The association and intervention effect between eHealth literacy and lifestyle behaviors among Chinese university students

ABSTRACT Objective: Our aim was to evaluate the association between eHealth literacy and lifestyle behaviors to intervene among Chinese university students. Method: The Chinese eHealth Literacy Scale (C-eHEALS) questionnaire was used to investigate the eHealth literacy level and association with lifestyle behaviors among Chinese university students. Independent sample t-test and Pearson’s correlation coefficient were used by statistical software SPSS v20. Results: In the first round, 5,151 university students participated in the study, including 71.46% female and 28.54% male, aged 18–22 (93.13%).The average eHealth literacy score was 26.81 ± 5.83. Four lifestyle behaviors (e.g., exercise, smoking, drinking and sleeping) were all significantly correlated with eHealth literacy scores and demonstrated significant differences. In the second investigation (N = 2,939), the average eHealth literacy score was 31.64 ± 6.44, a notable improvement compared with the first investigation. Conclusion: Those in the group with high eHealth literacy scores have a healthier lifestyle than those in the low-score group. Training in eHealth-related resources is a positive measure to improve university students’ eHealth literacy.


INTRODUCTION
With the increasing use of Internet and mobile technology, everyone can access information anywhere and at any time (1) . The Internet has become the main source of health-related information (2) . More and more teenagers use the Internet to obtain health information (3,4) , including university students (5) . The ability to find, understand and evaluate health-related information from electronic resources and apply it solving health problems is called eHealth literacy (6) . eHealth literacy has been regarded as a public health goal in the 21 st century and a major challenge facing global health care. While the current generation of university students can obtain a large amount of health information online, access alone cannot ensure that students skillfully search for such health information; their ability to obtain and evaluate electronic health information still has much room for improvement (7) .
University students comprise a special social group, a balanced diet, reasonable nutrition supply and eating habits are particularly important critical to their physical and mental health development. Healthy lifestyle behaviors, such as regular exercise, good sleep, and breakfast, have an important impact on their lives (8) . However, university students are prone to engaging in dangerous health behaviors (9) , such as smoking and drinking. It is crucial for university students to obtain a healthy lifestyle to protect and promote their health, and to maintain these behaviors in adulthood (10) . Lifestyle is defined as voluntary activities of daily life, such activities are a regular part of daily life and can seriously affect one's health (11) . Therefore, eHealth literacy is an important factor for university students in maintaining a healthy lifestyle and good health (12) .
The eHealth literacy scale, an 8-item questionnaire designed to measure self-perceived eHealth literacy skills, is comprised of six core skills, or literacies: traditional literacy, health literacy, information literacy, scientific literacy, media literacy, and computer literacy (6) . Research showed that in the general population, those with higher levels of eHealth knowledge demonstrated a healthier lifestyle than those with lower levels (13) . In the case of college students, few studies have detailed the relationship between eHealth literacy and lifestyle behaviors such as regular exercise, healthy diet and regular sleep, such studies have been conducted in Taiwan, Greece and the United States (14)(15)(16) . The impact of eHealth literacy on lifestyle behavior varied by country, cultural background and Internet use (2,17,18) . To date, such studies are lacking in China. Accordingly, we set out to evaluate the eHealth literacy level of Chinese university students and the associations with lifestyle behaviors.

Study deSign
This non-experimental comparative correlation study used quantitative research methods with intervention. The intervention measure carried out more than two eHealth-related trainings for 5,151 participants, and randomly selected 2,939 participants for a second analysis to explore the association between eHealth and lifestyle behaviors among Chinese university students, in order to verify eHealth literacy levels and to measurement the effectiveness of eHealth training intervention.

Sample definition
University students were recruited from Xinyang University in China, with the stated goal of examining associations between eHealth literacy and lifestyle behaviors among Chinese university students. Two rounds of investigation were conducted from October to December 2021.

Selecton criteria
All participants were native Mandarin speakers majoring in liberal arts and science, from freshman to senior years. Most were aged 18-22 years old. Participants who did not complete the survey were excluded.

data collection inStrument
The research was conducted in two-stages at two months apart. After the first part, participants were trained at least twice in eHealth-related resources. The aim of the second interview was to explore whether eHealth-related training improved eHealth literacy of university students. Nine indicators, including sex, age, only child, origin, parental education level, major, grade, and number of Internet devices were collected, via the Chinese version of the eHealth Literacy Scale (C-EHEALS) questionnaire (19) .The C-eHEALS comprises 8 items to which participants respond on a 5-point Likert scale, ranging from 1 for "strongly disagree" to 5 for "strongly agree", with a total score varying 8 and 40. Data were collected through the online questionnaire created with Wenjuanxing software. Participants were recruited by WeChat, a social media application widely used in China. WeChat was chosen because users are verified, rendering virtually zero possibilities of fake profiles. The researchers sent the questionnaire link to a group of teachers on WeChat and asked them to share it with their students. The questionnaire was anonymous and participants did not receive any payment.
The data are presented through descriptive statistics (mean, standard deviation, frequency, percentage), according to the nature of the variables (quantitative). Reliability and validity of the questionnaire was verified through Kaiser-Meyer-Olkin (KMO) test and Cronbach's Alpha. The correlation between variables was determined by independent sample t-test and Pearson's correlation coefficient. The statistical significance was 0.1% and the analyses were assisted by statistical software SPSS v20.

ethical aSpectS
This study was performed in compliance with the Helsinki Declaration guidelines. All procedures relevant to study participants were approved by the ethics committee of Xinyang University. Participation was voluntary; participants were informed of the study objective and context and provided their written informed consent regarding privacy and information management policies.

aSSociationS of participantS characteriSticS with c-ehealS literacy
The average C-eHEALS score of male was 1.95 higher than that of females (p < 0.001, Table 1), with significant difference between the two. The average C-eHEALS score of university students from town was significantly higher than that of countryside (p < 0.001), while the C-eHEALS with high parental education was also significantly higher than that of students with low parental education (p < 0.001). Overall, the characteristics of sex, region, parental education level, and major had a significant impact on the eHealth literacy scores of Chinese university students.

lifeStyle BehaviorS
For lifestyle behaviors of university students in China, exercise, breakfast, smoking, drinking and sleeping were statistically analyzed ( Table 2). To further study the correlation of C-eHEALS with lifestyle behaviors, C-eHEALS was divided into two levels, low (≤ 26) and high (> 26), with an average score of 26 points according to eHealth literacy ( Table 2). Comparing lifestyle behaviors, 67.59% of university students in the low group, exercise regularly (≥ 1-2 days/week), compared to 76.75% in the high group. Further, 91.29% vs. 93.76% of participants in the low and high groups regularly eat breakfast, respectively. The proportion of university students who neither smoke nor drink was 96.33% and 90.78% in the low group, respectively, vs. 95.39% and 87.92% in the high group, slightly lower than the former. As for sleeping, 86.05% and 89.28% participants in the low and high C-eHEALS groups slept for above 7-8 hours, respectively. Generally, in the low C-eHEALS group, the participants' proportion is slightly lower than that of high group, excluding the lifestyles without smoking or drinking. Overall, participants in the high group demonstrated a healthier lifestyle than those in the low group.

aSSociationS of lifeStyle BehaviorS with c-ehealS literacy
To analyze associations of lifestyle behaviors with eHealth literacy, Pearson correlation analysis was conducted ( Table 3). As can be seen, there was a significant positive correlation between exercise, smoking, drinking and sleeping with C-eHEALS, respectively. There was no significant correlation between breakfast with C-eHEALS.
To validate the eHealth literacy level of university students and to measure the effectiveness of eHealth training intervention, a second round of questionnaire survey was launched two months later (Table 4). A total of 2,939 university students who had participated the first survey were randomly selected to carry out the second survey. Between surveys and the respondents were trained twice or more on eHealth literacy. Results show that participants in the high group have a healthier lifestyle than those in the low group, consistent with the first survey. The mean and standard deviation of eHealth literacy increased from 26.81 ± 5.83 (N = 5,151) to 31.64 ± 6.44 (N = 2,939). Compared with the first survey, the C-eHEALS score of five lifestyle behaviors improved, while with regular lifestyle had a higher C-eHEALS score than those with irregular lifestyle (Table 5). Based on unhealthy lifestyle behaviors of the two-stage study, such as five lifestyle behaviors of exercise (none), breakfast (none), drinking (≥ 3 times/week), sleeping (≤ 6 hours/day) and smoking (everyday), the participants in both steps had a low C-eHEALS score. Thus, eHealth training is a positive intervention. Overall, those in the high group demonstrate a healthier lifestyle than those in the low group. After eHealth literacy training, the ability to identify and evaluate eHealth information had improved. Training in eHealth related resources is an effective way of improving the eHealth literacy of university students.
In certain Asian, American and European countries, the eHealth scores of the general population were also relatively high, ranging from 28.1 to 30.5 (24,25) . Although the score in this study is low, it is still higher than that of Japanese adults (23.4) (26) and university students(23.6) (23) . The eHealth literacy score increased to 31.64 after participants trained for twice or more, indicating that the training of eHealth-related resources is effective in improving university students' eHealth literacy.
During the COVID-19 pandemic, the Internet has been a particularly important mode for the dissemination of information. China offers a higher and more reliable source of health information, providing people with knowledge and suggestions on COVID-19 health protection than before (27) . The Chinese government has increasingly aimed to provide health-related information on social media, while numerous American and international websites provides health and medical information    with Chinese (28) . Thus, eHealth literacy training has the potential to quickly improve the eHealth literacy of university students. Conversely, the relative lack of an effective online medical system in Japan is considered central to the low level of eHealth literacy in Japan compared with Europe (29) . Accordingly, colleges and universities in China and elsewhere should strengthen health and medical science education, optimize network health information services, fortify the training of eHealth-related resources, and provide a good environment for improving the evaluation and application ability of college students' eHealth information. These measures will help discourage so as to urge them to change dangerous lifestyle behaviors and improve overall quality of life. Among limitations of this study only eHealth-related resource training intervention was chosen without other intervention measures for comparison. Health professionals require further eHealth literacy research to explore a variety of interventions, in order to help university students achieve healthier lifestyle behaviors.

CONCLUSION
This study used quantitative research methods with intervention to comprehensively analyze the intervention and association between eHealth literacy and lifestyle behaviors among Chinese university students. We found a positive association between university students' eHealth literacy and lifestyle behaviors. Those in the high-score eHealth literacy group demonstrate a healthier lifestyle than those in the low-score group. Training in health-related resources was a useful measure in improving university students' eHealth literacy. Most college students have poor exercise behaviors, a factor that requires special consideration when carrying out eHealth-related resource training, especially for the low eHealth literacy group.