It is important to test survey instruments before using them to collect data. Pretesting can help authors identify questions that do not make sense to participants, as well as problems with questionnaires that might lead to biased answers. Thus, pretesting was conducted to develop and test the adequacy of the research instrument designed by the authors. Exploratory factor analysis was used to assess the reliability of the survey instrument. For the pretest sample, a purposive sample of 250 college students was drawn from 3 schools in Taiwan. Each participant was mailed a questionnaire, and 207 usable (completed) questionnaires were returned, resulting in an effective response rate of 82.8%.

This study was a cross-sectional study in Taiwan. We recruited 700 college students from 14 schools to participate in the survey in December 2015. The participants completed the questionnaire in their schools. After eliminating the respondents who had not completed the entire survey or who gave invalid responses, 556 valid surveys (79.4%) were retained. Among these 556 valid respondents, 207 (37.2%) studied in the northern region of Taiwan, 154 (27.7%) studied in the central region of Taiwan, 170 (30.6%) studied in the southern region of Taiwan, and 25 (4.5%) studied in the eastern region of Taiwan.

We gathered the respondents’ individual factors, including the information about the frequency of seeking information on health issues, the frequency of eating organic food, the degree of health concern, and the students’ major. The frequency of seeking information on health issues and eating organic food was measured by asking how often the students sought general health-related information and ate organic food and was rated based on the responses on a scale from 1 (never) to 5 (always).

The students’ degree of health concern was measured by 1 item asking about their perception of health concerns (“Are you concerned about your health?”) and was rated on a scale from 1 (strongly unconcerned) to 5 (strongly concerned).

The major dimension was divided into the participants who were majoring in medical fields and the participants who were not. In a subsequent analysis, the 2 groups were transformed into dummy variables. We used the nonmedical group as the reference group.

eHealth Literacy was assessed by Chiang et al’s eHealth Literacy Scale (EHLS), which has been validated for Taiwan college students. The 3 subscales can be distinguished and show good internal consistency [10]. The individual item reliability of the 12-item EHLS ranged from 0.36 to 0.74. The standardized factor loadings ranged from 0.60 to 0.86 (P<.001). Composite reliability ranged from 0.75 to 0.84, and the average variance extracted for each dimension ranged from 0.50 to 0.52.

The EHLS is a reliable and valid measure of functional eHealth literacy (3 items), interactive eHealth literacy (4 items), and critical eHealth literacy (5 items). Answers were given on a 5-point Likert scale ranging from 5 (total agreement) to 1 (total disagreement). Mean scores for eHealth literacy scale were calculated by summing the item scores divided by the total number of items, resulting in a score ranging from 1 (lower eHealth literacy) to 5 (higher eHealth literacy).

The Health-Promoting Lifestyle Scale (HPLS) was developed following a thorough review of the literature [1,11,12]. It contains 6 dimensions, which are as follows:

1. Self-actualization: attitudes toward and expectations of life (5 items, eg, willingness to try new things and challenges).

2. Health responsibility: paying attention to and taking responsibility for one’s own health (4 items, eg, discussions about health-related issues with health professionals).

3. Interpersonal support: a sense of intimacy and close relationships (4 items, eg, maintaining good relationships with others).

4. Exercise: regular exercise patterns (4 items, eg, exercise at least three times a week).

5. Nutrition: meal patterns and food choices (3 items, eg, intake of fiber-rich foods).

6. Stress management: ability to cope with stress (3 items, eg, a good balance between work and life). The items were answered using a 5-point Likert scale with scores ranging from 1 (never) to 5 (always).

An exploratory factor analysis (principal components extraction) revealed that the Kaiser-Meyer-Olkin test value was .89 (χ²₂₅₃＝2528.70, P<.05), Bartlett sphericity test was significant (P<.05), factor loadings ranged from 0.59 to 0.81, and the explained variance was 69.8%. The high Cronbach alpha coefficients (0.86 for self-actualization, 0.87 for health responsibility, 0.84 for interpersonal support, 0.87 for exercise, 0.75 for nutrition, 0.71 for stress management, and 0.92 for the total scale) demonstrated high internal consistency.

Health literacy is a cognitive skill to empower individuals to take responsibility for their health and to adopt an appropriate lifestyle to keep themselves healthy resulting in personal benefit [6,27]. According to IMeHU, the promotion of individual eHealth literacy influences an individual’s health decision making and subsequently influences future actions that may help achieve better health [8]. The findings of the study showed that individuals with adequate health literacy have the knowledge and ability to make healthy choices and adopt healthy lifestyles to engage in a range of physical and mental health-enhancing actions [28]. Thus, Hypothesis 1 was partly supported. However, the study found that individuals with higher critical eHealth literacy engage in more health-promoting activities than those with functional and interactive literacy. In particular, critical literacy affects all dimensions of health-promoting behaviors. Critical literacy allows individuals to evaluate health issues and recognize risks and benefits as well as to advocate for themselves [29], thus enabling college students to engage in health-enhancing actions.

Notably, the finding of a lower influence of functional and interactive than critical eHealth literacy on health-promoting lifestyles is quite reasonable. Functional and interactive literacy are basic levels and the processing involved in functional and interactive eHealth literacy does not engage as deeply with issues as critical eHealth literacy do. According to the involvement theory [30], critical literacy is a more advanced cognitive skill than functional and interactive literacy. It is not sufficient for individuals to obtain health information; they must further evaluate and use the information to make decisions about their health. This may explain why functional and interactive eHealth literacy are less influential than critical eHealth literacy.

Consistent with Pender’s HPM and some other previous studies [19,21-24], this study found that participants with greater health concerns tended to adopt all 6 positive health-promoting lifestyles, with medical majors adopting 4 health behaviors (with the exception of exercise and nutrition). Individuals who frequently sought health information demonstrated better exercise and health responsibility. The findings largely supported the Hypothesis 2. The findings are also consistent with the social cognitive theory, suggesting that individuals’ medical knowledge can prompt individuals to adopt health-promoting behaviors. As medical school students have better cognitive understanding and perceptions of health information than nonmedical majors do, they are more willing to engage in appropriate health behaviors.

Consistent with previous studies [5,10,26], our findings revealed that participants with medical majors and greater health concerns and those who frequently sought health information tended to have better functional, interactive, and critical eHealth literacy than other students did. Therefore, Hypothesis 3 was largely supported. The findings verified Bodie and Dutta’s IMeHU [8], indicating that eHealth literacy is influenced by a person’s educational background, intrinsic interest in health, and Internet use history. Medical school students have more medical knowledge [31] and therefore possess greater eHealth literacy than nonmedical school students. Individuals who have greater health concern and frequently use Web-based health resources are likely to pay more attention to their health and thus are likely to increase their eHealth literacy.

This study found that college students who frequently consumed organic food demonstrated better exercise and health responsibility than other students. Previous studies have shown that insufficient information and knowledge about organic labeling affects the distinction between organic food and conventional food [32]. Customers who consume organic food may need to understand the attributes and standards of organic food through greater efforts such as involvement in related information and discussion with relevant professionals. Consequently, it is reasonable that college students who frequently consume organic food demonstrate better health responsibility. In addition, some studies indicate a strong link between organic food choices and perceived healthfulness, well-being, and quality of life [33]. Regular consumers of organic food may have a high internal locus of control and naturally pay more attention to the positive benefits of food to maintain a healthy lifestyle [25,34]. Therefore, these consumers are ready to adopt healthy actions such as regular exercise and are accountable for their own personal health. It is also likely that people who are physically active pay more attention to their health and therefore buy organic food.

The study found that the frequency of organic food consumption did not predict the nutritional dimension. Previous studies lack strong evidence that organic foods are significantly more nutritious than conventional foods, and a number of studies have revealed that consumers’ choice of organic food depends on the perceived benefits of organic food [25,35,36]. Researchers have found that health is one of the most prominent motives for organic food consumption [25]. The perceived benefits of food safety, environmental protection, quality, and consumers’ perceptions of and attitudes toward labeling systems, message framing, and local origin are also identified as motivating factors for the consumption of organic food. The Taiwan food scandal involved a series of food safety incidents that came to light in 2014. This situation may have further strengthened Taiwan college students’ motivation to purchase organic food for food safety and reasons other than nutrition. Moreover, they could obtain appropriate nutrients via a balanced diet. Future studies might examine additional factors that characterize college students’ preferences and behavior toward organic food products.

The study found that the frequency of organic food consumption did not predict the nutrition dimension. According to previous studies, price is a factor that influences organic food consumption. Compared with conventional food, the overpricing of organic food can be considered an important barrier to the purchase desire of consumers [37,38]. Moreover, studies lack strong evidence that organic foods are significantly more nutritious than conventional foods [25]. Therefore, given the high price and uncertain benefits of organic food, students do not necessarily consume organic food to achieve the nutritional aspects of healthy living such as the intake of fiber-rich foods.

Notably, the frequency of organic food consumption did not predict any dimensions of eHealth literacy. This result may be caused by food safety awareness. Various food safety incidents worldwide have increased consumers’ concern about the safety of foods and are considered primary reasons for the increasing demand for organic food, which is perceived as healthier and safer [32,39]. Regardless of their level of health literacy, customers who buy organic products may be affected by their perceptions of the safety of the food rather than by the knowledge of organic food. Furthermore, eHealth literacy involves a complex interplay of basic literacy skills, the ability to successfully navigate the dominant language framework (English) and culture utilized for Web-mediated communication, and sufficient levels of technology adoption and proficiency [40]. When consumers shop for organic food in Taiwan, they need to look for the “CAS Organic” label. However, the label does not provide knowledge about the food, food sources, and nutritional facts. If consumers want to understand the nutritional facts of organic food, they need to seek, identify, understand, and use information about organic food. However, more than 90% of Web-based content is in English and is developed from the cultural perspectives of English speakers [41]. It is difficult for speakers of English as a second language to understand, extract, and evaluate eHealth information about organic food.

College students may have a positive attitude toward organic foods and high eHealth literacy but may not consume natural foods due to the higher price of these foods or a lack of convenience. Most Taiwan college students live on campuses, where the accommodations are not suitable for cooking, and they often eat restaurant food. In addition, there are few organic food courts. Even if students cook for themselves, they may not be able to afford organic food, which is more expensive than other food.

Therefore, the relationships among eHealth literacy, health-promoting behaviors, and organic food consumption require further studies to identify other mediating variables.