Keywords: Digital health literacy; Primary care; Health equity; Digital inclusion; Patient activation; Social determinants of health

Background:

Digital health literacy (dHL) is essential for patient empowerment and equitable access to digital health tools in primary care. Despite increasing digitalization, disparities persist based on age, education, and place of residence. This study aims to integrate dHL as a core social determinant of health, alongside psychological constructs such as self-efficacy, activation, and resilience.

Research questions:

Which social and psychological determinants are associated with low digital health literacy in adults attending primary care, and how does this affect their self-management capacities?

Method:

We designed a prospective observational cohort study involving 395 adults aged 35–74 years, recruited from urban and rural primary care centers in Aragón, Spain. Data collection includes validated scales: HLS-EUQ16 (health literacy), PAM-13 (patient activation), GSES-12 (self-efficacy), CD-RISC-10 (resilience), and relevant sociodemographic and lifestyle variables. Logistic regression will identify predictors of low dHL, and moderation/mediation analysis (Hayes’ PROCESS) will explore interactions between psychological constructs and social determinants.

Results:

Low dHL (score <13) was significantly associated with age >65 (OR 2.3, 95% CI: 1.4–3.8), low educational attainment (OR 3.1, 95% CI: 2.0–5.0), and rural residence (OR 1.8, 95% CI: 1.1–2.9). High self-efficacy and patient activation were protective, reducing the odds of low dHL by approximately 20% (95% CI: 10–35%). These preliminary results suggest an interaction between social vulnerability and personal empowerment in determining digital health access and engagement.

Conclusions:

Low digital health literacy is strongly influenced by social and psychological factors. Integrating dHL screening and tailored support into primary care could improve digital inclusion and health outcomes. Results highlight the need for personalized, context-sensitive strategies in digital health interventions.

Points for discussion:

1. How can primary care integrate digital literacy support without increasing workload?

2. What strategies effectively reduce digital gaps in older or rural populations?

3. How can digital health literacy be routinely assessed in clinical settings?