eHealth literacy levels and associated factors among nursing students: A global systematic review and meta-analysis

The rapid digital transformation of healthcare highlights the importance of electronic health literacy (eHealth literacy) for nursing students. However, existing global evidence regarding their eHealth literacy levels and associated factors remains fragmented.

To determine the overall level of e-health literacy among nursing students worldwide, analyze its associated factors and associations with health outcomes, and provide evidence-based support for nursing education reform in the digital age.

A systematic search was conducted in eight Chinese and international databases, including PubMed, for cross-sectional studies published from the inception of each database through June 1, 2026. Study quality was assessed using the AHRQ scale, and random-effects meta-analyses and meta-regression analyses were performed using Stata 19.0. This systematic review protocol was registered in advance with PROSPERO (Registration No.: CRD420261418156).

A total of 20 cross-sectional studies involving 12,390 nursing students across 11 countries were ultimately included. The pooled eHEALS score for nursing students worldwide was29.51 (95% CI: 28.42-30.61), indicating an overall level slightly above average; however, there was extremely high heterogeneity among studies (I² = 99.4%, P < 0.001). Senior-year students demonstrated significantly higher levels of literacy than junior-year students (SMD = 0.50, 95% CI: 0.41-0.59, P < 0.001); gender had no significant overall effect on literacy (SMD = -0.04, 95% CI: -0.35-0.27, P = 0.803). Regression analysis showed that living in an urban area (β = 4.24, P < 0.001) and having good economic conditions (β = 0.79, P < 0.001) were exploratory study-level indicators associated with higher literacy. Digital health literacy was moderately positively correlated with health-promoting behaviors (r = 0.42, 95% CI: 0.35-0.49, P < 0.001) and was significantly associated with lower levels of anxiety (OR = 0.95, 95% CI: 0.92-0.99, P = 0.006).

Overall, the digital health literacy of nursing students worldwide is acceptable, but regional digital divides remain prominent. Systematic nursing education may help enhance digital health literacy, which is associated with more positive health behaviors and mental health outcomes. Institutions need to refine their digital health curriculum systems, focusing on cultivating students' abilities in information evaluation and AI-assisted decision-making to meet the evolving demands of digital healthcare and artificial intelligence.