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In the digital age, electronic health literacy (eHealth literacy) of community-dwelling older people plays a potentially important role in their health behaviors which are critical for health outcomes. Researchers have documented that self-efficacy and self-care ability are related to this relationship. This study aimed to assess the relationship between eHealth literacy and health promotion behaviors among older people living in communities and explore the chain mediating role of self-efficacy and self-care ability. For this cross-sectional study, we used data from 425 older adults at 3 communities in Qingdao, Shandong Province in Northeastern China, from June to September 2021. Path analysis using the structural equation model was performed. We found that eHealth literacy was significantly associated with health promotion behaviors in older people. Additionally, eHealth literacy indirectly affected health promotion behaviors through self-efficacy and self-care ability, respectively. In addition, the chain mediation effect was identified in the relationship of eHealth literacy and health promotion behaviors: eHealth literacy→ self-efficacy→ self-care ability→ health promotion behaviors. These findings offer promising directions for developing interventions to modify older adults’ health behaviors through enhancing their eHealth literacy. These interventions should integrate components that target improving the self-efficacy and self-care ability of older people.
Population aging is a global issue. In China, in particular, the population of people aged over 65 has reached 176.03 million, accounting for 12.6% of the total population in China [1]. The health status of older people is of great importance to the healthy development of society. However, the surge in the older adult population poses a challenge to the health care system, as older people face unique challenges with health problems, such as higher rates of physical and mental health issues [2, 3]. However, in the face of various health problems, few older people adopt effective health behaviors [4]. Research shows that the level of health promotion behaviors of older people needs to be improved [5]. Lacking health promotion behaviors can threaten the health of older people [6]. Therefore, encouraging older people to adopt healthy behaviors is conducive to improving the health status of older adults and reducing the health cost for society.
Many factors influence the (non)adoption of health promotion behaviors, such as self-efficacy, social support, health concept, and health knowledge [7, 8]. Health literacy, the ability of individuals to actively access information that is beneficial to them, has a significant influence on health promotion behaviors [9]. Research shows that high health literacy can facilitate individuals’ understanding of disease severity and adoption of disease prevention behaviors [10, 11]. Recently, during the COVID-19 pandemic, health literacy has influenced both vaccination hesitation and adherence to preventive measures of the general public [12, 13]. Therefore, many scholars have recommended helping individuals adopt health promotion behaviors by improving their health literacy [14, 15].

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In recent years, the convenience and low cost of the internet have enabled it to be an important way to export health knowledge, therefore, researchers began to pay attention to electronic health literacy (eHealth literacy), defined as the ability to search, find, understand, and evaluate health information through network resources and use the acquired information to process and solve health problems [16]. The effect of eHealth literacy on health has attracted significant attention from researchers [17]. Studies have shown that patients with higher eHealth literacy are more likely to manage their health by using the information obtained from the network [18], and poor eHealth literacy can hinder patients’ ability to manage their medications [19]. In the process of medical decision-making, patients strive to improve their electronic health literacy to manage their health [20]. Especially during the time of COVID-19, the relationship between eHealth literacy and health behaviors has been widely explored [21, 22]. People with extensive experience in using the internet are more protective and aware of the importance of taking proactive health measures after an illness has occurred.
Studies have demonstrated the positive effects of eHealth literacy on health among the general population. However, older adults face unique challenges when using the internet, such as poor eyesight and limited mobility, which may affect their interest in using the internet and reduce the frequency of internet use [23]. Moreover, most older adults use the internet to socialize and get news, instead of obtaining health information. Approximately 40% of elderly participants have used the internet to access health information [24, 25]. Therefore, the relationship between eHealth literacy and health promotion behaviors in the older population needs to be further explored.

Previous studies have also indicated that eHealth literacy can influence health promotion behaviors through self-care ability and self-efficacy, respectively [20, 26, 27, 28], but the interactions among these pathways have not been examined. In this study, we aimed to address the gaps by focusing on the mechanisms by which eHealth literacy influences health promotion behaviors. Particularly, we focused on the correlation of eHealth literacy, self-efficacy, self-care ability, and health promotion behaviors, and the relationship among them.
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Firstly, the KAB model is a theoretical model of behavioral intervention aimed at changing human health behaviors [29]. According to the model, knowledge refers to the process of individuals receiving health knowledge and is the basis of their health behavior change. Beliefs are attitudes based on the individual’s reflection on the knowledge received, which is gradually transformed into positive beliefs and is the driving force behind the individual’s health behavior change. Behavior is action, which refers to the transformation of health-damaging behaviors by individuals who uphold positive beliefs and attitudes based on their acquired and perceived health knowledge [30]. The KAB model proposes that knowledge can directly and indirectly influence behavior by changing one’s beliefs [31]. In previous studies, self-efficacy has often been used to measure individuals’ beliefs. The information people gain from the internet will increase their knowledge and improve their self-efficacy [32]. At the same time, some studies have shown that the self-efficacy of older people may be related to eHealth literacy. Older people with lower eHealth literacy are less able to access, use, and judge online health information, which may affect their confidence and attitudes to change health behaviors [33].

Secondly, in recent years, Fotoukian and colleagues [34] developed the Health Empowerment theory as the process by which patients actively develop and utilize their knowledge and abilities, develop confidence, gain self-development and self-satisfaction, and increase their sense of self-efficacy to manage their illness, manage their lives, and promote their health. Health empowerment theory suggests that health behavior change requires improving an individual’s capacity for self-care [35]. The key to improving self-care ability is to encourage individuals to make full use of their knowledge and other available resources [36]. The information that older people access from the internet is an important health resource [37]. Moreover, an individual’s sense of healthy beliefs is an important psychological resource.
The data used in this study were obtained from a multicenter cross-sectional survey that investigated patients’ eHealth literacy in Qingdao, Shandong Province, China, from June to September 2021. Patients were selected from a convenience sample of three communities. Older adults were eligible if they were aged ≥ 60 years and were able to communicate. We excluded persons with severe mental illness, severe hearing or visual impairment, or severe physical illness that prevented them from participating in this study. Additionally, we excluded people who dropped out during the study or answered questionnaires incompletely.
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One of the authors (A.W.) established a long-term research collaboration with the three communities. She first contacted the community health service center managers to explain the purpose and significance of the study and to obtain their consent and cooperation. Then, two uniformly trained researchers (Y.W. and Y.Z.) recruited participants and collected data onsite. Potential participants were older people who visited the community health service center during the data collection period. After explaining the purpose and significance of the study and obtaining consent, the questionnaires were distributed to participants and the participants were informed of the precautions and requirements for completing the questionnaires in a standardized instructional language. For those who needed help, the researchers read
Firstly, the KAB model is a theoretical model of behavioral intervention aimed at changing human health behaviors [29]. According to the model, knowledge refers to the process of individuals receiving health knowledge and is the basis of their health behavior change. Beliefs are attitudes based on the individual’s reflection on the knowledge received, which is gradually transformed into positive beliefs and is the driving force behind the individual’s health behavior change. Behavior is action, which refers to the transformation of health-damaging behaviors by individuals who uphold positive beliefs and attitudes based on their acquired and perceived health knowledge [30]. The KAB model proposes that knowledge can directly and indirectly influence behavior by changing one’s beliefs [31]. In previous studies, self-efficacy has often been used to measure individuals’ beliefs. The information people gain from the internet will increase their knowledge and improve their self-efficacy [32]. At the same time, some studies have shown that the self-efficacy of older people may be related to eHealth literacy. Older people with lower eHealth literacy are less able to access, use, and judge online health information, which may affect their confidence and attitudes to change health behaviors [33].

Secondly, in recent years, Fotoukian and colleagues [34] developed the Health Empowerment theory as the process by which patients actively develop and utilize their knowledge and abilities, develop confidence, gain self-development and self-satisfaction, and increase their sense of self-efficacy to manage their illness, manage their lives, and promote their health. Health empowerment theory suggests that health behavior change requires improving an individual’s capacity for self-care [35]. The key to improving self-care ability is to encourage individuals to make full use of their knowledge and other available resources [36]. The information that older people access from the internet is an important health resource [37]. Moreover, an individual’s sense of healthy beliefs is an important psychological resource.
The data used in this study were obtained from a multicenter cross-sectional survey that investigated patients’ eHealth literacy in Qingdao, Shandong Province, China, from June to September 2021. Patients were selected from a convenience sample of three communities. Older adults were eligible if they were aged ≥ 60 years and were able to communicate. We excluded persons with severe mental illness, severe hearing or visual impairment, or severe physical illness that prevented them from participating in this study. Additionally, we excluded people who dropped out during the study or answered questionnaires incompletely.
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One of the authors (A.W.) established a long-term research collaboration with the three communities. She first contacted the community health service center managers to explain the purpose and significance of the study and to obtain their consent and cooperation. Then, two uniformly trained researchers (Y.W. and Y.Z.) recruited participants and collected data onsite. Potential participants were older people who visited the community health service center during the data collection period. After explaining the purpose and significance of the study and obtaining consent, the questionnaires were distributed to participants and the participants were informed of the precautions and requirements for completing the questionnaires in a standardized instructional language. For those who needed help, the researchers read
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