{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T15:50:44Z","timestamp":1753890644384,"version":"3.41.2"},"reference-count":134,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,1,24]],"date-time":"2025-01-24T00:00:00Z","timestamp":1737676800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Digit. Health"],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>The Internet allows cancer patients to access information about their disease at any time. However, the quality of online information varies widely and is often inaccurate or does not provide all the details patients need to make informed decisions. Additionally, patients\u2019 often limited ability to find and evaluate cancer-related online information can lead to misinformation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Objective<\/jats:title><jats:p>An interactive e-learning environment to promote digital health literacy will be developed and evaluated for effectiveness.<\/jats:p><\/jats:sec><jats:sec><jats:title>Primary hypothesis<\/jats:title><jats:p>Cancer patients who use the e-learning environment (IG1.1\u2013IG1.3) or the content of the environment as a non-interactive PDF file (IG2) will show greater improvement in their digital health literacy from baseline to 8 weeks after baseline compared to patients who receive no such intervention, but are referred to a standard information brochure.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The hypothesis will be tested in a stratified randomized controlled superiority trial with five parallel groups and the primary endpoint of digital health literacy. In an e-learning environment, patients will learn strategies to use when searching for reliable cancer-related online information. During development, a prototype will be refined through focus groups and tested for usability by experts and patients. 660 cancer patients will be recruited using convenience sampling and randomly assigned in a 3:1:1 ratio to IG1.1-IG1.3 (three variants of the environment), IG2, or the control group. Two thirds of the 660 participants will be recruited through the German Cancer Information Service (CIS) and one third through non-CIS routes. Allocation will follow stratified randomization, accounting for recruitment route (CIS vs. non-CIS) and cancer type (breast cancer vs. other cancers), with variable block length. The primary outcome, digital health literacy, will be measured at baseline, 2 weeks, and 8 weeks after baseline.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>If the results support the primary hypothesis, then the e-learning environment could empower patients to retrieve more reliable information about their disease. Concerns about the generalizability of the results, since a disproportionate number of inquiries to the CIS come from breast cancer patients, are addressed by a proportionally stratified randomization strategy and diversified recruitment routes.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fdgth.2025.1455143","type":"journal-article","created":{"date-parts":[[2025,1,24]],"date-time":"2025-01-24T07:13:59Z","timestamp":1737702839000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Development and effectiveness evaluation of an interactive e-learning environment to enhance digital health literacy in cancer patients: study protocol for a randomized controlled trial"],"prefix":"10.3389","volume":"7","author":[{"given":"Lukas","family":"Lange-Drenth","sequence":"first","affiliation":[]},{"given":"Hellena","family":"Willemer","sequence":"additional","affiliation":[]},{"given":"Mirjam","family":"Banse","sequence":"additional","affiliation":[]},{"given":"Anke","family":"Ernst","sequence":"additional","affiliation":[]},{"given":"Anne","family":"Daubmann","sequence":"additional","affiliation":[]},{"given":"Anja","family":"Holz","sequence":"additional","affiliation":[]},{"given":"Christiane","family":"Bleich","sequence":"additional","affiliation":[]},{"given":"Susanne","family":"Weg-Remers","sequence":"additional","affiliation":[]},{"given":"Holger","family":"Schulz","sequence":"additional","affiliation":[]}],"member":"1965","published-online":{"date-parts":[[2025,1,24]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1117","DOI":"10.1007\/s00520-009-0615-5","article-title":"What are the unmet supportive care needs of people with cancer? A systematic review","volume":"17","author":"Harrison","year":"2009","journal-title":"Support Care Cancer"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1048","DOI":"10.1002\/pon.1305","article-title":"Information satisfaction in breast and prostate cancer patients: implications for quality of life","volume":"17","author":"Davies","year":"2008","journal-title":"Psychooncology"},{"key":"B3","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1054\/bjoc.2000.1573","article-title":"Information needs of patients with cancer: results from a large study in UK cancer centres","volume":"84","author":"Jenkins","year":"2001","journal-title":"Br J Cancer"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1183","DOI":"10.1007\/s00520-010-0935-5","article-title":"A survey of internet utilization among patients with cancer","volume":"19","author":"Castleton","year":"2011","journal-title":"Support Care Cancer"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1189","DOI":"10.1007\/s00520-008-0419-z","article-title":"Internet use by cancer survivors: current use and future wishes","volume":"16","author":"van de Poll-Franse","year":"2008","journal-title":"Support Care Cancer"},{"key":"B6","doi-asserted-by":"publisher","first-page":"e163","DOI":"10.2196\/jmir.6830","article-title":"Health-related internet use in people with cancer: results from a cross-sectional study in two outpatient clinics in Sweden","volume":"19","author":"Mattsson","year":"2017","journal-title":"J Med Internet Res"},{"article-title":"Social media use continues to rise in developing countries but plateaus across developed ones: Pew Research Center (2018)","year":"","author":"Poushter","key":"B7"},{"year":"","key":"B8","article-title":"Private Haushalte in Der Informationsgesellschaft \u2013Nutzung Von Informations- Und Kommunikations-Technologien (2020)"},{"key":"B9","doi-asserted-by":"publisher","first-page":"e6299","DOI":"10.1002\/pon.6299","article-title":"Social media use and health promotion among cancer survivors","volume":"33","author":"Atarere","year":"2024","journal-title":"Psychooncology"},{"key":"B10","doi-asserted-by":"publisher","first-page":"S63","DOI":"10.1016\/j.pec.2010.09.004","article-title":"Internet use leads cancer patients to be active health care consumers","volume":"81","author":"Lee","year":"2010","journal-title":"Patient Educ Couns"},{"key":"B11","doi-asserted-by":"publisher","first-page":"1843","DOI":"10.1007\/s00432-018-2703-8","article-title":"Ehealth literacy in patients with cancer and their usage of web-based information","volume":"144","author":"Heiman","year":"2018","journal-title":"J Cancer Res Clin Oncol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1007\/s11764-011-0179-5","article-title":"Health-related internet use among cancer survivors: data from the health information national trends survey, 2003-2008","volume":"5","author":"Chou","year":"2011","journal-title":"J Cancer Surviv"},{"key":"B13","doi-asserted-by":"publisher","first-page":"6171","DOI":"10.7314\/APJCP.2014.15.15.6171","article-title":"In whom do cancer survivors trust online and offline?","volume":"15","author":"Shahrokni","year":"2014","journal-title":"Asian Pac J Cancer Prev"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e9","DOI":"10.2196\/jmir.5729","article-title":"Internet health information seeking and the patient-physician relationship: a systematic review","volume":"19","author":"Tan","year":"2017","journal-title":"J Med Internet Res"},{"key":"B15","doi-asserted-by":"publisher","first-page":"E355","DOI":"10.1016\/j.clgc.2015.12.020","article-title":"Robotic prostatectomy on the web: a cross-sectional qualitative assessment","volume":"14","author":"Borgmann","year":"2016","journal-title":"Clin Genitourin Cancer"},{"key":"B16","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1215\/15228517-2005-008","article-title":"Quality of health information on the internet in pediatric neuro-oncology","volume":"8","author":"Hargrave","year":"2006","journal-title":"Neuro Oncol"},{"key":"B17","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1159\/000381739","article-title":"What cancer patients find in the internet: the visibility of evidence-based patient information - analysis of information on German websites","volume":"38","author":"Liebl","year":"2015","journal-title":"Oncol Res Treat"},{"key":"B18","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1097\/DCR.0000000000000011","article-title":"Systematic review of internet patient information on colorectal cancer surgery","volume":"57","author":"Wasserman","year":"2014","journal-title":"Dis Colon Rectum"},{"key":"B19","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1038\/s41391-021-00473-7","article-title":"Instagram and prostate cancer: using validated instruments to assess the quality of information on social media","volume":"25","author":"Xu","year":"2022","journal-title":"Prostate Cancer Prostatic Dis"},{"key":"B20","doi-asserted-by":"publisher","first-page":"248","DOI":"10.5173\/ceju.2022.151","article-title":"Quality of bladder cancer information on YouTube","volume":"75","author":"Garc\u00eda-Cano-Fern\u00e1ndez","year":"2022","journal-title":"Cent European J Urol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"e188","DOI":"10.2196\/jmir.4721","article-title":"Twitter social media is an effective tool for breast cancer patient education and support: patient-reported outcomes by survey","volume":"17","author":"Attai","year":"2015","journal-title":"J Med Internet Res"},{"key":"B22","doi-asserted-by":"publisher","first-page":"e2775","DOI":"10.1097\/MD.0000000000002775","article-title":"The source and credibility of colorectal cancer information on twitter","volume":"95","author":"Park","year":"2016","journal-title":"Medicine"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1437","DOI":"10.1001\/jamaoncol.2023.2947","article-title":"Assessment of artificial intelligence chatbot responses to top searched queries about cancer","volume":"9","author":"Pan","year":"2023","journal-title":"JAMA Oncol"},{"key":"B24","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1016\/j.eururo.2023.07.004","article-title":"How well do artificial intelligence chatbots respond to the top search queries about urological malignancies?","volume":"85","author":"Musheyev","year":"2024","journal-title":"Eur Urol"},{"year":"","key":"B25","article-title":"NCCN guidelines"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1459","DOI":"10.1001\/jamaoncol.2023.2954","article-title":"Use of artificial intelligence chatbots for cancer treatment information","volume":"9","author":"Chen","year":"2023","journal-title":"JAMA Oncol"},{"key":"B27","doi-asserted-by":"publisher","first-page":"875","DOI":"10.1007\/s00192-014-2615-3","article-title":"Patient-focused websites related to stress urinary incontinence and pelvic organ prolapse: a discern quality analysis","volume":"26","author":"Duenas-Garcia","year":"2015","journal-title":"Int Urogynecol J"},{"key":"B28","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1016\/j.pec.2016.08.028","article-title":"Understanding online health information: evaluation, tools, and strategies","volume":"100","author":"Beaunoyer","year":"2017","journal-title":"Patient Educ Couns"},{"key":"B29","doi-asserted-by":"publisher","first-page":"106997","DOI":"10.1016\/j.ypmed.2022.106997","article-title":"Electronic health literacy and health-related outcomes among older adults: a systematic review","volume":"157","author":"Xie","year":"2022","journal-title":"Prev Med"},{"key":"B30","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1007\/s11764-022-01260-6","article-title":"Factors influencing the E-health literacy in cancer patients: a systematic review","volume":"17","author":"Zhang","year":"2023","journal-title":"J Cancer Surviv"},{"key":"B31","doi-asserted-by":"publisher","first-page":"e9","DOI":"10.2196\/jmir.8.2.e9","article-title":"eHealth literacy: essential skills for consumer health in a networked world","volume":"8","author":"Norman","year":"2006","journal-title":"J Med Internet Res"},{"key":"B32","doi-asserted-by":"publisher","first-page":"e27","DOI":"10.2196\/jmir.8.4.e27","article-title":"eHEALS: the eHealth literacy scale","volume":"8","author":"Norman","year":"2006","journal-title":"J Med Internet Res"},{"key":"B33","doi-asserted-by":"publisher","first-page":"e30644","DOI":"10.2196\/30644","article-title":"eHealth literacy instruments: systematic review of measurement properties","volume":"23","author":"Lee","year":"2021","journal-title":"J Med Internet Res"},{"key":"B34","doi-asserted-by":"publisher","first-page":"e23367","DOI":"10.2196\/23367","article-title":"Patients with cancer searching for cancer- or health-specific web-based information: performance test analysis","volume":"23","author":"Lange-Drenth","year":"2021","journal-title":"J Med Internet Res"},{"key":"B35","doi-asserted-by":"publisher","first-page":"e27","DOI":"10.2196\/jmir.6709","article-title":"Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills","volume":"19","author":"van der Vaart","year":"2017","journal-title":"J Med Internet Res"},{"key":"B36","doi-asserted-by":"publisher","first-page":"e27","DOI":"10.2196\/jmir.2428","article-title":"Measuring actual eHealth literacy among patients with rheumatic diseases: a qualitative analysis of problems encountered using health 1.0 and health 2.0 applications","volume":"15","author":"van der Vaart","year":"2013","journal-title":"J Med Internet Res"},{"volume-title":"Gesundheitskompetenz Der Bev\u00f6lkerung in Deutschland Vor Und W\u00e4hrend Der Corona Pandemie: Ergebnisse Des Hls-Ger 2","year":"2021","author":"Schaeffer","key":"B37"},{"key":"B38","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1016\/j.poetic.2011.02.001","article-title":"Rethinking internet skills: the contribution of gender, age, education, internet experience, and hours online to medium- and content-related internet skills","volume":"39","author":"van Deursen","year":"2011","journal-title":"Poetics"},{"key":"B39","doi-asserted-by":"publisher","first-page":"e86","DOI":"10.2196\/jmir.1840","article-title":"Does the eHealth literacy scale (eHEALS) measure what it intends to measure? Validation of a Dutch version of the eHEALS in two adult populations","volume":"13","author":"van der Vaart","year":"2011","journal-title":"J Med Internet Res"},{"key":"B40","doi-asserted-by":"publisher","first-page":"289","DOI":"10.48009\/1_iis_2005_289-295","article-title":"An investigation of self-reported computer literacy: is it reliable?","volume":"6","author":"Merritt","year":"2005","journal-title":"Issues Inf Syst"},{"key":"B41","doi-asserted-by":"publisher","first-page":"917","DOI":"10.1007\/s11135-020-01031-4","article-title":"Ict skills measurement in social surveys: can wetrustself-reports?","volume":"55","author":"Palczy\u0144ska","year":"2020","journal-title":"Qual Quant"},{"key":"B42","doi-asserted-by":"publisher","first-page":"199","DOI":"10.15760\/comminfolit.2016.10.2.24","article-title":"Do people overestimate their information literacy skills? A systematic review of empirical evidence on the Dunning-Kruger effect","volume":"10","author":"Mahmood","year":"2016","journal-title":"Comminfolit"},{"key":"B43","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/9781119239086.ch0","article-title":"Introduction: getting the most from this resource","volume-title":"E-Learning and the Science of Instruction","author":"Clarke","year":"2016"},{"key":"B44","doi-asserted-by":"publisher","first-page":"4","DOI":"10.3991\/ijet.v17i08.29885","article-title":"Investigating learners\u2019 experience of autonomous learning in E-learning context","volume":"17","author":"Khan","year":"2022","journal-title":"Int J Emerg Technol Learn"},{"article-title":"Highlighting the advantages and disadvantages of E-learning","year":"","author":"Akhter","key":"B45"},{"key":"B46","doi-asserted-by":"publisher","first-page":"31801","DOI":"10.3402\/meo.v21.31801","article-title":"Eqclinic: a platform for learning communication skills in clinical consultations","volume":"21","author":"Liu","year":"2016","journal-title":"Med Educ Online"},{"key":"B47","doi-asserted-by":"publisher","first-page":"e5251","DOI":"10.7717\/peerj.5251","article-title":"Effects of two-week E-learning on eHealth literacy: a randomized controlled trial of Japanese internet users","volume":"6","author":"Mitsuhashi","year":"2018","journal-title":"PeerJ"},{"key":"B48","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1007\/s10734-009-9247-4","article-title":"Analysing feedback processes in an online teaching and learning environment: an exploratory study","volume":"59","author":"Espasa","year":"2009","journal-title":"High Educ"},{"key":"B49","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1177\/18479790231203107","article-title":"Impact of interactivity on learning outcome in online learning settings: ordinal logit model","volume":"15","author":"Leem","year":"2023","journal-title":"Int J Eng Bus Manag"},{"key":"B50","doi-asserted-by":"publisher","first-page":"293","DOI":"10.1016\/j.learninstruc.2004.06.005","article-title":"The cognitive benefits of interactive videos: learning to tie nautical knots","volume":"14","author":"Schwan","year":"2004","journal-title":"Learn Instr"},{"key":"B51","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1080\/10494820600924750","article-title":"Designing social presence in E-learning environments: testing the effect of interactivity on children","volume":"14","author":"Tung","year":"2006","journal-title":"Interact Learn Environ"},{"key":"B52","first-page":"14","article-title":"The influence of interactive and non-interactive E-book on the learning effectiveness of high and low achievement nursing students","author":"Chang","year":"2019"},{"key":"B53","doi-asserted-by":"publisher","first-page":"874181","DOI":"10.3389\/fpsyg.2022.874181","article-title":"The impact of E-learning systems on motivating students and enhancing their outcomes during COVID-19: a mixed-method approach","volume":"13","author":"Yahiaoui","year":"2022","journal-title":"Front Psychol"},{"key":"B54","first-page":"453","article-title":"Engagement factors and motivation in E-learning and blended-learning projects","author":"Priego","year":"2013"},{"key":"B55","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3389\/fdgth.2021.764079","article-title":"Effect of engagement with digital interventions on mental health outcomes: a systematic review and meta-analysis","volume":"3","author":"Gan","year":"2021","journal-title":"Front Digit Health"},{"key":"B56","doi-asserted-by":"publisher","first-page":"926","DOI":"10.3389\/fpsyg.2020.00926","article-title":"The concept and components of engagement in different domains applied to ehealth: a systematic scoping review","volume":"11","author":"Kelders","year":"2020","journal-title":"Front Psychol"},{"key":"B57","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1007\/s10916-020-01591-w","article-title":"Extensive review of persuasive system design categories and principles: behavioral obesity interventions","volume":"44","author":"Sittig","year":"2020","journal-title":"J Med Syst"},{"key":"B58","first-page":"255","article-title":"Using persuasive system design principles to evaluate two next generation digital learning environments","author":"Cheong","year":"2017"},{"key":"B59","doi-asserted-by":"publisher","first-page":"485","DOI":"10.17705\/1cais.02428","article-title":"Persuasive systems design: key issues, process model, and system features","volume":"24","author":"Oinas-Kukkonen","year":"2009","journal-title":"Commun Assoc Inf Syst"},{"key":"B60","doi-asserted-by":"publisher","first-page":"355","DOI":"10.1177\/1460458214559432","article-title":"Trust in health information websites: a systematic literature review on the antecedents of trust","volume":"22","author":"Kim","year":"2016","journal-title":"Health Informatics J"},{"key":"B61","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1016\/j.ijmedinf.2016.04.005","article-title":"The relationship between persuasive technology principles, adherence and effect of web-based interventions for mental health: a meta-analysis","volume":"96","author":"Wildeboer","year":"2016","journal-title":"Int J Med Inform"},{"key":"B62","doi-asserted-by":"publisher","first-page":"E20","DOI":"10.2196\/jmir.3.2.e20","article-title":"What is E-health?","volume":"3","author":"Eysenbach","year":"2001","journal-title":"J Med Internet Res"},{"key":"B63","doi-asserted-by":"publisher","first-page":"e97","DOI":"10.2196\/jmir.4883","article-title":"The effectiveness of self-management mobile phone and tablet apps in long-term condition management: a systematic review","volume":"18","author":"Whitehead","year":"2016","journal-title":"J Med Internet Res"},{"key":"B64","doi-asserted-by":"publisher","first-page":"e41","DOI":"10.2196\/jmir.8793","article-title":"Health information technology continues to show positive effect on medical outcomes: systematic review","volume":"20","author":"Kruse","year":"2018","journal-title":"J Med Internet Res"},{"key":"B65","doi-asserted-by":"publisher","first-page":"464","DOI":"10.1377\/hlthaff.2011.0178","article-title":"The benefits of health information technology: a review of the recent literature shows predominantly positive results","volume":"30","author":"Buntin","year":"2011","journal-title":"Health Aff"},{"key":"B66","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1007\/s10488-010-0319-7","article-title":"Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda","volume":"38","author":"Proctor","year":"2011","journal-title":"Adm Policy Ment Health"},{"key":"B67","doi-asserted-by":"publisher","first-page":"e7586","DOI":"10.1136\/bmj.e7586","article-title":"Spirit 2013 explanation and elaboration: guidance for protocols of clinical trials","volume":"346","author":"Chan","year":"2013","journal-title":"BMJ Br Med J"},{"key":"B68","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research electronic data capture (redcap)\u2013a metadata-driven methodology and workflow process for providing translational research informatics support","volume":"42","author":"Harris","year":"2009","journal-title":"J Biomed Inform"},{"year":"","key":"B69","article-title":"Afgis-Transparenzkriterien"},{"year":"","key":"B70","article-title":"Gesundheits-Apps: Worauf Sollte Ich Achten?"},{"volume-title":"Digitale Gesundheitskompetenz in Deutschland","year":"2020","author":"Kolpatzik","key":"B71"},{"year":"","key":"B72","article-title":"Suchen Und Finden: Gesundheitsinformationen Im Internet"},{"year":"","key":"B73","article-title":"Gesundheitskompetenz St\u00e4rken"},{"year":"","key":"B74","article-title":"Gute Praxis Gesundheitsinformation"},{"article-title":"Leitlinienreport Zur \u201eLeitlinie Evidenzbasierte Gesundheitsinformation","year":"","author":"L\u00fchnen","key":"B75"},{"volume-title":"Nationaler Aktionsplangesundheitskompetenz. Die Gesundheitskompetenz in Deutschland St\u00e4rken","year":"2018","author":"Schaeffer","key":"B76"},{"volume-title":"Gesundheitskompetenz: Verst\u00e4ndlich Informieren Und Beraten. Material- Und Methodensammlung Zur Verbraucher- Und Patientenberatung F\u00fcr Zielgruppen Mit Geringer Gesundheitskompetenz","year":"2017","author":"Schmidt-Kaehler","key":"B77"},{"key":"B78","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1016\/j.zefq.2015.11.005","article-title":"Gute praxis gesundheitsinformation","volume":"110","year":"2016","journal-title":"Z Evid Fortbild Qual Gesundhwes"},{"year":"","key":"B79","article-title":"How to evaluate health information on the internet: questions and answers: national institutes of health (2022)"},{"year":"","key":"B80","article-title":"Evaluating health information"},{"year":"","key":"B81","article-title":"Evaluating solcial medi: John Hopkins Seridan Librarys"},{"article-title":"Using persuasive system design principles to evaluate two next generation digital learning environments","year":"2016","author":"Cheong","key":"B82"},{"key":"B83","first-page":"262","article-title":"Combining user-centered design with the persuasive systems design model: the development process of a web-based registration and monitoring system for healthcare-associated infections in nursing homes","volume":"6","author":"Beerlage-de Jong","year":"2014","journal-title":"Int J Adv Life Sci"},{"article-title":"Ihr Weg Durch Die Krebserkrankung: Krebsinformationsdienst - Deutsches Krebsforschungszentrum (DKFZ)","year":"","author":"Hiller","key":"B84"},{"key":"B85","doi-asserted-by":"publisher","first-page":"e111","DOI":"10.2196\/jmir.1672","article-title":"A holistic framework to improve the uptake and impact of ehealth technologies","volume":"13","author":"van Gemert-Pijnen","year":"2011","journal-title":"J Med Internet Res"},{"key":"B86","doi-asserted-by":"crossref","first-page":"207","DOI":"10.4324\/9781315385907-10","article-title":"Human-centred design","volume-title":"Ehealth Research, Theory and Development","author":"Burns","year":"2018"},{"key":"B87","doi-asserted-by":"publisher","first-page":"e22598","DOI":"10.2196\/22598","article-title":"Identifying persuasive design principles and behavior change techniques supporting End user values and needs in eHealth interventions for long-term weight loss maintenance: qualitative study","volume":"22","author":"Asbjornsen","year":"2020","journal-title":"J Med Internet Res"},{"key":"B88","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual Res Psychol"},{"key":"B89","first-page":"105","article-title":"The cognitive walkthrough method: a practitioner\u2019s guide","volume-title":"Usability Inspection Methods","author":"Wharton","year":"1994"},{"key":"B90","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1016\/j.ijmedinf.2008.10.002","article-title":"A comparison of usability methods for testing interactive health technologies: methodological aspects and empirical evidence","volume":"78","author":"Jaspers","year":"2009","journal-title":"Int J Med Inform"},{"key":"B91","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1111\/j.1467-8535.2005.00521.x","article-title":"Reflecting on the think-aloud method for evaluating E-learning","volume":"37","author":"Cotton","year":"2006","journal-title":"Br J Educ Technol"},{"key":"B92","doi-asserted-by":"publisher","first-page":"781","DOI":"10.1016\/j.ijmedinf.2004.08.003","article-title":"The think aloud method: a guide to user interface design","volume":"73","author":"Jaspers","year":"2004","journal-title":"Int J Med Inform"},{"key":"B93","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1109\/47.867942","article-title":"Thinking aloud: reconciling theory and practice","volume":"43","author":"Boren","year":"2000","journal-title":"IEEE Trans Prof Commun"},{"key":"B94","doi-asserted-by":"publisher","first-page":"784","DOI":"10.1007\/s00103-022-03548-5","article-title":"Digital health literacy of pupils. Level and associations with physical activity and dietary behavior","volume":"65","author":"Dadaczynski","year":"2022","journal-title":"Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz"},{"key":"B95","doi-asserted-by":"publisher","first-page":"e24097","DOI":"10.2196\/24097","article-title":"Digital health literacy and web-based information-seeking behaviors of university students in Germany during the COVID-19 pandemic: cross-sectional survey study","volume":"23","author":"Dadaczynski","year":"2021","journal-title":"J Med Internet Res"},{"key":"B96","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1111\/bjet.12138","article-title":"Validation of the instructional materials motivation survey (IMMS) in a self-directed instructional setting aimed at working with technology","volume":"46","author":"Loorbach","year":"2014","journal-title":"Br J Educ Technol"},{"article-title":"Eortc translation manual 2017","year":"","author":"Bottomley","key":"B97"},{"key":"B98","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1186\/s13012-017-0635-3","article-title":"Psychometric assessment of three newly developed implementation outcome measures","volume":"12","author":"Weiner","year":"2017","journal-title":"Implement Sci"},{"key":"B99","doi-asserted-by":"publisher","first-page":"143","DOI":"10.18148\/srm\/2008.v2i3.1669","article-title":"The three-step test-interview (TSTI): an observation-based method for pretesting self-completion questionnaires","volume":"2","author":"Hak","year":"2008","journal-title":"Surv Res Methods"},{"key":"B100","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1080\/13645570600656264","article-title":"An application of the three-step test-interview (TSTI): a validation study of the Dutch and Norwegian versions of the \u2018illegal aliens scale\u2019","volume":"9","author":"Hak","year":"2006","journal-title":"Int J Soc Res Methodol"},{"key":"B101","doi-asserted-by":"publisher","first-page":"12","DOI":"10.3163\/1536-5050.97.1.003","article-title":"\u201cPartnering with seniors for better health\u201d: computer use and internet health information retrieval among older adults in a low socioeconomic community","volume":"97","author":"Chu","year":"2009","journal-title":"J Med Libr Assoc"},{"key":"B102","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1007\/s12126-010-9074-z","article-title":"Technology and aging project: training outcomes and efficacy from a randomized field trial","volume":"36","author":"Woodward","year":"2010","journal-title":"Ageing Int"},{"key":"B103","doi-asserted-by":"publisher","first-page":"e90","DOI":"10.2196\/jmir.1880","article-title":"Effects of an eHealth literacy intervention for older adults","volume":"13","author":"Xie","year":"2011","journal-title":"J Med Internet Res"},{"key":"B104","doi-asserted-by":"publisher","first-page":"940","DOI":"10.1089\/tmj.2018.0184","article-title":"The effects of a theory-based patient portal E-learning program for older adults with chronic illnesses","volume":"25","author":"Nahm","year":"2019","journal-title":"Telemed J E Health"},{"article-title":"Blockrand: randomization for block random clinical trials","year":"","author":"Snow","key":"B105"},{"key":"B106","doi-asserted-by":"publisher","first-page":"1120","DOI":"10.1007\/s00103-019-02996-w","article-title":"Trends in cancer information services over 25 years: an analysis of inquiries from patients and relatives made to the cancer information service of the German cancer research center from 1992 to 2016","volume":"62","author":"Rosset","year":"2019","journal-title":"Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz"},{"volume-title":"Krebs in Deutschland F\u00fcr 2019\/2020","year":"2023","author":"Ronckers","key":"B107"},{"key":"B108","doi-asserted-by":"publisher","first-page":"655","DOI":"10.1093\/biomet\/63.3.655","article-title":"On closed testing procedures with special reference to ordered analysis of variance","volume":"63","author":"Ruth","year":"1976","journal-title":"Biometrika"},{"article-title":"Nlme: linear and nonlinear mixed effects models. r package version 3.1-163 (2023)","year":"","author":"Pinheiro","key":"B109"},{"key":"B110","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1093\/aje\/kwi187","article-title":"When is baseline adjustment useful in analyses of change? An example with education and cognitive change","volume":"162","author":"Glymour","year":"2005","journal-title":"Am J Epidemiol"},{"key":"B111","doi-asserted-by":"publisher","first-page":"93","DOI":"10.2307\/271083","article-title":"Change scores as dependent variables in regression analysis","volume":"20","author":"Allison","year":"1990","journal-title":"Sociol Methodol"},{"key":"B112","doi-asserted-by":"publisher","first-page":"104038","DOI":"10.1016\/j.jml.2019.104038","article-title":"How to capitalize on a priori contrasts in linear (mixed) models: a tutorial","volume":"110","author":"Schad","year":"2020","journal-title":"J Mem Lang"},{"article-title":"Emmeans: estimated marginal means, aka least-squares means. R package version 1.10.4","year":"","author":"Lenth","key":"B113"},{"key":"B114","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v045.i07","article-title":"Amelia ii: a program for missing data","volume":"45","author":"Honaker","year":"2011","journal-title":"J Stat Softw"},{"key":"B115","doi-asserted-by":"crossref","DOI":"10.1002\/9780470316696","volume-title":"Multiple Imputation for Nonresponse in Surveys","author":"Rubin","year":"1987"},{"volume-title":"Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach","year":"2013","author":"Hayes","key":"B116"},{"volume-title":"Health Literacy in Canada: A Healthy Understanding","year":"2008","author":"Murray","key":"B117"},{"article-title":"The health literacy of America\u2019s adults: results from the 2003 national assessment of adult literacy (NCES 2006\u2013483)","year":"","author":"Me","key":"B118"},{"key":"B119","doi-asserted-by":"publisher","first-page":"1053","DOI":"10.1093\/eurpub\/ckv043","article-title":"Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU)","volume":"25","author":"Sorensen","year":"2015","journal-title":"Eur J Public Health"},{"key":"B120","first-page":"1","article-title":"Health literacy interventions and outcomes: an updated systematic review","volume":"199","author":"Berkman","year":"2011","journal-title":"Evid Rep Technol Assess"},{"key":"B121","doi-asserted-by":"publisher","first-page":"9714","DOI":"10.3390\/ijerph120809714","article-title":"Relationship between health literacy, health-related behaviors and health status: a survey of elderly Chinese","volume":"12","author":"Liu","year":"2015","journal-title":"Int J Environ Res Public Health"},{"key":"B122","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1186\/s12889-020-08498-8","article-title":"Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults","volume":"20","author":"Svendsen","year":"2020","journal-title":"BMC Public Health"},{"volume-title":"What is the Evidence on Existing Policies and Linked Activities and Their Effectiveness for Improving Health Literacy at National, Regional and Organizational Levels in the Who European Region?","year":"2018","author":"Rowlands","key":"B123"},{"key":"B124","doi-asserted-by":"publisher","first-page":"1320","DOI":"10.1080\/10810730.2015.1018638","article-title":"Health literacy and health-related quality of life among a population-based sample of cancer patients","volume":"20","author":"Halverson","year":"2015","journal-title":"J Health Commun"},{"key":"B125","doi-asserted-by":"publisher","first-page":"e35","DOI":"10.2196\/jmir.1581","article-title":"Internet skills performance tests: are people ready for eHealth?","volume":"13","author":"van Deursen","year":"2011","journal-title":"J Med Internet Res"},{"key":"B126","doi-asserted-by":"publisher","first-page":"968806","DOI":"10.3389\/fdgth.2022.968806","article-title":"Assessing the validity of digital health literacy instrument for secondary school students in Ghana: the polychoric factor analytic approach","volume":"4","author":"Agormedah","year":"2022","journal-title":"Front Digit Health"},{"key":"B127","doi-asserted-by":"publisher","first-page":"1259412","DOI":"10.3389\/fpubh.2023.1259412","article-title":"Research into the relationship between digital health literacy and healthy lifestyle behaviors: an intergenerational comparison","volume":"11","author":"Cetin","year":"2023","journal-title":"Front Public Health"},{"key":"B128","doi-asserted-by":"publisher","first-page":"e12369","DOI":"10.1111\/opn.12369","article-title":"Psychometric comparisons of measures of eHealth literacy using a sample of Korean older adults","volume":"16","author":"Kim","year":"2021","journal-title":"Int J Older People Nurs"},{"key":"B129","doi-asserted-by":"publisher","first-page":"390","DOI":"10.1002\/hpja.580","article-title":"Adaptation and validation of the digital health literacy instrument for Portuguese university students","volume":"33","author":"Martins","year":"2022","journal-title":"Health Promot J Austr"},{"key":"B130","doi-asserted-by":"publisher","first-page":"1294183","DOI":"10.3389\/fpubh.2023.1294183","article-title":"Validation of the digital health literacy assessment among the university students in China","volume":"11","author":"Nie","year":"2023","journal-title":"Front Public Health"},{"key":"B131","doi-asserted-by":"publisher","first-page":"e17856","DOI":"10.2196\/17856","article-title":"Testing the digital health literacy instrument for adolescents: cognitive interviews","volume":"23","author":"Park","year":"2021","journal-title":"J Med Internet Res"},{"key":"B132","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3390\/ijerph19074092","article-title":"Digital health literacy related to COVID-19: validation and implementation of a questionnaire in hispanic university students","volume":"19","author":"Rivadeneira","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"B133","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3390\/ijerph20043293","article-title":"Comparison of eHealth literacy scale (eHEALS) and digital health literacy instrument (DHLI) in assessing electronic health literacy in Chinese older adults: a mixed-methods approach","volume":"20","author":"Xie","year":"2023","journal-title":"Int J Environ Res Public Health"},{"year":"","key":"B134","article-title":"80% Der Bev\u00f6lkerung Sprechen Zu Hause Ausschlie\u00dflich Deutsch"}],"container-title":["Frontiers in Digital Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fdgth.2025.1455143\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,24]],"date-time":"2025-01-24T07:14:10Z","timestamp":1737702850000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fdgth.2025.1455143\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,24]]},"references-count":134,"alternative-id":["10.3389\/fdgth.2025.1455143"],"URL":"https:\/\/doi.org\/10.3389\/fdgth.2025.1455143","relation":{},"ISSN":["2673-253X"],"issn-type":[{"type":"electronic","value":"2673-253X"}],"subject":[],"published":{"date-parts":[[2025,1,24]]},"article-number":"1455143"}}