Introduction

The issue of health literacy, although a relatively new concept in health promotion that came into general acceptance only in the late 20th century, is today an important concern in public health. The concept of health literacy encompasses a wide range of social and environmental interventions that are designed to benefit and protect health and quality of life by addressing and preventing the root causes of disease (World Health Organization, 2020). Health literacy is defined as having knowledge, motivation, and competence necessary to access, understand, evaluate, and apply information in daily life to make decisions about health services, disease prevention, and health promotion and to protect and enhance quality of life (Duong et al., 2018). The concept of eHealth literacy was elucidated in Norman and Skinner (2006) and defined as the ability to define, understand, and apply the information gained as a result of research on the Internet to provide solutions to health problems (Norman & Skinner, 2006). eHealth literacy plays an important role in increasing the capacity of students who are trained in the field of health to provide, interpret, and understand the basic health information and services necessary to make correct decisions related to patient health (Sharma et al., 2019).

Access to and selection of correct health information is very important for healthcare professionals (S. Kim & Jeon, 2020). Choosing correct health information for healthcare professionals is a basic skill gained in the undergraduate education process that further develops after graduation in line with one's area of specialization. Learning success relies heavily on a student's motivation, attitude, and self-efficacy, and technological developments in recent years have affected student learning abilities (S. Kim & Jeon, 2020; Sharma et al., 2019).

Digital technologies have become an integral part of modern education and changed the methods by which students learn (Tang & Chaw, 2016). Distance education, which has become widespread worldwide with the advance of digital technologies, is a method of education that provides easy and convenient access to learning opportunities through online learning resources such as online libraries and digital media (Prior et al., 2016). The effectiveness of distance education also relates closely to the digital technology self-efficacy of students (S. Kim & Jeon, 2020; Prior et al., 2016). In addition, the widespread use of online resources to access information about diseases and treatment by individuals in the community (Parnell et al., 2019), factors affecting health literacy level in terms of literature selection (H. Kim & Xie, 2017; Manganello et al., 2017), and undergraduate students' competence in health literacy (Sharma et al., 2019) should all be considered when designing online education content.

Midwives are health professionals who play an important role in the health, education, and care of patients. Midwifery students attend both theoretical and practical courses, including laboratory and clinical practice, during their undergraduate education that prepare them well for their professional responsibilities. The proliferation of the Internet and mobile phones has provided a very powerful platform for online learning that has been used to transfer knowledge, skills, and continuity of education in undergraduate midwifery education settings (Briones, 2015; J. H. Kim & Park, 2019). Some compulsory courses in Turkey such as foreign languages, Turkish literature, and basic information technology are already provided online to all undergraduate students, including midwifery students. Thus, midwifery students in Turkey have an extant familiarity with the online education experience (Kaçan & Gelen, 2020). During the COVID-19 pandemic, midwifery education and training in Turkey was reformatted completely to be delivered online. Midwifery students were quickly forced to adapt to this new education model for both practicum and theoretical courses. Therefore, the aim of this study was to determine the relationship between eHealth literacy and the learning self-efficacy levels of midwifery students in the context of distance education provided during the COVID-19 pandemic.

Methods Design, Data Collection, and Sample

Female midwifery students currently enrolled in a midwifery undergraduate program in Turkey were recruited as participants. Male midwifery students were not included because of the small number of male students enrolled in these programs in Turkey (Higher Education Institution, 2019). This study was conducted between June 5, 2020, and July 1, 2020 (i.e., during the 2019–2020 spring term). Snowball sampling was used for data collection. One midwifery student began to share an online questionnaire voluntarily through her social media accounts with the request that the questionnaire be reshared. In total, 578 midwifery students enrolled as participants.

The inclusion criteria for this study were as follows: (a) being a female midwifery student, (b) volunteered to participate, and (c) at least 70% of courses attended are online. The exclusion criterion was being unwilling to participate.

The national core education program for undergraduate midwifery was delivered via distance education in the Spring Term 2019–2020 (Higher Education Institution, 2016) because of the ongoing COVID-19 pandemic. Courses were designed as synchronous lessons of, at most 20 minutes, using a videoconferencing application run through the universities' information management systems. All of the synchronous lessons were recorded and shared with students through these systems. The information management systems of universities enable lecturers to send instant or time-interval online examinations, case studies, and other materials, and to give feedback for each, and enable students to submit their video-recorded activities and written examinations.

Measures

To collect research data, an online questionnaire prepared by the researchers using the literature, the eHealth Literacy Scale (eHEALS) for Adolescents, and the Online Technologies Self-Efficacy Scale (OTSES). All questions were mandatory.

Questionnaire

The questionnaire consists of two parts. Respondent demographic information, including age, grade, place of residence, family structure, and income status, was collected in the first part. Questions on distance education, time spent on the Internet, Internet connection problems, satisfaction with distance education, the effect of distance education on student learning, whether theoretical and applied courses should continue to be given by distance education, and views on distance education were collected in the second part.

eHealth Literacy Scale for Adolescents

eHEALS was developed by Norman and Skinner in 2006 to assess traditional literacy, health literacy, obtaining information, scientific research, media literacy, and computer literacy. This scale consists of eight items that assess the perception of respondents regarding using the Internet in health-related issues. Scale items are arranged using a 5-point Likert-type scale, with 1 = strongly disagree, 2 = disagree, 3 = indecisive, 4 = agree, and 5 = strongly agree. The range of total possible scores is 8–40, with higher scores indicating a higher eHealth literacy level. The Cronbach's alpha for eHEALS was found to be .88 in the first development study and .78 in a 2014 evaluation of the validity and reliability of the Turkish version of eHEALS in adolescents (Coşkun & Bebiş, 2015). The Cronbach's alpha value of the scale in this study was found to be .94.

Online Technologies Self-Efficacy Scale

The validity and reliability of the Turkish version of the OTSES, originally developed by Miltiadou and Yu (2000), was performed by Horzum and Cakir (2009) with a Cronbach's alpha value of .94. The “Internet Competency” subscale covers four subscales consisting of nine items, the “Synchronous Interaction” subscale includes four items, the “Asynchronous Interaction 1” subscale includes nine items, and the “Asynchronous Interaction 2” subscale includes seven items. The range of total possible scores for the OTSES is 29–145, with higher scores indicating higher levels of self-efficacy perception. In this study, the Cronbach's alpha value was found to be .98 for the total of the scale and ranged from .92 to .97 for the subscales.

Ethical Considerations

This study was approved by the Scientific Research Council of Bartin University (reference number: 2020-SBB-0108/June 3, 2020). All of the recruited students were informed of the objective of the study and invited to participate in the study via an email message. To ensure the confidentiality of participant information, no identification information was collected in the online questionnaire.

Data Analysis

Descriptive statistics of frequencies, percentages, means, and standard deviations were calculated. Frequency, percentage, mean, and standard deviation were used to report the demographic and distance education characteristics. Independent samples t test, analysis of variance, and Pearson correlation coefficient were used to analyze normally distributed data, and Mann–Whitney U and Kruskal–Wallis tests were used to analyze nonnormally distributed data. All data were analyzed using IBM SPSS Statistics 25.0 (IBM Inc., Armonk, NY, USA), and level of significance was set to p < .05.

Results

The average age of the 578 participants was 21 (SD = 1.83) years. One third (34.4%) were first-year students and lived in a big city, 82.5% came from a nuclear family, and 68.3% defined their family's income level as “median” (Table 1).

Table 1. - Differences in eHealth Literacy and Online Technologies Self-Efficacy, by Demographic Characteristics (N = 578) Category n % eHEALS OTSES Internet Competencies Subscale Synchronous Interaction Subscale Asynchronous Interaction I Subscale Asynchronous Interaction II Subscale Total Score Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Age (years; mean and SD) 21.10 1.83  ≤ 20 239 41.3 27.41 6.91 27.10 6.12 11.40 2.82 26.50 6.15 19.01 4.69 84.02 6.92  ≥ 21 339 58.7 29.17 7.21 28.01 6.76 12.11 3.15 28.29 6.92 20.14 5.61 88.55 7.21   t and p −2.943 .003 −1.640 .101 −2.787 .005 −3.218 .001 −2.546 .009 −2.732 .006 Program year  ① First year 199 34.4 27.43 6.62 27.39 6.01 11.50 2.84 26.79 5.88 19.12 4.70 84.80 17.41  ② Second year 146 25.3 28.08 7.65 26.89 6.78 11.42 3.13 26.63 7.19 19.05 5.44 83.99 21.03  ③ Third year 123 21.3 29.67 6.94 28.22 6.92 12.19 3.10 28.67 7.06 20.45 5.57 89.52 20.77  ④ Fourth year 110 19.0 29.36 7.29 28.40 6.53 12.50 3.05 28.89 6.52 20.65 5.52 90.45 20.15   F and p 3.326 .019 1.568 .196 4.054 .007 4.496 .004 3.624 .013 3.728 .011  Post hoc, LSD ① < ③; ① < ④ ① < ③; ① < ④; ② < ③; ② < ③ ① < ③; ① < ④; ② < ③; ② < ④ ① < ③; ① < ④; ② < ③; ② < ④ ① < ③; ① < ④; ② < ③; ② < ④ Residential area  ① Village 94 16.3 28.01 6.74 25.77 6.13 10.91 2.63 26.27 6.09 19.05 4.73 82.00 17.19  ② District 155 26.8 29.42 6.36 28.48 5.86 12.14 2.82 28.32 5.88 19.96 5.02 88.90 17.84  ③ Province 146 25.3 27.86 7.70 27.40 6.79 11.95 3.12 27.44 7.03 20.18 5.35 86.97 20.88  ④ Metropol 183 31.7 28.31 7.44 28.06 6.85 11.91 3.27 27.64 7.21 19.35 5.66 86.96 21.33   F and p 1.438 .231 3.818 .010 3.533 .015 1.892 .130 1.263 .286 2.449 .063  Post hoc, LSD ① < ②; ① < ③; ① < ④ ① < ②; ① < ③; ① < ④ Family type  Nuclear family 477 82.5 28.38 7.04 27.69 6.43 11.79 3.04 27.48 6.62 19.61 5.23 86.58 19.62  Single parent– extended  family 101 17.5 28.75 7.58 27.36 6.94 11.94 3.03 27.88 6.88 19.96 5.49 87.14 20.51   t and p 22321 a .245 0.470 .639 −0.445 .656 −0.549 .583 0.599 .550 −0.259 .796 Income level  ① Low 74 12.8 25.32 9.02 25.96 8.09 11.24 3.44 26.28 7.86 18.24 6.00 81.73 23.69  ② Median 395 68.3 28.94 6.71 27.54 6.28 11.85 2.91 27.57 6.49 19.70 5.06 86.65 18.92  ③ High 109 18.9 28.74 6.70 29.12 5.89 12.09 3.15 28.35 6.33 20.56 5.38 90.12 19.30   F and p 8.353 < .001 5.402 .005 1.798 .167 2.127 .120 4.310 .014 4.014 .019  Post hoc, LSD ① < ②; ① < ③ ① < ③; ② < ③ ① < ②; ① < ③ ① < ②; ① < ③

Note. Age range: 18–33 years. eHEALS = eHealth Literacy Scale; OTSES = Online Technologies Self-Efficacy Scale; LSD = least significant difference.

a Mann-Whitney U Test.

Differences in eHealth Literacy

The average eHEALS total score was 28.44 (SD = 7.13; Table 2). A statistically significant difference was found between eHEALS score and several demographic factors and perspectives on distance education. Participants who were < 20 years old (t = 2.943, p = .003), were in their first year (F = 3.326, p = .019), and identified their family income as “low” (F = 8.353, p < .001) earned relatively lower eHEALS scores (Table 1). Similarly, those who spent less than an hour a day on the Internet (F = 5.233, p < .001), had low satisfaction with distance education (KW = 18.163, p < .001), and wanted to continue theoretical courses through distance education (t = 2.314, p = .021) earned relatively lower eHEALS scores (Table 3).

Table 2. - Correlations Between eHealth Literacy and Online Technologies Self-Efficacy (N = 578) Variable M SD 1 2 2a 2b 2c 2d 1. eHealth Literacy Scale 28.44 7.13 1 2. Online Technologies Self-Efficacy Scale 86.68 19.76 .541** [0.17, 0.22] 1 2a. Internet Competency 27.63 6.52 .533** [0.51, 0.66] .928** [2.72, 2.91] 1 2b. Synchronous Interaction 11.82 3.04 .472** [0.94, 1.28] .907** [5.68, 6.13] .826** [1.67, 1.87] 1 2c. Asynchronous Interaction 1 27.55 6.67 .507** [0.47, 0.62] .943** [2.72, 2.88] .833** [0.77, 0.86] .803** [0.34, 0.39] 1 2d. Asynchronous Interaction 2 19.67 5.28 .458** [0.52, 0.72] .886** [3.18, 3.46] .714** [0.81, 0.95] .714** [0.42, 0.48] .780** [0.92, 1.05] 1

**Correlation is significant at the .01 level (two-tailed).

Table 3. - Differences in eHealth Literacy and Online Technologies Self-Efficacy, by Participant Perceptions of Distance Education (N = 578) Category n % eHEALS OTSES Mean SD Internet Competencies Subscale Synchronous Interaction Subscale Asynchronous Interaction I Subscale Asynchronous Interaction II Subscale Total Score Mean SD Mean SD Mean SD Mean SD Mean SD Daily time spent on the Internet  ① 1 hour and less 30 5.2 23.63 8.74 23.63 9.52 10.40 3.84 23.60 8.04 17.27 5.72 74.90 25.76  ② 2–4 hours 247 42.7 28.70 6.40 27.69 5.86 11.67 2.85 27.39 6.18 19.60 4.92 86.35 18.05  ③ 5–7 hours 199 34.4 28.42 7.48 27.57 6.96 11.85 3.16 27.36 7.07 19.59 5.53 86.37 21.16  ④ 8 hours and more 102 17.6 29.27 7.18 28.79