The relationship between e-health literacy and health-promoting behaviors of Turkish hospital nurses

Abstract

The increase in information technologies has made it easy to access much health information online. In this context, e-health literacy emerges as a skill for acquiring health information. Obtaining health information through information technology for health promotion requires e-health literacy. The aim of this study was to examine the e-health literacy and the health-promoting behaviors of Turkish hospital nurses directly involved in patient care. This descriptive and cross-sectional study was carried out with 451 nurses working in two large training and research hospitals in Izmir between June and August 2019. Data were collected using the Turkish version of the Healthy Lifestyle Behavior Scale II and the Turkish version of the e-Health Literacy Scale. Descriptive statistics and multiple linear regression analysis were used for data analysis. Nurses were found to have moderate levels of healthy lifestyle behaviors (130.56 ± 21.90) and e-health literacy (29.87 ± 5.39). There was significant relationship between the e-health literacy levels of the nurses and their overall health-promoting behaviors (R = .349; F = 12,381; p = 0.013), health responsibility (R = .326; F = 10,567; p = 0.014), spiritual development (R = .242; F = 5.276; p = 0.001) and interpersonal relations (R = .343; F = 9.896; p = 0.001) scores. The results of this study showed that the development of strategies to improve the e-health literacy of nurses may contribute to the maintenance of health-promoting behaviors of both nurses and their patients.

Keywords

e-health health-promoting behaviors health promoting hospital nurses e-health literacy

Introduction

Today, the increase in information technologies and widespread use of the internet has made it easy to access much health information online (1 –3). In this context, e-health literacy emerges as a skill for acquiring health information (4). E-health literacy is defined as searching, finding, understanding, interpreting health information via electronic sources, and the ability to apply the acquired health information to address and solve a health problem. Obtaining health information through information technology for health promotion requires e-health literacy. E-health literacy requires understanding and applying health information, use of computers or smartphones, reading skills, and use of the internet (5). A previously conducted study has reported that 72% to 99% of internet users use the internet as a tool to access health-related information (3). A study carried out in Turkey showed that 31% of adults use the internet as a source of health information (6). The benefits of the internet such as low cost, and quick and anonymous access to information, have made it a preferred option for accessing health-related information (7). The rapid development of information and communication technologies such as the internet and mobile technology has affected the health field and all other fields of science (8,9). In line with these technological developments, e-health literacy is becoming important for society and health workers to gain easier access to evidence-based health information and to protect and improve health (10). Concomitantly, healthy lifestyle behaviors such as healthy nutrition, avoidance of smoking and alcohol consumption, regular physical activity and stress management are universally considered as the basic components of evidence-based guidelines (11). In the current health system, nurses have an important role in maintaining and improving public health (12). In addition, nurses spend more time with patients compared to other healthcare professionals (13).

Nurses encounter situations that involve reading, understanding and translating health information while providing care to their patients. Nurses are professional users of information technologies as caregivers. They use computers equipped with electronic health records and various technological features particularly to monitor the patients and to provide care. All of these increase the e-health literacy of the nurses (1). Nurses with e-health literacy can identify, use and evaluate eligible health resources for themselves and their patients, and improve high-quality nursing care (1,14,15). Nurses with high e-health literacy levels have positive healthy lifestyle behaviors (stress management, interpersonal relations, self-actualization, health responsibility, etc.) (1). It has been stated in the literature that the nurses with positive healthy lifestyle behaviors provide more accurate advice to their patients about the importance of health-promoting behaviors, become a positive role model for them and have a positive effect on the quality of patient care (16 –18).

It is important that by using critical e-health literacy, nurses and nursing students understand the importance of personal healthy lifestyle behaviors and integrate them into their own lives (12). The integration of these behaviors into their own lives leads to high patient satisfaction and compliance. At the same time, it is important to integrate e-health literacy and health promotion concepts into the nursing education curriculum in order to teach the skills to develop healthy lifestyle behaviors (12,19). There are a limited number of studies that examined the relationship between e-health literacy and health behaviors of hospital nurses in international literature. In the Turkish literature, there were no studies examining the relationship between e-health literacy and the health-promoting behaviors of the nurses. Therefore, there is a need for examining the relationship between e-health literacy and the health-promoting behaviors of hospital nurses directly involved in patient care.

The aim of this study was to examine and determine the relationship between e-health literacy and health-promoting behaviors of Turkish hospital nurses.

Answers to the following questions were sought in the study:

What are the e-health literacy levels of nurses?

What are the health-promoting behavior levels of nurses?

Is there any relationship between e-health literacy and health-promotion behaviors of nurses?

Method

Study design and participants

The population of the study, descriptive and cross-sectional, consisted of nurses with at least 6 months in their profession who work in two large training and research hospitals located in the center of Izmir, the third-largest city of Turkey, and are directly involved in patient care (n: 1118). The study sample consisted of 451 nurses (participation rate: 40.3%) who agreed to participate voluntarily in the study. Taking the study of Cho et al. (1) as a reference, the sample size, measured by taking type I error 0.05 and type II error 0.20 (according to 0.80 power) in the G Power 3.1.9.4 program, was determined to be 208.

Instruments

Data were collected using a demographic questionnaire, the Turkish version of the Healthy Lifestyle Behavior Scale II and the Turkish version of the e-Health Literacy Scale.

The questionnaire was prepared by the researchers after the review of the relevant literature (1,20). The form consisted of nine questions on the nurses’ characteristics such as age, gender, marital status, educational background, unit of work, work schedule, total monthly family income, frequency of using the internet for online research in the workplace, and perceived level of computer use skills (basic, medium, good).

Health-promoting behaviors of the nurses were measured with the Turkish version of the Healthy Lifestyle Behavior Scale II (21 –23). The scale includes 52 items and six subscales. Subscales are as follows: spiritual development (9 items, development of inner sources), health responsibility (9 items, active sense of responsibility for his/her well-being), physical activity (8 items, determines the frequency of physical activity of an individual), nutrition (9 items, determines the individual’s meal selection, regulation and food selection), interpersonal relationships (9 items, determines the relationships of the individual with others), stress management (8 items, determines the individual’s ability to cope with stress). It is a 4-point Likert type scale (1 = never, 2 = sometimes, 3 = often, 4 = always). All items on the scale are positive. The total score ranges from 52 to 208. The Cronbach’s alpha value of the Turkish version for the whole scale is 0.94 and between 0.79 and 0.87 for subscales (23). In this study, the Cronbach’s alpha value for the whole scale was found as 0.93 and between 0.70 and 0.86 for subscales.

The e-health literacy of the nurses was measured with the Turkish version of the e-Health Literacy Scale (5,24). The scale consists of 8 items measuring perceived skills of using information technology for health. It is a 5-point Likert type scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). The total score ranges from 8 to 40. A high score shows a positive e-health literacy level. The Cronbach’s alpha value of the Turkish version of the scale is 0.78 (24). In this study, the Cronbach’s alpha value of the scale was found to be 0.88.

Ethical consideration

Ethics committee approval was obtained from the university to which the researchers are affiliated (Decision no. 4689-GOA) before collecting the data. The written permission was obtained from the Izmir Provincial Directorate of Health. Informed consent was obtained from the nurses who volunteered to participate in the study.

Data collection

Data collection was carried out on different days between June and August 2019, after obtaining the necessary permissions for the study. Before the data collection, the researchers went to both hospitals and visited the nurses, directly involved in patient care, at their units [general departments (internal, surgical), intensive care, outpatient clinic, endoscopy unit, outpatient unit, operating room]. Researchers regularly visited the units every weekday during the data collection period in order to reach all nurses (working in different shifts, being on leave, being on sick leave, etc.). After the researchers informed the nurses about the purpose of the study in the units where they worked, the volunteer nurses completed the data collection tools in the units where they worked. It took approximately 20–25 minutes to complete the data collection tools. The researchers encouraged the participants to fill in the self-report instrument without any assistance and in private.

Data analyses

The data of the study were analyzed using SPSS version 22. p < 0.05 was considered statistically significant. Descriptive statistics (number, percentage, mean and standard deviation) were used to evaluate the data. The relationship of nurses’ e-health literacy and demographic characteristics with their health promotion behaviors was evaluated by multiple linear regression analysis. Seven models were created to determine the relationship of health-promoting behaviors total score and six sub-scales with demographic variables and e-health literacy. First, in multiple linear regression analysis, all demographic variables (age, gender, marital status, educational background, unit of work, work schedule, total monthly family income, frequency of using the internet for online research in the workplace, perceived level of computer use skills) were included in the model and then e-health literacy was included to examine whether it added to the explained variance. Among the models formed as a result of multiple linear regression analysis, models with the highest variance explained in the prediction of health-promoting behaviors and subscales were preferred.

Results

Demographic characteristics

A total of 451 volunteer nurses (40.3% response rate) participated in the study. Table 1 shows the demographic characteristics of the nurses. The mean age of the participants was 37.0 ± 7.24 years, while 89.4% of them were female and 63.2% were married. A total of 61.9% of the nurses had a bachelor degree and 17.1% of them had a postgraduate degree. A total of 51.9% of the nurses were working in general departments (internal and surgery), 71.8% of them were working both day and night shifts. A total of 64.3% of the nurses stated that their monthly total family income varies between USD700 and USD1400. Approximately one-third of nurses (34.6%) stated that they conduct searches on the internet at work almost every day, while more than half of them (57.0%) were found with a perceived level of computer usage skills at a medium level.

Table 1.

Demographic characteristics (n: 451).

Characteristics	n	%
Age (Mean ± SD)	(37.0 ± 7.24)
18–25	29	6.4
26–35	150	33.3
36–45	234	51.9
46 and older	38	8.4
Gender
Female	403	89.4
Male	48	10.6
Marital status
Married	285	63.2
Single	166	36.8
Educational status
High schools and equivalent	30	6.7
Associate degree	65	14.4
Bachelor degree	279	61.9
Postgraduate degree (master/doctorate)	77	17.1
Unit where she/he works
General departments (internal, surgery)	234	51.9
Intensive care	86	19.1
Other (polyclinics, endoscopy unit, outpatient unit, operating room)	131	29.0
Work schedule
Night shift (night shift only)	13	2.9
Night/day shift (both night and day shift)	324	71.8
Day shift (day shift only)	114	25.3
Family income (monthly)
Less than 700 USD	86	19.1
700–1400 USD	290	64.3
1401–2100 USD	57	12.6
More than 2100 USD	18	4.0
Frequency of conducting searches on the internet at work
Never	110	24.4
Once every few months	78	17.3
Once a month	107	23.7
Almost everyday	156	34.6
Perceived computer use skills
Basic level	115	25.5
Medium level	257	57.0
Good level	79	17.5

Health-promoting behaviors and e-health literacy levels of nurses

Table 2 shows the nurses’ levels of health-promoting behaviors and e-health literacy. Total mean scores of nurses’ health-promoting behaviors were 130.56 ± 21.90 (range, 52–208), while among the subscales, the maximum score was obtained from the interpersonal relationship (25.52 ± 4.48) (range, 9–36) and the minimum score from the physical activity (17.43 ± 5.42) (range, 8–32). The total mean scores of the nurses for e-health literacy was 29.87 ± 5.39 (range, 8–40).

Table 2.

Health-promoting behaviors and e-health literacy level (n: 451).

Health-promoting behaviors	Mean ± SD
Total scale score (range, 52–208)	130.56 ± 21.90
Health responsibility (range, 9–36)	21.82 ± 4.40
Physical activity (range, 8–32)	17.43 ± 5.42
Nutrition (range, 9–36)	21.58 ± 4.28
Spiritual development (range, 9–36)	25.22 ± 4.75
Interpersonal relations (range, 9–36)	25.52 ± 4.48
Stress management (range, 8–32)	18.97 ± 4.37
e-health literacy
Total scale score (range, 8–40)	29.87 ± 5.39

M: mean; SD: standard deviation.

The relationship between the e-health literacy and health-promoting behaviors of the nurses

Table 3 presents the results of multiple linear regression analysis that show the association of the variables with the total score of health-promoting behaviors and subscales. The analysis results indicated a significant relationship between the e-health literacy levels of the nurses and their health-promoting behaviors (total) (R = 0.349; F = 12.381; B = 0.469, %95 CI =0.09–0.83; p = 0.013), health responsibility (R = 0.326; F = 10.567; B = 0.09, %95 CI = 0.01–0.17; p = 0.014), spiritual development (R = 0.242; F = 5.276; B = 0.14, %95 CI = 0.05–0.22; p = 0.001) and interpersonal relations (R = 0.343; F = 9.896; B = 0.12, %95 CI = 0.05–0.20; p = 0.001) scores.

Table 3.

The relationship between the e-health literacy of the nurses and their health-promoting behaviors (n: 451).

	Health-promoting behavior			Health responsibility			Physical activity			Nutrition			Spiritual development			Interpersonal relations			Stress management
	B	95% CI	P	B	95% CI	P	B	95% CI	P	B	95% CI	P	B	95% CI	P	B	95% CI	P	B	95% CI	P
e-health literacy	0.469	0.09–0.83	0.013	0.09	0.01–0.17	0.014	0.069	−0.02–0.16	0.150	0.031	−0.04–0.10	0.414	0.14	0.05–0.22	0.001	0.12	0.05–0.20	0.001	0.028	−0.04–0.10	0.455
Gender	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Age	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	−0.074	0.10–1.31	0.010	–	–	–
Marital status	9.783	5.57–13.99	0.000	1.229	0.37–2.08	0.005	2.417	1.34–3.48	0.000	–	–	–	–	–	–	1.346	0.46–2.22	0.003	2.489	1.64–3.33	0.000
Educational status	–	–	–	–	–	–	–	–	–	–	–	–	0.547	−0.04–,1.13	0.068	–	–	–	–	–	–
Unit worked	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Work schedule	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Family income	4.685	1.76–7.60	0.002	0.66	0.06–1.5	0.029	0.793	0.05–1.53	0.036	–	–	–	–	–	–	0.904	0.30–1.50	0.003	0.797	0.20–1.39	0.000
Frequency of doing internet research at work	1.994	0.27–3.71	0.023	0.576	0.22–0.92	0.001	–	–	–	–	–	–	–	–	–	0.296	0.05–0.65	0.102	0.371	−0.03–0.70	0.031
Perceived computer use skills	4.012	0.81–7.20	0.014	0.790	0.14–1.44	0.017	1.008	0.22–1.78	0.011	1.114	0.49–1.73	0.000	0.669	−0.02–1.36	0.058	0.549	−0.10–1.20	0.102	–	–	–
R²	0.122			0.106			0.077			0.034			0.059			0.118			0.085
F	12,381			10,567			9.281			7,829			9,276			9,896			10,388

CI: %95 confidence interval; eHL: e-health literacy.

p < 0.05.

The multiple regression analysis results showed that there was no relationship between e-health literacy and physical activity, nutrition or stress management (p > 0.05).

Discussion

This study is the first research showing the relationship between e-health literacy and health-promoting behaviors of nurses in Turkish society working in a hospital and directly involved in patient care, since we did not come across any other study in the literature. The findings of the study showed that nurses’ health-promoting behaviors were at moderate levels. Some previous studies have similarly stated that the health-promoting behaviors of nurses and nursing students working in the hospital are at moderate levels (1,25,26). There are studies conducted in Kenya and Indonesia stating that nurses’ health-promoting behaviors are at low levels and they do not practice health-promoting behaviors as a lifestyle (27,28). Previous studies conducted with different groups in Turkey have shown that the health-promoting behaviors of academic personnel (29), factory workers (30), adults with chronic diseases (31,32), nurses and other health workers (33 –37) were at moderate levels. The health-promoting behaviors of nurses, who are trained and assigned to meet the health care needs of society, are expected to be high (38). As a matter of fact, it has been reported that nurses with high levels of health-promoting behaviors provide higher quality nursing care (39). The findings of this study have shown that nurses could not adequately transfer their knowledge and experience to their lifestyle behaviors while marital status, income level, frequency of conducting searches on the internet at work, computer use skills and e-health literacy level were found to be the factors associated with the health-promoting behaviors of nurses. In this study, single nurses’ health-promoting behaviors (total score, physical activity, interpersonal relationships, stress management) were found to be higher than married nurses. In the literature, there are different opinions on the relationship between marital status and health-promoting behaviors (25,31,33,36). There are previously conducted studies stating that marriage has positive effects on physical and mental health and that marriage has the function of regulating healthy lifestyle behaviors (40,41). However, there is also another study stating that single nurses have more positive health behaviors since they have less responsibility in their personal lives and spend more time on themselves (36). Research findings confirm that marital status affects the health-promoting behaviors of the nurses.

The findings also indicated that the health-promoting behavior scores (total score, health responsibility, nutrition, spiritual development, interpersonal relations, stress management) of the nurses increased significantly with the increase in their income levels. Some studies conducted with nurses in Turkey have shown that there is no relationship between health-promoting behavior and level of income (37,42). On the other hand, many studies have reported a positive relationship between the health promotion behaviors of nurses and nursing students and their income levels (25,26,36). The findings of this study showed that the economic status level affects the health behaviors of nurses. Good economic status affects healthy lifestyle behaviors positively. In the health-promoting model, it was stated that as the income level increases, the level of having positive health behavior increases (25,36).

The findings of the study indicated that as the nurses’ frequency of conducting searches on the internet at work and their perceived level of computer use skills increase, their health-promoting behavior scores (total score, health responsibility) positively increase. The frequency of conducting searches on the internet at work and the ability to use computers are among the factors that support nurses’ e-health literacy (9). In this study, although the e-health literacy level of nurses was slightly higher than the e-health literacy level of Turkish nursing students (43), it was similar to adult healthy women (44). The higher e-health literacy levels of nurses working in the hospital than nursing students can be explained by their higher education levels and their consistent access to health information in the hospital. The findings also indicated that nurses’ e-health literacy level is an important determinant of positive health-promoting behaviors (total score, health responsibility, spiritual development, interpersonal relations). In the literature, there are studies reporting that individuals with high e-health literacy display positive health-promoting behaviors (1,10,45). The fact that individuals with high e-health literacy have easier access to health-related information on the internet is considered to be the reason for this (10,46). In a study conducted among Korean internet users, e-health literacy has been reported to be the most correlated variable of health-promoting behaviors (45). In another study carried out with university students, students with high levels of e-health literacy were found to be more successful in health-promoting behaviors (10,47). These findings suggest that nurses having the necessary knowledge, skills and tools to use electronic health resources increases their positive health-promoting behaviors. In other words, the study showed that nurses having high e-health literacy levels are effective in maintaining a healthier lifestyle.

Limitations

The study has some limitations. The data of the study were obtained with a cross-sectional design and self-reported questionnaire, and the working conditions could not be examined. Therefore, it was not possible to examine the causal relationships between e-health literacy and health-promoting behaviors. The participants’ answers are open to social desirability bias.

Conclusion

This study, as the first to examine the relationship between the e-health literacy and health-promoting behaviors of hospital nurses in Turkey, showed that nurses’ health-promoting behaviors and e-health literacy were at moderate levels. The results indicated that the health-promoting behaviors of the nurses positively correlated with a high level of e-health literacy, frequency of conducting searches on the internet at work, and high levels of perceived computer use skills. Furthermore, marital and economic status were found to be the determinants of nurses’ health-promoting behaviors. Based on these findings, to contribute to maintaining healthy lifestyle behaviors of both nurses and the patients they are responsible for, hospital administrations are recommended to develop strategies to increase the e-health literacy of nurses.

Practice implications

The findings of this study are important for hospital administrations and health managers. It is important to improve the e-health literacy of nurses working in the hospital in order to increase their healthy lifestyle behaviors. The study findings showed that nurses working in hospitals with high proficiency in searching, finding, understanding and interpreting the health information via electronic resources and the ability to apply the acquired health information to address and solve a health problem have better health promotion behaviors (such as health responsibility, spiritual development, interpersonal relationships). Based on the findings of this study, hospital administrations and health leaders are recommended to develop strategies to create environments and resources supporting the improvement of e-health literacy of nurses. There is also a need for interventions and education programs designed to improve the health-promoting behaviors and e-health literacy of nurses.

Footnotes

Acknowledgements

We would like to thank all participating nurses for their roles in the completion of this study.

Contributions

Study design: MOH, HY; data collection: HY, MOH; data analysis: MOH, HY; and manuscript preparation: MOH, HY.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Huri Yoğurtcu

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