Health and Digital Health Literacy in Community-Dwelling Older Adults: Effects of a Health Promotion-Based Psychoeducational Intervention

Abstract

The main aim of this study is to evaluate the effect of a health promotion-based psychoeducational intervention on Health Literacy (HL) and Digital Health Literacy (DHL) levels in older people. This one-group pre–post design study includes a sample of community-dwelling older people, at risk of social isolation, sedentary lifestyles, or physical deterioration. A multidimensional assessment protocol, with specific measures of HL and DHL, was applied before and after the intervention. The psychoeducational intervention includes 20 sessions, conducted by a multidisciplinary team and focused on four core areas (Health Promotion, Interpersonal Relationships and Citizens’ Rights, Health Literacy, and Digital Health Literacy). Non-parametric statistics tests (Wilcoxon signed-rank test) were used, since data did not follow a normal distribution. Seventy-nine older persons participated, with a mean age of 71.7 (SD = 4.6), mostly female (66%) and with basic education (91%). There was a statistically significant increase in the mean total HL score (Z = −3.132; p = 0.002; effect size r = 0.76) and DHL score (Z = −4.735; p < 0.001; effect size r = 0.61) after the intervention, reflecting an improvement in HL and DHL levels. This study showed that this intervention was effective in improving the HL and DHL levels of older adults. These results are particularly noteworthy, considering that HL and DHL are modifiable factors that influence self-management, as well as health outcomes in older adults.

1. Introduction

There has been exponential growth in the number of older people worldwide, with an expected increase from 900 million to 2.1 billion between 2015 and 2050. It is also estimated that the number of people aged 80 or over will triple between 2020 and 2050, reaching 426 million [1]; contributing to these figures is the considerable increase in average healthy life expectancy. This trend of population aging is also evident in Portugal, which is currently the fifth-oldest country in the world, with 24.1% of the population aged 65 or over and an aging index of 192.4 older people for every 100 young people [2].

The literature in the field of aging has been focusing on the importance of community interventions for older people, consisting of multidisciplinary programs aimed at improving health and well-being in the community [3]. Research projects associated with community intervention projects allow for a broader analysis of health conditions, social interactions, and contextual factors that can affect the well-being, quality of life of older adults [4] and often impact Health Literacy (HL) levels.

The WHO [1] highlights the importance of the proportion of years lived and ensuring that these years are lived in health and well-being, which depends on ease of access to healthcare, enabling good management of the social environment, and psychological distress. This knowledge about health and access to healthcare is associated with the level of HL.

Several studies have shown that HL is strongly associated with health outcomes in older people [5]. Therefore, assessing the level of HL in older people can help guide psychoeducational sessions and health professionals to develop intervention strategies, and manage and treat health problems in these people [6].

HL is defined as “the knowledge, motivation and competences to access, understand, appraise and apply health information to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life throughout the course of life” [7,8].

In 2011, a study was conducted in Europe using a comparative European Health Literacy survey (HLS-EU-Q), which revealed that, although the results indicate that more than 10% of the total population surveyed had an inadequate level of HL, this proportion varied between 1.8% and 26.9% depending on the country [9]. In Portugal, according to the results of the Health Literacy Survey in Portugal [10] and in comparison, with the countries participating in the Health Literacy Survey [9], the Portuguese population had one of the lowest percentages of HL at the ‘excellent’ level (8.6%), significantly below the European Union average (16.5%). At the ‘sufficient’ level, Portugal stood out, ranking second with 42.4%, compared to the European average of 36%. In terms of ’problematic’ and ’inadequate’ literacy levels, Portugal had a higher percentage than the EU average in the first case (38.1% vs. 35.2%) and lower in the second (10.9% vs. 12.4%), with older people having lower HL.

Inadequate levels of HL are reflected in excessive hospital admissions, use of emergency services and poor adherence to healthy behaviors, reducing quality of life [5,11]. Therefore, it is crucial to implement interventions aimed at promoting HL, as higher levels of HL are associated with enhanced outcomes. Improving HL can promote healthy behaviors, prevent physical and cognitive disabilities, help healthcare services to optimise use outcomes [3], and minimize the need for long-term care for older adults [12].

The digital transition of health services in Portugal, combined with the gap in Digital Health Literacy (DHL) among older people, poses significant challenges to equitable healthcare access. DHL is broadly defined as the application of core HL competencies in digitally mediated environments [13]. It refers to how HL is mobilized when health information is digital, interactive, and often patient-generated, such as through patient portals, mobile applications, telehealth services, and wearable devices. In addition to HL competencies, DHL requires specific digital and technological skills, as well as the ability to engage with digital health systems that are accessible and usable.

In Portugal, although access to the internet and digital technologies may not constitute a major barrier in some regions, national statistics indicate that among individuals aged 65–74 years, only 18.5% report having basic or above-basic digital skills [14]. This finding suggests that a substantial proportion of Portuguese older adults have limited experience with digital technologies. When combined with the insufficient DHL identified in this population group [15], these limitations compromise older adults’ ability to search for, navigate, understand, and critically evaluate online health information, thereby restricting their capacity to manage and improve their health [6,16]. This disparity not only constitutes a barrier to healthcare access but also contributes to psychological stress among older people.

Previous research has demonstrated a positive association between HL and DHL, particularly in relation to information comprehension. Studies have shown that the ability to use digital resources is associated with higher levels of both HL and DHL [17]. Furthermore, DHL tends to be positively associated with health behaviors and mediates the relationship between online information use and behavior change in older adults, suggesting that adequate HL is necessary but not sufficient without DHL [18].

Therefore, the development of DHL interventions that incorporate educational and training components should be considered to improve the DHL of older people [16] and, consequently, facilitate access to reliable health information and services, while supporting appropriate health-related decision-making.

In this context, the primary aim of this study was to evaluate the effect of a health promotion-based psychoeducational intervention on the HL and DHL levels of community-dwelling older people. In addition, the following two secondary aims were defined: (1) to assess the levels of HL and DHL in this sample, and (2) to characterize the health and psychosocial profile of the participants.

Within this framework, the main research question planned is: (1) What are the effects of a health promotion-based psychoeducational intervention on improving participants’ HL and DHL? Therefore, the main hypothesis of the study is that participation in this psychoeducational intervention can improve the HL and DHL of these older adults.

2. Materials and Methods

2.1. Study Design and Sample Recruitment

This study is part of a community research project entitled “FelizIdade” (Happy Aging), developed by a social and parish center of a municipality located in the northern part of the country, with the main purpose of promoting active, healthy and informed aging through health promotion initiatives for community-dwelling older people.

The current study adopted a one-group pre- and post-test design to assess the effects of health promotion-based psychoeducational intervention on HL and DHL levels. Due to time constraints and the difficulty of randomizing several groups during the study period, a single-group pre–post design was assumed.

Participants were community-dwelling older adults living in one of six parishes within a municipality located in the northern part of the country. A meeting was held with all parish council chairpersons to publicize and present the project. Information about this project was displayed in these entities to recruit potential interested parties. After registration, the inclusion criteria were validated, followed by an invitation to participate in the project.

The following inclusion criteria were considered: (1) age 65 or older; (2) residence in one of the six parishes covered by the program, (3) proficiency in spoken and written Portuguese, and (4) availability to participate in psychoeducational sessions. Participants with moderate to severe cognitive impairment, as well as those with any condition that could compromise their ability to understand the research protocol, unable to read and write or engage meaningfully in the intervention, were excluded.

The study was carried out between January and December 2024 and convenient sampling techniques were used to select the participants.

2.2. Ethics Issues

The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of a Higher Education Institution (protocol code CE/CES-CESPU-03/23).

The ethical procedures required for research involving human subjects were safeguarded. Firstly, all participants were informed about the purpose and objectives of the study. Participants were informed that this was a three-phase study, as well as the duration of the study and the approximate time it would require of them. Then, written informed consent was taken from each of those (or by their legal representative) who agreed to participate in the study.

All data collected were confidential and were entered into a database built specifically for this research, with each participant’s personal information being identified only by a numeric code created for this project and designed to prevent the identification of the data subject. No form of compensation, monetary or otherwise, was offered to participants.

2.3. Pre- and Post-Intervention Assessment

At baseline (pre-intervention), sociodemographic data (age, sex, marital status, education, employment status and previous profession) and health-related data (chronic diseases, daily medication, and number of hours of sleep) were collected from participants. Additionally, a multidimensional assessment protocol was applied in two moments: pre-intervention (baseline assessment) and post-intervention, using standardized and validated assessment instruments: (1) HLS-EU-PTQ16—European Health Literacy Survey Questionnaire—16 items (Health Literacy) [8,19]; (2) eHEALS—eHealth Literacy Scale (Digital Health Literacy) [13,20]; (3) 6CIT—Six-Item Cognitive Impairment Test (Cognitive Impairment) [21,22]; (4) PWBS—Psychological Well-Being Scale (Psychological Well-Being) [23,24]; (5) GDS-8—Geriatric Depression Scale (Depressive symptoms) [25,26]; (6) GAI—Geriatric Anxiety Inventory (Anxious symptoms) [27,28]; and (7) UCLA-LS—The UCLA Loneliness Scale (Feelings of loneliness) [29,30].

2.4. Psychoeducational Intervention

The psychoeducational sessions were conducted over a six-month period between March and September 2024 (excluding August). The psychoeducational intervention included 20 sessions, each with a duration of 60 min, a mean of 3 sessions per month, conducted by a multidisciplinary team, with expertise in different subjects (nurse, physiotherapists, psychologist, social educator, nutritionist and pharmaceutical) and focused on four core areas (Health Promotion, Interpersonal Relationships and Citizens’ Rights, HL, and DHL). This intervention aimed to provide information, develop skills and promote critical reflection on topics related to core areas, including HL and DHL, using participatory methods such as group dynamics, guided discussions and practical activities. The sessions were held in groups, in the community, organized in public spaces of the parish councils.

In Health Promotion, sessions were held on nutrition and hydration, raising awareness of healthy eating and the importance of water consumption at this age. Sessions developed in the field of physiotherapy and mobility addressed issues related to physical exercise and mobility. During the health promotion sessions, medication management and use were addressed as key reflection points, covering aspects such as the use of prescribed medication, concerns related to self-medication and strategies for preventing missed doses.

In the field of Interpersonal Relations and Citizens’ Rights, groups were developed to promote interpersonal relationships, discussion and reflection on some decision-making issues concerning older people.

The DHL sessions were developed to enhance digital skills, thereby enabling older adults to improve their DHL competencies. These included sessions focused on accessing the Portuguese health platform [National Health Service Contact Centre (SNS24)]. During these sessions, participants had the opportunity to develop skills for accessing electronic prescriptions, online appointments, teleconsultations, healthcare appointment scheduling and viewing test results, where applicable.

2.5. Outcome Measures

The primary outcome measure was HL levels among older adults, which were determined by analyzing scores/changes over time on the HLS-EU-PTQ16 in intervention participants. For the HLS-EU-PTQ16 total score, the 16 questions were dichotomized: the answers ‘difficult’ and ‘very difficult’ were given a value of 0, and the answers ‘easy’ and ‘very easy’ were given a value of 1. The responses ‘I don’t know’ were considered missing values and were not included in the total score. For the questionnaire to be valid, at least 14 questions must be answered. The scoring system used considered the total score as the sum of the values assigned to each of the 16 items. Thus, the following levels of health literacy were considered: inadequate (≤8), problematic (from 9 to 12) and adequate (≥13) [8,19].

The secondary outcome was DHL levels among older adults, which were assessed by analyzing scores/changes over time on the eHEALS. The scoring involves rating each of the 8 items on a 5-point Likert scale (from “strongly disagree” to “strongly agree”), with a total score ranging from 8 to 40, where higher scores reveal greater DHL [13,20].

2.6. Statistical Analysis

Sociodemographic and health-related characteristics of the sample and outcomes will be summarized using descriptive statistics. For the qualitative variables, the following measures were calculated: absolute frequencies (number of valid cases—N) and relative frequencies (percentage of valid cases—%). For the quantitative variables, descriptive statistics were calculated for central tendency (mean—M), dispersion (standard deviation—SD), and extreme values (minimum—Min and maximum—Max).

Subsequently, to assess the effects of the psychoeducational intervention on HL and DHL in older adults, a comparison of the outcome measures (HLS-EU-PT-Q16 and eHEALS) was performed before and after the intervention.

Non-parametric statistics tests were used, since data did not follow a normal distribution (as assessed by the Kolmogorov–Smirnov test). For paired comparisons between pre- and post-intervention measures, the Wilcoxon signed-rank test was applied.

The Wilcoxon effect size (r) was used as a measure of effect magnitude, using the following formula [r = Z/√N]. Cohen’s criteria were used to classify the magnitude of this effect [0.10–<0.3 (small effect), 0.30–<0.5 (moderate effect) and ≥0.5 (large effect)] [31].

In all hypothesis tests, a significance level of 5% (p-value < 0.05) was considered. Statistical analyses were performed using IBM^® SPSS^® Statistics for Windows, version 30.0 (IBM Corp., Armonk, NY, USA) software.

3. Results

3.1. Sociodemographic and Health-Related Results

Initially, 80 seniors were selected, with only 78 seniors completing the psychoeducational intervention. Two seniors did not complete the project due to acute illness. This final sample had a mean age of 71.67 (SD = 4.6) years, and the majority were female (65.8%), married (82.3%), with elementary education (91.1%) and retired due to age (91.1%) (

Table 1. Sociodemographic characterization of participants.

n = 79
Age, mean (SD 1)	71.66 (4.64)
Sex	n (%)
Male	27 (34.2)
Female	52 (65.8)
Marital Status
Single	2 (2.5)
Married/civil union	65 (82.3)
Divorced/separated	1 (1.3)
Widowed	11 (13.9)
Education Level
Illiterate/no degree completed	1 (1.3)
Basic education (4 years)	72 (91.1)
Preparatory education (6–9 years)	3 (3.8)
Secondary education (12 years)	3 (3.8)
Work Status
Retired due to age	72 (91.1)
Retired due to disability	7 (8.9)
Who do you live with?
Alone	9 (11.4)
Spouse	64 (81.0)
Children	2 (2.5)
Other family members	3 (3.8)
Nursing home	1 (1.3)

¹ SD = Standard deviation.

).

Regarding health-related information, it was found that 51 of the 79 participants reported having at least one chronic disease (mostly hypertension and/or diabetes mellitus), with 93.7% (n = 74/79) indicating that they took daily medication. The average total hours of sleep were 7.09 (SD = 1.22).

3.2. Pre-Test Results

According to the results of the multidimensional assessment protocol (pre-intervention evaluation), most of the participants reported depressive symptoms (57%), severe anxiety symptoms (72.2%), and feelings of loneliness (53.2%). Regarding psychological well-being, the mean total score of PWBS was 71.37 (SD = 14.10), with the domains of personal growth (mean = 12.72) and self-acceptance (12.65) representing the highest mean values.

Regarding the HL levels, approximately 14.8% revealed problematic to inadequate levels, based on the HLS-EU-PTQ16 results, and the total mean was 14.51 (SD = 3.26). In the pre-intervention, 13.8% of the sample was not considered in the analysis due to invalid questionnaires (more than 14 questions unanswered or answered with “I don’t know”). In the DHL assessment instrument (eHEALS), the mean score was 19.79 (SD = 7.44) (

Table 2. Multidimensional assessment protocol results (pre-intervention).

n = 79
Health Literacy (HLS-EU-PTQ16) (n = 61)	n (%)
Adequate	52 (85.2)
Problematic	5 (8.2)
Inadequate	4 (6.6)
Digital Health (eHEALS)	Mean (SD 1)
	19.79 (7.44)
Cognitive Impairment (6CIT)	n (%)
Without cognitive impairment	59 (74.7)
With cognitive impairment	20 (25.3)
Psychological Well-Being Scale (PWBS)	Mean (SD 1)
Autonomy	11.20 (2.93)
Environmental mastery	11.30 (2.38)
Personal growth	12.72 (2.16)
Positive relations with others	11.46 (2.96)
Purpose in life	12.04 (3.07)
Self-acceptance	12.65 (3.13)
Total	71.37 (14.10)
Depressive symptoms (GDS-8)	n (%)
Without depressive symptoms	34 (43.0)
With depressive symptoms	45 (57.0)
Anxiety symptoms (GAI)	n (%)
Absent to mild anxiety	22 (27.8)
Severe anxiety symptoms	57 (72.2)
Loneliness (UCLA)	n (%)
Without loneliness	37 (46.8)
With feelings of loneliness	42 (53.2)

¹ SD = Standard deviation; HLS-EU-PTQ16—European Health Literacy Survey Questionnaire; eHEALS—eHealth Literacy Scale; 6CIT—Six-Item Cognitive Impairment Test; PWBS—Psychological Well-Being Scale; GDS-8—Geriatric Depression Scale; GAI—Geriatric Anxiety Inventory; UCLA-LS—The UCLA Loneliness Scale.

).

3.3. Post-Test Results and Comparison

As shown in

Table 3. Comparison of the results of the HLS-EU-PTQ16 (HL) and eHEALS (DHL) before and after the psychoeducational intervention.

	Psychoeducational Intervention
	Before	After	Z	p-Value	Effect Size (r)
Health Literacy (HLS-EU-PTQ16) (n = 61)	Mean (SD 1)	Mean (SD 1)
Total	14.51 (3.26)	15.67 (1.09)	−3.132	p = 0.002	0.76
	n (%)	n (%)
Adequate	52 (85.2)	57 (93.4)
Problematic	5 (8.2)	4 (6.6)
Inadequate	4 (6.6)	-
Digital Health (eHEALS) (n = 79)	Mean (SD 1)	Mean (SD 1)
Total	19.79 (7.44)	25.18 (7.37)	−4.735	p < 0.001	0.61

¹ SD = Standard deviation; HLS-EU-PTQ16—European Health Literacy Survey Questionnaire; eHEALS—eHealth Literacy Scale; Z = Wilcoxon signed-ranks test; Effect size (r) [r = Z/√N]; the bold characters in the p-Value column refer to the significant p-values (p < 0.05).

, there was a significant increase in the mean total score on the HL assessment instrument (HLS-EU-PTQ16) after the psychoeducational intervention (mean = 14.51 vs. 15.67, Z = −3.132; p = 0.002), with a large effect size (r = 0.76). Of the 61 participants, 17 showed a change between the two moments. Furthermore, in the second assessment, no participants presented inadequate HL levels.

Furthermore, the Wilcoxon test indicated a significant difference between DHL assessments before and after the intervention (mean = 19.79 vs. 25.18, Z = −4.735; p < 0.001), with a large effect (r = 0.61). This result demonstrates an increase in DHL levels among older adult participants.

4. Discussion

This study aims to evaluate the effects of a health promotion-based psychoeducational intervention on improving HL and DHL levels in community-dwelling older people.

Based on the comparative analysis, the increase in the post-intervention mean values of the total HL and DHL assessment measures indicates this psychoeducational intervention was associated with improvements in the HL and DHL levels of older adults living in the community. This finding is further corroborated by the observed increase in participants achieving adequate HL levels following the intervention, accompanied by a reduction in cases classified as problematic and the complete absence of individuals with inadequate HL levels.

These results are consistent with intervention studies to promote HL in older adults, e.g., [3,32,33,34]. Evidence suggests that psychoeducational interventions, including health education, self-care sessions, and tailored communication, show promising evidence for improving HL among community-dwelling older adults. For example, a recent systematic review [33] of 34 studies with older adults (≥65 years) found that HL interventions (e.g., individual sessions, workshops, pharmacist-led discussions and illustrated materials) led to improvements in understanding, accessing, and using health information. Another systematic review [34] identified three interventional studies examining HL interventions targeting medication use in older adults and concluded that HL interventions can positively influence medication management and be effectively delivered by various healthcare professionals using tailored communication strategies.

These findings highlight that community intervention is key to improving HL levels among older people, which will be reflected in improved health indicators and healthcare outcomes [3].

Regarding DHL, a significant increase in DHL levels was observed after the psychoeducational sessions, which is in line with previous studies, e.g., [6,35,36]. For instance, a review and meta-analysis [35] assessed the effectiveness of DHL interventions for older adults, incorporating seven studies with a total of 710 participants. Overall, the findings indicate that DHL training can substantially improve older adults’ capacity to engage with digital health tools, such as accessing electronic prescriptions, online appointments, and the Portuguese patient portal SNS24. These skills will allow these older adults better access to available healthcare and resources, including information about their health, and the use of online health information that enables them to make informed health decisions. On the other hand, and considering the electronic prescription system in Portugal, the ability to access the SNS24 health portal allows access to the prescription guide, improving effective therapeutic adherence. In a more recent systematic review [36] of experimental studies published between 2020 and 2024, the authors examined the effectiveness of DHL initiatives in improving patient outcomes and verified that these interventions consistently enhance health literacy, medication adherence, and patient self-confidence. Moreover, the authors point to DHL as a key driver for improving health equity and advancing progress toward Sustainable Development Goal-3 (SDG- 3).

In fact, the literature demonstrates that older people who use technologies and platforms are more able to access, manage, and use health information to improve their health [6]. In this way, improving DHL skills will allow older adults to better access health knowledge and resources, which could lead to better health management. This improvement in DHL also enables older people to access and more easily understand the digital health platforms and technological resources widely used in healthcare.

In addition, this study aimed to assess HL and DHL levels in this sample. The findings of the current study indicate that the sample’s level of HL is comparatively high when contrasted with studies examining the HL levels of the Portuguese population [10], as well as with other research assessing HL among older adults [9]. These are some possible explanations for this result. Firstly, a convenience sample was used, which may have led to a possible selection of older people who were already interested in the topic or who wanted to understand it better. On the other hand, it is necessary to consider the potential social desirability bias in the participants’ responses, which may also have influenced some of the findings. It is also necessary to consider the significant number of invalid questionnaires, due to ‘don’t know’ responses to many questions. These questionnaires were not considered in the analysis, as recommended by the authors of the instrument, but these responses may, in themselves, represent low levels of literacy.

It is also important to note that according to the literature, many HL measurement tools have been validated in different populations or target groups, but older adults have specific characteristics that may affect the usefulness and validity of measurement tools [37,38].

Regarding what concerns DHL, the mean scores of eHEALS were slightly lower (namely in pre-intervention) than those reported in other studies with older samples and using the same measure [15,39,40,41]. For example, in a recent Portuguese study [15], with older adults recruited from the Health Family Unit (Primary Care), the eHEALS-PT24 mean score was 23.31. Another study conducted in Spain [41] with Hispanic older people with type 2 diabetes found that the average total score was 22.35.

Another secondary aim of this study was to characterize the health and psychosocial profile of the participants. The results of this profile highlight that the sample was of advanced age and predominantly female, married and with low levels of education. Furthermore, the dimensions in the PWBS with higher averages were personal growth and self-acceptance, indicating that individuals perceive themselves as being in constant development, embracing challenges and accepting both their strengths and limitations, thus reflecting greater psychological maturity and life satisfaction [23].

It should also be noted that participants in this study reported high levels of anxiety and depression symptoms on the pre-intervention assessment. This finding aligns with the recent literature, which indicates that the prevalence of depression among older adults is higher than that observed in younger populations [42]. Several factors contribute to this incidence, such as the gradual decline in physical, psychological, and social functions in older adults due to aging, the onset of chronic diseases, health conditions, loneliness and contextual situations such as withdrawal and lack of social support. In addition, loneliness contributes to a higher risk of depression in older adults and cognitive impairment, e.g., [43,44]. This may also partly explain the high number of cases that reported feelings of loneliness.

This study highlights the importance of developing community-based health promotion psychoeducational intervention and its beneficial impact on enhancing HL and DHL among older adults. These results are particularly noteworthy, considering that HL and DHL are modifiable factors that influence self-management as well as health outcomes in older adults. Another strength of the study was its contribution to characterizing the levels of HL and DHL in this sample of community-dwelling older people, as well as their physical and mental health profile.

The results of the present work should take into consideration some limitations. Firstly, this is a single-site study with a convenience sample that is predominantly female and has low levels of education, which limits the generalizability of the results. In addition, the high number of invalid HLS-EU-PTQ16 questionnaires may reflect lower levels of HL and therefore also influence this generalization. Secondly, the single-group pre–post-test design, without a control group, limits causal inference due to several factors, such as the risk of confounding or Hawthorne effects. Thirdly, the use of self-assessment measures and the possible effects of social desirability should also be mentioned. Lastly, the absence of long-term follow-up did not allow knowing the durability of the gains in HL and DHL from this intervention.

Therefore, it is important to extend the study to include a larger sample of older adults from the community and adopt an experimental or quasi-experimental design to analyze causal inference to clarify the cause-and-effect relationship of this intervention on an outcome. Moreover, it would also be relevant to incorporate additional variables and areas for future intervention, such as psychological distress and loneliness. The inclusion of observation measures to identify real-world changes after intervention in patient behavior and outcomes would also be an improvement.

The present findings have foremost implications for future policy and practice, since they support the need to integrate psychoeducational programs focused on health and digital skills as active aging strategies, to be promoted by different services, particularly in the areas of health and social intervention, or by public entities (e.g., parish councils, municipal councils). These interventions will strengthen autonomy, informed decision-making and access to digital health resources, contributing to more appropriate use of services, better adherence to treatments and a reduction in inequalities. Public policies should therefore support the systematic and sustainable implementation of this type of intervention tailored to the needs of older people, promoting inclusive and person-centered approaches.

In conclusion, the psychoeducational intervention developed and tested in this study was associated with improvements in the HL and DHL levels of older adults living in the community. In this regard, it is equally important that health and social institutions, as well as researchers, coordinate and work together to improve older people’s ability to assess and understand health information, and to make informed health decisions. On the other hand, there is a transition to digital, with an increasing number of health services using technological platforms and resources. Therefore, it is increasingly urgent to develop DHL skills among older people so they can remain integrated and have equal access to health services.