The mediating effects of self-efficacy, family health, and perceived stress on the relationship between perceived social support and eHealth literacy in nursing students: a structural equation model

With the rapid development of electronic technological innovations, electronic media such as internet-enabled mobile devices have become crucial channels for information acquisition and communication. People often search for health information online [1]. eHealth literacy refers to the ability to find, access, comprehend, and assess health-related information from digital platforms and subsequently use this information to manage health concerns [2]. For healthcare professionals, especially nurses, the skill to find effective and reliable health information is essential [3]. As future key members in the healthcare sector, nursing students benefit significantly from possessing eHealth literacy, which is vital for their professional development and the quality of healthcare services they provide [4, 5]. In the medical field, knowledge updates rapidly, with new research findings, treatment methods, and technologies continually emerging. Nursing students with eHealth literacy can utilize online resources to stay informed about these new developments, adopt new technologies, and enhance their professional competence, thereby offering higher-quality healthcare services to patients [3, 5]. Elevating eHealth literacy among nursing students helps shape well-rounded healthcare professionals, meeting societal demands, and promoting the advancement of the healthcare industry [4].

Nursing students face a uniquely demanding educational experience that combines rigorous academic coursework with extensive clinical practice. The need for practical skills, emotional resilience, ethical decision-making, interdisciplinary collaboration, and continuous learning sets nursing education apart from many other academic disciplines [6]. Social support may assist them in dealing with these challenges and improve their mental health [7]. Prior studies have confirmed the influence of perceived social support on eHealth literacy [8‐10]. Meanwhile, the eHealth literacy levels among nursing students still require improvement [5].

Currently, there remains a gap in understanding how perceived social support affects eHealth literacy. Bandura’s Social Cognitive Theory emphasizes the interplay between personal, environmental, and behavioral factors [11]. In this framework, perceived social support and family health are considered environmental factors, while self-efficacy and perceived stress are personal factors. These factors may interact to collectively affect individual behavior, such as eHealth literacy [11]. Specifically, perceived social support may enhance self-efficacy, helping nursing students cope with psychological stress, and may support improvements in their eHealth literacy [12‐14]. Family health also plays a critical role by providing emotional support and a stable home environment, which may indirectly foster eHealth literacy [15, 16]. This study aims to explore the relationship between perceived social support and eHealth literacy among Chinese nursing students, focusing on how personal factors (self-efficacy, perceived stress) and environmental factors (perceived social support, family health) interact to affect eHealth literacy. By gaining a deeper understanding of these interactions, this study will help to provide scientific evidence to improve nursing students’ eHealth literacy, offering strategies and new approaches for nursing education.

Perceived social support refers to the perception of available resources or supportive social relationships obtained through social interactions [17], typically encompassing support from parents, friends, teachers, and others. It has been widely acknowledged as a critical factor influencing health behaviors and outcomes [18]. A study conducted on Korean women undergoing breast cancer treatment found that social support significantly impacts eHealth literacy [8], indicating that those who perceive higher support levels are more likely to engage with and benefit from eHealth resources. Similarly, research involving primary care providers in China also found a significant link between social support and eHealth literacy [9]. Furthermore, a study of 947 college students in China found a similar association between social support and eHealth literacy [10]. Within contemporary society, the role of perceived social support may be significant in facilitating individuals’ engagement with eHealth resources, thereby enhancing their eHealth literacy [9].

Self-efficacy refers to an individual’s confidence in their capacity to plan and carry out the actions necessary to handle future situations, serving as a decisive factor influencing behavior [19]. It affects how individuals cope with challenges, their perseverance in the face of difficulties, and their overall engagement in health-promoting activities [20]. According to Social Cognitive Theory, social support can enhance self-efficacy by providing encouragement, modeling effective behaviors, and offering instrumental assistance [11]. Previous research has shown that social support increases self-efficacy, which in turn promotes health behaviors [12]. A cross-sectional mixed methods study confirmed the impact of self-efficacy on eHealth literacy among adolescents [13]. Therefore, high perceived social support may boost individuals’ confidence in their ability to use digital health resources, thereby enhancing their eHealth literacy [11‐13].

Family health refers to the overall health and well-being of family members and the family unit as a whole, playing a crucial role in maintaining health and preventing disease [21]. A healthy family creates an environment of belonging and shared care among its members, enhancing their health and quality of life [21]. Research has shown that social support is a positive predictor of family functioning [22]. Families with higher perceived social support can create a supportive environment that provides emotional stability and exhibits strong communication patterns and effective problem-solving skills, all of which contribute to overall family health [23, 24]. Studies have also found that a healthy family environment can boost individuals’ confidence in using eHealth resources, thereby improving their eHealth literacy [15, 16]. Family Systems Theory [25] provides a deeper understanding of these relationships by positing that individuals cannot be understood in isolation from their family unit, as family members are interconnected and interdependent. Within this theoretical framework, perceived social support and eHealth literacy are not simply individual attributes but are instead deeply embedded in the family environment. Therefore, in conditions of high perceived social support and family health, the eHealth literacy of family members may enhance the eHealth literacy of the entire family unit.

Perceived stress reflects a person’s thoughts or feelings regarding their current degree of stress [26]. Nursing students often encounter high levels of stress [6], making effective stress management crucial for maintaining their academic performance and mental health [27]. The stress-buffering model suggests that social support aids individuals in managing crises, better adapting to environmental changes, and increaseing their sense of security and confidence in the face of stress [28]. Additionally, nursing students’ self-efficacy has been proven to significantly affect perceived stress [14]. Therefore, we hypothesize that perceived social support may reduce perceived stress through the mediation of self-efficacy. Moreover, family health is adversely affected by high levels of stress [29]. Families with strong social support networks may tend to exhibit lower stress levels, promoting healthier interactions and environments, which benefit family health, encourage better health behaviors, and ultimately enhance eHealth literacy [15, 16].

Based on previous research findings, this study suggests the following hypotheses (Fig. 1):

This study explored the mediating roles of self-efficacy, family health, and perceived stress in the relationship between perceived social support and eHealth literacy among nursing students in China. In general, the results indicated that the perceived social support had a negative direct effect, a positive indirect effect, and a positive total effect on eHealth literacy. Self-efficacy and family health emerge as pivotal mediating factors, indicating the pathways through which perceived social support affects eHealth literacy. Perceived social support, through a chain mediation of self-efficacy, perceived stress, and family health, indirectly affects the Chinese nursing students’ eHealth literacy.

This study indicated a significantly negative direct effect of perceived social support among nursing students on their eHealth literacy. Therefore, the H1 hypothesis was supported. Previous studies have predominantly underscored the beneficial role of social support in promoting health behaviors and outcomes [37‐39], diverging from our findings. We hypothesize this inconsistency may stem from the degree of reliance nursing students place on social support. Within nursing education, various factors such as extensive knowledge acquisition, skill training, clinical internship requirements, stringent assessment and evaluation criteria [40], as well as encountering challenges like managing emergencies during clinical internships [41], may prompt them to seek more social support for coping and adaptation to gain a sense of security and confidence [42]. While social support can offer valuable resources and assistance, an overreliance on others’ support may diminish individual autonomy and self-learning capabilities [43], which can reduce their motivation to actively engage in health-related tasks and subsequently affect the cultivation of their eHealth literacy. Hence, we emphasize the significance of fostering students’ autonomy and problem-solving abilities in nursing education to mitigate excessive reliance on external support. Future research should delve deeper into the potential mechanisms and boundary conditions of this relationship, furnishing insights for tailored interventions and educational strategies aimed at enhancing eHealth literacy across nursing students.

Our findings indicated that perceived social support positively affected eHealth literacy through the mediating role of self-efficacy, thereby supporting the H2 hypothesis. This finding was consistent with Bandura’s Social Cognitive Theory, which suggested that self-efficacy is crucial to individuals’ motivation, behavior, and achievement [11]. Perceived social support serves as an important psychosocial resource that individuals may use to deal with challenges and adversities across various life domains [44]. Previous research has shown that social support fosters individuals’ self-efficacy [45]. Nursing students who perceive higher perceived social support may develop stronger beliefs in their ability to effectively navigate and utilize electronic health resources. Individuals with strong self-efficacy are more inclined to actively seek and utilize digital health information, overcome technological barriers, and critically evaluate the credibility and relevance of online health resources [46], which can contribute to their eHealth literacy. Our study underscores the significant roles of perceived social support and self-efficacy in promoting individuals’ eHealth literacy, contributing to a better understanding of the psychosocial factors shaping individuals’ engagement with digital health resources.

Our study revealed that perceived social support among nursing students positively affected eHealth literacy through the mediating role of family health. Thus, the H3 hypothesis was supported. Meanwhile, consistent with the Family Systems Theory [25], individual behavior can be influenced by family circumstances. Previous research has also demonstrated that social support can positively predict family functioning, enabling families to cope with dysfunction and promote family health [22]. Parents have an important role in fostering healthy lifestyles, and a health-promoting family environment encourages individuals to make healthier choices [47]. Therefore, a supportive and health-conscious family environment may facilitate open discussions about health issues and encourage the effective use of digital health tools for health management [15, 16]. By recognizing the impact of family-level factors on eHealth literacy, healthcare practitioners and policymakers can devise interventions and educational programs targeted at the family level to promote eHealth literacy, empowering individuals to take an active role in managing their health.

This study discovered that perceived social support could indirectly affect the eHealth literacy of nursing students in China through a chain mediation effect of self-efficacy, perceived stress, and family health, thereby supporting the H4 hypothesis. Furthermore, the findings offer empirical evidence for Social Cognitive Theory [11], which emphasizes the role of both individual and environmental factors in shaping behavior. Meanwhile, this finding also aligns with the stress-buffering model [28], which suggests that social support increases individual feelings of security and confidence in coping with stress. Previous studies indicated that perceived social support enhances individuals’ self-efficacy, with higher perceived social support may exhibit greater self-efficacy [45, 48]. Nursing students with high self-efficacy are often more confident and optimistic, better equipped to handle challenges and stress, thus potentially experiencing lower perceived stress [49]. When they perceive lower stress, they may demonstrate more positive changes conducive to family health, such as improved mental health, enhanced emotional support, healthier lifestyles, and improved communication, fostering a relaxed and enjoyable family atmosphere [29, 50, 51]. Higher levels of family health may suggest a supportive family environment, potentially increasing their access to health-related resources and aiding in the cultivation of eHealth literacy [15]. This study suggested the importance of comprehensive interventions in nursing education and practice that target not only nursing students’ capacities but also broader social and family environments to promote optimal development in eHealth literacy.

The findings indicated that perceived social support had a direct negative effect on eHealth literacy. However, its total effect remains positive through mediating mechanisms, highlighting the complexity of the relationship between perceived social support and eHealth literacy. This relationship may also be affected by other factors or pathways. For instance, personality traits and cultural backgrounds can affect how nursing students perceive and utilize social support [52]. Additionally, environmental factors such as the accessibility of eHealth resources and the quality of digital health information may impact the association between social support and eHealth literacy [53]. These findings underscore the need for targeted interventions to optimize the positive effect of perceived social support on eHealth literacy while mitigating potential drawbacks. Future research should explore the mechanisms that connect social support to eHealth literacy, aiming to develop targeted strategies for effectively promoting eHealth literacy among nursing students.

This study had several limitations. First, while our sample consisted of 967 nursing students from various regions and diverse educational backgrounds, the extent to which our findings can be generalized may still be restricted. To enhance external validity, future studies should aim to incorporate participants from a broader range of geographic and cultural backgrounds. Second, given the cross-sectional design of this study, establishing causality among the variables is not possible. Longitudinal designs in future research could provide a more thorough exploration of the causal relationships involved. Third, the reliance on self-reported data raises concerns about potential social desirability and recall biases. Future studies should utilize objective measurement instruments to confirm the accuracy of self-reported information.

This study explored the relationship between perceived social support and eHealth literacy in Chinese nursing students, demonstrating the positive effect of perceived social support on eHealth literacy through a mediating role of self-efficacy, perceived stress, and family health. It underscored the interconnection of individual and environmental factors in cultivating health behaviors, highlighting the importance of a holistic approach in nursing education and practice. The findings suggest that nursing education programs should focus on supporting social support systems and fostering a healthy family environment to enhance nursing students’ eHealth literacy. It provides valuable insights into the mechanisms through which perceived social support impacts eHealth literacy, offering practical strategies for developing well-rounded, competent nursing professionals, ultimately contributing to their professional development and the quality of healthcare services they provide.