In the past, individuals were likely to obtain health information from written sources such as books, magazines, newspapers, or brochures. The advent of the internet has drastically changed health information, and the internet is widely used to obtain this information. However, the skills needed to collect information through the internet differ from those needed to collect information from books and leaflets. People need to not only be health literate but also have capabilities, resources, and motivation to find, understand, and appraise health information when using digital services and technology [1]. Therefore, to obtain a complete overview of people’s skills in obtaining and using health information, it is more necessary to measure electronic health (eHealth) literacy than to measure health literacy [2].

eHealth literacy is an extension of the health literacy concept. Health literacy refers to an individual’s ability to understand health care information and to make appropriate decisions [3]. eHealth literacy, which consists of skills related to health literacy and digital literacy [1], is defined as the ability to seek, find, understand, and appraise health information from electronic sources and to apply the knowledge gained to address or solve health problems [4]. Based on Nutbeam’s concept [5], eHealth literacy includes functional, interactive, and critical levels. At the most basic level, functional eHealth literacy refers to basic reading and writing skills and basic knowledge of health conditions and health systems. Interactive eHealth literacy refers to communicative and social skills that can be used to abstract information and derive meaning from different forms of communication. The highest level of critical eHealth literacy builds on functional and interactive literacy and involves the most advanced cognitive skills that can be applied to critically analyze information, discern the quality of health websites, and use good information to make informed decisions about health [6,7].

eHealth literacy has become an important topic in the health fields. Studies have found that individuals with high eHealth literacy are more likely to adopt healthy behaviors [6,8] and demonstrate better health responsibility and self-actualization [7]. Recently, access to health services and the relational dynamics between patients and health care providers have been transformed by Web-based health information-seeking behaviors [9] and eHealth literacy [10]. Therefore, the aim of this study is to examine the extent to which functional, interactive, and critical eHealth literacy are associated with college students’ utilization of health services.

Andersen [11] suggests four relevant aspects of the utilization of health services, each reflecting different aspects of the care-seeking process (Figure 1). The type of utilization indicates what kind of service is obtained and who provides it (eg, hospital, physician, dentist, or pharmacist). The site of the medical care encounter is the place where the care is received (eg, physician’s office, hospital clinic, or emergency room). The purpose of the visit signifies the reasons for care-seeking such as a need for preventive, illness-related, or custodial care. The time interval for a visit can be represented by contact, volume, or continuity measures [12].

Gender has been identified as a predisposing factor of health services utilization [13-16]. As increasing numbers of studies investigate the relationship between gender and health services utilization in different contexts, important inconsistencies have been reported. For example, some studies have found that females are more likely than males to visit physicians [17] and tend to use more outpatient services [18]. Studies have also found that females perceive a greater need for mental health treatment [19] and have a higher tendency to use all services, except informal providers, than males [20]. However, other studies have shown that females suffering from illness report seeking health care less frequently than men [21]. Females were found to be more likely to report discrimination in health care and less likely to receive preventive health services [22]. Furthermore, other studies have found no statistically significant evidence of a relationship [23,24]. College students are an educated and transition-age population group. They are in the upper part of the distribution in terms of their resources. Previous studies have indicated that the combination of education [25] and women’s autonomy [26] appear to attenuate gender disparities in health services utilization. Therefore, we want to investigate whether there are gender differences in the four aspects of health services utilization among college students.

Individuals with limited health literacy are at an increased risk of poorer health outcomes. Systematic reviews have demonstrated that low health literacy is consistently associated with more hospitalizations, greater use of emergency care, and lower receipt of mammography screening and influenza vaccine [27]. In contrast, higher health literacy supports effective involvement in care processes. Studies have shown that individuals with adequate health literacy are more likely to be satisfied with care [28] and use preventive health services [29].

Web-based health information-seeking behaviors and eHealth literacy are transforming the physician-patient relationship and health services [9,10]. People who use eHealth resources (eg, health websites) are more likely to be well prepared for clinical visits, ask more related questions, learn more about their health care, and take actions to enhance their health than those who do not [30]. Studies have shown that internet use is associated with increased use of health care services and better-perceived outcomes of internet use for health purposes [31], including the decision to use health services and the way individuals communicate with physicians and request referrals to specialist care [32]. In addition, studies have shown that individuals with higher eHealth literacy are more likely to have knowledge of and a screening history for colorectal cancer [33] and more effective interactions with their physicians [34]. Moreover, some studies have found a set of indirect effect paths, via health information seeking and empowerment, showing a positive relationship between eHealth literacy and health care utilization [35]. However, these studies did not examine the effect of the three levels of eHealth literacy on the four aspects of medical services usage. Therefore, the research question examined for this study is as follows: Are the associations between the three levels of eHealth literacy and the four aspects of health services utilization among college students positive or negative?

First, peer review was used to confirm the content validity of the HSUS. Second, we used Amos 6.0 (IBM Corp, Armonk, NY, USA) to perform CFA to identify the best measurement models for the eHLS and HSUS. Finally, SPSS 18.0 (IBM Corp, Armonk, NY, USA) was used to conduct hierarchical multiple regression analysis. We performed four hierarchical multiple regression analyses to examine the explanatory power of the four aspects of health services utilization. We determined the order in which the variables were entered into the model based on logical or theoretical considerations. Thus, gender was entered in step 1, and the three levels of eHealth literacy were entered in step 2.

The study was reviewed and approved by the Institute of Education at the National Sun Yat-Sen University, Taiwan. The study adopted an anonymous questionnaire, in line with the government’s institutional review board rules for exempt review. The questionnaire instructions informed the participants of the research purpose and confidentiality and indicated that they had the right to refuse to participate at any time. The participants received the questionnaire and gifts at the same time; even if a participant decided to drop out of the investigation, he or she still received the gifts (a pen and an L-folder). This approach was intended to be fair to each participant, to avoid the impact of gift incentives on the participants, and to provide compensation for the participants.

Among all participants, the mean score of functional eHealth literacy was 3.66 (SD 0.70), of interactive eHealth literacy was 3.67 (SD 0.67), and of critical eHealth literacy was 3.65 (SD 0.69), indicating that college students had medium or above levels of eHealth literacy.

In HSUS, the mean score of the type aspect was 3.36 (SD 0.75), of site was 3.32 (SD 0.77), of purpose was 3.70 (SD 0.81), and of time interval was 2.37 (SD 0.80). This result indicated that college students had a certain degree of ability to make good use of various kinds of health care services and a multitiered health care system and to receive health care services based on different needs, although they did not frequently use outpatient care.

In the analysis of Model 1 (see Multimedia Appendix 2), male and female groups were transformed into dummy variables. We used the male group as the reference group. Multimedia Appendix 2 indicates that membership in the female group was negatively related to the purpose aspect of health services utilization, yielding a low explanatory power of 2%. However, the R² value is very low to nil.

When comparing Models 1 and 2 (see Multimedia Appendix 3), the level of explanatory power for the 4 health services utilization aspects increases by 6%-16%. Moreover, Multimedia Appendix 3 shows that when controlling for gender, interactive and critical eHealth literacy are both positively related to three aspects of health services utilization. Functional eHealth literacy is negatively related to the time interval aspect.

This study found no gender difference in health services utilization among Taiwanese college students. There was a statistically significant correlation between eHealth literacy and health services utilization. Finally, among the three eHealth literacy levels, functional eHealth literacy showed the lowest correlation to health services utilization.

The study found no significant gender differences in health utilization. Notably, the R² value of gender on the purpose aspect was low enough to be ignored. The association between gender and service utilization has been inconsistent across studies. Some studies have found gender differences in health services utilization [17-22], whereas others have found no statistically significant evidence of a relationship [23,24]. The study sample was educated and age-restricted, specifically, young people and college students, who are in the upper part of the distribution in terms of resources. To some extent, education can improve the ability of individuals to increase their knowledge of modern health care, make decisions regarding their own health, and realize the benefits of using health services. There is ample evidence that education is a significant factor of service utilization [41,42]. Thus, the educated and age-restricted sample may attenuate gender disparities in health services utilization among Taiwanese college students.

Consistent with previous studies [43-45], this study found that functional eHealth literacy was negatively related to the time interval aspect. Functional literacy refers to basic reading and writing skills and the ability to understand and use health information [5]. Poor functional health literacy hinders individuals’ full understanding of personal health, disease, and treatment [46]. Individuals with low functional literacy may receive ineffective care because they do not comprehend medical care directions [44], and they may have insufficient problem-solving abilities or be unlikely to change their behavior based on new information [45]. In this study, the shorter time interval indicates the higher frequency of medical use. Taiwan’s National Health Insurance (NHI) system uses a third-party payer mechanism to cover medical expenses, making it extremely convenient and inexpensive for individuals to obtain care. Short or negligible waiting times stand out as hallmarks of the NHI system. However, the NHI system has also resulted in a surge in the “volume” of care provided and a sharp rise in medical expenses. Under the convenient NHI system, Taiwanese college students with inadequate functional eHealth literacy may visit physicians frequently in order to achieve the same therapeutic goal.

This study found that interactive eHealth literacy was positively related to the type, site, and time interval aspects of health services utilization. Under Taiwan’s NHI system, the insured can visit any NHI-contracted hospital, clinic, pharmacy, or medical laboratory for access to health care. In recent years, the NHI Administration inaugurated a new copayment fee schedule and referral to a multitiered health care system to encourage patients to seek treatment for basic ailments at local clinics and then obtain referrals to regional hospitals or medical centers if more advanced treatment or tests are necessary. Interactive literacy involves more advanced cognitive and literacy skills that can be used to actively participate in everyday activities and to transfer the information received to one’s own situation [5]. Interactive health literacy can augment one’s ability to act independently, enhance motivation, and improve self-confidence [47], thus enabling Taiwanese college students to choose suitable types of and sites for health care services. It is worth noting that interactive health communication has the potential to improve the practice of medicine and the structure of health care systems but may also cause harm [48]. Studies have found that >15% of internet users said they felt overwhelmed and confused by the amount of information they found on the web. Another 54% of internet users said that the information they found led them to ask their physician a new question or to visit another physician to obtain a second opinion [49]. Thus, Taiwanese college students with high interactive literacy may visit physicians frequently in order to clarify or confirm confusing Web-based information and their illness condition.

This study found that critical eHealth literacy was positively related to the type, site, and purpose aspects of health services utilization. Taiwan’s NHI system provides not only outpatient care service but also integrated preventive health care service. The goals of integrated preventive health care service include increasing the utilization of preventive care services, the early detection and intervention of high-risk and preclinical cases, and integrating the three levels of prevention, namely, health promotion and education, early detection and treatment, and the medical care system. Critical literacy involves the most advanced cognitive skills, which can be applied to critically analyze information and to use this information to exert greater control over life events and situations [5]. Critical literacy allows individuals to evaluate health issues and recognize risks and benefits as well as to advocate for themselves [50], thus enabling Taiwanese college students to choose suitable types of and sites for health care services. It also increased the utilization of health care services based on different needs (eg, preventive care, custodial care, and illness-related care).

Finally, the study found that functional eHealth literacy showed the lowest correlation to health services utilization among the three eHealth literacy levels. Functional health literacy rarely involves interactive communication and does not provide individuals with the skills to take action in their own community [51]. It is not sufficient for individuals to obtain health information; they must further evaluate and use it to make decisions about their health. Thus, in the process of functional eHealth literacy, individuals do not engage as deeply with issues as they do in the processes of interactive and critical eHealth literacy. Another explanation is that age and education play considerable roles in functional eHealth literacy. Many studies have shown that adults with functional health literacy are more likely to be younger and have higher levels of education [52,53]. The participants (average age, 21.51 years) in this study were higher education students, which facilitates functional eHealth literacy. Functional eHealth literacy showed the lowest correlation to health services utilization among the three eHealth literacy levels in this educated and age-restricted sample. Previous studies have also found that functional eHealth literacy has the lowest correlation to health behaviors and health-promoting lifestyles among college students [6-8].

The study sample was educated and age-restricted. Population characteristics are noted as direct factors of health services utilization [11,13]. However, this study did not collect information on participant variables such as socioeconomic status or marital status. Thus, the findings should not be overgeneralized and should be interpreted in light of the sample’s homogeneity. Additionally, our measure of health services utilization was not validated in the published literature. Future studies should develop and construct an HSUS. Moreover, this study found that functional eHealth literacy was related only to the time interval aspect of health services utilization. Other mediating or confounding variables may exist that should be taken into consideration such as health information seeking and increased empowerment through information seeking [35].

The establishment of a link between the three levels of eHealth literacy and the four aspects of health services utilization is the unique contribution of this study. Over the past decade, few attempts have been made to examine other components of eHealth literacy, such as the ability to extract and critically analyze information and use it to make decisions, which should be part of interactive and critical eHealth literacy. Notably, this study found that functional and interactive eHealth literacy were related to the time interval aspect. This finding has important implications for health care providers, who should provide patients with information leaflets to help them understand their illness and, thereby, reduce the waste of medical resources. Given that no significant gender differences in health services utilization were identified, the educated and age-restricted sample appeared to attenuate gender disparities in health services utilization. The associations among gender, age, education, and health services utilization are worth examining in further studies.