JMIR Publications

ABSTRACT

Background:

Background:

The rapid digitalization of healthcare has reshaped access to medical services. However, older adults often remain disadvantaged due to the digital divide. E-health literacy (EHL) is increasingly recognized as a determinant of health-related quality of life (HRQoL), yet its mechanisms and subgroup differences in China are underexplored.

Objective:

Objective:

To examine the association between EHL and multidimensional HRQoL among Chinese older adults, with a focus on the mediating roles of attitudes toward own aging (ATOA) and self-efficacy (SE), and heterogeneity by residence and lifestyle.

Methods:

Methods:

A cross-sectional survey (July–November 2024) included 8,364 adults aged ≥55 years from four provinces using stratified multistage sampling. HRQoL was measured by physical health (PH), mental health (MH), and life satisfaction (LS). EHL was assessed with eHEALS, ATOA with the Philadelphia Geriatric Center Morale Scale subscale, and SE with the General Self-Efficacy Scale. Analyses employed Seemingly Unrelated Regressions (SUR), PROCESS macro mediation with 5,000 bootstraps, and subgroup regressions.

Results:

Results:

EHL was positively associated with PH (β = 0.128, p < 0.001), MH (β = 0.143, p < 0.001), and LS (β = 0.067, p < 0.001). ATOA and SE significantly mediated these associations (all p < 0.001). For MH, inconsistent mediation was observed: the direct effect was negative (β = –0.069, p < 0.01), but indirect effects were positive, yielding a positive total effect. For LS, the effect was fully mediated by ATOA and SE. Subgroup analyses showed stronger effects in urban residents (PH: β = 0.237, MH: β = 0.214, LS: β = 0.083, all p < 0.001) and non-exercisers (PH: β = 0.322, p < 0.001).

Conclusions:

Conclusions:

EHL is strongly associated with HRQoL among older adults in China. Its effects on MH and LS operate primarily through psychosocial pathways, while PH benefits directly. The findings highlight EHL’s compensatory role, particularly for rural residents and non-exercisers, underscoring its importance in digital inclusion and healthy aging policies. Clinical Trial: This study was approved by the Ethics Committee of Zhongda Hospital, Southeast University (2024ZDSYLL294-Y01). Informed consent was obtained from all participants. Anonymous data collection was employed to ensure confidentiality, and no personal identifiers such as names were included in the study materials. The research strictly adhered to the principles of the Declaration of Helsinki (1964), the Council for International Organizations of Medical Sciences (CIOMS) International Ethical Guidelines, and the World Health Organization’s standards and procedures for research involving human subjects.