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In the rapidly developing use of the Internet in society, eHealth literacy—having the skills to utilize health information on the Internet—has become an important prerequisite for promoting healthy behavior. However, little is known about whether eHealth literacy is associated with health behavior in a representative sample of adult Internet users.
The aim of this study was to examine the association between eHealth literacy and general health behavior (cigarette smoking, physical exercise, alcohol consumption, sleeping hours, eating breakfast, eating between meals, and balanced nutrition) among adult Internet users in Japan.
The participants were recruited among registrants of a Japanese Internet research service company and asked to answer a cross-sectional Internet-based survey in 2012. The potential respondents (N=10,178) were randomly and blindly invited via email from the registrants in accordance with the set sample size and other attributes. eHealth literacy was assessed using the Japanese version of the eHealth Literacy Scale. The self-reported health behaviors investigated included never smoking cigarettes, physical exercise, alcohol consumption, sleeping hours, eating breakfast, not eating between meals, and balanced nutrition. We obtained details of sociodemographic attributes (sex, age, marital status, educational attainment, and household income level) and frequency of conducting Internet searches. To determine the association of each health behavior with eHealth literacy, we performed a logistic regression analysis; we adjusted for sociodemographic attributes and frequency of Internet searching as well as for other health behaviors that were statistically significant with respect to eHealth literacy in univariate analyses.
We analyzed the data of 2115 adults (response rate: 24.04%, 2142/10,178; male: 49.74%, 1052/2115; age: mean 39.7, SD 10.9 years) who responded to the survey. Logistic regression analysis showed that individuals with high eHealth literacy were significantly more likely to exhibit the good health behaviors of physical exercise (adjusted odds ratio [AOR] 1.377, 95% CI 1.131-1.678) and eating a balanced diet (AOR 1.572, 95% CI 1.274-1.940) than individuals with low eHealth literacy.
We found that some health behaviors, including exercise and balanced nutrition, were independently associated with eHealth literacy among Japanese adult Internet users.
According to an estimate of the Communications Usage Trend Survey in 2013, 82.8% of Japan’s general population are Internet users [
In an information society, health literacy is growing in importance with respect to public health, and health care involves effectively using health information from multiple sources [
In this context, health information primarily relates to such electronic resources as the Internet and other technologies. Health information has notably assumed an important role in health promotion among the general public through the widespread use of personal computers and smartphones/mobile phones [
Previous studies of eHealth literacy have largely focused on defining the term [
The aim of the Healthy Japan 21 (second term) campaign of Japan’s Ministry of Health, Labour and Welfare is to prevent chronic diseases and improve daily health behavior with respect to smoking, exercise, alcohol, rest, and dietary habits among Japanese adults [
The study participants were recruited from the registrants of a Japanese Internet research service company called MyVoice Communication, Inc; the recipients were asked to respond to a cross-sectional Internet-based survey in 2012. In this study, we recruited individual Internet users because eHealth literacy is necessary to access online health information. We believed that an Internet survey would be appropriate for this study because responders to such a survey are clearly able to use the Internet effectively. The research company had approximately 1,180,000 voluntarily registered participants in 2012, and it obtained detailed sociodemographic data from each participant on registration. In this study, we aimed to collect data from 2000 men and women aged 20 to 59 years. We intended to minimize selection bias caused by proportional differences in terms of sex and age; therefore, we allocated the registered participants equally to eight sample groups categorized by sex and age (20-29, 30-39, 40-49, and 50-59 years), with n=250 in each group. The Internet research service company randomly chose the potential respondents from the registered participants in accordance with the sample sizes: N=10,178; male: 20-29 years, n=2275; 30-39 years, n=1255; 40-49 years, n=880; 50-59 years, n=699; female: 20-29 years, n=1979; 30-39 years, n=1362; 40-49 years, n=963; and 50-59 years, n=765. In addition, the Internet research service company blindly selected the potential respondents such that the authors and other registered participants were unable to identify those individuals.
The company invited registrants to participate in the survey by email. The number of potential respondents in each stratified sample group was determined by dividing the quota (n=250) by the response rate for the corresponding sociodemographic group. That response rate was computed based on the results of many previous surveys conducted by the research company. The questionnaires were placed in a protected area of a website, and the potential respondents received a specific URL in their invitation email. Potential respondents were able to log on to the protected area of the site using a unique ID and password. After the desired number of participants had voluntarily signed an online informed consent form and completed the sociodemographic data information form, further participants were no longer accepted. Reward points valued at 150 yen were provided as incentives for participation (US $1 was equivalent to approximately 82 yen in 2012). This study was approved by the Ethics Committee of Waseda University, Tokyo, Japan (No: 2011-245).
The research company provided categorized data as follows: sex (male, female); age group (20-29, 30-39, 40-49, and 50-59 years); marital status (not married, married); education level (up to high school, 2-year college or career college, college graduate or above); and household income level (<5 million yen, ≥5 million yen).
We assessed the frequency of information searches on the Internet in terms of daily conducted searches. We did so because one study found a positive association between eHealth literacy and the frequency of Internet searches [
We used the Japanese version of the eHealth Literacy Scale (eHEALS) to assess the eHealth literacy levels of participants [
Belloc and Breslow [
With respect to smoking status, the questionnaire included an item about whether participants had ever smoked. Physical exercise was assessed by asking participants about their weekly frequency. Alcohol consumption was determined by inquiring about the weekly frequency. Number of sleeping hours was evaluated in terms of daily sleeping hours. Eating breakfast and eating between meals were categorized as follows: every day, almost every day, sometimes, and never. Balanced nutrition was grouped into three categories: eating a nutritionally balanced diet, eating with little regard to nutritional balance, and not eating a balanced diet. In accordance with previous studies [
We divided J-eHEALS score into one of two categories (high or low) relative to the median group value (median 24.02, IQR 19.19-27.82); we did so in accordance with previous studies that used eHEALS to analyze the association between eHealth literacy level and health behavior and health information seeking [
We received the data for 2142 adults (response rate: 21.04%, 2142/10,178) from the research company. We excluded respondents with incomplete data (missing rate: 1.26%, 27/2142) and therefore analyzed the data of 2115 adults who provided complete information for the study variables.
Sociodemographic characteristics of participants (N=2115).
Characteristics | n (%) | ||
Male | 1052 (49.74) | ||
Female | 1063 (50.26) | ||
20-29 | 527 (24.92) | ||
30-39 | 530 (25.06) | ||
40-49 | 531 (25.11) | ||
50-59 | 527 (24.92) | ||
≤High school graduate | 502 (23.74) | ||
Two-year college or career college | 541 (25.58) | ||
≥College graduate | 1072 (50.69) | ||
<5 million | 1000 (47.28) | ||
≥5 million | 1115 (52.72) | ||
Not married | 887 (41.94) | ||
Married | 1228 (58.06) | ||
Every day | 1524 (72.06) | ||
No every day | 591 (27.94) |
In the univariate analyses, sleeping hours (
Association between eHealth literacy and health behavior.
Health behavior | OR (95% Cl) | AORa (95% Cl) | ||
Cigarette smoking | 0.866 (.729-1.029) | .10 | 0.862 (0.711-1.046) | .13 |
Physical exercise | 1.470 (1.215-1.779) | <.001 | 1.377 (1.131-1.678) | .001 |
Alcohol consumption | 0.847 (0.712-1.007) | .06 | 0.876 (0.727-1.055) | .88 |
Sleeping hours | 1.039 (0.870-1.240) | .67 | 1.069 (0.890-1.282) | .48 |
Eating breakfast | 1.198 (0.968-1.484) | .10 | 1.023 (0.814-1.286) | .84 |
Eating between meals | 0.988 (0.829-1.177) | .89 | 1.044 (0.863-1.262) | .66 |
Balanced nutrition | 1.764 (1.445-2.153) | <.001 | 1.572 (1.274-1.940) | <.001 |
a Adjusted for sociodemographic factors, frequency of Internet searching, and other health behaviors that were statistically significant with respect to eHealth literacy in univariate analyses.
After controlling for sociodemographic variables, frequency of Internet searching, and other health behavior, this study found that adult Internet users with high eHealth literacy were significantly more likely to have good health behavior, such as physical exercise and balanced nutrition, than individuals with low eHealth literacy. However, we found no significant association between eHealth literacy and cigarette smoking, alcohol consumption, sleeping hours, eating breakfast, or eating between meals.
This study is the first to examine the association between eHealth literacy and the general health behaviors of cigarette smoking, physical exercise, alcohol consumption, sleeping habits, eating breakfast, eating between meals, and balanced nutrition among Internet adult users in Japan. After controlling for covariates, we found eHealth literacy to be associated with the good health behavior of physical exercise and balanced nutrition among Internet users. The results of this study support those of the IMeHU [
This study demonstrates that high eHealth literacy may promote the healthy behavior of physical exercise and balanced nutrition among the general population of Internet users. One study among college students found that eHealth literacy promotes such healthy behavior as exercising; eating low-fat foods, low-sugar cereals, and vegetables and fruit; and always having quality sleep [
One study has found that functional eHealth literacy and critical eHealth literacy displayed a positive predictive power with respect to eating and exercise behavior, although critical eHealth literacy was able only to positively predict sleep behaviors [
We found that the mean eHEALS score among Japanese Internet users was lower than that previously reported in the United States [
This study has a number of limitations. First, the participants were recruited from a single Japanese Internet research service company; thus, the relationships assessed may have been biased because of the potentially nonrepresentative nature of this sample as general Japanese Internet users [
Second, health behavior and eHealth literacy were assessed only using a self-administered questionnaire. Inaccuracies in estimating health behavior and eHealth literacy level were thus unavoidable. Moreover, some studies have reported that eHEALS is inappropriate because it does not assess the ability to use Web 2.0 [
Among Japanese adult Internet users, we found some health behaviors, including exercise and balanced nutrition, to be independently associated with eHealth literacy. In rapidly developing Internet user societies, further research is needed to identify the mechanisms linking eHealth literacy with health information seeking and health behavior toward designing effective strategies more precisely for promoting healthy behavior.
adjusted odds ratio
eHealth Literacy Scale
Integrative Model of eHealth Use
This investigation was supported by Grants-in-Aid for Scientific Research (No: 22700688) from the Japan Society for the Promotion of Science and Global COE Program “Sport Sciences for the Promotion of Active Life” from the Japan Ministry of Education, Culture, Sports, Science and Technology.
None declared.