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Volume 17, Issue 2 (2025)
Iran J War Public Health 2025, 17(2): 197-203 |
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Received: 2025/03/20 | Accepted: 2025/05/3 | Published: 2025/06/25
Received: 2025/03/20 | Accepted: 2025/05/3 | Published: 2025/06/25
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Niazy S, Abadi N, Radhi M, Al-Eqabi Q, AL-Thabhawee G. Impact of Digital Health Literacy on Quality of Life among People with Physical Disabilities. Iran J War Public Health 2025; 17 (2) :197-203
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1- Department of Community, Bagdad Medical-Technical Institute, Middle Technical University, Baghdad, Iraq
2- Department of Community Health Nursing, College of Nursing, Baghdad University, Baghdad, Iraq
3- Department of Community Health Techniques, College of Health & Medical Techniques-Kufa, Al-Furat Al-Awsat Technical University, Najaf, Iraq
4- Department of Community, Medical-Technical Institute/Kut, Middle Technical University, Baghdad, Iraq
2- Department of Community Health Nursing, College of Nursing, Baghdad University, Baghdad, Iraq
3- Department of Community Health Techniques, College of Health & Medical Techniques-Kufa, Al-Furat Al-Awsat Technical University, Najaf, Iraq
4- Department of Community, Medical-Technical Institute/Kut, Middle Technical University, Baghdad, Iraq
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Introduction
The rapid advancement of digital technologies has transformed healthcare delivery and access, particularly through the integration of e-health services. These innovations have enabled patients to access medical consultations, health information, and self-management tools from the comfort of their homes, reducing the need for in-person visits and minimizing barriers to care. Additionally, e-health services facilitate timely communication between healthcare providers and patients, allowing for more responsive and personalized care. This shift not only enhances patient convenience but also supports the management of chronic conditions by providing continuous monitoring and timely interventions. Digital health literacy (DHL), defined as the ability to seek, understand, evaluate, and apply health information from digital sources, has emerged as a crucial determinant of health outcomes within the realm of digital technology [1]. As more healthcare services move online, individuals with higher levels of DHL can better navigate e-health platforms, leading to improved health management and outcomes. Conversely, those with limited digital skills may face barriers to accessing vital health information, exacerbating existing health disparities.
Among vulnerable populations, including individuals with physical disabilities, DHL is vital in enabling individuals to make informed health decisions and navigate complex healthcare systems [2, 3]. Despite the potential of DHL to bridge health disparities, evidence indicates that people with physical disabilities often encounter significant barriers in accessing and effectively using digital health information due to challenges related to mobility, sensory impairments, and a lack of tailored digital content [4, 5]. These barriers can lead to frustration and disengagement, ultimately hindering individuals from benefiting fully from available digital health resources. By prioritizing accessibility and inclusivity in digital health initiatives, we can enhance the overall effectiveness of these resources and empower individuals with physical disabilities to take charge of their health and well-being.
Physical disabilities, characterized by limitations that restrict mobility and physical functioning, are frequently associated with chronic health conditions and a reduced quality of life (QoL) [6]. These disabilities can hinder individuals’ ability to engage in daily activities, leading to feelings of isolation and frustration. Furthermore, the physical limitations often exacerbate existing health issues, creating a cycle where individuals may experience increased pain, fatigue, and mental health challenges, such as anxiety and depression. Access to appropriate healthcare services and supportive resources is crucial for individuals with physical disabilities, as timely interventions can mitigate some of the negative effects associated with their conditions. QoL in this population is influenced not only by physical barriers but also by access to health information, social support, and engagement in health-promoting behaviors [7]. Digital health technologies, including mobile health applications, online consultations, and electronic health records, offer new opportunities for self-management, rehabilitation, and continuity of care [8]. Research has consistently demonstrated a positive association between DHL and health-related QoL [9, 10]. Individuals with higher levels of digital health literacy are better equipped to access, understand, and utilize health information from various digital sources, which can lead to more informed health decisions and improved self-management of chronic conditions. This empowerment not only enhances their ability to navigate healthcare systems effectively but also fosters greater engagement in preventive health behaviors, ultimately contributing to better overall health outcomes. Enhancing DHL can empower individuals with physical disabilities to actively participate in their healthcare and make informed choices, thereby improving their QoL [11].
An emerging body of literature highlights the role of e-health service usage as a mediating factor in the relationship between DHL and health outcomes [12, 13]. E-health services—including telemedicine, online appointment booking, health tracking tools, and interactive patient portals—can significantly enhance healthcare accessibility and efficiency for individuals with physical disabilities [14]. By providing remote access to healthcare professionals, telemedicine eliminates the need for travel, which can be particularly challenging for those with mobility limitations. This convenience not only saves time but also reduces the physical and emotional strain associated with attending in-person appointments. These services allow users to overcome physical barriers to healthcare access, reduce travel burdens, and maintain regular contact with health professionals. By leveraging these e-health services, individuals with physical disabilities can experience improved continuity of care, better communication with healthcare teams, and ultimately, enhanced health outcomes. As healthcare systems continue to integrate these digital solutions, it is essential to ensure that they are designed with accessibility in mind, catering to the diverse needs of all patients, particularly those with disabilities. However, the actual utilization of these services is closely linked to individuals’ perceived self-efficacy and confidence in their ability to navigate digital systems—factors that are connected to DHL [15]. Research has shown that individuals with higher levels of DHL are more likely to use e-health tools effectively and frequently, leading to better management of their health and increased satisfaction with care [16].
Despite this, the mediating role of e-health service utilization in the relationship between DHL and QoL remains underexplored, particularly among individuals with physical disabilities. While previous studies have examined these parameters independently, few have investigated their interplay within a single conceptual model [17]. DHL holds substantial promise for improving the QoL among individuals with physical disabilities. The usage of e-health services may serve as a critical mediating pathway through which digital literacy translates into improved health outcomes. By enabling individuals to access real-time health information and support, e-health services empower patients to make informed decisions about their health and wellness. For instance, patients who can effectively utilize telehealth platforms are more likely to attend virtual consultations, adhere to treatment plans, and monitor their health metrics, leading to better disease management and prevention.
This study aimed to address gaps in the scientific literature by examining how DHL impacts the QoL among individuals with physical disabilities and exploring the mediating effect of e-health service utilization. The study sought to inform future initiatives in the realm of digital health policies, training, and technology development, considering the unique needs of this marginalized group. By systematically analyzing the relationship between DHL and QoL, the research can provide valuable insights that guide healthcare providers and policymakers in creating targeted interventions that enhance access to care for individuals with physical disabilities.
Materials and Methods
Study design
This descriptive, cross-sectional study design was performed on individuals with physical disabilities, with e-health service utilization serving as a mediating parameter. This design enabled the researchers to evaluate the relationships among the examined parameters at a specific point in time through the use of standardized self-report questionnaires.
Study setting
The study was conducted at the Babylon Center for the Rehabilitation of the Disabled, located in Babylon, Iraq. The data collection process was completed over three months, from February to April 2025.
Study sample
The sample consisted of individuals with physical disabilities who were registered at the Babylon Center during the study period. A purposive sampling approach was utilized to recruit participants who met the study criteria. The required sample size was determined using G*Power software (version 3.1), assuming a medium effect size (0.30), a significance level of 0.05, and a power of 0.80 for multiple regression analysis involving three predictors. The minimum required sample size was 84 participants. To account for potential non-response or incomplete data, a total of 120 participants were recruited.
Inclusion and exclusion criteria
Inclusion criteria included individuals aged 18 years or older, a confirmed diagnosis of a physical disability, the ability to read and understand Arabic, and willingness to provide informed consent. Exclusion criteria were the presence of cognitive or intellectual disabilities that could interfere with understanding the questionnaire items, acute medical conditions at the time of data collection, and refusal to participate.
Study tools
Digital health literacy was measured using a modified version of the e-Health Literacy Scale (eHEALS), originally developed based on prior research [18]. The scale included eight items rated on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” A sample item was “I know how to find useful health resources on the internet.”
E-health Service Utilization was measured using a researcher-developed scale based on the World Health Organization’s Digital Health Interventions framework. The scale comprised six items assessed on a five-point frequency scale ranging from “never” to “very often.” A sample item was: “In the past month, how frequently did you use a mobile app or website to manage your medications or appointments?”
QoL was assessed using the WHOQOL-BREF tool developed by the World Health Organization [19]. This tool included 26 items covering four domains, including physical, psychological, social, and environmental. Items were rated on a five-point Likert scale, and a sample item was “How satisfied are you with your ability to perform daily living activities?”
Validity and reliability
The content validity of the study was established by a panel of five experts in the fields of rehabilitation nursing and digital health. The modified and newly developed tools were pilot-tested on a separate group of 15 participants to assess their internal consistency. The Cronbach’s alpha coefficients were 0.89 for the World Health Organization’s Digital Health Interventions framework, 0.86 for the e-health services utilization scale, and 0.92 for the WHOQOL-BREF, indicating high levels of reliability.
Data collection
Participants were approached personally at the Babylon Center. The purpose of the study was explained, and informed consent was obtained. Data were collected through self-administered questionnaires in a quiet, private location to ensure confidentiality. For participants who experienced physical difficulties in completing the questionnaire, trained research assistants provided assistance without influencing their responses.
Statistical analysis
Data were analyzed using SPSS version 26. Descriptive statistics, such as means, standard deviations, frequencies, and percentages, were used to describe the demographic characteristics and examine parameters. Pearson’s correlation coefficient was employed to assess the relationships among DHL, e-health service utilization, and QoL. Multiple linear regression analysis was conducted to determine the direct impact of DHL on QoL. Furthermore, the mediating role of e-health service utilization was examined using Hayes’ PROCESS macro (Model 4), with a bootstrapping of 5,000 samples to compute 95% confidence intervals for the indirect effect. A p-value of <0.05 was considered statistically significant.
Findings
A total of 120 individuals with physical disabilities participated in the study. The majority of participants were male (60.0%), with the highest percentage falling within the 30-44 age group (38.3%). In terms of education, 43.3% had attained college-level education or higher, while 6.7% had no formal education. Nearly half of the participants were unemployed (47.5%), followed by those who were employed (31.7%) and retired (20.8%). Regarding the type of disability, musculoskeletal conditions were the most common (30.0%), followed by neurological impairments (28.3%). The duration of disability varied, with 35.0% having lived with a disability for 1-5 years and 30.8% for 6-10 years. Notably, 80.0% of participants reported having access to the Internet (Table 1).
Table 1. Demographic characteristics of people with physical disabilities
The mean score of DHL, measured using the eHEALS Scale, was 3.72±0.68, indicating generally high self-reported skills in accessing and understanding digital health information. The mean score of e-health services utilization was 3.10±0.88, reflecting moderate usage of digital tools for health-related tasks. QoL, assessed through the WHOQOL-BREF, had a mean score of 3.54±0.59, suggesting a fairly high level of perceived well-being among the individuals across physical, psychological, social, and environmental domains.
DHL was positively and significantly correlated with both e-health service utilization (r=0.56, p<0.001) and QoL (r=0.42, p<0.001), indicating that higher literacy levels were associated with greater digital health engagement and improved QoL. Additionally, the use of e-health services was significantly associated with QoL (r=0.48, p<0.001), supporting its potential mediating role in the relationship between digital literacy and QoL (Table 2).
Table 2. Pearson correlation matrix between parameters
Both DHL (β=0.28, p=0.003) and e-health service utilization (β=0.39, p<0.001) were identified as significant predictors, explaining approximately 39% of the variance in QoL (adjusted R²=0.38, p<0.001). Thus, improvements in DHL and the active use of e-health services positively impacted the overall QoL among individuals with physical disabilities (Table 3).
Table 3. Multiple linear regression predicting quality of life
The overall impact of DHL on QoL was significant (B=0.47, 95% CI [0.31, 0.62]). When controlling for e-health services utilization, the direct effect remained significant (B=0.27, 95% CI [0.09, 0.44]), and the indirect effect of e-health services utilization was also significant (B=0.20, 95% CI [0.09, 0.33]). These effects provide empirical support for the mediating role of e-health services utilization, indicating that part of the impact of DHL on QoL is transmitted through increased engagement with digital health services (Table 4).
Table 4. Mediation analysis of the effect of digital health literacy on quality of life through e-health service utilization (Hayes’ PROCESS Model 4)
In Model 1, DHL alone significantly predicted QoL, accounting for 26% of the variance (ΔR²=0.26, p<0.001), with a standardized beta coefficient (β=0.42) indicating a moderate positive relationship. In Model 2, after including e-health services utilization in the model, the predictive power increased, with the overall explained variance rising to 38% (adjusted R²=0.38). The effect of DHL remains significant (β=0.27), although reduced, suggesting a partial mediation. Notably, e-health services utilization emerged as a strong independent predictor (β=0.39, p<0.001; Table 5).
Table 5. Hierarchical multiple regression analysis predicting quality of life
The low literacy-low use group (28% of the sample) showed the lowest scores across all measures, including an average QoL score of 2.97, reflecting their limitations in digital and service engagement. The moderate literacy-moderate use group, constituting the largest share (43%), exhibited intermediate levels on all scales, with a QoL mean of 3.49. The high literacy-high use group (29%) demonstrated the highest levels of digital literacy (4.32) and e-health utilization (4.20), correlating with the highest reported QoL (4.02). These profiles support the gradient relationship between digital health engagement and well-being, suggesting that tailored interventions for each group could enhance e-health equity and overall QoL satisfaction among individuals with physical disabilities (Table 6).
Table 6. Latent profile analysis of digital health literacy and e-health use
Discussion
This study examined the effect of DHL on the QoL among individuals with physical disabilities, with a focus on the mediating role of e-health service utilization. Individuals with higher levels of DHL were more likely to engage with e-health services, which in turn enhanced their overall well-being. These results underscored the transformative potential of digital tools in reducing health disparities in populations with mobility challenges.
The descriptive data revealed particularly high ratings in DHL, moderate use of e-health services, and relatively high levels of perceived QoL. These findings suggest that the observed population possessed a strong foundation of digital skills, which can be leveraged for health promotion and disease management. The reported DHL score is consistent with other research using the eHEALS scale, including Radcliffe, finding average scores of around 3.5 among individuals with chronic conditions. A high DHL reflects confidence in finding, evaluating, and utilizing online health information, which is especially critical for individuals with physical disabilities who may face barriers to in-person care [20].
There was a significant positive relationship between DHL and both e-health utilization and QoL. E-health utilization was also significantly associated with QoL, supporting the hypothesis that digital engagement is a key factor in improving QoL. These outcomes align with findings from Alhawas et al., demonstrating that higher DHL correlates with increased e-health tool utilization, which ultimately relates to improved chronic disease self-management and mental health outcomes. Similarly, Zhang et al. found that the use of e-health platforms enhances the mental and social aspects of QoL [21].
In regression analysis, both DHL and e-health service utilization significantly predicted QoL. Together, they accounted for 39% of the variance, indicating that both independent and mediating parameters play critical roles. Cho et al. found that DHL significantly predicts health outcomes and that this relationship is strengthened when individuals actively use digital health tools. The predictive value of DHL and e-health utilization on QoL is further supported by evidence of similar regression patterns among older adults with disabilities [6, 23, 24].
The Hayes PROCESS mediation model (Model 4) confirmed that e-health utilization significantly mediated the relationship between DHL and QoL. The overall effect of DHL on QoL was significant, and the indirect effect through e-health usage remained substantial. This mediating effect aligns with findings by Hu et al., finding that access to e-health systems facilitated by DHL improves QoL in individuals with disabilities, particularly through better access to care and increased health knowledge [25].
Hierarchical regression analysis indicates that DHL alone accounted for 26% of the variance in QoL. When e-health usage was added, the explained variance increased to 38%, confirming its significant additional value. The reduction in the β of DHL from Model 1 to Model 2 (from 0.42 to 0.27) indicated a partial mediation. The additive effect of e-health usage corroborates findings by Alhawas et al., demonstrating that e-health engagement enhances the impact of DHL on health outcomes [1]. This highlights the importance of not only possessing digital skills but also actively utilizing them to achieve optimal health benefits.
There were three distinct individual profiles. The high literacy-high use group had the highest QoL, followed by the moderate and low literacy groups. This demonstrates a gradient relationship; as DHL and e-health engagement increase, so does the QoL. This is supported by Zhao et al., who emphasized that individuals with higher DHL and active digital health usage experience better physical and mental health outcomes [26]. The gradient effect is also reflected in studies by Norman & Skinner [18], who first developed the eHEALS and established its predictive validity in digital health behavior. These findings collectively strengthen the importance of improving DHL to promote e-health engagement and enhance the QoL for individuals with physical disabilities [27-31]. Investment in digital training and inclusive health technology is essential for bridging the digital divide in vulnerable populations.
The findings outline a clear pathway: increased digital literacy leads to more frequent and effective use of digital health tools, which undoubtedly impacts health and QoL. The use of e-health services plays a key mediating role. Healthcare systems and policymakers should invest in digital literacy programs tailored to the needs of this population, with a primary focus on utilizing e-health systems for appointments, health coaching, and self-management. Mobile applications should be made user-friendly, and telehealth services should be more accessible and inclusive. Nurses, social workers, and caregivers should be trained to assist patients in using digital tools, and public awareness campaigns can normalize and encourage the use of e-health among the most vulnerable groups.
Conclusion
DHL significantly improves the QoL of individuals with physical disabilities, especially when they effectively use e-health services.
Acknowledgments: The authors would like to thank all the participants who permitted them to interview them for their close cooperation and participation.
Ethical Permissions: Ethical approval was obtained from the Research Ethics Committee of the College of Health and Medical Techniques/Kufa, Al-Furat Al-Awsat Technical University (date: 05/02/2025, number: 372/2).
Conflicts of Interests: Nothing declared by the authors.
Authors' Contribution: Niazy SM (First Author), Introduction Writer/Main Researcher (20%); Abadi NN (Second Author), Assistant Researcher/Discussion Writer (20%); Radhi MM (Third Author), Methodologist (20%); Al-Eqabi QAK (Fourth Author), Assistant Researcher (20%); AL-Thabhawee GDM (Fifth Author) Statistical Analyst (20%)
Funding/Support: The present study was not financially supported.
The rapid advancement of digital technologies has transformed healthcare delivery and access, particularly through the integration of e-health services. These innovations have enabled patients to access medical consultations, health information, and self-management tools from the comfort of their homes, reducing the need for in-person visits and minimizing barriers to care. Additionally, e-health services facilitate timely communication between healthcare providers and patients, allowing for more responsive and personalized care. This shift not only enhances patient convenience but also supports the management of chronic conditions by providing continuous monitoring and timely interventions. Digital health literacy (DHL), defined as the ability to seek, understand, evaluate, and apply health information from digital sources, has emerged as a crucial determinant of health outcomes within the realm of digital technology [1]. As more healthcare services move online, individuals with higher levels of DHL can better navigate e-health platforms, leading to improved health management and outcomes. Conversely, those with limited digital skills may face barriers to accessing vital health information, exacerbating existing health disparities.
Among vulnerable populations, including individuals with physical disabilities, DHL is vital in enabling individuals to make informed health decisions and navigate complex healthcare systems [2, 3]. Despite the potential of DHL to bridge health disparities, evidence indicates that people with physical disabilities often encounter significant barriers in accessing and effectively using digital health information due to challenges related to mobility, sensory impairments, and a lack of tailored digital content [4, 5]. These barriers can lead to frustration and disengagement, ultimately hindering individuals from benefiting fully from available digital health resources. By prioritizing accessibility and inclusivity in digital health initiatives, we can enhance the overall effectiveness of these resources and empower individuals with physical disabilities to take charge of their health and well-being.
Physical disabilities, characterized by limitations that restrict mobility and physical functioning, are frequently associated with chronic health conditions and a reduced quality of life (QoL) [6]. These disabilities can hinder individuals’ ability to engage in daily activities, leading to feelings of isolation and frustration. Furthermore, the physical limitations often exacerbate existing health issues, creating a cycle where individuals may experience increased pain, fatigue, and mental health challenges, such as anxiety and depression. Access to appropriate healthcare services and supportive resources is crucial for individuals with physical disabilities, as timely interventions can mitigate some of the negative effects associated with their conditions. QoL in this population is influenced not only by physical barriers but also by access to health information, social support, and engagement in health-promoting behaviors [7]. Digital health technologies, including mobile health applications, online consultations, and electronic health records, offer new opportunities for self-management, rehabilitation, and continuity of care [8]. Research has consistently demonstrated a positive association between DHL and health-related QoL [9, 10]. Individuals with higher levels of digital health literacy are better equipped to access, understand, and utilize health information from various digital sources, which can lead to more informed health decisions and improved self-management of chronic conditions. This empowerment not only enhances their ability to navigate healthcare systems effectively but also fosters greater engagement in preventive health behaviors, ultimately contributing to better overall health outcomes. Enhancing DHL can empower individuals with physical disabilities to actively participate in their healthcare and make informed choices, thereby improving their QoL [11].
An emerging body of literature highlights the role of e-health service usage as a mediating factor in the relationship between DHL and health outcomes [12, 13]. E-health services—including telemedicine, online appointment booking, health tracking tools, and interactive patient portals—can significantly enhance healthcare accessibility and efficiency for individuals with physical disabilities [14]. By providing remote access to healthcare professionals, telemedicine eliminates the need for travel, which can be particularly challenging for those with mobility limitations. This convenience not only saves time but also reduces the physical and emotional strain associated with attending in-person appointments. These services allow users to overcome physical barriers to healthcare access, reduce travel burdens, and maintain regular contact with health professionals. By leveraging these e-health services, individuals with physical disabilities can experience improved continuity of care, better communication with healthcare teams, and ultimately, enhanced health outcomes. As healthcare systems continue to integrate these digital solutions, it is essential to ensure that they are designed with accessibility in mind, catering to the diverse needs of all patients, particularly those with disabilities. However, the actual utilization of these services is closely linked to individuals’ perceived self-efficacy and confidence in their ability to navigate digital systems—factors that are connected to DHL [15]. Research has shown that individuals with higher levels of DHL are more likely to use e-health tools effectively and frequently, leading to better management of their health and increased satisfaction with care [16].
Despite this, the mediating role of e-health service utilization in the relationship between DHL and QoL remains underexplored, particularly among individuals with physical disabilities. While previous studies have examined these parameters independently, few have investigated their interplay within a single conceptual model [17]. DHL holds substantial promise for improving the QoL among individuals with physical disabilities. The usage of e-health services may serve as a critical mediating pathway through which digital literacy translates into improved health outcomes. By enabling individuals to access real-time health information and support, e-health services empower patients to make informed decisions about their health and wellness. For instance, patients who can effectively utilize telehealth platforms are more likely to attend virtual consultations, adhere to treatment plans, and monitor their health metrics, leading to better disease management and prevention.
This study aimed to address gaps in the scientific literature by examining how DHL impacts the QoL among individuals with physical disabilities and exploring the mediating effect of e-health service utilization. The study sought to inform future initiatives in the realm of digital health policies, training, and technology development, considering the unique needs of this marginalized group. By systematically analyzing the relationship between DHL and QoL, the research can provide valuable insights that guide healthcare providers and policymakers in creating targeted interventions that enhance access to care for individuals with physical disabilities.
Materials and Methods
Study design
This descriptive, cross-sectional study design was performed on individuals with physical disabilities, with e-health service utilization serving as a mediating parameter. This design enabled the researchers to evaluate the relationships among the examined parameters at a specific point in time through the use of standardized self-report questionnaires.
Study setting
The study was conducted at the Babylon Center for the Rehabilitation of the Disabled, located in Babylon, Iraq. The data collection process was completed over three months, from February to April 2025.
Study sample
The sample consisted of individuals with physical disabilities who were registered at the Babylon Center during the study period. A purposive sampling approach was utilized to recruit participants who met the study criteria. The required sample size was determined using G*Power software (version 3.1), assuming a medium effect size (0.30), a significance level of 0.05, and a power of 0.80 for multiple regression analysis involving three predictors. The minimum required sample size was 84 participants. To account for potential non-response or incomplete data, a total of 120 participants were recruited.
Inclusion and exclusion criteria
Inclusion criteria included individuals aged 18 years or older, a confirmed diagnosis of a physical disability, the ability to read and understand Arabic, and willingness to provide informed consent. Exclusion criteria were the presence of cognitive or intellectual disabilities that could interfere with understanding the questionnaire items, acute medical conditions at the time of data collection, and refusal to participate.
Study tools
Digital health literacy was measured using a modified version of the e-Health Literacy Scale (eHEALS), originally developed based on prior research [18]. The scale included eight items rated on a five-point Likert scale ranging from “strongly disagree” to “strongly agree.” A sample item was “I know how to find useful health resources on the internet.”
E-health Service Utilization was measured using a researcher-developed scale based on the World Health Organization’s Digital Health Interventions framework. The scale comprised six items assessed on a five-point frequency scale ranging from “never” to “very often.” A sample item was: “In the past month, how frequently did you use a mobile app or website to manage your medications or appointments?”
QoL was assessed using the WHOQOL-BREF tool developed by the World Health Organization [19]. This tool included 26 items covering four domains, including physical, psychological, social, and environmental. Items were rated on a five-point Likert scale, and a sample item was “How satisfied are you with your ability to perform daily living activities?”
Validity and reliability
The content validity of the study was established by a panel of five experts in the fields of rehabilitation nursing and digital health. The modified and newly developed tools were pilot-tested on a separate group of 15 participants to assess their internal consistency. The Cronbach’s alpha coefficients were 0.89 for the World Health Organization’s Digital Health Interventions framework, 0.86 for the e-health services utilization scale, and 0.92 for the WHOQOL-BREF, indicating high levels of reliability.
Data collection
Participants were approached personally at the Babylon Center. The purpose of the study was explained, and informed consent was obtained. Data were collected through self-administered questionnaires in a quiet, private location to ensure confidentiality. For participants who experienced physical difficulties in completing the questionnaire, trained research assistants provided assistance without influencing their responses.
Statistical analysis
Data were analyzed using SPSS version 26. Descriptive statistics, such as means, standard deviations, frequencies, and percentages, were used to describe the demographic characteristics and examine parameters. Pearson’s correlation coefficient was employed to assess the relationships among DHL, e-health service utilization, and QoL. Multiple linear regression analysis was conducted to determine the direct impact of DHL on QoL. Furthermore, the mediating role of e-health service utilization was examined using Hayes’ PROCESS macro (Model 4), with a bootstrapping of 5,000 samples to compute 95% confidence intervals for the indirect effect. A p-value of <0.05 was considered statistically significant.
Findings
A total of 120 individuals with physical disabilities participated in the study. The majority of participants were male (60.0%), with the highest percentage falling within the 30-44 age group (38.3%). In terms of education, 43.3% had attained college-level education or higher, while 6.7% had no formal education. Nearly half of the participants were unemployed (47.5%), followed by those who were employed (31.7%) and retired (20.8%). Regarding the type of disability, musculoskeletal conditions were the most common (30.0%), followed by neurological impairments (28.3%). The duration of disability varied, with 35.0% having lived with a disability for 1-5 years and 30.8% for 6-10 years. Notably, 80.0% of participants reported having access to the Internet (Table 1).
Table 1. Demographic characteristics of people with physical disabilities
The mean score of DHL, measured using the eHEALS Scale, was 3.72±0.68, indicating generally high self-reported skills in accessing and understanding digital health information. The mean score of e-health services utilization was 3.10±0.88, reflecting moderate usage of digital tools for health-related tasks. QoL, assessed through the WHOQOL-BREF, had a mean score of 3.54±0.59, suggesting a fairly high level of perceived well-being among the individuals across physical, psychological, social, and environmental domains.
DHL was positively and significantly correlated with both e-health service utilization (r=0.56, p<0.001) and QoL (r=0.42, p<0.001), indicating that higher literacy levels were associated with greater digital health engagement and improved QoL. Additionally, the use of e-health services was significantly associated with QoL (r=0.48, p<0.001), supporting its potential mediating role in the relationship between digital literacy and QoL (Table 2).
Table 2. Pearson correlation matrix between parameters
Both DHL (β=0.28, p=0.003) and e-health service utilization (β=0.39, p<0.001) were identified as significant predictors, explaining approximately 39% of the variance in QoL (adjusted R²=0.38, p<0.001). Thus, improvements in DHL and the active use of e-health services positively impacted the overall QoL among individuals with physical disabilities (Table 3).
Table 3. Multiple linear regression predicting quality of life
The overall impact of DHL on QoL was significant (B=0.47, 95% CI [0.31, 0.62]). When controlling for e-health services utilization, the direct effect remained significant (B=0.27, 95% CI [0.09, 0.44]), and the indirect effect of e-health services utilization was also significant (B=0.20, 95% CI [0.09, 0.33]). These effects provide empirical support for the mediating role of e-health services utilization, indicating that part of the impact of DHL on QoL is transmitted through increased engagement with digital health services (Table 4).
Table 4. Mediation analysis of the effect of digital health literacy on quality of life through e-health service utilization (Hayes’ PROCESS Model 4)
In Model 1, DHL alone significantly predicted QoL, accounting for 26% of the variance (ΔR²=0.26, p<0.001), with a standardized beta coefficient (β=0.42) indicating a moderate positive relationship. In Model 2, after including e-health services utilization in the model, the predictive power increased, with the overall explained variance rising to 38% (adjusted R²=0.38). The effect of DHL remains significant (β=0.27), although reduced, suggesting a partial mediation. Notably, e-health services utilization emerged as a strong independent predictor (β=0.39, p<0.001; Table 5).
Table 5. Hierarchical multiple regression analysis predicting quality of life
The low literacy-low use group (28% of the sample) showed the lowest scores across all measures, including an average QoL score of 2.97, reflecting their limitations in digital and service engagement. The moderate literacy-moderate use group, constituting the largest share (43%), exhibited intermediate levels on all scales, with a QoL mean of 3.49. The high literacy-high use group (29%) demonstrated the highest levels of digital literacy (4.32) and e-health utilization (4.20), correlating with the highest reported QoL (4.02). These profiles support the gradient relationship between digital health engagement and well-being, suggesting that tailored interventions for each group could enhance e-health equity and overall QoL satisfaction among individuals with physical disabilities (Table 6).
Table 6. Latent profile analysis of digital health literacy and e-health use
Discussion
This study examined the effect of DHL on the QoL among individuals with physical disabilities, with a focus on the mediating role of e-health service utilization. Individuals with higher levels of DHL were more likely to engage with e-health services, which in turn enhanced their overall well-being. These results underscored the transformative potential of digital tools in reducing health disparities in populations with mobility challenges.
The descriptive data revealed particularly high ratings in DHL, moderate use of e-health services, and relatively high levels of perceived QoL. These findings suggest that the observed population possessed a strong foundation of digital skills, which can be leveraged for health promotion and disease management. The reported DHL score is consistent with other research using the eHEALS scale, including Radcliffe, finding average scores of around 3.5 among individuals with chronic conditions. A high DHL reflects confidence in finding, evaluating, and utilizing online health information, which is especially critical for individuals with physical disabilities who may face barriers to in-person care [20].
There was a significant positive relationship between DHL and both e-health utilization and QoL. E-health utilization was also significantly associated with QoL, supporting the hypothesis that digital engagement is a key factor in improving QoL. These outcomes align with findings from Alhawas et al., demonstrating that higher DHL correlates with increased e-health tool utilization, which ultimately relates to improved chronic disease self-management and mental health outcomes. Similarly, Zhang et al. found that the use of e-health platforms enhances the mental and social aspects of QoL [21].
In regression analysis, both DHL and e-health service utilization significantly predicted QoL. Together, they accounted for 39% of the variance, indicating that both independent and mediating parameters play critical roles. Cho et al. found that DHL significantly predicts health outcomes and that this relationship is strengthened when individuals actively use digital health tools. The predictive value of DHL and e-health utilization on QoL is further supported by evidence of similar regression patterns among older adults with disabilities [6, 23, 24].
The Hayes PROCESS mediation model (Model 4) confirmed that e-health utilization significantly mediated the relationship between DHL and QoL. The overall effect of DHL on QoL was significant, and the indirect effect through e-health usage remained substantial. This mediating effect aligns with findings by Hu et al., finding that access to e-health systems facilitated by DHL improves QoL in individuals with disabilities, particularly through better access to care and increased health knowledge [25].
Hierarchical regression analysis indicates that DHL alone accounted for 26% of the variance in QoL. When e-health usage was added, the explained variance increased to 38%, confirming its significant additional value. The reduction in the β of DHL from Model 1 to Model 2 (from 0.42 to 0.27) indicated a partial mediation. The additive effect of e-health usage corroborates findings by Alhawas et al., demonstrating that e-health engagement enhances the impact of DHL on health outcomes [1]. This highlights the importance of not only possessing digital skills but also actively utilizing them to achieve optimal health benefits.
There were three distinct individual profiles. The high literacy-high use group had the highest QoL, followed by the moderate and low literacy groups. This demonstrates a gradient relationship; as DHL and e-health engagement increase, so does the QoL. This is supported by Zhao et al., who emphasized that individuals with higher DHL and active digital health usage experience better physical and mental health outcomes [26]. The gradient effect is also reflected in studies by Norman & Skinner [18], who first developed the eHEALS and established its predictive validity in digital health behavior. These findings collectively strengthen the importance of improving DHL to promote e-health engagement and enhance the QoL for individuals with physical disabilities [27-31]. Investment in digital training and inclusive health technology is essential for bridging the digital divide in vulnerable populations.
The findings outline a clear pathway: increased digital literacy leads to more frequent and effective use of digital health tools, which undoubtedly impacts health and QoL. The use of e-health services plays a key mediating role. Healthcare systems and policymakers should invest in digital literacy programs tailored to the needs of this population, with a primary focus on utilizing e-health systems for appointments, health coaching, and self-management. Mobile applications should be made user-friendly, and telehealth services should be more accessible and inclusive. Nurses, social workers, and caregivers should be trained to assist patients in using digital tools, and public awareness campaigns can normalize and encourage the use of e-health among the most vulnerable groups.
Conclusion
DHL significantly improves the QoL of individuals with physical disabilities, especially when they effectively use e-health services.
Acknowledgments: The authors would like to thank all the participants who permitted them to interview them for their close cooperation and participation.
Ethical Permissions: Ethical approval was obtained from the Research Ethics Committee of the College of Health and Medical Techniques/Kufa, Al-Furat Al-Awsat Technical University (date: 05/02/2025, number: 372/2).
Conflicts of Interests: Nothing declared by the authors.
Authors' Contribution: Niazy SM (First Author), Introduction Writer/Main Researcher (20%); Abadi NN (Second Author), Assistant Researcher/Discussion Writer (20%); Radhi MM (Third Author), Methodologist (20%); Al-Eqabi QAK (Fourth Author), Assistant Researcher (20%); AL-Thabhawee GDM (Fifth Author) Statistical Analyst (20%)
Funding/Support: The present study was not financially supported.
Keywords:
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