Abstract
-
Purpose
Digital health literacy is essential for health management among children and adolescents, with multicultural youth being particularly vulnerable to challenges in accessing, appraising, and using digital health information. This study aimed to develop a digital health literacy improvement program (DHL-Up) tailored to multicultural children and adolescents and evaluate its effectiveness.
-
Methods
Guided by the Transactional Model of eHealth Literacy and the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model, a five-session program was developed to strengthen functional, communicative, critical, and translational digital health literacy. A non-equivalent control group pretest–posttest design was used. The participants included 31 multicultural children and adolescents aged 10–15 years (experimental group: 14; control group: 17). The experimental group participated in a 5-week online program (60 minutes per session) delivered to small groups via Zoom. Data were collected before and after the intervention and analyzed using descriptive statistics, independent t-tests, Mann-Whitney U tests, chi-square tests, and Fisher’s exact tests.
-
Results
The experimental group showed significantly greater improvements in digital health literacy (t=2.73, p=.011) and the usefulness of Internet health information (t=3.11, p=.004) than the control group. No significant difference was found for information overload (t=-0.17, p=.854).
-
Conclusion
This study developed and validated a tailored digital health literacy intervention for multicultural children and adolescents, demonstrating its applicability in schools, public health centers, and community settings. These findings provide foundational evidence to support the institutionalization of digital health literacy education and highlight its potential to mitigate digital health information disparities among vulnerable populations.
-
Key words: Adolescent; Child; Cultural diversity; Health equity; Health literacy
INTRODUCTION
In 2023, the number of children and adolescents from multicultural families in South Korea reached 308,402, a 61.2% increase from 2013, accounting for 4.1% of the total child and adolescent population [
1]. As the age distribution of this population shifts, the proportion of those enrolled in elementary, middle, and high schools increases, highlighting the need to strengthen health-related support for school-aged multicultural children and adolescents [
2].
Children and adolescents from multicultural families are at greater risk of adverse health outcomes than those from monocultural families because of socioeconomic disadvantages, limited access to health information, low parental health literacy, and cultural differences in health beliefs [
3,
4]. When parents have limited proficiency in the host country’s language, children often serve as language brokers within the family, which can hinder accurate interpretation and use of health information [
3,
5]. Furthermore, the rapid digitalization of health information environments has increased not only the volume but also the complexity of available health information, contributing to a cognitive burden and information overload among users [
6]. Given that health information requires medical and contextual understanding, even digitally proficient individuals may find it challenging to critically appraise and apply such information [
7]. These difficulties can lead to the avoidance or passive acceptance of health information, diminishing its perceived usefulness and weakening the motivation to engage with it [
8,
9].
Digital health literacy, defined as the ability to seek, understand, evaluate, and apply health information in digital contexts [
9], has become a core competency for effective health management as healthcare digitalization accelerates [
10]. Higher levels of digital health literacy support informed decision-making, alleviate information overload, strengthen self-management, and promote health equity [
11,
12]. Moreover, digital health literacy fosters an intrinsic motivation to perceive such information as a meaningful resource for health management and its application in daily life [
9,
13]. Conversely, low digital health literacy increases vulnerability to misinformation and irrational health behaviors, which contribute to health disparities among socioeconomically disadvantaged populations [
3,
14].
Digital environments have become key channels for multicultural children and adolescents to access and utilize health information [
12]. Previous studies have shown that multicultural children and adolescents actively use digital technology to search for, understand, and share health information with themselves and their families [
15]. Such experiences may facilitate the integrated development of digital and health literacy, thereby contributing to better health management and decision-making. In addition, online networks play a critical role in enabling multicultural youths to identify trustworthy health information and develop a shared understanding of health management [
15]. Despite this active engagement with digital health information, there remains a lack of digital health literacy interventions specifically designed for multicultural children and adolescents, as most existing programs target adults or older adults [
10,
16]. As youths are growing up in technology-rich environments, they increasingly access and navigate health information in digital settings. As such, developmentally tailored interventions are essential to promote healthy behaviors and reduce health inequities in this population [
11].
The Transactional Model of eHealth Literacy (TMeHL) conceptualizes digital health literacy as a dynamic, interaction-driven, and context-dependent competency that evolves through engagement with digital health environments. It comprises the functional, communicative, critical, and translational dimensions that develop in a hierarchical and interdependent manner [
9]. This model provides a useful theoretical foundation for designing interventions tailored to the developmental needs and contextual realities of multicultural adolescents living in increasingly digitalized environments. Therefore, this study aimed to develop a digital health literacy improvement program (DHL-Up) for multicultural children and adolescents based on TMeHL and evaluate its effects on digital health literacy, information overload, and the usefulness of Internet health information. The study hypotheses are as follows:
Hypothesis 1. Changes in digital health literacy from pre- to post-intervention differ between the experimental and control groups.
Hypothesis 1-1. Changes in functional digital health literacy differ between groups.
Hypothesis 1-2. Changes in communicative digital health literacy differ between groups.
Hypothesis 1-3. Changes in critical digital health literacy differ between groups.
Hypothesis 2. Changes in information overload differ between groups.
Hypothesis 3. Changes in the usefulness of Internet health information differ between groups.
METHODS
Ethical statements: This study was approved by the Institutional Review Board (IRB) of Seoul National University (IRB No. 2502/002-008). Informed consent was obtained from all participants.
1. Research Design
This quasi-experimental study employed a non-equivalent control group pretest–posttest design to evaluate the effectiveness of a digital health literacy improvement program for multicultural children and adolescents. The study was registered with the Clinical Research Information Service (Register No. KCT0010329) and was conducted in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs guidelines [
17].
The participants in this study were multicultural children and adolescents aged 10–15 years, who understood the purpose of the study and voluntarily agreed to participate. Considering that the study procedures were conducted in Korean, only those able to adequately comprehend and participate in the study were included. The inclusion criteria were: (1) children and adolescents with at least one foreign-born parent; (2) currently enrolled in elementary or middle school in South Korea, with no difficulties in basic communication in Korean (reading, writing, and speaking); and (3) no physical impairments or disabilities that would interfere with the use of digital devices.
The sample size was calculated using G*Power ver. 3.1 (Heinrich-Heine-Universität Düsseldorf), with reference to a previous study that developed and evaluated a web-based program to improve digital literacy among elementary school students [
18]. Assuming that the pre–post change in the control group was zero, the anticipated effect size for the between-group difference was set at 1.07. Based on an independent t-test, a minimum of 15 participants per group was required, assuming a significance level (α) of .05 and a power (1–β) of .80. Due to recruitment challenges related to the accessibility and availability of the target population, the experimental group did not reach the target sample size. Consequently, 31 participants were included in the final analysis, with 14 in the experimental group and 17 in the control group.
The conceptual framework of this study is grounded in the TMeHL proposed by Paige et al. [
9] (
Figure 1). TMeHL conceptualizes digital health literacy as a cyclical process that is continuously shaped and expanded through individuals’ digital health experiences and contextual factors, reflecting the dynamic, bidirectional, and interactive nature of an evolving digital environment. In this study, the contextual factors influencing digital health literacy were classified into task-oriented factors (i.e., channels and sources of digital health information) and user-oriented factors (i.e., daily Internet usage, prior health knowledge, desire for health information, and demographic characteristics). To minimize linguistic heterogeneity among participants, Korean was used as the primary language throughout the intervention. In addition, the noise factors identified by Paige et al. [
9] were considered in the program design, specifically physical noise (e.g., restricting intervention participation to PCs and tablets) and physiological noise (e.g., physical limitations and subjective health status).
DHL-Up was structured around the four dimensions of the TMeHL: functional, communicative, critical, and translational digital health literacy. Functional digital health literacy refers to the basic skills required to search for and comprehend digital health information. Communicative digital health literacy refers to the ability to exchange health information effectively in digital environments and adapt communication strategies accordingly. Critical digital health literacy involves evaluating the credibility, relevance, and potential risks of digital health information. Translational digital health literacy encompasses the ability to apply digital health information across multiple ecological contexts, representing a higher-order competency that develops cumulatively from the preceding dimensions. Given the complexity and developmental nature of the translational dimension, full mastery was not expected within a short-term intervention; thus, this study focused on promoting initial application through practice-based activities, and this dimension was excluded from the outcome measurement.
Based on this theoretical framework, the present study identified digital health literacy, information overload, and the usefulness of Internet health information as the primary outcome variables. Information overload is regarded as a representative noise factor that hinders the effective use of digital health information, and its negative influence is presumed to be moderated by one’s level of digital health literacy. That is, digital health literacy may function as a buffering mechanism that mitigates the disruptive influences inherent in digital information environments. In contrast, perceived usefulness denotes the extent to which individuals regard digital health information as a valuable resource for managing their health in daily life, reflecting the process through which digital health literacy is internalized and translated into a personal capacity for health management. Taken together, this study hypothesized that DHL-Up would result in significant between-group differences in changes in digital health literacy, information overload, and the usefulness of Internet health information among multicultural children and adolescents.
4. Measurements
1) General and digital health-related characteristics
Items were developed to reflect variables that may influence digital health literacy among multicultural children and adolescents. The key variables included age, sex, grade, academic performance, parents’ country of origin and educational level, economic status, average daily Internet usage, channels and sources of health information transactions, prior health knowledge, desire for health information, subjective health status, and physical limitations.
2) Digital health literacy
Digital health literacy was measured using the eHealth Literacy Scale developed and validated by Lee [
19]. The scale consists of 31 items across three subdomains (functional, communicative, and critical eHealth literacy) rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). The total scores range from 31 to 155, with higher scores indicating higher levels of digital health literacy. Cronbach’s α reported by Lee [
19] ranged from .90 to .93 across subdomains. In this study, Cronbach’s α was .91 for functional, .93 for communicative, .95 for critical, and .96 for the total scale.
3) Information overload
Information overload is the cognitive burden that occurs when the amount of information to be processed exceeds an individual’s processing capacity [
20]. This study used the information overload subscale of the Technology Overload Scale developed by Karr-Wisniewski and Lu [
20]. Based on the Korean-translated and validated version of Lee et al. [
21], the selected terminology was modified with the authors’ permission to align it with the purpose of this study. The subscale consists of three items rated on a 7-point Likert scale (–3=strongly disagree, 3=strongly agree). The total scores range from –9 to 9, with higher scores indicating a greater level of information overload. Cronbach’s α was .87 in Lee et al. [
21] and .78 in this study.
4) Usefulness of Internet health information
Usefulness of Internet health information refers to the extent to which individuals believe that online health information is helpful for improving and managing their health status [
22]. The construct was measured using the scale developed by Noh et al. [
22], which consists of three items rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). The total scores range from 3 to 15, with higher scores indicating greater perceived usefulness of Internet health information. Cronbach’s α was .82 in the original study and .80 in this study.
5) Program satisfaction
Program satisfaction was measured using a 10-item questionnaire developed by the researcher based on the training program reaction evaluation criteria proposed by Lee and Pershing [
23]. The items assess satisfaction with program expectations; clarity, usefulness, and engagement; effectiveness of materials and instructional strategies; clarity of explanations; appropriateness of structure and learning environment; applicability to daily life; and overall satisfaction. Responses are rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree).
The participants were multicultural children and adolescents aged 10–15 years, enrolled in elementary or middle schools in South Korea, and used Korean as their primary language of instruction. Convenience sampling was used to recruit an accessible population. With IRB approval, recruitment notices detailing the eligibility criteria were posted at two community child centers in Gwangju and Jeonnam. Data were collected by the researcher from January to March 2025 through a self-administered online survey via Google Forms (Google LLC).
Participants were allocated to the experimental or control group at the time of recruitment based on their ability to attend scheduled intervention sessions rather than participant preference to minimize potential self-selection bias. Once the required sample size for each group was secured, the pre- and posttest survey links were distributed concurrently, prior to the intervention and immediately upon its completion. The experimental group received the intervention, whereas the control group did not receive any intervention. A small incentive was provided to participants for survey completion and intervention participation. No participants withdrew during the data collection, resulting in a final sample of 14 in the experimental group and 17 in the control group (
Figure 2).
1) Development of DHL-Up
The program was developed using the ADDIE instructional design (
Figure 3). In the analysis phase, a literature review was conducted to identify the four dimensions of digital health literacy and core competencies (knowledge, skills, and attitudes). In-depth interviews were conducted with seven multicultural children and adolescents to explore their digital health literacy levels and program requirements. Furthermore, the feasibility of implementation was examined by analyzing physical, technological, and social environmental factors. In the design phase, the overall program structure was formulated based on the analysis results. The program comprised five weekly 60-minute sessions, structured in alignment with the hierarchical domains of digital health literacy. Specific learning objectives were established for each session based on the conceptual attributes of the respective literacy components. Appropriate instruments for measuring the program outcomes and participant satisfaction were either selected or developed. Support strategies were established to ensure the fidelity of the online implementation, including platform preparation, user guidance, digital etiquette training, and real-time attendance monitoring. Detailed session plans and e-learning materials were produced during the development phase. Content validity was assessed by seven school health teachers, yielding an item-level content validity index (I-CVI ≥0.86) and a scale-level content validity index (S-CVI/Ave=0.99). The suitability of the e-learning materials was further evaluated using the Health Education Materials Assessment Tool, with a total score of 96.4% indicating high clarity, comprehensibility, and appropriateness.
The final program consisted of educational and practice-based activities designed to enhance the functional, communicative, critical, and translational dimensions of digital health literacy among multicultural children and adolescents (
Table 1).
2) Intervention
DHL-Up was delivered by the researcher to 14 multicultural children and adolescents aged 10–15 years through five weekly 60-minute synchronous online sessions conducted via Zoom (Zoom Video Communications Inc.). The participants were organized into three small groups (four to five participants each) to accommodate their schedules (Groups 1–3), and the same intervention procedures were applied across all groups. Each session followed a standardized structure consisting of an introduction, core activities, and wrap-up. The sessions began with a brief review of the content and an overview of the session objectives, followed by lectures, guided practice, and group discussions. Practice-based activities were conducted in real time using digital materials and tools (e.g., digital worksheets and web-based resources), with immediate verbal feedback provided to guide task performance and confirm understanding. The sessions concluded with a summary of key points and guidance for applying the acquired skills to health-related contexts.
To mitigate the potential limitations of online delivery (e.g., reduced engagement and constrained interaction), the program incorporated strategies designed to strengthen social, cognitive, and teaching presence. Multimodal materials (e.g., videos and images) and interactive elements (e.g., live polls and quizzes) were used to sustain attention and promote active involvement, whereas case-based activities were incorporated to facilitate critical thinking and applications in daily life. Collaborative activities (e.g., Q&As, presentations, and discussions) were included to support interactions between participants and the instructor, and a point-based incentive system was used to encourage motivation and a sense of accomplishment. Points were awarded based on in-session engagement, completion of assigned tasks, and collaborative interactions. At the beginning of each session, cumulative points were briefly shared to promote the self-monitoring of engagement. Prior to implementation, Zoom readiness was verified, and participants received a brief orientation on platform use and session procedures, along with digital etiquette guidance. Real-time monitoring and individual communication channels were used throughout the program to address questions and technical issues promptly.
A preliminary assessment of digital device ownership and Internet access indicated that some participants lacked appropriate equipment; therefore, laptop computers were loaned to nine participants for the duration of the program, along with prior instructions on device use. The attendance rates were 88.0% (Group 1), 90.0% (Group 2), and 88.0% (Group 3), with absence due to personal circumstances (e.g., illness or visiting a parent’s country of origin). To support the continuity of learning, participants who missed a session received session materials, including worksheets, key summaries, and comprehension quizzes. Intervention fidelity was ensured through adherence to standardized session manuals and platform operation guidelines, and was monitored using session records documenting attendance, task completion, and participant engagement.
7. Data Analysis
Data were analyzed using IBM SPSS/WIN ver. 25.0 (IBM Corp.). A two-tailed significance level of p<.05 was applied for all statistical tests. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to analyze the participants’ general and digital health-related characteristics. Homogeneity between the experimental and control groups at baseline was examined using the Mann-Whitney U test, independent t-test, Fisher’s exact test, and chi-square test. Differences in the pre- and post-change scores between the groups were analyzed using independent t-tests, and effect sizes were calculated using Cohen’s d. Program satisfaction was analyzed using mean and standard deviation.
RESULTS
1. General and Digital Health-Related Characteristics of Participants and Baseline Homogeneity of Outcome Variables between Groups
The homogeneity of general characteristics, digital health-related characteristics, and baseline outcome variables was examined, and no significant between-group differences were observed (
Supplement 1). A total of 31 participants took part in the study, with 14 in the experimental group and 17 in the control group. The mean age of the participants was 11.06±1.00 years. Most participants were in the 4th to 6th grades of elementary school (n=29; 93.6%). Regarding parents’ countries of origin, 15 fathers (48.4%) were from Korea and 19 mothers (61.3%) were from Southeast Asian countries. Sixteen participants (51.6%) had parents from non-Korean countries of origin. The most common source of health information was parents (n=14; 45.2%), and the most frequently used channels for health information were social networking services (SNS) and messaging apps (38.7%), followed by online video platforms (35.5%).
1) Hypothesis testing
Table 2 presents the results of the hypothesis testing for differences in pre- and post-change scores between the experimental and control groups. Digital health literacy increased by 20.64 points in the experimental group, whereas it decreased by 0.71 points in the control group. The difference in the change scores between the two groups was statistically significant (t=2.73,
p=.011), supporting Hypothesis 1. Information overload decreased by 2.36 points in the experimental group and by 2.00 points in the control group; however, the difference in change scores between the two groups was not statistically significant (t=–0.17,
p=.854). Thus, Hypothesis 2 is not supported. Usefulness of Internet health information increased by 2.86 points in the experimental group, whereas it decreased by 0.71 points in the control group. The difference in the change scores between the groups was statistically significant (t=3.11,
p=.004), supporting Hypothesis 3. No adverse events or unintended effects related to the intervention were observed or reported during the study period.
2) Program satisfaction
Program satisfaction was assessed among 14 participants in the experimental group using a 10-item questionnaire rated on a 5-point Likert scale. The mean score was 44.07±4.46 out of a possible 50 points, indicating a high level of satisfaction with DHL-Up (
Supplement 2).
DISCUSSION
This study developed and evaluated DHL-Up for multicultural children and adolescents, grounded in TMeHL and systematically designed using the ADDIE model. The five-session program operationalized the hierarchical dimensions of digital health literacy—functional, communicative, critical, and translational—providing a structured progression of competencies necessary for accessing, understanding, exchanging, evaluating, and applying digital health information to support health management in daily life.
The needs assessment findings indicated that multicultural children and adolescents did not differ substantially from their non-multicultural peers in terms of health interests or perceived health-related needs. Their primary areas of interest were developmentally normative and daily life–relevant topics, including dietary habits, weight management, pubertal changes, emergency response, and common health issues. Rather than assuming cultural uniformity, the program intentionally incorporated cultural heterogeneity and individual lived experiences that shaped engagement with digital health information. Accordingly, the content emphasized culturally neutral and universally relevant health themes, while learning activities were designed to facilitate culturally grounded meaning-making and personalized knowledge application. For example, in the healthy eating session, participants compared the nutritional attributes of culturally familiar foods and identified feasible modifications that aligned with their practices and goals. This culturally responsive approach aligns with the TMeHL premise that digital health literacy is context-dependent and develops through dynamic interactions between individuals and their environment. By integrating individual and contextual differences and flexibly refining the intervention based on participant feedback and emerging needs, the program demonstrated inclusive adaptability to children and adolescents from diverse cultural backgrounds.
Importantly, this study adopted a strength-based perspective by viewing multicultural children and adolescents as active agents capable of interpreting and using health information, rather than passive recipients. Socioculturally responsive strategies enabled participants to discern and apply personally relevant and contextually appropriate health information, positioning DHL-Up as a culturally sensitive and inclusive nursing intervention that advances equity in health education for culturally diverse youths.
The experimental group showed a significant improvement in overall digital health literacy compared to the control group. Prior studies among general school-aged children in South Korea reported mean eHealth literacy scores of approximately 28–29 out of 40 on the eHEALS [
24,
25]. In contrast, the mean baseline score in this study was 93.36 out of 155. Although direct comparisons are limited because of differences in measurement tools, these findings indicate that multicultural children and adolescents may have relatively lower levels of digital health literacy than their non-multicultural peers. Following the intervention, the mean score of the experimental group increased to 118.64, approaching the levels previously reported in general school-aged populations. These findings suggest that DHL-Up may enhance digital health literacy among multicultural children and adolescents and has the potential to serve as a practical nursing intervention to reduce disparities in access to and use of digital health information.
Although functional and communicative digital health literacy increased significantly in the experimental group compared with the control group, no significant between-group differences were observed in critical digital health literacy. This finding aligns with the assertion by Paige et al. [
9] that higher-order literacy skills develop progressively based on lower-order skills. Critical health literacy involves the ability to consider social determinants of health, engage in problem-solving, and take informed action [
26]. Given their reliance on advanced cognitive processes, short-term interventions may be insufficient to generate substantial improvement, underscoring the need for sustained and repeated educational efforts. Although translational digital health literacy was included as a component of the intervention, it was not assessed as an outcome in this study. Translational digital health literacy is a higher-order competence that builds upon functional, communicative, and critical skills and develops cumulatively over time [
9]. Accordingly, rather than attempting to detect mastery-level changes within a short-term intervention, the present study adopted a process-oriented approach, emphasizing the initial application through guided practice in this domain (e.g., synthesizing information from credible sources and creating brief digital health messages). Given its developmental nature, detecting meaningful changes in translational digital health literacy may require interventions of sufficient duration and intensity to support repeated and sustained practice along with a longitudinal design capable of capturing translation into practice in real-world contexts. Future research should include follow-up assessments and behavioral indicators to examine how competencies acquired through interventions are applied to health-related behaviors and decision-making in everyday life.
Information overload decreased in both groups, although between-group differences were not statistically significant. Baseline levels of information overload were generally low and comparable to those in previous studies, including those among Korean university students [
21]. This pattern may reflect the characteristics of digital natives, as children and adolescents are continuously exposed to digital environments from an early age. In South Korea, Internet usage among teenagers reached 99.4% in 2023 [
27], and the routinization of digital platform use has been suggested to reduce cognitive sensitivity to information stimuli [
28]. Additionally, prolonged exposure to information-rich digital environments may lead to cognitive adaptation or habituation, making short-term changes in perceived information overload less apparent. Since information overload reflects subjective cognitive appraisal, self-report measures may be less sensitive to such subtle changes, particularly among digitally experienced youths. Moreover, excessive Internet use and digital multitasking have been reported to exacerbate the cognitive burden when navigating complex health information environments [
29]. In digital contexts, information overload is influenced not only by information volume, but also by complexity, urgency, ambiguity, and modes of delivery [
21]. Overall, these findings suggest that information overload among multicultural children and adolescents is shaped by individual information processing abilities, as well as broader contextual and psychosocial factors. Accordingly, future interventions should consider patterns of digital exposure and psychosocial contexts to reduce cognitive burden and promote the meaningful use of health information.
The usefulness of Internet health information increased significantly in the experimental group. Perceived usefulness is a key predictor of individuals’ behavioral intentions and actual behavior in digital health environments [
13]. Prior research has identified the credibility of health information, previous information-use experiences, and level of artificial intelligence literacy as determinants of perceived usefulness [
13,
22,
30]. Among youth, successful experiences in locating credible and personally relevant health information have been shown to positively shape subsequent information use [
8]. From this perspective, DHL-Up may have contributed to increased perceived usefulness by providing participants with opportunities to search for reliable digital health information and apply it to real-life contexts, thereby reinforcing their perception of Internet-based health information as a valuable resource for health management.
This study had several limitations. First, because the group assignment was determined by participant availability at the time of program implementation, baseline equivalence between the groups could not be fully ensured. Second, voluntary participation may have introduced a self-selection bias, with children and adolescents who were more interested in health information or familiar with digital environments being more likely to participate, limiting sample representativeness. Third, as only multicultural children and adolescents with sufficient Korean proficiency were included, the generalizability of the findings to those with lower proficiency, who may be at a greater risk of digital health inequities, is limited. Finally, although short-term effects were identified through pre–post comparisons, the absence of follow-up assessments prevented the examination of long-term effects and actual behavioral changes.
Nevertheless, this study is meaningful in that it highlights the digital health literacy gap and related health inequities from a nursing perspective and suggests directions for future research to address these issues. Furthermore, the findings provide foundational evidence to inform the development of digital health education and curriculum improvements for children and adolescents, and may support the integration of such interventions into community-based health promotion and prevention strategies.
CONCLUSION
This study developed and evaluated a digital health improvement program (DHL-Up) for multicultural children and adolescents. Guided by the TMeHL and structured using the ADDIE instructional design model, a five-session program was tailored to reflect the needs and characteristics of the target population. The intervention resulted in significant improvements in digital health literacy and the usefulness of Internet health information among participants, supporting its potential as a nursing intervention for youths with limited ability to navigate digital health information. DHL-Up can be delivered by school and public health nurses as part of prevention-oriented health education using structured, activity-based sessions to build children’s and adolescents’ skills in accessing, communicating, evaluating, and applying digital health information in daily contexts. These findings offer a basis for educational initiatives to strengthen nurses’ digital healthcare competencies for person-centered care in digital health environments and may inform policy and implementation strategies to reduce inequalities in access to health information and promote health equity.
Given that digital health literacy is a multifaceted construct shaped not only by individual skills but also by broader social determinants of health, interventions for digitally disadvantaged populations should move beyond one-time hardware-focused assistance toward software-based approaches that support ongoing capacity building. To ensure systematic and sustained implementation, digital health literacy education should be embedded within the community infrastructure, such as schools, public health centers, community childcare centers, and multicultural family support centers. Ultimately, enhancing digital health literacy should be viewed as a shared societal responsibility that requires institutional commitment and policy action, rather than as an outcome achievable through individual efforts alone.
Based on these findings, we propose several recommendations for future research. First, studies with larger and more diverse samples employing randomized controlled trial designs are needed to further validate the program’s effectiveness. Second, the program development should incorporate multilingual components to accommodate the diverse linguistic backgrounds of multicultural children and adolescents. Third, longitudinal studies are required to examine the long-term effectiveness and sustainability of interventions. Finally, future research should empirically investigate whether improvements in digital health literacy lead to lasting changes in health-related behaviors.
ARTICLE INFORMATION
Supplementary material
Figure 1.Theoretical framework of the study.
Figure 2.Flowchart of the study. DHL-Up, digital health literacy improvement program.
Figure 3.Digital health literacy improvement program (DHL-Up) development process based on the ADDIE model. HEMAT, health education materials assessment tool; I-CVI, item-level content validity index; S-CVI, scale-level content validity index.
Table 1.Contents of the digital health literacy improvement program (DHL-Up) for multicultural children and adolescents
|
Session |
Duration (min) |
Contents |
Teaching methods |
|
1 |
60 |
Overview of digital health literacy |
Individual practice; lecture; self-assessment; presentation; feedback |
|
• Introduction to the digital health literacy improvement program |
|
• Creating a digital passport |
|
• Digital etiquette |
|
• Definition and importance of digital health literacy |
|
• Establishing my SMART health management plan |
|
2 |
60 |
Functional digital health literacy |
Lecture; individual practice; discussion |
|
• Concepts, types, and functions of digital health resources |
|
• Basic Internet terminology |
|
• Tips for searching online health information: website scanning techniques, effective search terms |
|
• Choosing healthy snacks: searching, comparing, and analyzing nutrition information online |
|
• Creating a healthy snack box for my family (assignment) |
|
• Managing search and browsing history for privacy protection (supplement) |
|
3 |
60 |
Communicative digital health literacy |
Lecture; individual practice |
|
• Characteristics of online and offline communication |
|
• Sharing health information online: benefits, risks, SHARE strategy |
|
• Ask Me 3® health communication support tool |
|
• Evaluation of online health communication (supplement) |
|
4 |
60 |
Critical digital health literacy |
Lecture; individual practice; discussion |
|
• Definition of misinformation and the risks of false health information |
|
• 5W’s criteria for evaluating online health information |
|
• Analysis and evaluation of online health information using the 5W’s framework |
|
• Domestic and international guidelines for countering (health) misinformation (supplement) |
|
• Evaluation methods by source type (supplement) |
|
• List of trusted digital health resources (supplement) |
|
5 |
60 |
Translational digital health literacy |
Lecture; individual practice; presentation; feedback; ceremony; reward; debriefing |
|
• Reorganizing health information using digital tools: creating a card news (slide-type infographic) |
|
• Reviewing progress on my SMART health management plan |
|
• Completion ceremony for the digital health literacy improvement program |
Table 2.Comparison of the outcome variables between the two groups
|
Variable |
Mean±SD |
t (p) |
ES (d) |
|
Pretest |
Posttest |
Difference (post–pre) |
|
Digital health literacy |
|
|
|
2.73 (.011) |
0.99 |
|
Exp. (n=14) |
93.36±25.20 |
114.00±19.32 |
20.64±23.50 |
|
|
|
Con. (n=17) |
97.12±18.58 |
96.41±17.12 |
–0.71±20.02 |
|
|
|
Functional |
|
|
|
2.13 (.042) |
0.77 |
|
Exp. (n=14) |
26.36±6.80 |
32.29±5.78 |
5.93±8.47 |
|
|
|
Con. (n=17) |
28.71±6.14 |
27.94±5.45 |
–0.76±8.91 |
|
|
|
Communicative |
|
|
|
4.16 (<.001) |
1.50 |
|
Exp. (n=14) |
31.00±10.23 |
36.29±8.61 |
5.29±4.46 |
|
|
|
Con. (n=17) |
31.71±8.52 |
31.11±8.54 |
–0.59±3.41 |
|
|
|
Critical |
|
|
|
1.80 (.082) |
0.65 |
|
Exp. (n=14) |
36.00±9.48 |
45.43±11.49 |
9.43±13.56 |
|
|
|
Con. (n=17) |
36.71±7.14 |
37.35±10.61 |
0.65±13.43 |
|
|
|
Information overload |
|
|
|
–0.17 (.854) |
–0.06 |
|
Exp. (n=14) |
0.86±3.37 |
–1.50±4.94 |
–2.36±5.93 |
|
|
|
Con. (n=17) |
1.18±5.19 |
–0.82±3.78 |
–2.00±5.57 |
|
|
|
Usefulness of Internet health information |
|
|
|
3.11 (.004) |
1.12 |
|
Exp. (n=14) |
9.71±2.81 |
12.57±1.83 |
2.86±3.37 |
|
|
|
Con. (n=17) |
10.06±2.02 |
9.35±1.87 |
–0.71±3.02 |
|
|
REFERENCES
- 1. Ministry of the Interior and Safety. Status of foreign residents in local government in 2023 [Internet]. Ministry of the Interior and Safety; 2024 [cited 2025 Mar 9]. Available from: https://www.mois.go.kr/frt/bbs/type001/commonSelectBoardArticle.do?bbsId=BBSMSTR_000000000014&nttId=113261
- 2. Ministry of Gender Equality and Family. The 4th basic plan for multicultural family support policy [Internet]. Ministry of Gender Equality and Family; 2023 [cited 2025 Mar 19]. Available from: https://www.mogef.go.kr/mp/pcd/mp_pcd_s001d.do?mid=plc503&bbtSn=704956
- 3. Seidl K, Stauch L, Affengruber L, Sommer I, Wahl A, Rojatz D, et al. Conceptualization of health literacy from the perspective of children and adolescents: a meta-ethnography. Sci Rep. 2025;15(1):5697. https://doi.org/10.1038/s41598-025-89371-9
- 4. Kim J. Health disparities of multicultural adolescents in South Korea: an exploratory study. Chorogusan Childfund; 2019.
- 5. Orellana MF, Dorner L, Pulido L. Accessing assets: immigrant youth’s work as family translators or “para-phrasers”. Soc Probl. 2003;50(4):505-524. https://doi.org/10.1525/sp.2003.50.4.505
- 6. Jia C, Li P. Generation Z’s health information avoidance behavior: insights from focus group discussions. J Med Internet Res. 2024;26:e54107. https://doi.org/10.2196/54107
- 7. Lee H, Oh S. Health consciousness and health information orientation on health information searching behaviors of middle-aged adults. J Korean Soc Inf Manag. 2021;38(3):73-99. https://doi.org/10.3743/KOSIM.2021.38.3.073
- 8. Freeman JL, Caldwell PH, Bennett PA, Scott KM. How adolescents search for and appraise online health information: a systematic review. J Pediatr. 2018;195:244-255. https://doi.org/10.1016/j.jpeds.2017.11.031
- 9. Paige SR, Stellefson M, Krieger JL, Anderson-Lewis C, Cheong J, Stopka C. Proposing a transactional model of eHealth literacy: concept analysis. J Med Internet Res. 2018;20(10):e10175. https://doi.org/10.2196/10175
- 10. Choi SK, Chun H, Choi EJ. Review of recent digital health literacy programs in Europe and the United States. Korean J Health Educ Promot. 2022;39(4):15-28. https://doi.org/10.14367/kjhep.2022.39.4.15
- 11. Kim J, Livingston MA, Jin B, Watts M, Hwang J. Fundamentals of digital health literacy: a scoping review of identifying core competencies to use in practice. Adult Learn. 2024;35(3):131-142. https://doi.org/10.1177/10451595231178298
- 12. Yameogo AR, Délétroz C, Sasseville M, Amil S, Da SM, Bodenmann P, et al. Effectiveness of interventions to improve digital health literacy in forced migrant populations: protocol for a mixed methods systematic review. JMIR Res Protoc. 2023;12:e50798. https://doi.org/10.2196/50798
- 13. Choi H, Jin M. Determinants of health-promoting behavior among eHealth consumers in South Korea: a longitudinal path analysis. J Korean Biol Nurs Sci. 2024;26(3):206-217. https://doi.org/10.7586/jkbns.24.017
- 14. Taba M, Allen TB, Caldwell PH, Skinner SR, Kang M, McCaffery K, et al. Adolescents’ self-efficacy and digital health literacy: a cross-sectional mixed methods study. BMC Public Health. 2022;22(1):1223. https://doi.org/10.1186/s12889-022-13599-7
- 15. Santos MG, Gorukanti AL, Jurkunas LM, Handley MA. The health literacy of U.S. immigrant adolescents: a neglected research priority in a changing world. Int J Environ Res Public Health. 2018;15(10):2108. https://doi.org/10.3390/ijerph15102108
- 16. Barbati C, Maranesi E, Giammarchi C, Lenge M, Bonciani M, Barbi E, et al. Effectiveness of eHealth literacy interventions: a systematic review and meta-analysis of experimental studies. BMC Public Health. 2025;25(1):288. https://doi.org/10.1186/s12889-025-21354-x
- 17. Des Jarlais DC, Lyles C, Crepaz N. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004;94(3):361-366. https://doi.org/10.2105/ajph.94.3.361
- 18. Lee E. The development and effect of web-based program for improving elementary student's digital literacy attitude [master's thesis]. Seoul: Ewha Womans University; 2018.
- 19. Lee SR. A study for developing eHealth literacy scale [dissertation]. Seoul: Hanyang University; 2018.
- 20. Karr-Wisniewski P, Lu Y. When more is too much: operationalizing technology overload and exploring its impact on knowledge worker productivity. Comput Human Behav. 2010;26(5):1061-1072. https://doi.org/10.1016/j.chb.2010.03.008
- 21. Lee AR, Son S, Kim KK. Information and communication technology overload and social networking service fatigue: a stress perspective. Comput Hum Behav. 2016;55:51-61. https://doi.org/10.1016/j.chb.2015.08.011
- 22. Noh GY, Choi J, Kwon MS. A test of extended technology acceptance model on health information seeking on the internet. Korea J Broadcast Telecommun Stud. 2013;27(5):49-85.
- 23. Lee SH, Pershing JA. Dimensions and design criteria for developing training reaction evaluations. Hum Resour Dev Int. 2002;5(2):175-197. https://doi.org/10.1080/13678860110053678
- 24. Choi S, Bang KS, Shin DA. eHealth literacy, awareness of pandemic infectious diseases, and healthy lifestyle in middle school students. Children (Basel). 2021;8(8):699. https://doi.org/10.3390/children8080699
- 25. Park BK. Factors influencing eHealth literacy of middle school students in Korea: a descriptive cross-sectional study. Healthc Inform Res. 2019;25(3):221-229. https://doi.org/10.4258/hir.2019.25.3.221
- 26. Nutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072-2078. https://doi.org/10.1016/j.socscimed.2008.09.050
- 27. Ministry of Science and ICT. Survey on the Internet usage [Internet]. Korean Statistical Information Service; 2024 [cited 2025 Mar 19]. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=127&tblId=DT_MH001_MI002&conn_path=I2
- 28. Baumgartner SE. The effects of digital media and media multitasking on attention problems and sleep. In: Nesi J, Telzer EH, Prinstein MJ, editors. Handbook of adolescent digital media use and mental health. Cambridge University Press; 2022. p. 317-337. https://doi.org/10.1017/9781108976237.017
- 29. Yang CC, Ariati J, Pham T, Smith C. Motives for digital social multitasking (DSMT) and problematic phone use among adolescents. J Adolesc. 2023;95(4):811-823. https://doi.org/10.1002/jad.12155
- 30. Lee J, Oh HJ. Determinants of continuous use of generative AI: focusing on the extended technology acceptance model (ETAM) and AI literacy. Korean J Advert Public Relat. 2024;26(3):96-140. https://doi.org/10.16914/kjapr.2024.26.3.96
