community members using learner verification methodology [33,34]; they were further refined in consultation with the community advisory board for cultural relevance and comprehension. Baseline items were administered by bilingual (ie, English and Spanish) study coordinators at the time of interview. To minimize literacy issues, all questions were read aloud for all participants.

A single item, gathered from the Pew Research Center [8] and used in previous OHI behavioral studies among Latino adults [4,35], assessed OHI-seeking usage: “Have you previously personally searched for health information on the Internet/Online for yourself or for others? For example, [have you] sought on Google/Yahoo information on high blood pressure, healthy recipes, or efficient exercises?” Response options were yes or no.

eHealth literacy was assessed only among participants who reported engaging in OHI seeking. Thus, the number of participants for whom eHealth literacy was assessed was lower than that for those responding to the other measures. The Spanish-translated eHealth Literacy Scale (eHEALS) [9,36] was administered to assess eHealth literacy, including knowledge, comfort, and perceived skills at finding, evaluating, and applying OHI to health problems. The eHEALS [9] comprises eight items scored on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), and aims to reflect the individuals’ own perceptions of their knowledge and skills at using eHealth information [9,37]. The final result is the sum of all items and ranges from 8 to 40, with higher scores reflecting a higher level of eHealth literacy. The validity and reliability of the eHEALS has been demonstrated across various health conditions [38,39], ages [40-42], and languages [43], including Spanish [36]. Following other studies with similar target populations, the cutoff for high eHealth literacy was set at 26 [10,38,44-48]. Thus, in maintaining consistency in terminology with the literature, this study defined high self-perceived eHealth literacy as an eHEALS score equal to or greater than 26 out of 40, and low self-perceived eHealth literacy was defined as an eHEALS score of less than 26 [10,38,44-48].

Sociodemographic variables assessed included age, gender, race and ethnicity, marital status, education, health insurance status, employment status, and income. Additionally, as aggregated data in prior literature masked substantial heterogeneity within the Latino population, we assessed parental foreign-born status and participant foreign-born status; if foreign-born, the country of origin and years lived in the United States were also assessed [30].

Seven constructs of the PHM were assessed in this study using 26 total items referenced from prior CRC studies [24,25,27,28,30,49-52]. For each item assessing PHM constructs, response options were based on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Four items assessed salience and coherence, or the perception that performing a health behavior is consistent with their beliefs about how to protect and maintain health [24-26,29,30,49,50]. Three items assessed perceived susceptibility, or one’s perceived personal risk for developing CRC or colon polyps [24,25,30,49]. Two items assessed cancer worry, or one’s concern that completing CRC screening will reveal a health concern [24,26,29,30,49,50,53].

Two items measured response efficacy, or the belief that adopting a behavior will be effective in reducing disease threat [24,29,30,49,50]. Four items measured social influence, or the influence of family members and doctors or health professionals on an individual’s willingness to comply with CRC screening [24,26,29,30,49,50]. Five items assessed religiosity, or the extent to which religious beliefs might influence medical decision–making, such as CRC screening [29,30,51,54]. Six items measured self-efficacy for screening using FIT, or attitudes and confidence toward completing FIT testing [24-26,29,30,49,55]. For each respective construct, the corresponding items’ scores reported by participants were added together; construct total scores were used for analyses.

Sociodemographic characteristics and PHM constructs were summarized using descriptive statistics. The assessment details for each research question are discussed in the following four sections.

Sociodemographic characteristics are described in Table 1 and in the main reported outcomes of Gwede et al [30]. In total, 67% (51/76) of participants were female. The mean age of the participants was 57.2 (SD 6.0) years (range 50-74). In total, 62% (47/76) of participants reported not completing high school. In addition, 41% (31/76) of participants reported being unemployed and having an annual income of less than US $10,000. Further, 75% (57/76) of participants lacked health insurance. In total, 93% (71/76) of participants reported being born outside of the United States. Among those born outside of the United States, a majority (49/71, 69%) reported Mexico as their country of birth. Further, among those born outside of the United States, the mean length of time reported living in the United States was 23.4 (SD 10.9) years (range 2-56).

OHI has become more routine in health care interactions and health education for patients and caregivers [3-5]. Yet, greater emphasis on eHealth may disproportionately affect groups with limited eHealth literacy. Healthy People 2030 continues the national effort initiated in 2010 in recognition of the importance of HC and HIT to support better communication, care, and outcomes toward achieving health equity [56]. There is a dearth of information available in the literature that communicates specifically on factors (eg, sociodemographic characteristics and health beliefs) associated with OHI seeking and eHealth literacy among SD Latino adults.

In this study, nearly three-quarters (54/76, 71%) of participants reported not having personally sought OHI for themselves or others. Among those for whom eHealth literacy was assessed (22/76, 29%), nearly one-third (6/22, 27%) had an eHEALS score of less than 26, indicating self-perceived low eHealth literacy. In this study, preliminary findings suggest that higher educational attainment was associated with an increased likelihood of having sought OHI. Although further research to confirm directionality is necessary, this association between higher educational attainment and seeking OHI among SD Latino adults is consistent with prior findings on OHI behaviors conducted among English-speaking populations [57,58]. Specifically, Jacobs et al [58] highlight that a heavy reliance on e-technologies for disseminating health information may increase the likelihood of further perpetuating health disparities; they suggest a need for interventions and efforts focused on developing training and services to boost internet self-efficacy tailored to patients’ learning styles and their cultural and demographic characteristics to reduce this digital disparity.

This study was conducted among SD Latino adults of whom the majority were born outside of the United States, which is acutely different from studies conducted among participants preferring the English language [57,58]. Our efforts are preliminary and, thus, additional research is needed to explore the relationships between educational attainment and OHI seeking among various groups who prefer non-English languages and groups newly arrived in the United States. Of interest, in our exploration of factors associated with the act of OHI seeking, there was a high proportion of individuals who had not sought OHI (54/76, 71%). This lack of OHI seeking may disproportionately affect SD Latino adults, as reliance on eHealth resources continues to gain emphasis in the United States [3-5] and globally [59]. Indeed, our efforts are cautiously interpreted, yet our data signal a timely opportunity to examine the reasons preventing OHI-seeking behaviors among SD Latino adults aged 50 to 75 years, as well as the potential for intervention research. Thus, in recognizing this distinction, considerations for culture and language are a fertile area of future research examining reasons for the lack of OHI seeking (eg, learning styles and preferences, availability and access to Spanish-language computer resources, knowledge, and technological skills, such as search strategies, among others). In considering culture, previous studies exploring OHI behaviors suggested that younger, English-dominant Latino and Hispanic generations may be OHI brokers for older generations of SD Latino adults [4,35,60]. Therefore, whether OHI seeking could be facilitated by intergenerational co-learning approaches is an avenue for future exploration. In a study examining digital health disparities among ethnically diverse older adults who prefer the English language [61], researchers suggested important steps to close this digital divide, including cultural adaptation based on preferences for receiving health information. Research has found that personal instruction through the process of internet use and assistance with using new digital devices helps older adults to adopt a daily habit of internet use [62]. However, whether these outcomes may be replicated among SD Latino adults aged 50 to 75 years remains to be examined. Further still, the literature communicates that smartphone ownership offers no statistically significant difference relevant to race or ethnicity [63] and is the primary source of internet use among all Latino adults [63]. Thus, considerations for examining the potential of leveraging smartphones for interventions on promoting OHI seeking among SD Latino adults is worth noting. Moreover, in addition to reaching underserved populations in health centers [64], community libraries offer another potential avenue for engaging with diverse community members [65].

In our study, exploratory findings suggest that higher eHealth literacy was preliminarily associated with higher self-efficacy for FIT screening (β=1.20, 95% CI 0.14-2.26; P=.02) among SD Latino adults. This preliminary finding suggests that further investigation is warranted. Future in-depth examinations are necessary to confirm directionality of association. Prior to this study, the literature did not communicate specifically regarding findings that have examined eHealth literacy and self-efficacy for CRC screening. Efforts by Park et al [66] conveyed an association between higher levels of eHealth literacy and greater confidence in seeking online cancer information. Yet, the study was completed among English-language participants; importantly, the “confidence” examined by Park et al [66] differs from our use of “self-efficacy” that we occupy via the PHM.

This preliminary study communicates promising results suggesting that increased eHealth literacy may be associated with increased self-efficacy for CRC screening with FIT. While this study’s results must be replicated in a larger sample, these findings are encouraging and set an important small guiding step in suggesting that eHealth literacy skills development might benefit self-efficacy of CRC screening. Future appropriately powered research is necessary to examine whether eHealth literacy training and building self-efficacy for CRC screening may ultimately impact CRC screening uptake.

This study has several limitations and strengths to acknowledge. First, the study was conducted in the context of a small pilot trial, underpowered for inferential analyses. Thus, our findings should be interpreted cautiously and call for further study in larger samples of SD Latino individuals. Second, this study did not assess access to the internet nor barriers to OHI seeking, limiting potential findings. Third, Latino ethnicity is shared among many Americans from various backgrounds and, most certainly, does not comprise a homogenous group. Characteristics of Latino adults vary by region. In this study, participants communicated their Latino ethnicity, and most were of Mexican heritage, thus potentially limiting generalizability. Yet, the sample representing 10 different Latin American countries offers preliminary evidence of feasibility for recruiting Latino adults from diverse backgrounds into future studies.

There are several implications to consider and acknowledge. First, to reach the Healthy People 2030 HC and HIT objectives, it is necessary to expand research efforts to highlight and address barriers and leverage facilitators to OHI behaviors; it is also necessary to increase access to the internet. Second, future intervention research to promote eHealth literacy should examine and consider how cultural background and language affect access, health care use, successful use of eHealth resources, and behavior change. Finally, this study provided preliminary findings that suggested a need for pursuing further research on promoting OHI-seeking behaviors and eHealth literacy training that may impact CRC self-efficacy and, ultimately, CRC screening behaviors. Nevertheless, larger research studies are needed to corroborate these findings before clear implications for practice can be reached.

This preliminary study adds to an extremely small evidence base and is the first to communicate findings on the assessment and analyses of OHI seeking and eHealth literacy in the context of the PHM among SD Latino adults. A high proportion of SD Latino participants in our study have not sought OHI for themselves or others, thus limiting their access to beneficial resources. In light of the growing use and reliance on technologies in health care, factors preventing OHI seeking remain to be further examined. In addition, there is a need for resources to improve eHealth literacy among SD Latino adults. Our study communicates preliminary evidence that higher eHealth literacy is occurring among those with higher self-efficacy for CRC screening. Appropriately powered research in the future is warranted to further examine this preliminary finding. Additionally, the next logical step that future research should examine is whether eHealth literacy training and building self-efficacy for CRC screening could increase the uptake of CRC screening.