This cross-sectional study evaluated associations between digital health literacy (DHL) and health-related quality of life (HRQoL) among older adults with type 2 diabetes enrolled in primary care chronic disease registries in Huai'an, China. The analysis also examined whether proactive health behaviours (PHB) mediated this association and whether aspects of the digital healthcare environment modified these relationships.
The study used a cross-sectional survey completed from July to August 2025. Participants were recruited by convenience sampling from primary healthcare chronic disease management registries in Huai'an. The sample comprised 1,053 older adults with type 2 diabetes. Further details on participant inclusion/exclusion criteria, recruitment procedures, or response rates were not reported in the source.
HRQoL was measured using the EuroQol five-dimensional three-level questionnaire (EQ-5D-3L) to generate a utility score and the EuroQol Visual Analogue Scale (EQ-VAS) as a supplementary outcome. DHL, PHB, and four single-item indicators of the digital healthcare environment (including measures such as remote service use and online health management use) were assessed with structured instruments. The source reports mean scores and standard deviations for key measures but does not provide the full item lists or scoring ranges in this summary.
Associations were estimated with adjustment for covariates (specific covariates were not detailed in the source summary). Indirect-association (mediation) analyses used 5,000 bias-corrected bootstrap resamples to estimate confidence intervals. Effect-modification (interaction) analyses applied heteroscedasticity-consistent type 3 (HC3) standard errors. Sensitivity analyses were performed; interactions that reached significance under HC3 inference were evaluated for robustness and reproduced in sensitivity tests where noted.
Among the 1,053 participants, reported sample summary statistics were:
No additional demographic breakdowns, comorbidity data, or baseline clinical characteristics were provided in the source summary.
The adjusted total association between DHL and EQ-5D-3L utility was statistically significant (B = 0.000569; 95% CI 0.000228 to 0.000910). However, the direct association of DHL with utility, after accounting for PHB, was not significant (B = 0.000152; p = 0.338).
A statistically significant indirect association was observed through proactive health behaviours: DHL → PHB → HRQoL (B = 0.000418; bias-corrected 95% CI 0.000260 to 0.000619). This indirect pathway accounted for 73.5% of the total association between DHL and the EQ-5D-3L utility score. These results indicate that, in this cross-sectional sample, higher DHL was associated with better HRQoL largely via higher levels of PHB.
The supplementary EQ-VAS outcome was examined separately; an exploratory positive interaction between PHB and remote-service use was observed for EQ-VAS but characterized as exploratory and not conclusive for the primary outcome.
Four single-item indicators of the digital healthcare environment were tested as potential effect modifiers. For the primary EQ-5D-3L utility outcome there was no robust evidence that the digital environment modified the association between DHL and HRQoL. Two interactions — with remote service use and online health management use — reached statistical significance only under HC3 inference, but these findings were not reproduced in sensitivity analyses, reducing confidence in their robustness.
For the EQ-VAS outcome, one exploratory PHB-by-remote-service-use interaction suggested a positive modifying effect, but this was presented as exploratory and not confirmed as a primary finding.
In this sample of older adults with type 2 diabetes in Chinese primary care, higher digital health literacy was associated with better health-related quality of life, and most of this association appeared to operate indirectly through greater proactive health behaviours. The absence of a robust direct effect suggests that DHL may influence HRQoL primarily by enabling or promoting health-related actions rather than by a direct effect on perceived health status.
Limitations reported or implied by the source include the cross-sectional design, which precludes causal inference, the convenience sampling approach, and limited reporting of participant characteristics in the summary. Additionally, interaction findings with the digital healthcare environment were not robust across sensitivity analyses.
The authors recommend further longitudinal and interventional research to clarify causal relationships and to test whether improving digital health capabilities or promoting proactive health behaviours can improve HRQoL among older adults with type 2 diabetes.