# The Impact of eHealth Literacy on Health Behaviors for Non-communicable Disease Prevention Among University Students in Japan and Indonesia

## TL;DR

This study explores how eHealth literacy affects health behaviors in university students in Japan and Indonesia, highlighting differences in how digital health information influences lifestyle choices.

## Contribution

The study provides cross-cultural insights into eHealth literacy's impact on health behaviors in high- and middle-income countries.

## Key findings

- eHealth literacy had a direct positive effect on healthy lifestyle behaviors.
- The impact of eHealth literacy was partially mediated by the effects of the COVID-19 pandemic.
- Metric invariance was supported across Japan and Indonesia, but not scalar invariance.

## Abstract

Background

Non-communicable diseases account for 71% of global deaths. Health behaviors are fundamental for prevention. Previous studies have indicated that health literacy, such as functional, interactive, and critical, affects people’s health behaviors. Health information is widely available online. Young people tend to access the Internet for information, which highlights the importance of eHealth literacy. Although previous studies have assessed eHealth literacy in single-country contexts, cross-cultural comparisons between high- and middle-income nations remain limited, particularly in understanding its role during global health crises. The COVID-19 pandemic has dramatically accelerated the shift toward seeking digital health information, fundamentally changing how students access and utilize health resources. However, whether eHealth literacy could mitigate the impact of COVID-19 on lifestyle remains unclear. Therefore, this study aimed to examine the impact of eHealth literacy on health behaviors among university students in Japan and Indonesia providing unique insights into cross-cultural differences.

Methodology

This cross-sectional study used a self-administered, web-based questionnaire. The participants were first- to fourth-year nursing students from universities in both countries. eHealth literacy and health behaviors were evaluated via the e-Health Literacy Scale (eHLS) and Healthy Lifestyle Scale for University Students (HLSUS), respectively. Structural equation modeling was conducted to evaluate the impact of eHLS on HLSUS, adjusting for potential confounders. A multigroup structural equation model was used to assess configural, metric, and scalar invariance.

Results

In total, 99 and 407 responses were obtained from Japan and Indonesia, respectively (response rates: Japan, 23.9%; Indonesia, 89.6%). The direct effect of eHLS on HLSUS was 0.33; the indirect effect via the impact of COVID-19 was 0.06. The metric invariance, although not scalar, was supported in the model that included data from both countries.

Conclusions

eHealth literacy universally could influence health behaviors among Japanese and Indonesian university students. However, it did not fully mitigate the effects of COVID-19. Enhancing eHealth literacy could support better health behaviors among university students.