Introduction

The Centers for Disease Control and Prevention (CDC) describes chronic diseases as “conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.” Chronic diseases, such as cardiac disease, cancer, and diabetes, are leading causes of mortality and disability worldwide1. Besides, the prevalence of chronic diseases and multimorbidity is on the rise2,3. Behavioral and nutritional changes, including increased smoking and diets high in fat and sugar, have contributed to a global increase in the incidence of obesity, metabolic diseases, and cancer4.

Chronic conditions continue to be a significant public health problem in Türkiye. Chronic diseases account for 68.9% of all deaths in Türkiye, with circulatory system diseases ranking first among causes of mortality at 33.4%5. Among individuals aged 15 years and older, the prevalence of having a single chronic condition is 22%, while the rate for those with two or more chronic diseases is 13.7%6. In addition, the prevalence of risk factors leading to chronic diseases remains high. In the general population, the prevalence rates are reported as 32.8% for hypertension, 30.5% for smoking, and 33.3% for obesity7.

Cancer and other chronic diseases share common risk factors such as aging and unhealthy lifestyle habits—including smoking, poor diet, physical inactivity, obesity, and alcohol use8,9. Certain non-cancer chronic conditions may also predispose individuals to cancer, independent of these shared risk factors. A prospective cohort study in Taiwan with 405,878 patients followed up over an average of 8.7 years reported that chronic diseases contributed to more than one-fifth (20.5%) of cancer incidence and more than one-third (38.9%) of cancer-related deaths9. Diabetes is also consistently associated with a moderate increase in cancer risk10 and recognized as a risk factor for several solid malignancies, including pancreatic, liver, colorectal, breast, and endometrial cancers11. Patients with cardiovascular diseases are also at higher risk for multiple cancer subtypes and cancer-related mortality12. A previous study demonstrated that patients with hypertension had a 1.6-fold increased risk of renal cell carcinoma13. It was also shown that hypertension is associated with an 11% increased risk of colorectal cancer14 and a 7% increased risk of breast cancer14,15. Furthermore, a plethora of studies linked lung diseases (e.g., chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema) with an elevated risk of lung cancer16.

Cancers represent a significant public health concern with a considerable economic burden in the 21 st century. They are responsible for nearly one in six deaths from non-communicable diseases (NCDs; 16.8%) and one in four deaths (22.8%) globally. They are also a significant contributor to premature mortality from NCDs, accounting for approximately three out of every 10 global deaths among individuals aged 30–69 (30.3% of the total) and stand among the three primary causes of death within this age group in 177 out of 183 countries17. In Türkiye, cancers represent the second leading cause of mortality, accounting for about one-third (29.1%) of preventable deaths18.

The avoidance of risk factors, coupled with early diagnosis and prompt treatment, is key to the reduction of the global cancer burden19, leading numerous countries to offer cancer screening programs for the general population20. The screening of the general population for solid organ cancers, including breast, colorectal, and cervical cancers, satisfies the criteria for an efficient screening program21,22. Nonetheless, current cancer prevention strategies predominantly focus on lifestyle-related risk factors and tend to overlook non-cancer chronic conditions as modifiable contributors to cancer risk23,24. In this sense, it was suggested that future cancer prevention frameworks should expand their scope to explicitly address non-cancer chronic diseases as potential targets for intervention9. Moreover, the extant literature does not yield a definitive answer as to whether the presence of a chronic disease constitutes an obstacle to screening. Some argue against routine screening in older adults and sick populations as the increased risk of death from other causes (e.g., cardiovascular disease and infection) may limit the benefits of screening25,26. On the other hand, it is argued that early detection of cancer should be regarded as a fundamental aspect of standard clinical practice, given its detrimental impact on life expectancy and the elevated prevalence of specific types of cancer among older adults and chronic patients27,28.

A review of the literature on cancer diagnosis in patients with chronic illnesses reveals a complex interplay between the presence of a chronic disease and cancer progression. While some chronic diseases, including dementia, neurological disorders, pulmonary conditions, cardiovascular disease, and major psychiatric disorders, appear to confer an elevated risk of advanced cancer stage at diagnosis, some others (e.g., hypertension, dyslipidemia, and benign gastrointestinal and musculoskeletal disorders) are linked to a reduced likelihood of advanced stage diagnosis29.

A growing body of evidence from research on chronic patients’ participation in cancer screening programs indicates that those with multiple chronic health problems, particularly those with severe disabilities, are less likely to engage in screening for breast, cervical, and colorectal cancers30,31,32,33. Moreover, individuals with HIV infection34, depression35, obesity36,37, and chronic renal failure38 were reported to be less likely to participate in cancer screening. In contrast, individuals with musculoskeletal disorders39 and chronic liver disease40 are more likely to undergo cancer screening. Heterogeneous effects were reported among people with diabetes41,42. However, a lack of awareness regarding risk factors and screening procedures, apprehension about potential test results, inadequate knowledge about screening, and negative emotional responses represent the primary obstacles to screening in patients with chronic conditions38.

Health literacy is key to managing chronic conditions and adherence to treatment regimens, as well as adherence to early detection behaviors for cancer43,44. Inadequate health literacy is associated with poor comprehension of medical conditions45, reduced adherence to recommended treatments46, elevated medical costs47,48, and a diminished inclination to participate in preventive interventions, including cancer screening programs49.

Encompassing the capacity to access, comprehend, evaluate, and utilize health information to make well-informed decisions, health literacy has emerged as a pivotal component of health-related intervention and strategy plans in the context of acute and chronic diseases, disadvantaged communities, and the general population50. However, despite a plethora of evidence that individuals with chronic conditions are among the groups that require greater access to health information51, the majority lack the capacity to accurately define and utilize it52. Furthermore, the prevalence of chronic diseases increases with age53 and is negatively associated with poor socioeconomic status54. Individuals with a chronic disease also demonstrate lower levels of computer and health literacy55.

The term eHealth literacy was first proposed by Norman and Skinner in 2006. The concept refers to “the ability to search, find, understand, and evaluate health information from electronic sources and to apply the acquired knowledge to health problems”56. As a relatively novel concept, it has only recently begun to gain traction in academic discourse57. Norman and Skinner revised the definition of the concept by modifying the US Institute of Medicine (IOM) definition (2004). eHealth literacy is a multidimensional construct comprising three interrelated dimensions: the individual (the capacity to process information and manage one’s own health), the system (access to functional digital services and their adaptability to individual needs), and the interaction between them (the ability to actively engage with digital services, perceive them as safe and in control, and feel motivated to engage with digital services)58,59. Conceptualizing eHealth literacy as an integration of multiple literacies, Norman and Skinner proposed that this construct comprises six core competencies rooted in the principles of social cognitive theory and self-efficacy theory60: traditional literacy, health literacy, information literacy, scientific literacy, media literacy, and computer literacy56,61. Following the development of the concept, they operationalized eHealth literacy through the creation of the eHealth Literacy Scale (eHEALS)56. The scale underwent extensive validation and reliability testing across multiple languages and was widely employed in research across countries62.

In this digital age, people are increasingly turning to the internet as a source of health information. This shift provides new avenues for managing chronic diseases and facilitates continuous, two-way communication between healthcare professionals and patients63,64. In Türkiye, the rate of households with internet access is high, at 95.5%65, and internet usage for the purpose of accessing health-related information is pervasive66. Nevertheless, internet usage among individuals aged 55–74 years remains relatively low in Türkiye. A slightly more than half of men (57%) and only 41% of women in this age group report internet usage. In contrast, the corresponding figures are significantly higher in several European countries: 88% of men and 84% of women in Germany; 83% of men and 85% of women in France; and an equal 96% for both men and women in Switzerland67.

Prior research among individuals with a chronic condition demonstrated that advanced eHealth literacy is associated with enhanced access to health information, self-management of care, health-promoting behaviors, and reduced mortality68,69. Moreover, eHealth can assist patients in attaining their health objectives and foster a sense of personal responsibility for their well-being70. Individuals with superior eHealth literacy are better able to obtain accurate health information, assess the quality of that information, demonstrate enhanced self-management capacity, establish more effective connections with healthcare practitioners, and participate in treatment and nursing decision-making processes71,72. Community members must participate in screening programs to observe the benefits of community-based cancer screening programs, such as reducing cancer-specific mortality rate, cancer-specific fatality rate, and cancer-specific complication/sequelae rate, preventing recurrence and metastasis, and increasing patients’ quality of life73. Studies with a foci of the general population showed that that contributing to cancer awareness and knowledge is a valuable strategy for promoting participation in cancer screening74,75,76. Moreover, it is essential to accurately measure the attitudes of individuals getting or not getting screened to reliably predict their behaviors77.

For example, individuals with insufficient health literacy were found to demonstrate low rates of participation in various cancer screening tests, including mammography, fecal occult blood tests, colonoscopies, and Pap smears78,79,80,81,82,83. Yet, the existing literature lacks research that addresses eHealth literacy and cancer screening attitudes in patients with chronic conditions. It should also be noted that individuals with a chronic disease must navigate the complexities of their processes while also facing an elevated risk of developing certain types of cancer. Moreover, screening for certain cancer types may not be advised in the context of specific chronic diseases. In this complex situation, one prerequisite for chronic patients to cooperate with their physicians is to have a high level of health/eHealth literacy, even though disabilities or other handicaps can make the use of technology difficult (Watkins & Xie, 2014). Although evidence supporting the link between cancer and chronic diseases is steadily growing, there is still no standardized practice for routinely conducting cancer screenings among individuals with chronic conditions within current healthcare systems. In such cases, the decision to screen often depends on factors such as physician preference, the type and prognosis of the chronic disease, and patient preferences.

Overall, the principal aim of this study is to identify factors that may influence cancer screening behaviors among individuals with chronic diseases. The secondary aim of this study is to explore the cancer screening behaviors and eHealth literacy levels of individuals with chronic diseases from diverse backgrounds and to examine the effect of their eHealth literacy on their cancer screening attitudes.

Materials and methods

This cross-sectional study included 300 individuals receiving inpatient treatment in the internal medicine, pulmonology, cardiovascular surgery, and neurology wards in the single training and research hospital of a Central Anatolian province with a population of 350,000. Participants aged 30 years and older were diagnosed with a chronic disease at least six months ago, were conscious, had the cognitive ability to respond to survey questions, could communicate verbally, and agreed to participate in the research voluntarily.

We collected the data face-to-face using the eHealth Literacy Scale (eHEALS) and the Attitude Scale for Cancer Screening (ASCS) in the mentioned wards between August 1 and November 30, 2023. Given that the recommended age range for cancer screening programs is 30–70 years, the validity and reliability of the ASCS were tested with participants in this age group. Therefore, the ASCS was administered only to patients aged 30 to 70 years (n = 163). In contrast, the eHEALS was administered to all individuals who consented to participate and satisfied the inclusion criteria (n = 300). To facilitate data analysis using two separate scales, we set 30 years as the lower age limit for our sample. During data collection, only five patients under the age of 30 were admitted to the wards, which further supported our age restriction. We did not use a predetermined sampling method; instead, we administered the questionnaire to all eligible and voluntary patients hospitalized in the relevant wards during the data collection period. We tracked new admissions daily. In total, 320 patients were admitted to the clinic during the study period, of whom 20 were excluded for not meeting the inclusion criteria.

We performed a pilot study with the data of ten patients prior to the main study and finalized the questionnaire form. The data of these ten pilot study participants were not included in the main analyses. Besides, we calculated the statistical power of the study using the GPower-3.1.9.4 program at a 95% confidence interval (CI). The relationship between cancer screening attitudes and eHealth literacy was assumed to be 0.259. Accordingly, we calculated the power as 0.99 for a sample size of 300 and 0.95 for a sample size of 163, with an alpha level of 0.05.

Data collection tools

We collected the data using a demographic information form, designed to elicit participants’ and disease-related characteristics besides their sociodemographic information, the eHEALS, and the ASCS.

Demographic information form

Based on a review of relevant literature (Aytepe & Donmez, 2022; Kurtoğlu et al., 2022), the form used in our study was developed for this study. We generated a 17-question demographic information form to elicit participants’ sociodemographic characteristics (e.g., age, gender, educational attainment, employment, marital status, smoking, and internet usage), clinical features related to their chronic disease, and cancer screening practices.

eHealth literacy scale

The eHEALS was designed by Norman and Skinner (2006) and adapted into Turkish by84. The scale consists of 5-point Likert-type 2 items about internet usage (1 = Not useful/important at all, 5 = Very useful/important) and 8 items about internet attitudes (1 = Strongly disagree, 5 = Strongly agree). The items about internet usage are not considered in scoring, so one may get the lowest and highest total scores as 8 and 40, respectively. Higher eHEALS scores indicate greater eHealth literacy56. In this study, we calculated the internal consistency of the total eHEALS score to be 0.99.

Attitude scale for cancer screening

Yıldırım Oztürk et al. developed the scale to assess cancer screening attitudes of people aged 30–70 years. Age range was specified as 30–70 since the minimum age requirement for the “National Cancer Screening Program” was 30 (for cervix cancer) and the maximum age requirement was 70 (for colorectal cancer). The five-point Likert-type scale consists of 24 items (1 = Strongly disagree, 5 = Strongly agree). Six items on the scale (items 17, 18, 19, 20, 21, 22, 23, and 24) are reverse-scored. One may obtain the lowest and highest scores as 24 and 120; the higher total scores indicate a positive attitude toward cancer screening. While the authors calculated the internal consistency of the scale to be 0.95 in the original study85, we found it to be 0.95 in this study.

Ethical considerations

The Research Ethics Committee of Nigde Omer Halisdemir University granted ethical approval to our study (No: 2023/06 dated 04/03/2023), and we obtained written informed consent from all participants. We strictly followed the ethical principles outlined in the Declaration of Helsinki in each research phase.

Data analysis

We analyzed the data using the free trial version of Statistical Package for Social Sciences (SPSS) for Windows 25.0. The data are presented as number (n), percentage (%), mean (M), and standard deviation (SD). We accepted the data to normally distribute when skewness and kurtosis values fall within ± 286. While adopting parametric tests for normally distributed data, we performed non-parametric tests for the data exhibiting non-normal distribution in sub-groups of participants’ sociodemographic characteristics.

While the Independent samples t-test and Mann-Whitney U test were adopted to make independent pair-wise comparisons, we performed a one-way analysis of variance (ANOVA) with post-hoc (Bonferroni) and Kruskal Wallis-H test for multiple independent comparisons. For reliability concerns, we calculated the internal consistency of the participant’s scores on both scales. The relationship between eHealth literacy and cancer screening attitudes was uncovered with Persons’ correlation analysis, and we ran a simple linear regression analysis to determine if eHealth literacy significantly predicts cancer screening attitudes. We accepted a p-value of < 0.05 as statistically significant in all analyses.

Findings

We present the sociodemographic characteristics of 300 participating chronic patients in Table 1. We found the mean age to be 67.99 ± 13.09 years (30–90 years). More than half of the participants (54.3%) were aged 30–70, 52.3% were males, Of them, 44.3% had only a primary school education, and more than one in four (27.3%) were illiterate. The majority were married (80.7%), and 31.3% of female participants identified as housewives. Additionally, over half of them (56%) did not have a regular source of income (Table 1).

Table 1 Participants’ sociodemographic characteristics.
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The majority (90%) of participants were non-smokers. Hypertension (64.0%), diabetes (58.3%), and chronic obstructive pulmonary disease (COPD) (30.0%) were the most prevalent diseases among participants. More than half of them (65.3%) reported two or more chronic conditions. We discovered that 66.3% visited their physicians on a regular basis, 34.3% adhered to a dietary regimen, and 87.7% had regular medication adherence. Only 20.0% were knowledgeable about cancer screening programs, particularly breast cancer (50.0%). A total of 36.3% of the participants had previously undergone cancer screening, with the most commonly performed screening being mammography (50.0%). The top three factors that facilitated cancer screening among participants were guidance from a healthcare worker, family encouragement, and the presence of symptoms. In contrast, the primary barriers to screening were the absence of complaints, lack of knowledge, and advanced age (Table 2).

Table 2 Participants’ health characteristics.
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We determined that 71.3% lacked the ability to utilize the internet. Of those having the ability to use the internet, 69.8% did so for health-related purposes. Facebook was the most frequently utilized platform for searching health-related content (45.0%). Finally, 7.9% of internet users had previously acquired some information about cancer screening programs online (Table 3).

Table 3 Participants’ internet usage characteristics.
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Participants’ mean scores on the scales are demonstrated in Table 4.

Table 4 Participants’ mean scores on the scales.
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Our findings showed significant differences between participants’ eHEALS scores and their age, educational attainment, employment, and smoking (p < 0.05). In other words, those aged 71 and younger, those with a higher education diploma, those employed, and smokers had significantly higher eHEALS scores. Yet, patients with COPD and hypertension scored significantly lower on the eHEALS (p < 0.05).

On the other hand, we administered the ASCS only to participants aged 30–70 years (n = 163) and found no significant difference between their sociodemographic characteristics and ASCS scores (p > 0.05). Nevertheless, participants knowledgeable about cancer screening programs and those getting screened for cancer before had significantly higher ASCS scores (p < 0.05).

The results also yielded that those with higher internet usage ability scored significantly higher on the eHEALS and ASCS (p < 0.05). Furthermore, participants with health-related internet usage and previous attempts to learn about cancer screening programs online had significantly higher scores on the eHEALS (p < 0.05; Table 5).

Table 5 Participants’ scores by their sociodemographic Characteristics, clinical Features, and internet usage.
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Participants with poor eHealth literacy (M = 86.53, SD = 20.67) had significantly lower cancer screening attitude scores than those with sufficient eHealth literacy (M = 96.70, SD = 19.71), t(161) = −2.933 (p < 0.05). Besides, we found a weak positive relationship between participants’ eHealth literacy and cancer screening attitudes (r = 2.59, p < 0.01).

The regression analysis showed that eHealth literacy significantly predicted cancer screening attitudes (p < 0.05; Table 6). In this regard, 6.4% of the change in participants’ cancer screening attitude scores was explained by their eHealth literacy scores (Adjusted R2 = 0.064). Therefore, it can be asserted that increased eHealth literacy has a positive effect on one’s cancer screening attitudes.

Table 6 Impact of eHealth literacy on Cancer screening attitudes.
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Discussion

This study was designed to examine cancer screening behaviors and eHealth literacy levels among patients with a chronic disease from diverse backgrounds, with a particular focus on the influence of eHealth literacy on cancer screening attitudes. In our study, we focused on a cohort characterized by various disadvantages, including poor education, high comorbidity, the presence of chronic diseases requiring inpatient care, advanced age, and low income.

Over the past two centuries, the average life expectancy of the global population has increased exponentially, largely attributable to advancements in modern medicine and effective public health initiatives. Yet, the increase in life expectancy has also resulted in a concomitant rise in the prevalence of chronic diseases, including cancer87. The term chronic disease is used to describe conditions that necessitate adherence to a treatment plan for efficient control. Even though the relevant literature reports varying adherence rates among those with a chronic disease88,89,90,91,92, we discovered that 62.8% of our patients had a strict adherence to treatment (i.e., dietary regimen, regular visits to a healthcare professional, and regular medication).

A substantial body of literature exists on the determinants of cancer screening behaviors93,94,95. Nevertheless, despite the rising prevalence of chronic disease, there remain gaps in our understanding of the impact these conditions have on cancer screening behaviors among patients and medical practitioners4,29,96,97. The prevailing approach in clinical practice guidelines, typically centered on a single chronic disease, has limitations in fully addressing the needs of patients with multimorbidity98. Therefore, a personalized approach that considers the specific conditions and preferences of individuals is essential for the efficient management of chronic diseases99,100. Designing and implementing standardized protocols for the management of chronic diseases is anticipated to be a protracted process. Consequently, there may be a degree of variability in the decision to undertake cancer screening in patients with chronic diseases, contingent on the individual physician’s perspective. For this very reason, it seems critical to understand the roles of e/Health literacy and cancer screening attitudes, particularly among those with a chronic disease, in collaborating with their physician regarding cancer screening.

As part of the cancer screening program in Türkiye, individuals are recommended to participate in the following practices: annual clinical breast examination for breast cancer, biennial mammography for women aged 40–69, a quinquennial HPV-DNA test for women aged 30–65 for cervical cancer, a biennial fecal occult blood test, along with a decennial colonoscopy, for both men and women aged 50–70 for colorectal cancer101. Nevertheless, the general population exhibits a relatively low level of participation in cancer screening in Türkiye in comparison to other countries. In the United States, for example, the rate of mammography screening among women aged 50–74 years is 78.0%102, the rate of Pap smear among women aged 45–64 years is 73.5%103, and the rate of colorectal cancer screening among people aged 50–75 years is 74.0%104. However, the most recent data in Türkiye demonstrates these rates to be 7.3%, 7.2%, and 2.4%, respectively18. From this perspective, one critical factor in increasing early detection rates and reducing mortality may be disseminating cancer-related information to the general population. Along with the trend of health-related internet usage, the Turkish Ministry of Health, as well as other non-profit organizations, engage in offering an increasing number of online cancer information resources105,106.

In contrast to the general population, the risk of cancer is typically elevated in individuals with a chronic disease. As an illustration, the likelihood of developing cancer increases in patients with inflammatory rheumatic disorders, chronic kidney failure, Type 2 diabetes, and COPD107,108. Despite the elevated risk of cancer, preexisting chronic conditions may impede patients’ engagement in cancer screening, prompt them to seek assistance for new and/or evolving symptoms, and influence clinicians’ decisions concerning the utilization of diagnostic procedures29. Some chronic ailments that necessitate regular follow-ups potentially also facilitate earlier diagnostic opportunities109. In all cases, patients’ profound awareness of their disease is pivotal in fostering a collaborative relationship with their physician.

Although we did not discover a significant difference in cancer screening attitudes between those with and without comorbidity, a previous study demonstrated that the presence of multiple chronic conditions has a deleterious impact on female patients’ engagement in mammography110. A high comorbidity burden was linked with an increased likelihood of colorectal cancer screening but a decreased likelihood of breast and cervical cancer screening (Kurani et al., 2020). In a separate investigation of individuals with chronic kidney disease (CKD), participants identified several factors that influenced their preferences regarding cancer screening, including seeking guidance from their attending clinician or transplant team, comprehending pre-and post-test results, and being able to access information tailored to patients with CKD regarding cancer screening108.

Our findings indicated moderately favorable cancer screening attitudes among participants and that about one in three had undergone a cancer screening test, with nearly half of this group having received mammography. While cancer screenings are free of charge and widely accessible at the primary care level in Türkiye, participation rates in screenings remain significantly below the desired level111. Hence, it seems critical to understand the factors that facilitate or hinder participation in cancer screening. In this study, we identified guidance from a healthcare professional as the most significant facilitating factor in getting screened for cancer. Similarly, prior research on breast and colorectal cancer screening indicated that a physician’s recommendation is robustly correlated with the decision to undergo a cancer screening112,113,114,115,116,117. It was postulated that physicians’ familiarity with their patients’ concerns and expectations would heighten their propensity to recommend screening, particularly in countries lacking standard protocols. Furthermore, a close and long-standing patient-physician relationship could facilitate a more conducive atmosphere for deliberating the merits and disadvantages of screening, consequently reducing the number of redundant tests (Bringedal et al., 2019). A previous investigation into the experiences of individuals living with chronic liver disease revealed an intriguing correlation between a sense of inclusion in the decision-making process regarding one’s condition and higher rates of receiving cancer screening (Li et al., 2017). From this vantage point, it is crucial for patients to possess elevated e/Health literacy, thereby fostering heightened awareness of their concerns and expectations, which, in turn, facilitates more efficacious communication with the physician. As other factors facilitating cancer screening included family guidance and the absence of symptoms, awareness training on cancer screening could be recommended to target families. In addition, it is important to present cancer symptoms in a simple, understandable manner, particularly for older individuals. Providing services that enhance cancer screening accessibility for older adults is also essential. For instance, older adults living alone could benefit from tailored services, such as companion support, transportation assistance, and mobile cancer screening units.

In our study, one-third of participants indicated that the absence of any symptoms/complaints might hinder undergoing cancer screening. A similar study examining attitudes toward mammography revealed that 24.8% of women reported that the absence of any symptoms constituted a barrier to receiving screening112. In this study, the mean cancer screening attitude score was 89.66 ± 20.86. In a series of studies conducted with disparate populations, the attitude scores pertaining to cancer screening exhibited consistency118,119,120,121, with positive correlations observed with prior cancer-related knowledge and getting screened before. Additional barriers to cancer screening included insufficient knowledge and advanced age. Therefore, it is essential to expand awareness programs starting at the primary care level and ensure that age and age-related factors are highlighted in these programs.

Our findings showed that while participants with higher levels of education exhibited more favorable attitudes toward cancer screening, their ASCS scores did not significantly differ by their sociodemographic characteristics. Prior research indicated a positive correlation between educational attainment and screening behaviors and attitudes122,123. Besides, a review of the literature on mammography revealed that although a lack of health education and poor educational attainment124,125 may be risk factors for non-participation in screening programs, high educational levels and prior knowledge about cancer screening are strongly associated with higher participation in these programs126. The present study demonstrated that participants having received mammography adopted more favorable attitudes regarding cancer screening. As breast cancer is the most prevalent type among women, implementation of intensified awareness programs within the broader social context and across healthcare institutions may have resulted in a positive attitudinal shift among women toward mammography.

The ability to utilize the internet is key to developing eHealth literacy. It should also be noted that the utility of internet resources is contingent upon the user’s possession of sufficient eHealth literacy127. Despite evidence that eHealth-based interventions for chronic diseases have yielded positive outcomes in Türkiye with increased access to the internet128,129,130,131, our participants exhibited limited proficiency in internet usage skills. In fact, nearly three out of four participants had no access to the internet. This result may stem from the participants’ significant exposure to disadvantaged sociodemographic characteristics (e.g., advanced age, low income, and poor education). In a previous eHealth literacy study, almost half (47.0%) of chronic disease patients reported using the internet127. Seven out of every 10 participants with access to the internet utilized it to acquire health-related information, which overlaps with a previous study reporting that 72% of American adult internet users searched for health information online132. Our analysis also yielded that participants with higher degrees of internet usage skills significantly scored higher in the eHEALS and ASCS.

The mean eHealth literacy score of our chronic patients (M = 14.17) was relatively lower than those reported in research in Türkiye133,134 and other countries53,127,135,136, which may be since the majority of our sample were older adults. Consistent with our findings, a previous study showed that older adults, particularly those aged 75 years and older, lag behind younger individuals in adopting digital technologies137. Another study found that only 17% of adults aged 60 years and older used the internet and that eHealth literacy was negatively correlated with age138. In our study, more than one in four participants were illiterate, which likely contributed to their limited internet usage, particularly for health purposes. Therefore, it is crucial to consider initiatives designed to enhance internet usage for health purposes, particularly for older adults with low educational levels and illiteracy. For example, activating voice command features for illiterate individuals and delivering health-related information through videos could prove valuable. Furthermore, given that individuals without traditional literacy often rely on audiovisual content and assisted methods to access digital health information, their eHealth literacy experience may differ from that of literate individuals. Moreover, given the relatively high frequency of illiterate participants in our sample, the findings for this subgroup may not be generalizable to the general population. We recommend that future studies develop and validate multimodal, supported eHealth literacy measurement tools tailored to diverse literacy levels. In this study, over half of our participants lacked a steady income, which may have adversely affected both their internet usage and eHealth literacy. It may be advisable for governments to offer subsidized or free internet access (e.g., Wi-Fi or devices), particularly for low-income older adults. In our study, individuals with two or more chronic conditions also exhibited lower eHealth literacy scores compared to those with only one chronic condition. Similarly, a study conducted on comorbidity also found that individuals with multiple chronic conditions had lower eHEALS scores compared to those without comorbidities139.

As with previous research, we could reveal that younger age groups140,141, those with higher educational attainment127,142, and employed participants127,141 had higher eHEALS scores. However, Xie (2011) recruited a sample of older adults for group sessions to improve their eHealth literacy levels. The intervention led to a significant improvement in their eHealth literacy levels of older participants. Therefore, intervention programs designed to enhance eHealth literacy should be considered for older patients.

Contrary to expectations, smokers had higher eHEALS scores, implying that individuals may sometimes remain unable to transform health-related knowledge about addiction into attitudes and behaviors. Nevertheless, our analysis yielded that participants with greater eHealth literacy had more favorable attitudes toward cancer screening. Similarly, prior research demonstrated that individuals with higher eHealth literacy adopt more desirable knowledge, attitudes, and behaviors with regard to cancer screening144,145. Furthermore, eHealth literacy accounted for 6.4% of the variance in cancer screening attitudes.

The novel contribution of our study may be the investigation of eHealth literacy and cancer screening attitudes among a hospitalized chronic patient sample. It must be acknowledged, however, that we carried out the study on patients suffering from specific chronic diseases and hospitalized in specific wards of a single hospital, thereby limiting the generalizability of the data set to all chronic patients. Moreover, as our findings relied on data from hospitalized patients, the results might differ for patients with better disease management and prognosis or those who are treated on an outpatient basis. Therefore, future research should focus on chronic patients of varying prognoses (e.g., those followed up at primary care centers and outpatient clinics). In addition, lower eHealth literacy levels in this study compared to the general population with chronic diseases may be attributed to the rate of relatively older patients in our cohort (45.7% aged 70 years and above). Therefore, future studies should consider sociodemographic factors when designing data collection. A further limitation of this study may be the cross-sectional design of this study, which precludes the drawing of causal inferences regarding the relationships between the study variables. It is recommended that future intervention studies focus on improving eHealth literacy and promoting cancer screening behaviors among individuals with chronic conditions.

Although screening protocols have not yet been fully integrated into healthcare systems and debates around their applicability continue, current evidence highlights an elevated cancer risk among chronic patients. This underscores the need to prioritize this population in cancer screening efforts. In the absence of standardized procedures, however, raising awareness among such patients becomes critical. We carried out this study on a specific cohort of chronic patients, with a particular focus on those receiving inpatient treatment. Despite their heightened cancer risk, our findings indicated that they exhibited low levels of eHealth literacy and moderate attitudes toward cancer screening. Thus, we hypothesize that poor e-health literacy adversely affects the prognosis of the disease and the length of hospital stay, as it impairs the ability to effectively manage chronic diseases. Particularly in light of the inherent risks associated with chronic conditions, it is imperative to possess a high degree of eHealth literacy to facilitate collaboration with medical professionals.

Despite the pervasiveness of e-Health applications, a significant proportion of participants - approximately 75% - reported lacking the requisite digital skills to utilize these technologies. Fortunately, seven out of ten internet users reported using the internet to access health-related content. Therefore, awareness-raising initiatives for cancer screening programs should target the chronically ill to manage their diseases and associated risks. Hospitalization may be an excellent opportunity to raise awareness and implement a strategy for cancer screening at the earliest clinically possible time among those with chronic diseases. Moreover, chronic patients without internet skills should be recruited for relevant web-oriented training and activities, as increased internet literacy contributes to eHealth literacy.

Overall, the general population in Türkiye seems not to have the desired level of cancer screening attitudes and health literacy, which is more visible among disadvantaged groups, especially chronic patients. By identifying behaviors and attitudes toward cancer screening in a distinct population of chronic patients, the study offers some insights into the facilitators and barriers affecting attitudes and behaviors related to cancer screening. These findings could help to inform the development and implementation of targeted interventions at local, regional, and national levels to improve cancer screening uptake in at risk populations. Healthcare authorities should organize awareness-raising activities to enhance e/Health literacy and positive cancer screening attitudes, particularly among chronic patients, which will also pave the way for chronic patients to cooperate with their own physicians. Considering both facilitators and barriers to cancer among individuals with chronic conditions is likely to enhance the effectiveness of interventions.