Background. Health literacy and self-efficacy related to COVID-19 pandemic management are closely linked. Therefore, synthesis of relevant evidence regarding the positive aspects of health literacy and health-promoting protective measures among individuals during COVID-19 pandemic is necessary.
Objectives. To determine the influence of e-health literacy and health-promoting coronavirus disease 2019 (COVID-19) protective behaviors on the spread of infection during the COVID-19 pandemic.
Materials and methods. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, MEDLINE, PsycINFO, EMBASE, and Cochrane Library databases, as well as PROSPERO and ClinicalTrials.gov registry platforms were searched for eligible literature published from January 2020 to July 2022. Studies were included based on predefined Population, Intervention, Comparison, Outcomes and Study design (PICOS) criteria, and a summary of each study was prepared. To estimate the effect size, the standardized mean difference (SMD) of the evaluated parameters, e-health literacy and health-promoting COVID-19 protective behaviors was extracted. Using RevMan and MedCalc software, a meta-analysis was performed.
Results. Twelve eligible studies involving a total of 9854 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected individuals were included in the meta-analysis. The pooled SMD for e-health literacy was 40.39 (95% confidence interval (95% CI): 28.14–52.63), with the following heterogeneity values: Tau2 of 396.80, χ2 of 669.48, degrees of freedom (df) of 11, I2 of 98%, Z value of 6.47, and p < 0.001. Similarly, the pooled SM for COVID-19 protective behaviors was 15.90 (95% CI: 10.96–20.84) with Tau2 of 55.25, χ2 of 252.92, df of 11, I2 of 98%, Z of 6.31, and p < 0.001.
Conclusions. This study confirmed that e-health literacy and health-promoting COVID-19 protective behaviors have a strong positive impact on preventing the spread of COVID-19 infection and on its effective management. We recommend that interventions and applicable policies for promoting such e-literacy programs and preventative measures be given a high level of consideration.
Key words: e-health literacy, COVID-19, pandemic, COVID-19 protective behaviors, health-related behavior
The nearly 3-year-long coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on societies throughout the world. Globally, approx. 609 million confirmed cases of COVID-19 and approx. 6.5 million deaths have been reported as of September 2022.1 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted primarily through the respiratory droplets of SARS-CoV-2-infected patients or a direct contact with asymptomatic individuals.2, 3 Based on the reported evidence, the World Health Organization (WHO) issued national guidelines in numerous countries recommending the implementation of COVID-19 protective behaviors for droplet and contact precautions.4, 5 These preventative actions were suggested for the effective suppression of virus transmission and flattening of the COVID-19 pandemic curve. Health-promoting COVID-19 protective behaviors or preventative measures include maintaining an appropriate physical distance, regularly washing hands to ensure proper hand hygiene and wearing a face mask to prevent virus entry through nasal routes. These protective measures are highly effective at preventing viral transmission and infection spread.6, 7 Although the COVID-19 vaccine is readily available, it is necessary to engage in these precautionary measures after vaccination to enhance its efficacy.8, 9
Health-related education or health literacy is required to comprehend the significance of COVID-19 protective behaviors in the prevention and effective management of SARS-CoV-2 infections, as well as how and when to implement them. Health literacy familiarizes an individual with medical terms and enables them to comprehend drug prescriptions, usage instructions and doctor’s instructions for the prevention of health problems and better management when the need arises. It allows a person to assess the risks and benefits of a drug, and to navigate the complexities of the healthcare system.10 Health literacy is termed e-health literacy when it is acquired through the use of various electronic sources such as the Internet, television and social media applications.11
According to numerous studies, individuals with high e-health literacy are able to manage their health concerns in a better way and effectively implement COVID-19 protective behaviors. In their systematic review and meta-analysis, Li et al. reported that the preventive behaviors in response to the COVID-19 pandemic and compliance with the security regulations play a significant role in fighting COVID-19 pandemic.12 Liang et al. also noted that precautionary behaviors are highly effective and advantageous in the effective management of the pandemic.13 In their research on digital health literacy and online information-seeking behaviors among students during the COVID-19 pandemic, Htay et al. concluded that digital health literacy and online information play an essential role in the management and prevention of COVID-19.14 In their cross-sectional studies, Riiser et al.15 and Pechrapa et al.16 concluded that health literacy and the implementation of health-promoting COVID-19 protective measures are very effective in coping with the pandemic.
Posai et al. evaluated the health-promoting behaviors of hospitalized patients with non-communicable diseases during the 2nd wave of COVID-19 and reported the role of such behaviors in preventing the infection and its spread among patients.17 Likewise, many researchers conducted cross-sectional studies assessing the influence between e-health literacy and self-efficacy levels on implementing COVID-19 protective behaviors in individuals from different age groups during the pandemic.18, 19, 20, 21, 22, 23, 24, 25, 26 They confirmed the positive impact of effective disease management on preventing the infection.
In light of the significance of these parameters, the purpose of the present meta-analysis was to synthesize the relevant evidence regarding the positive results of health literacy and health-promoting protective measures among individuals from various age groups during the COVID-19 pandemic. In addition, the influence of these variables on the spread of infection and the social and cultural behavior of individuals during the COVID-19 pandemic was evaluated.
Materials and methods
Criteria for inclusion and exclusion
This study included articles published between January 2020 and July 2022 that describe the impact of health literacy and health-promoting COVID-19 protective behaviors on individuals during the COVID-19 pandemic.15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Only full-text articles were included, and studies with insufficient data or unrelated to the effect of health literacy and COVID-19 protective behaviors on individuals were excluded.
This meta-analysis is based on a comprehensive search based on PRISMA guidelines using, PubMed, MEDLINE, PsycINFO, EMBASE, and Cochrane Library databases, as well as PROSPERO and ClinicalTrials.gov registry platforms, conducted from January 2020 to July 2022.
The following terms were used to search for relevant studies: “COVID-19”, “coronavirus infection”, “pandemic”, “health literacy”, “COVID protective behavior”, “meta-analysis”, and “health-related behavior”. Regardless of language, publication status or study type, all included articles were chosen in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies were chosen randomly based on the Population, Intervention, Comparison, Outcomes and Study design (PICOS) criteria (prospective, retrospective, cross-sectional, or observational study). The inclusion criteria were as follows: 1) randomized controlled trials (RCTs) examining the effect of health literacy on individuals and RCTs that evaluated the effect of health-promoting behaviors during the COVID-19 pandemic; 2) standardized mean differences (SMDs) in COVID-19 management behaviors between a study group and a control group regarding the basis of their health literacy and implication of health-promoting COVID-19 protective behaviors were assessed as the primary outcome. Exclusion criteria encompassed clinical trials with patients already affected by COVID-19 and follow-up periods of less than a month. From the included studies, a concise study summary and event data were extracted.
Two authors (LY and CP) independently searched the appropriate sources for related studies. The primary focus was on the full-text articles; abstracts were only used if they contained adequate information for the meta-analysis. Outdated references were removed, and in their place, relevant research was incorporated as required by the inclusion criteria. In addition, 2 researchers (SR and RC) collected event data containing important variables independently from each study.
Data collection process
The methodological validity of the included research was independently assessed by 2 authors (LY and CP). Moreover, they evaluated the heterogeneity of the included experiments. One author (MKS) was responsible for resolving any difference of opinion between the other authors (LY and CP). With the assistance of RevMan software 5 (https://training.cochrane.org/online-learning/ core-software/revman/revman-5-download), we were able to calculate Deek’s funnel plot, the Cochran’s Q statistic and the I2 index in random bivariate mode to assess the heterogeneity.
The source of heterogeneity
The use of full-text publications as opposed to abstracts was investigated for heterogeneity. Other sources of heterogeneity included differences in the age of patients, number of patients, types of scales used to evaluate infections, and results of the studies.
Risk of bias assessment
The assessment of the potential for bias in the included studies was carried out, and the accompanying risk of bias summary and risk of bias graph were performed using the RevMan software 5.27
To evaluate the impact of preventive practices and health literacy among people of varying ages on the course of the COVID-19 pandemic, the mean scores of preventive behaviors and health literacy were taken along with their standard deviations (SDs), and the SMD and 95% confidence intervals (95% CIs) were calculated. The mean preventive practice score was calculated for the important preventive behaviors, such as using a tissue to cover one’s nose and mouth when sneezing or coughing, disposing of used tissues in the trash, not touching one’s eyes, nose or mouth with unwashed hands, and washing one’s hands with soap and water as soon as possible after engaging in any of the aforementioned activities. The SMD of the parameters expressing health literacy and health-promoting COVID-19 protective behaviors, as well as their respective 95% CIs, were calculated using the Mantel–Haenszel method28 with random bivariate effects utilizing RevMan software 5 along with their respective forest plots. This was done in conjunction with the parameters’ respective forest plots. The Tau2, χ2, I2, and Z values were utilized in an analysis to determine the degree of heterogeneity present in the included studies. If the p-value was less than 0.05, the study was regarded as statistically significant. The RevMan software 5 was used to perform the meta-analysis. Publication bias in the included studies was analyzed using Begg’s and Egger’s tests,29 and a funnel plot was generated using MedCalc software v. 20.218 (MedCalc Software Ltd., Ostend, Belgium) by graphing the proportion of each study against its standard error (SE).30 Using MedCalc software, the Bland–Altman plot31 was prepared to examine the level of agreement between the RCTs on health literacy and COVID-19 protective behaviors, and a box and whisker plot32 was utilized to compare the 2 parameters’ respective levels of effectiveness.
Results of a literature search
According to the PICOS criteria33 listed in Table 1, we identified a total of 1237 studies through electronic searches of various databases. We removed 242 studies as they did not pertain to the topic of interest, leaving 995 entries to be examined. In addition, erroneous references and duplications led to the exclusion of 724 papers, leaving only 271 for final screening. Out of the 271 studies, 215 were removed based on the inclusion criteria, and the eligibility of the remaining 56 studies was further evaluated. Insufficient evidence and improper comparison criteria to create 2×2 tables for review were the primary reasons for the omission. Figure 1 depicts the study flowchart according to the PRISMA recommendations. Twelve publications that met the inclusion criteria, i.e., were relevant to the issue and supplied sufficient data to produce a 2×2 table, were used in the meta-analysis. The twelve included trials, published from 2020 to 2022, included a total of 9854 participants of various ages during the COVID-19 pandemic, and the effects of health literacy and health-promoting COVID-19 protective behaviors on these individuals were compared. Individuals were assigned to the interventions at random, and the influence of these factors on the prevention of the spread of COVID-19 infections and its successful management were examined and analyzed statistically.
Table 2 provides a concise description of the studies included in this meta-analysis. It contains the study’s first author, year of publication, journal of publication, type of study, age of the patients, the purpose of the study, male/female (M/F) ratio, sample size, study location, evaluation scale, intervention results, study conclusion, and p-values indicating statistical significance of the data.
Risk of bias assessment
The assessment of the risk of bias for the included studies is provided in Table 3. The RevMan 5 software was used to conduct the risk of bias analysis, and we determined that the risk of bias was low, as evidenced by the risk of bias summary in Figure 2 and the risk of bias graph in Figure 3.
Using RevMan 5 software, the meta-analysis was completed. The publication bias was evaluated with MedCalc software v. 20.218. As indicated by the funnel plot (Figure 4) and the outcomes of Egger’s and Begg and Mazumdar tests, the publication bias risk in the current meta-analysis was low. Egger’s regression test reveals the degree of asymmetry of a funnel plot by calculating the intercept of the standard normal regression against the precision. While Begg and Mazumdar rank correlation test explains the relationship between the ranks of effect sizes and their variances, the Pearson’s rank correlation test does not. The data were considered statistically significant and at low risk of publication bias for p < 0.05. Since the significance threshold or p-value for both statistical tests in our meta-analysis was less than 0.05, i.e., 0.017 for Egger’s test and 0.045 for Begg’s test, this verifies the minimal likelihood of publication bias.35
The pooled SMD for health literacy (Figure 5) was 40.39 (95% CI: 28.14–52.63), with following heterogeneity values: Tau2 of 396.80, χ2 of 669.48, degrees of freedom (df) of 11, I2 of 98%, Z value of 6.47, and p < 0.001. Similarly, the pooled SMD for COVID-19 protective behaviors (Figure 6) was 15.90 (95% CI: 10.96–20.84) with Tau2 of 55.25, χ2 of 252.92, df of 11, I2 of 98%, Z of 6.31, and p < 0.001. A high SMD, greater than 1, for both examined parameters suggests that these factors are likely to have a favorable impact on the prevention and management of COVID-19.36 Both of these criteria have comparable and substantial effects on the prevention and management of COVID-19, as visible from the size of the boxes and the wide ranges and variability of the whiskers in Figure 7.37 The results of all the included studies are in strong alignment, as evident from the Bland–Altman plot shown in Figure 8. In the Bland–Altman plot, 95% of the data points were lying within ±2 s of the value of the mean differences.38
Taking into account all of these statistically significant meta-analysis results (p < 0.05), this study demonstrates that both health literacy and health-promoting COVID-19 protective behaviors contribute significantly to the proper management and prevention of spreading COVID-19 infections.
The goal of this meta-analysis was to examine the effects of health literacy and the application of COVID-19 preventative practices among individuals of various age. The recommended preventive behaviors are hand hygiene, the use of a face mask and keeping an appropriate physical distance, in addition to protective measures such as cough covering, house disinfection and daily vitamin C supplementation.39, 40, 41 For keeping the necessary physical distance, individuals are advised to stay at home, avoid large gatherings and crowded areas, and avoid all personal contact with others, particularly sick individuals.42, 43 Hand hygiene refers to the correct washing of hands with an alcohol-based hand rub, soap and water for a predetermined amount of time in order to remove any viruses that may have been contracted.44, 45 Health literacy is required to understand the advantages of these preventive and protective measures and their effect on health. Health literacy enables an individual to locate, comprehend and assess the value of recommended healthcare information and preventative measures in order to make informed decisions regarding their health and welfare.46, 47 In their cross-sectional study, Duong et al. found that e-health literacy helped in overcoming the dread, stress and despair brought about by the COVID-19 pandemic.48 Similarly, Seng et al. highlighted in their review study that health literacy has a significant impact on the ability to receive and absorb vital medical information during the COVID-19 pandemic.49 In their comprehensive review and meta-analysis, Barry et al. found that e-health literacy and the understanding of COVID-19 have a significant impact on the health management of emergency department patients.50 Similarly, Do et al. showed the positive results of health literacy and health-related behaviors in the management of COVID-19 symptoms during the worldwide pandemic with an odds ratio (OR) of 1.08 (95% CI: 1.04–1.13) and p < 0.001.51
In the present meta-analysis, we also investigated the influence of health literacy and health-promoting COVID-19 protective behaviors during the COVID-19 pandemic. We achieved statistically significant results with p < 0.05 and pooled SMD of 40.39 (95% CI: 28.14–52.63) for health literacy and 15.90 (95% CI: 10.96–20.84) for COVID-19 protective behaviors. Based on these findings, we urge that interventions and related policies encouraging these health literacy programs and preventative measures be given top priority.
The present study is limited by the fact that only English-language papers were considered, which may have resulted in a selection bias. In addition, the examination of parameters using different scales also influences outcomes to a degree. For a clearer evaluation of the effects of these parameters, it is also possible to include data from other relevant studies that mention proper documentation regarding the patient’s case history, clinical issues during drug administration, post-administration side effects, and associated complications. Similarly, only e-health literacy and health-promoting protective behaviors were examined as predictors of success; however, additional criteria such as the impact of various drugs and other social or psychological problems can be added to improve the results.
Health literacy and health-promoting COVID-19 protective behaviors have substantial favorable effects on the management of SARS-CoV-2 infections during the COVID-19 pandemic. Understanding and implementing these guidelines contributes significantly to the prevention of virus transmission and its effective management, regardless of age or gender. Individuals with a higher level of health literacy were more likely to adhere to recommended preventive measures and sustain healthier behaviors, such as healthy diet, physical activity and timely administering medications. During the COVID-19 pandemic, in-depth understanding of health-related issues considerably increased social and cultural wellbeing, and reduced the incidence of anxiety and sadness. Based on its statistically significant results (p < 0.05), the present meta-analysis shows that health literacy as an essential ability that must be acquired by all individuals, and the recommended preventive behaviors must be adopted if the COVID-19 pandemic is to be handled properly.