Internet technologies are considered as major developments in the last twenty years that affect all sectors around the globe as well as healthcare sector. Actually, as concluded in [1], Internet is recognised as primary mechanism for health-related information dissemination. Therefore, Internet has become an imperative in every attempt to improve healthcare [2]. Scholars [3], [4] identified the benefits of Internet for healthcare sector such as instant access to a vast array of information, improved communication between patients and doctors, and support for interpersonal interactions and social support. However, there are a number of constraints to be fulfilled, in order to contribute to better utilisation of Internet for healthcare purpose.
One of the main factors that determine the benefits of Internet usage for healthcare outcomes is associated to digital health literacy [5]. Digital health literacy is defined as degree to which individuals have the capability to obtain, process, and understand basic health information and services needed to make appropriate health decisions [5-7]. Furthermore, poor health literacy could drive to several adverse health outcomes, such as delayed diagnoses, poor adherence to treatment regimens, mortality, hospitalization and emergency care visits [8-9]. In the same vein, in [10], it is argued that comparing to individuals who have high health literacy, those with low health literacy have poorer health outcomes.
It is considered that poor health literacy is linked with unhealthy lifestyle behaviours such as poor diet, smoking and a lack of physical activity [11-14]. Actually, it is argued that sports activities establish a platform for learning various personal health-related skills that are not only related to motor skills [15-17]. In addition, previous scholars underline that health literacy is dependent on health behaviours such as sport-physical activity [7], [18-20].
However, in [21], it is indicated that there is limited data on the relation between health literacy and health promoting behaviours associated to sport-physical activity. Therefore, considering importance of sport- physical activities for digital health literacy, our first objective is to empirically examine this relationship. What more since little is known about the link of health literacy with health information-seeking type [22-23] this paper distinguishes between four digital health literacy indicators associated with different types of health-related information searched on the Internet i.e., general health information, information on a specific injury or condition, specific information on a medical treatment or procedure and information regarding second opinion after visiting doctor.
Moreover, one stream of literature specifically suggests that the digital health literacy is contingent upon socio-demographic characteristics [24-25]. As suggested in [7], investigating contingent factors associated to digital health literacy would also be of great importance because these might be objectives for further improvements. Technology acceptance suggests that individual demographics affect the embracement of new technologies [26-28]. Age is associated to demographic characteristics that represents experience (or lack of experience) with certain health issues [25], but also to the Internet utilisation. For instance, rates of poor health literacy are associated with older age, low income and low educational level [29-30]. Consequently, we build and test a model of the impact of sport-physical activity on digital health literacy by introducing a moderator factor, namely, age.
The main intended contribution of this study is therefore to develop a more detailed understanding of how and to what extent sport-physical activities enhance digital health literacy. Does age moderate relationship between sport- physical activities and digital health literacy? Answering these questions contributes to emerging research concerning the drivers that could help digital health literacy improvement. Actually, comparing to previous studies on the subject our analysis will include individuals from various age groups and countries since in order to enhance health literacy at the population level, the analysis needs to cover sample across various age groups and settings [17].
To address these questions empirically, we rely on the European citizens' digital health literacy data which is conducted by TNS Political & Social at the request of the European Commission, Directorate-General Communication Networks, Content and Technology (DG CONNECT). Respondents from different social and demographic groups were interviewed via telephone in their mother tongue on behalf of the European Commission. Noteworthy, respondents form 28 EU countries are present in the sample, what makes important factors when considering generalisability of the findings. In addition, as argued in [19], [31], [32] research is still lacking regarding the analysis on overall populations, due employing European citizens' digital health literacy data will give us possibility to obtain more general understanding concerning the link between digital health literacy and sport-physical activities.
The rest of this article is organized into four sections. In the next section, we present previous literature leading up to our hypotheses for direct and moderating effects. In the two subsequent sections, we detail our method and obtained results. In the final section, we discuss the obtained findings and practical implications.
The relationship between health literacy and sport-physical activities
Previous scholars [17], [20], [33], [34] have recognised the link between health literacy and health behaviours. More precisely, health behaviour is related to physical activity, fruit and vegetable consumption, smoking behaviour, breakfast consumption, alcohol consumption, and body mass index (BMI), all of which are known to be linked to health status and health outcomes [17-20], [35], [36]. Among above mentioned indicators that are associated with health behaviours, in [7] and [20] is identified physical activity as the important pathway between health literacy and health outcomes. Accordingly, in [17] is stressed out that sport-physical activities are associated with better coping skills needed in daily life what includes also health literacy empowerment. Moreover, in [37] is proposed that health promotion action, such as physical activities, creates an intermediate set of health promotion outcomes, including health literacy, which in turn affects health outcomes.
Empirical work investigating the link between health literacy and sport-physical activities has mainly confirmed the positive relationship. For instance, conducting a cross-sectional study using data from the Rush Memory and Aging Project, which includes 556 older persons, in [21] is found that higher health literacy scores were associated with more frequent participation in health promoting behaviours, including cognitive, physical and social activities. In the same sense, using data from The Netherlands on older people, in [7] is found a negative association between inadequate health literacy and physical activity. In addition, in [20] is confirmed the findings on the sample of 3,241 participants, showing that low health literacy was associated with insufficient physical activity, insufficient fruit and vegetable consumption, lack of regular breakfast consumption, obesity and low alcohol use, but not with smoking. Furthermore, working on the population-based survey among colorectal cancer (CRC) survivors, in [38] is demonstrated that CRC survivors with low health literacy did not meet the prescribed physical activity guidelines compared with survivors with medium or high health literacy. Moreover, the authors indicate that CRC survivors with low health literacy reported statistically significantly lower levels of mental and physical health-related quality of life and higher distress levels compared with survivors with medium and high health literacy. Working on the date from Finland among school children, in [17] is shown that perceived health literacy was higher among adolescents who participated in sports club activities.
Based on previous discussion, we posit that:
H1. Sport-physical activities have a positive impact on digital health literacy.
The moderating effect
Both health literacy and sport-physical activities are considered to be contingent upon socio-demographic characteristics. Moreover, socio-economic and demographic factors such as age, income, education and health status determine people’s probability to use the internet to seek health information [39-40]. Accordingly, in [40] is found that socio-demographic characteristics particularly age, education, income, perceived health and social isolation are associated with having access to the internet confirming that a ‘digital divide’ exists among various groups.
Considering that ageing populations presents fundamental European challenges, achieving enhancing health literacy level among different age groups is crucial. However, even that Internet offers the elderly population significant potential for remaining independent longer [41], the elderly lag behind in using and benefiting from information technology (IT) [42]. Accordingly, older adults are at a risk of low health literacy [32]. Moreover, rates of inadequate health literacy have been shown to be higher in adults with older age [14], [20], [43], [44]. The Canadian Council on Learning [45] even reported that health literacy decline begins in early adulthood and continues to fall into old age. The literature identified that the reason for not using IT among older adults are cognitive decline associated with aging processes and attitudes such as anxiety about computer use and the perception that the technology was not useful for them [46-47]. On other hand, younger population is considered to be more frequent health information seekers [25], [46], [48], [49].
Therefore, we present the following hypothesis:
H2. Age moderates negatively the relationship between sport-physical activities and digital health literacy.