Effectiveness of a Scenario-Based Interactive E-Book in Enhancing Nursing Students’ Health Literacy

Effectiveness of a Scenario-Based Interactive E-Book in Enhancing Nursing Students’ Health Literacy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of a Scenario-Based Interactive E-Book in Enhancing Nursing Students’ Health Literacy Pei-Ling Tseng, Chen-Yin Tung This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7532459/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2026 Read the published version in BMC Nursing → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: Health literacy is essential for safe and effective nursing practice, yet traditional teaching methods may not fully address students’ needs. This study evaluated a scenario-based interactive e-book designed to enhance nursing students’ health literacy performance. Methods: A quasi-experimental design was conducted with 55 fourth-year nursing students from a Taiwanese university. Students were assigned to an experimental group (n = 28) that received e-book instruction or a control group (n = 27) that received traditional teaching. The 26-item Health Literacy Performance Scale, demonstrating strong validity and reliability, was administered before and after the intervention. For educational parity, the control group accessed the e-book after data collection. Results: Generalized Estimating Equations revealed no significant effects of time or time × group interaction. However, after adjusting for age, the main effect of group was significant (p = .015). Post hoc analysis showed that the experimental group scored higher on the post-test (p = .035), particularly in interpreting health education materials, assessing care needs, and correct medication use. Discussion: Findings indicate that the scenario-based e-book effectively improved nursing students’ health literacy performance. This approach demonstrates practical value and suggests potential for broader application in nursing education to strengthen essential competencies. Interactive E-Book Health Literacy Clinical Scenario Nursing Students Nursing Education Figures Figure 1 1 INTRODUCTION The increasingly diverse and globalized healthcare environment requires nurses to care for patients from a wide range of cultural, linguistic, and health literacy backgrounds. Health literacy refers to an individual’s ability to obtain, understand, evaluate, and apply health information to make informed health decisions [ 1 ]. Digital health literacy emphasizes the capacity to locate and use health information and technologies within digital environments [ 2 ]. These competencies are essential for helping individuals actively participate in their own care and make well-informed health choices. In Taiwan, population-based surveys have uncovered gaps in health literacy. Using the Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ), Wei et al. (2017) reported that 14% of adults had inadequate health literacy, and 37.6% had limited literacy [ 3 ]. A systematic review by Duong and Chang (2024) found that 13.7–25.3% of Taiwanese adults exhibited inadequate health literacy. Similar challenges are documented internationally [ 4 ]. For example, in a study in Ireland, only a small number of 190 clinical nurses had adequate health literacy knowledge and experience [ 5 ]. Thai research across 104 hospitals showed that 55% of 1,697 nurses understood health literacy concepts, but fewer than 10% had attended training to improve patient literacy [ 6 ]. In Taiwan, a survey of 400 hospital and community nurses found generally low awareness of health literacy, with an average accuracy rate of only 51% [ 7 ]. Similar issues have been reported among Hong Kong nursing students during the COVID-19 pandemic [ 8 ], Chinese nursing students’ digital health literacy [ 9 ], and Turkish nurses, only 18.4% of whom had prior exposure to health literacy topics, despite a strong interest in further education [ 10 ]. Health literacy affects not only patients’ health behaviors and outcomes but also nurses’ ability to provide effective education and communication [ 6 , 11 ]. Nurses with strong health literacy skills are better able to assess patients’ literacy levels, tailor communication strategies, and ultimately improve quality of care. However, current nursing curricula do not consistently prepare students with the skills to apply health literacy principles in clinical settings [ 12 ]. Developing systematic and interactive educational strategies has therefore become essential to enhancing students’ understanding and practical application of health literacy, as well as their ability to adopt patient-centered communication approaches [ 13 ]. With the rise of digital technologies, health professions education has increasingly moved toward online and blended formats [ 14 ]. E-books, as digital learning resources, have proven effective in nursing education [ 15 ]. Their integration of text, images, videos, and interactive exercises allows learners to engage with content in flexible and personalized ways, enhancing motivation, satisfaction, and knowledge retention [ 16 , 17 ]. Interactive multimedia features, such as embedded videos, are especially valued by students for deepening conceptual understanding [ 15 , 18 ]. In Taiwan, digital learning has been applied in both classroom and community health settings, with studies indicating that interactive e-books can improve nursing students’ disease-specific skills, confidence, and self-efficacy [ 19 – 21 ]. These tools also enhance information literacy and health communication skills, particularly when students are tasked with designing and delivering their own multimedia educational resources. E-books provide several benefits over traditional teaching methods, including flexible content design, easy access, and the ability to simulate realistic clinical scenarios [ 11 , 22 ]. These interactive, context-based learning experiences can enhance nursing students’ ability to assess and respond to patients’ health literacy needs in clinical practice. Considering these gaps in health literacy education and the potential of interactive e-book technology, this study developed a systematic, interactive e-book aimed at improving nursing students’ health literacy competencies. Based on this rationale, we proposed the following hypotheses: H1 Nursing students will demonstrate varying baseline levels of health literacy performance. H2 Nursing students’ demographic and experiential factors (e.g., gender, age, internship experience, and healthcare work experience) will be significantly associated with their health literacy performance. H3 The use of a scenario-based interactive e-book will significantly improve nursing students’ overall health literacy performance. 2 METHODS 2.1 Study Design This study employed a quasi-experimental design with a two-group repeated measures approach and convenience sampling. Participants were fourth-year nursing students enrolled at a university in Taiwan. Classes were randomly assigned to either the experimental or control group. During the medical ethics course, the experimental group received an instructional intervention integrating the Health Literacy E-book into the regular curriculum, while the control group took the standard course without the e-book component. To minimize potential testing effects, both groups received a briefing on the study's purpose and procedures three weeks before the intervention, after which informed written consent was obtained from eligible and willing participants. Pre-test assessments using the Health Literacy Performance Scale were conducted prior to the course intervention, and the same scale was administered immediately after the intervention (post-test). Pre- and post-test data were paired for statistical analysis to evaluate the effectiveness of the intervention. To ensure equal access to educational resources, the control group received the Health Literacy E-book content after the study was completed, enabling all participants to benefit from the learning material. 2.2 Participants Participants were recruited from fourth-year nursing students at a private university in Taiwan through convenience sampling. According to statistical principles, a medium effect size (f = 0.25) was assumed, reflecting a moderate impact of the independent variable on the dependent variable, a value commonly used in experimental designs such as ANOVA [ 23 ]. An a priori power analysis was performed using G*Power 3.1.9.7, with the statistical model set as F tests – ANOVA: Repeated measures, within–between interaction, an effect size of 0.25, a significance level (α) of 0.05, and a statistical power (1–β) of 0.95. The required sample size was estimated at 54. Considering potential attrition and the course schedule, a total of 87 students from two classes enrolled in the Medical Ethics and Law course. One class (n = 44) was assigned to the experimental group, and the other (n = 43) to the control group. Both groups completed the pre-test before the intervention and the post-test immediately afterward. In the data collection process, 81 valid pre-test questionnaires were returned (43 from the experimental group and 38 from the control group), and 75 valid post-test questionnaires were collected (38 from the experimental group and 37 from the control group). Only students who completed both pre- and post-tests were included in the final analysis, resulting in 55 participants (28 in the experimental group and 27 in the control group), with an overall valid response rate of 63.2%. The mean age of participants was 22.91 years. Participant enrollment and assessment are shown in Fig. 1 . 2.3 Experimental Context and E-Book Development To improve nursing students’ health literacy performance, this study aimed to help them recognize and assess patients’ health literacy, explain medical information clearly, and promote positive nurse–patient interactions. An interactive digital e-book was created as the teaching tool. The e-book included various interactive features designed to improve learning outcomes, such as audio and image playback, interactive multiple-choice questions, pop-up tips, and embedded clinical videos. These features were intended to strengthen students’ ability to identify and respond to patient needs during clinical communication. To meet the 4A learning principles (anytime, anywhere, anyone, anyway) [ 24 ] and considering the time and cost involved in developing technology and learning resources, the e-book was developed in partnership with Hamastar Technology Co., Ltd., and delivered through its cloud-based eBookHub™ sharing platform. The content featured diverse and highly interactive instructional formats. Animated titles and content displays were used to quickly introduce and reinforce key concepts. Various interactive games—such as multiple-choice questions, drag-and-drop activities, and masking sticker exercises—were designed to increase engagement and enjoyment. Scenario-based comic strips, along with clinical scenario videos performed by cartoon characters or real actors, helped visualize abstract concepts and enhance learners’ understanding and application of health literacy. The teaching content consisted of five main components: Animated Introduction to Health Literacy: Animation presenting the definition of health literacy, accompanied by scripted audio narration to promote initial understanding and motivation. Comic Story Experience and Observation: Comic-based stories with guided audio narration to help students understand the needs of patients with low health literacy and appreciate the value of empathy and support. Scenario Videos and Quizzes: Videos showing patients’ communication challenges and misunderstandings, followed by brief quizzes to reinforce learning. Health Literacy Assessment and Clinical Awareness: Overview of common health literacy assessment tools and indicators of low health literacy, including clinical case quizzes to test the students’ recognition and judgment skills. Summary of Clinical Awareness and Strategies: Guidance on how nurses can detect and evaluate health literacy in clinical practice, a strategy summary, and scenario-based questions to consolidate practical application. The Health Literacy E-book could be accessed via the eBookHub™ cloud bookshelf platform on web browsers or through the eBookHub ™ mobile application for Android and iOS devices, enabling learning across multiple platforms and devices. 2.4 Questionnaires To assess the effectiveness of the Health Literacy E-book intervention, a structured questionnaire was used. The instrument consisted of two sections: (1) demographic information, including gender, age, comprehensive clinical nursing internship experience, and work experience in healthcare institutions, and (2) health literacy performance. The health literacy performance scale was adapted from the MMHLQ [ 3 ], with permission from the original author. Ten additional items were incorporated to reflect the dual role of nursing students as both users and providers of health literacy. The final scale comprised 26 items covering four domains: obtaining , understanding , evaluating , and applying health information, as well as the practice of promoting patients’ health literacy (Table 1 ). Each item was rated on a 4-point Likert scale (1 = very difficult, 2 = difficult, 3 = easy, 4 = very easy). Missing responses were considered missing data. The additional items were reviewed for content validity by a panel of five experts from various fields, including medicine, social sciences, health education, and health literacy, to ensure they were appropriate and clear. The revised instrument was then pilot-tested with 30 nursing students to evaluate reliability and validity. The scale showed excellent content validity (CVI = 0.97) and high internal consistency (Cronbach’s α = 0.96), confirming its suitability for the main study. Table 1 Scale Items for Measuring Health Literacy Performance No. Scale Item 1 For me, finding knowledge about diseases is… 2 For me, obtaining information about daily health care is… 3 For me, searching for necessary health information on the internet is… 4 For me, collecting additional information after receiving a health examination report is… 5 For me, understanding the instructions on a medication bag is… 6 For me, being able to care for a disease according to healthcare providers’ instructions is… 7 For me, understanding the explanations given by healthcare providers is… 8 For me, being able to use medications according to the instructions on the medication bag is… 9 For me, determining whether the obtained health information can solve a health problem is… 10 For me, determining whether the obtained health information is suitable for me is… 11 For me, determining whether the obtained health information is consistent with other information is… 12 For me, judging whether online health information is trustworthy is… 13 For me, applying health information to understand changes in my health condition is… 14 For me, applying health information to prepare for facing a disease is… 15 For me, applying health information to understand the results of a health examination is… 16 For me, applying health information to choose treatment methods is… 17 If I were a nurse, using the “Admission Nursing Assessment Form” to understand a patient’s health literacy level is… 18 If I were a nurse, observing a patient’s self-care ability through the teach-back method is… 19 If I were a nurse, helping a patient obtain medical information related to their diagnosed disease is… 20 If I were a nurse, helping a patient obtain necessary health or medical information unrelated to their diagnosed disease is… 21 If I were a nurse, assisting a patient in understanding medication bag instructions and using medications correctly is… 22 If I were a nurse, assisting a patient in interpreting the content of health education leaflets is… 23 If I were a nurse, assisting a patient in applying health information to analyze and select the appropriateness of different treatment options is… 24 If I were a nurse, assisting a patient in assessing further nursing care needs is… 25 If I were a nurse, guiding a patient to follow healthcare providers’ instructions for self-health management is… 26 If I were a nurse, helping a patient apply medical information to prepare for treatment is… Response scale: 1 = Very Difficult to 4 = Very Easy 2.5 Data Analysis All data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Baseline characteristics between the experimental and control groups were compared using the Chi-square test to confirm group homogeneity. The distribution of background variables was similar across groups (all p > .05), indicating suitability for the subsequent intervention effect analyses. To examine the influence of background variables, including gender, comprehensive clinical nursing internship experience, and work experience in healthcare institutions, between-group comparisons were performed using independent samples t-tests. Before conducting the intervention effect analysis, the Shapiro–Wilk test was used to check the normality of the data for each group at both measurement time points, considering the sample size ( .05). To evaluate within-group changes in health literacy performance, paired-samples t-tests were conducted separately for the experimental and control groups. The primary analysis of intervention effectiveness was conducted using Generalized Estimating Equations (GEE), a statistical approach suitable for repeated measures data that accounts for both the “time” factor (pre-test vs. post-test), the “group” factor (experimental vs. control), and their interaction. Although the GEE analysis did not produce a statistically significant interaction effect between time and group, supplementary analyses were performed following the recommendations of Wang et al. (2016)[ 25 ]. When the primary model does not show significant differences, especially with small samples, targeted comparisons at specific time points using t-tests with appropriate variance estimators can reveal meaningful trends. Therefore, independent samples t-tests were performed on the post-test data to further examine potential differences between groups. This supplementary analysis aimed to provide more precise comparisons and enhance the practical interpretability of the results. 2.6 Ethical Considerations This study was approved by the university’s Research Ethics Committee (Approval No. 202501HS020) and conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without penalty. All data were anonymized and used solely for research purposes to ensure confidentiality. 3 RESULTS 3.1 Differences in Health Literacy Performance by Background Variables To determine whether background variables affected participants’ health literacy performance, the difference score (d) between post-test and pre-test results was calculated and examined using independent-samples t-tests for four variables: gender, age, comprehensive clinical nursing internship experience, and work experience in healthcare institutions. The analysis showed no significant differences by gender, internship experience, or work experience (all p > .05). In the control group, older students scored significantly lower than younger students ( p = .033), although this result should be interpreted cautiously due to the lack of an intervention and the brief interval between tests. Detailed results are shown in Table 2 . Table 2 Background Variables and Health Literacy Performance Variable Experimental Group (n = 28) Control Group (n = 27) n Mean (SD) p n Mean (SD) p Gender Male 9 0.03 (0.19) .769 4 -0.03 (0.48) .960 Female 19 0.06 (0.28) 22 -0.04 (0.18) Age group High 14 0.05 (0.28) .867 18 -0.12 (0.14) .033* Low 14 0.04 (0.24) 9 0.09 (0.34) Internship experience Yes 27 0.06 (0.24) .058 26 -0.04 (0.24) .216 No 1 -0.42 (-----) 1 -0.35 (-----) Work experience Yes 16 0.02 (0.27) .595 12 0.04 (0.31) .128 No 12 0.08 (0.24) 15 -0.12 (0.14) * p < 0.05 3.2 Evaluation of the Effectiveness of Health Literacy Performance Paired-samples t-tests showed that the experimental group’s overall health literacy score increased significantly from pre-test to post-test ( p < .001), while the control group’s score decreased significantly during the same period ( p < .001). The gain in the experimental group was associated with a medium effect size (Cohen’s d ≈ 0.50), indicating a practically meaningful improvement in health literacy. Item-level analysis showed that 14 out of 26 items in the experimental group improved significantly, especially in areas related to acquiring, interpreting, and applying health information in clinical settings. In contrast, most significant changes in the control group were declines in performance, mainly in patient-support tasks such as helping patients use health information to evaluate treatment options and interpret health education materials. Full item-level statistics are available in Table 3 . Table 3 Nursing Students’ Health Literacy Performance Item Experimental Group (n = 28) Control Group (n = 27) Pre-test Mean (SD) Post-test Mean (SD) p Pre-test Mean (SD) Post-test Mean (SD) p 1 3.00 (0.54) 3.36 (0.49) .027* 2.93 (0.55) 3.26 (0.59) .133 2 3.29 (0.54) 3.54 (0.51) .052 3.37 (0.57) 3.56 (0.51) .094 3 3.54 (0.58) 3.64 (0.49) .001* 3.52 (0.58) 3.63 (0.49) .002* 4 3.43 (0.50) 3.32 (0.48) .009* 3.33 (0.56) 3.15 (0.60) .004* 5 3.50 (0.51) 3.71 (0.46) .011* 3.48 (0.70) 3.48 (0.58) .003* 6 3.61 (0.50) 3.68 (0.48) .003* 3.56 (0.58) 3.52 (0.58) < .001* 7 3.61 (0.50) 3.68 (0.48) .043* 3.44 (0.58) 3.52 (0.51) .062 8 3.71 (0.46) 3.75 (0.44) .003* 3.74 (0.53) 3.63 (0.57) < .001* 9 3.36 (0.56) 3.46 (0.58) .163 3.22 (0.64) 3.15 (0.66) .015* 10 3.25 (0.59) 3.50 (0.51) .342 3.00 (0.73) 3.04 (0.65) < .001* 11 3.25 (0.59) 3.57 (0.50) .197 2.93 (0.78) 3.26 (0.59) .001* 12 3.14 (0.71) 3.43 (0.57) .039* 2.70 (0.87) 2.96 (0.71) .003* 13 3.29 (0.46) 3.50 (0.51) .011* 3.04 (0.71) 3.15 (0.53) .345 14 3.32 (0.61) 3.43 (0.50) .007* 3.00 (0.73) 3.15 (0.53) .136 15 3.50 (0.51) 3.57 (0.50) < .001* 3.30 (0.54) 3.22 (0.42) < .001* 16 3.18 (0.67) 3.43 (0.57) .361 3.00 (0.62) 3.22 (0.58) .025* 17 3.00 (0.54) 3.18 (0.67) .032* 2.93 (0.68) 3.07 (0.62) .320 18 3.21 (0.50) 3.25 (0.52) < .001* 3.11 (0.58) 3.19 (0.56) .389 19 3.18 (0.48) 3.29 (0.54) .005* 3.15 (0.66) 3.11 (0.58) .436 20 3.11 (0.57) 3.25 (0.59) .058 3.04 (0.65) 2.89 (0.70) .024* 21 3.32 (0.61) 3.50 (0.58) .001* 3.41 (0.64) 3.30 (0.54) < .001* 22 3.86 (0.36) 3.46 (0.58) .005* 3.67 (0.62) 3.26 (0.53) .042* 23 3.75 (0.44) 3.32 (0.55) .007* 3.59 (0.64) 3.07 (0.62) .002* 24 3.75 (0.44) 3.32 (0.61) .383 3.70 (0.47) 3.07 (0.62) .284 25 3.75 (0.44) 3.32 (0.61) .017* 3.59 (0.75) 3.19 (0.48) .611 26 3.71 (0.46) 3.36 (0.61) .007* 3.70 (0.54) 3.07 (0.62) .359 Sum 3.41 (0.32) 3.45 (0.39) < .001* 3.29 (0.37) 3.24 (0.36) < .001* * p < 0.05 3.3 Overall Effectiveness of the Teaching Intervention To thoroughly assess the effectiveness of the intervention, a Generalized Estimating Equations (GEE) analysis was performed to examine the effects of time, group, and the time × group interaction on the outcome variables, with age included as a continuous covariate (Table 4 ). This adjustment was made because the independent samples t-test results (Table 2 ) showed that, among the four background variables examined, only age was significantly related to health literacy performance. The GEE analysis showed that neither the main effect of time nor the time × group interaction was statistically significant ( p > .05), indicating no meaningful differences between pre-test and post-test or among groups. However, after adjusting for age, the main effect of group was statistically significant ( p = .015), suggesting the experimental group performed better than the control group overall. Table 4 Nursing Students’ Health Literacy Performance: GEE Analysis Item 𝛽 Std. Error 95% CI p Intercept 51.32 23.89 [4.50, 98.14] .032* Age 1.69 1.05 [-0.36, 3.75] .107 Group (ref.=control group) -6.26 2.56 [-11.28, -1.24] .015* Time (ref.=pre-test) -1.21 1.23 [-3.61, 1.19] .322 Time*Group 2.55 1.70 [-0.78, 5.88] .134 * p < 0.05 As a supplementary analysis, independent samples t-tests were conducted to compare the experimental and control groups at pre-test and post-test. At pre-test, the experimental group had a mean score of M = 3.41 (SD = 0.32, 95% CI [− 1.66, 7.99]) and the control group had M = 3.29 (SD = 0.37). Levene’s test indicated equal variances, F(1, 53) = 0.056, p > .05. The independent samples t-test showed no significant difference between groups at baseline, t(53) = 1.315, p > .05. At post-test, the experimental group’s mean score was M = 3.45 (SD = 0.39, 95% CI [0.41, 11.02]), which was significantly higher than the control group’s M = 3.24 (SD = 0.36), t(53) = 2.159, p = .035. The effect size was medium (Cohen’s d = 0.56), indicating that the e-book intervention produced a meaningful short-term improvement in health literacy performance. 4 DISCUSSION 4.1 Interpretation of Key Findings This study showed that nursing students performed better in health literacy tasks related to obtaining and applying health information, such as “assisting patients in interpreting health education leaflets,” “assessing patients’ care needs,” and “using medication according to instructions.” However, their performance was noticeably lower in “evaluating the credibility of online health information” and “recognizing and assessing patients’ health literacy” (Table 3 ). These findings are consistent with Ramón-Arbués et al. (2023), who reported that although 57.4% of Spanish nursing students demonstrated adequate health literacy, their skills in evaluating information and making decisions needed improvement [ 12 ]. Similarly, Zhang et al. (2016) found that Chinese nursing students understood health information well but were less proficient in interacting with the healthcare system and critically evaluating information, highlighting the need to strengthen their critical appraisal skills [ 26 ]. Comparable patterns have been observed internationally. For example, while 76.5% of Namibian nursing students exhibited adequate comprehension skills, only 3.9% could effectively translate this into practice [ 27 ]. In Iran, Nesari er al. (2019) also reported that registered nurses in Tehran struggled with using health literacy assessment tools and applying teach-back strategies [ 5 ]. 4.2 Comparison with Previous Studies Analysis of background variables showed no significant differences in health literacy performance based on gender, internship experience, or work experience (Table 2 ), aligning with previous studies [ 9 , 28 – 30 ]. Notably, in the control group, older students scored significantly lower than younger students ( p = .033), which matches Wittenberg (2018), who found that more experienced oncology nurses in the U.S. reported greater difficulty in assessing and identifying patients with low health literacy [ 31 ]. Conversely, some studies have shown that health literacy improves with age and educational progress [ 26 , 28 – 30 ]. These differences could be due to the smaller sample size in the control group and the lack of educational intervention, or they might reflect different contextual factors influencing the relationship between age and health literacy. For example, Balmer et al. (2020) found that health literacy increased with age among nursing students in Pacific regions, but no such pattern was observed in Europe or Southeast Asia [ 32 ]. 4.3 Implications for Nursing Education and Practice The results highlight specific skill gaps among nursing students, especially in critical thinking and assessing patients’ health literacy, confirming earlier findings [ 5 , 12 , 31 ]. These gaps emphasize the need for nursing curricula to focus more on health literacy training, particularly in evaluating online health information and assessing patients’ health literacy, to improve overall professional competence. The e-book intervention in this study significantly improved health literacy performance in the experimental group compared to the control group ( p = .035), with a medium effect size (Cohen’s d = 0.56). In nursing education, a medium effect size indicates that the intervention can meaningfully enhance learning within limited instructional time, especially in information evaluation and clinical application. This finding supports previous research that promotes incorporating digital materials, interactive tasks, and clinical scenarios into instructional design to improve students’ ability to interpret and apply health information [ 11 , 20 , 33 , 34 ]. Previous studies have shown the benefits of interactive e-books in different settings. Wu et al. (2023) found that combining multimedia e-books with community health practicum significantly improved nursing students’ information literacy and health communication skills [ 20 ]. Tseng et al. (2025) revealed that an interactive e-book with simulation and gamification improved medical students’ learning results across three areas of health literacy [ 35 ]. Chang et al. (2019) noted that interactive e-books were especially helpful for low-achieving students, helping to narrow performance gaps [ 33 ]. Chang et al. (2025) showed that digital materials could enhance knowledge and response strategies for sexual harassment prevention among new nurses [ 34 ]. Bulfone et al. (2024), in a systematic review, emphasized that educational interventions and simulation training can promote health literacy skills [ 11 ]. 4.4 Educational Impact of the Intervention Further analysis in this study showed that the e-book intervention significantly improved skills in obtaining and evaluating health information as well as in patient interaction. Notably, post-test improvements were observed in “evaluating the credibility of online health information,” “using admission nursing assessment forms to assess patients’ health literacy,” “applying health information to understand changes in patient condition,” and “helping patients interpret medication instructions and use medications correctly.” These areas were identified as weaknesses before the intervention, indicating that the e-book effectively addressed these gaps. However, performance in “using teach-back to assess patients’ healthcare ability” and “applying health information to interpret health check-up results” remained relatively weaker, although slight improvements were observed. The e-book was developed with scenario simulation and choice-based learning features to enhance learner engagement and clinical reasoning. Its interactive design and well-organized content effectively support learning, echoing findings from Tseng et al. (2025) [ 35 ]. These results support the wider adoption of e-book-based learning in nursing education and clinical training programs. 4.5 Strengths and Limitations This study has several strengths. First, it employed a quasi-experimental design with both within-group and between-group comparisons, enhancing the validity of the findings. Second, the intervention was tailored to address specific skill gaps identified in prior research and incorporated interactive features designed to simulate clinical decision-making. Third, the study utilized a validated instrument (MMHLQ) with additional items developed and reviewed by multidisciplinary experts, ensuring content relevance and reliability. However, certain limitations should be acknowledged. The study was conducted at a single private university in Taiwan, which may limit the generalizability of the findings to other cultural or educational settings. The sample size, especially in some subgroups (e.g., students without internship experience), was relatively small, possibly impacting the reliability of subgroup analyses. The follow-up period was limited to the immediate post-intervention stage; thus, the long-term retention of health literacy skills was not evaluated. Moreover, self-reported measures may be influenced by social desirability bias, and objective performance assessments in real clinical environments were not conducted. 4.6 Future Research Future studies should adopt multi-center designs involving diverse nursing programs to improve the external validity of results. Larger, more balanced samples are necessary to better understand how demographic and experiential factors, especially age, influence health literacy outcomes. Long-term follow-up assessments are crucial to evaluate whether intervention effects are maintained over time. Additionally, incorporating objective performance-based measures, such as standardized patient encounters or observed structured clinical examinations (OSCEs), could provide a more thorough assessment of health literacy skills. Exploring the adaptability of interactive e-book interventions for other healthcare disciplines and in interprofessional education environments may also increase their reach and effectiveness. 5 CONCLUSION This study showed that although nursing students generally demonstrated good health literacy skills, there were still gaps in higher-level abilities such as evaluating health information, integrating it into clinical decision-making, and assessing patients’ health literacy. The interactive e-book intervention contributed to measurable short-term improvements in students’ ability to understand and apply health information. These findings support the integration of scenario-based, interactive digital learning tools into nursing curricula as a feasible strategy to strengthen health literacy competencies and enhance patient-centered care. 6 RELEVANCE FOR CLINICAL PRACTICE The findings of this study indicate that incorporating scenario-based, interactive e-books into nursing education can meaningfully improve students’ ability to obtain, interpret, and apply health information in clinical settings. By simulating realistic patient interactions and integrating multimedia learning tools, such interventions can better prepare nursing students to assess patients’ health literacy and promote safe and effective self-care practices. The e-book approach can be integrated into pre-licensure curricula and in-service training, offering a flexible, scalable method to strengthen the health literacy competencies of both future and practicing nurses. In turn, this may contribute to higher quality, patient-centered care and better health outcomes across diverse healthcare environments. Declarations Ethics Approval and Consent to Participate: This study was approved by the National Taiwan Normal University Research Ethics Committee (Approval No. 202501HS020; February 2025). Written informed consent was obtained from all participants prior to data collection. Consent for Publication : Not applicable. Availability of Data and Materials: The datasets generated and analyzed during the current study are available from the first author on reasonable request. Competing Interests: The authors declared no potential conflicts of interest concerning to the research, authorship, and publication of this article. Funding: This research did not receive any external funding and was self-funded by the first author. Acknowledgments : We sincerely thank Dr. Chiu-Lin Lai for her valuable guidance and technical support in developing the interactive e-book, particularly her expertise with the eBookHub TM platform. Author Contributions: Pei-Ling Tseng : Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Visualization, Writing – Original Draft. Chen-Yin Tung : Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing, Project Administration. All authors read and approved the final manuscript. References Brach, C. and L.M. Harris, Healthy people 2030 health literacy definition tells organizations: make information and services easy to find, understand, and use. Journal of general internal medicine, 2021. 36 (4): p. 1084-1085. Yang, K., Y. Hu, and H. Qi, Digital health literacy: bibliometric analysis. Journal of medical Internet research, 2022. 24 (7): p. e35816. Wei, M.-H., et al., Development of Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ). Taiwan Journal of Public Health, 2017. 36 (6): p. 556-570. Duong, H. and P. Chang, Topics Included in Health Literacy Studies in Asia: A Systematic Review. Asia Pacific Journal of Public Health, 2024. 36 (1): p. 8-19. Nesari, M., et al., Registered nurses' knowledge of and experience with health literacy. HLRP: Health Literacy Research and Practice, 2019. 3 (4): p. e268-e279. Nantsupawat, A., et al., Nurses' knowledge of health literacy, communication techniques, and barriers to the implementation of health literacy programs: A cross‐sectional study. Nursing & health sciences, 2020. 22 (3): p. 577-585. Chang, Y.-W., et al., Exploring knowledge and experience of health literacy for Chinese-speaking nurses in Taiwan: a cross-sectional study. International Journal of Environmental Research and Public Health, 2020. 17 (20): p. 7609. Smith, G.D., et al., Translation, cross-cultural adaptation, and validation of the Chinese version of the COVID-19 health literacy scale in nursing students. Nurse Education in Practice, 2023. 72 : p. 103784. Liu, L., et al., Digital health literacy among undergraduate nursing students in China: associations with health lifestyles and psychological resilience. BMC Medical Education, 2024. 24 (1): p. 1139. Güner, M.D. and P.E. Ekmekci, A survey study evaluating and comparing the health literacy knowledge and communication skills used by nurses and physicians. Inquiry: The Journal of Health Care Organization, Provision, and Financing, 2019. 56 : p. 0046958019865831. Bulfone, G., et al., Nursing students’ health literacy skills: A scoping review for driving research. International Journal of Educational Research Open, 2024. 7 : p. 100379. Ramón-Arbués, E., et al., Factors related with nursing students’ health literacy: a cross sectional study. Frontiers in Public Health, 2023. 11 : p. 1053016. Wilandika, A., M.G.R. Pandin, and A. Yusuf, The roles of nurses in supporting health literacy: a scoping review. Frontiers in public health, 2023. 11 : p. 1022803. O’Doherty, D., et al., Barriers and solutions to online learning in medical education–an integrative review. BMC medical education, 2018. 18 : p. 1-11. Bankar, M.N., et al., The Role of E-Content Development in Medical Teaching: How Far Have We Come? Cureus, 2023. 15 (8). Chang, T.-S., et al., Use of an interactive multimedia e-book to improve nursing students’'sexual harassment prevention knowledge, prevention strategies, coping behavior, and learning motivation: A randomized controlled study. Nurse Education Today, 2021. 105 : p. 104883. Regmi, K. and L. Jones, A systematic review of the factors–enablers and barriers–affecting e-learning in health sciences education. BMC medical education, 2020. 20 : p. 1-18. Pickering, J.D. and B.J. Swinnerton, Exploring the dimensions of medical student engagement with technology‐enhanced learning resources and assessing the impact on assessment outcomes. Anatomical Sciences Education, 2019. 12 (2): p. 117-128. Wu, T.-T., et al., Application and analysis of a mobile E-Book system based on project-based learning in community health nursing practice courses. Journal of Educational Technology & Society, 2018. 21 (4): p. 143-156. Wu, T.-T., Y.-C. Lu, and Y.-M. Huang, Effect of Multimedia E-Book Use on the Information Literacy of Nursing Students and Health Communication in Student-Led Large-and Small-Group Community Health Education Sessions. Sustainability, 2023. 15 (9): p. 7408. Yu, T.-Y., et al., Effects of an Interactive e-Book on Enhancing Nursing Students' Knowledge, Confidence, and Learning Self-efficacy of Nursing Skills: A Randomized Controlled Trial. Nurse Educator, 2024. 49 (1): p. E20-E25. Mills, A., Improving health literacy to support better health outcomes. Nursing Times, 2024. 120 (1): p. 26-29. Cohen, J., Statistical power analysis for the behavioral sciences . 2013: routledge. Dong, Z.Y., et al., Smart campus: definition, framework, technologies, and services. IET Smart Cities, 2020. 2 (1): p. 43-54. Wang, M., et al., Covariance estimators for generalized estimating equations (GEE) in longitudinal analysis with small samples. Statistics in medicine, 2016. 35 (10): p. 1706-1721. Zhang, Y., et al., Exploring health literacy in medical university students of Chongqing, China: a cross-sectional study. PloS one, 2016. 11 (4): p. e0152547. Munangatire, T., N. Tomas, and V. Mareka, Nursing students’ understanding of health literacy and health practices: a cross-sectional study at a university in Namibia. BMC nursing, 2022. 21 (1): p. 8. Ayaz-Alkaya, S. and H. Terzi, Investigation of health literacy and affecting factors of nursing students. Nurse Education in Practice, 2019. 34 : p. 31-35. González-López, J.R. and M. de los Angeles Rodríguez-Gázquez, Do health literacy levels of nursing students change throughout the study programme? A cross-sectional study. BMJ open, 2022. 12 (1): p. e047712. Ozen, N., et al. Health literacy of nursing students and its effective factors . in Nursing forum . 2019. Wiley Online Library. Wittenberg, E., Health literacy: exploring nursing challenges to providing support and understanding. Number 1/February 2018, 2018. 22 (1): p. 53-61. Balmer, D., et al., Nursing students and health literacy: The effect of region and programme level. Nurse education in practice, 2020. 42 : p. 102688. Chang, L., T.-T. Wu, and C.-Y. Su. The influence of interactive and non-interactive e-book on the learning effectiveness of high and low achievement nursing students . in International conference on innovative technologies and learning . 2019. Springer. Chang, T.-S., et al., Effectiveness of an e-book in enhancing knowledge, coping behaviors and preventive strategies for sexual harassment prevention among new nurses: A randomized controlled study. Nurse Education in Practice, 2025. 82 : p. 104198. Tseng, P.-L., et al., The effect of an interactive game-based e-book with simulative clinical scenarios on the health literacy competency among medical students in Taiwan. BMC Medical Education, 2025. 25 (1): p. 876. Additional Declarations No competing interests reported. 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10:28:03","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121838,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7532459/v1/105e53f65e3ddd6d788a7a26.html"},{"id":92937154,"identity":"dc798e4e-abbd-46a3-891a-cb6e9b798f20","added_by":"auto","created_at":"2025-10-07 10:28:03","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172136,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of students enrollment and assessment\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7532459/v1/107ed4c34d0be232b0221db6.jpeg"},{"id":108437671,"identity":"91e793b3-ca30-4e0b-ba7b-513419243c7d","added_by":"auto","created_at":"2026-05-04 16:01:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":673324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7532459/v1/67d2b7e7-b228-40c5-9154-e4f96c4eab9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a Scenario-Based Interactive E-Book in Enhancing Nursing Students’ Health Literacy","fulltext":[{"header":"1 INTRODUCTION","content":"\u003cp\u003eThe increasingly diverse and globalized healthcare environment requires nurses to care for patients from a wide range of cultural, linguistic, and health literacy backgrounds. Health literacy refers to an individual\u0026rsquo;s ability to obtain, understand, evaluate, and apply health information to make informed health decisions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Digital health literacy emphasizes the capacity to locate and use health information and technologies within digital environments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These competencies are essential for helping individuals actively participate in their own care and make well-informed health choices.\u003c/p\u003e\u003cp\u003eIn Taiwan, population-based surveys have uncovered gaps in health literacy. Using the Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ), Wei et al. (2017) reported that 14% of adults had inadequate health literacy, and 37.6% had limited literacy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A systematic review by Duong and Chang (2024) found that 13.7\u0026ndash;25.3% of Taiwanese adults exhibited inadequate health literacy. Similar challenges are documented internationally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For example, in a study in Ireland, only a small number of 190 clinical nurses had adequate health literacy knowledge and experience [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thai research across 104 hospitals showed that 55% of 1,697 nurses understood health literacy concepts, but fewer than 10% had attended training to improve patient literacy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In Taiwan, a survey of 400 hospital and community nurses found generally low awareness of health literacy, with an average accuracy rate of only 51% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similar issues have been reported among Hong Kong nursing students during the COVID-19 pandemic [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], Chinese nursing students\u0026rsquo; digital health literacy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and Turkish nurses, only 18.4% of whom had prior exposure to health literacy topics, despite a strong interest in further education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealth literacy affects not only patients\u0026rsquo; health behaviors and outcomes but also nurses\u0026rsquo; ability to provide effective education and communication [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nurses with strong health literacy skills are better able to assess patients\u0026rsquo; literacy levels, tailor communication strategies, and ultimately improve quality of care. However, current nursing curricula do not consistently prepare students with the skills to apply health literacy principles in clinical settings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Developing systematic and interactive educational strategies has therefore become essential to enhancing students\u0026rsquo; understanding and practical application of health literacy, as well as their ability to adopt patient-centered communication approaches [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith the rise of digital technologies, health professions education has increasingly moved toward online and blended formats [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. E-books, as digital learning resources, have proven effective in nursing education [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Their integration of text, images, videos, and interactive exercises allows learners to engage with content in flexible and personalized ways, enhancing motivation, satisfaction, and knowledge retention [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Interactive multimedia features, such as embedded videos, are especially valued by students for deepening conceptual understanding [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In Taiwan, digital learning has been applied in both classroom and community health settings, with studies indicating that interactive e-books can improve nursing students\u0026rsquo; disease-specific skills, confidence, and self-efficacy [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These tools also enhance information literacy and health communication skills, particularly when students are tasked with designing and delivering their own multimedia educational resources.\u003c/p\u003e\u003cp\u003eE-books provide several benefits over traditional teaching methods, including flexible content design, easy access, and the ability to simulate realistic clinical scenarios [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These interactive, context-based learning experiences can enhance nursing students\u0026rsquo; ability to assess and respond to patients\u0026rsquo; health literacy needs in clinical practice.\u003c/p\u003e\u003cp\u003eConsidering these gaps in health literacy education and the potential of interactive e-book technology, this study developed a systematic, interactive e-book aimed at improving nursing students\u0026rsquo; health literacy competencies. Based on this rationale, we proposed the following hypotheses:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eH1\u003c/strong\u003e\u003cp\u003eNursing students will demonstrate varying baseline levels of health literacy performance.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eH2\u003c/strong\u003e\u003cp\u003eNursing students\u0026rsquo; demographic and experiential factors (e.g., gender, age, internship experience, and healthcare work experience) will be significantly associated with their health literacy performance.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eH3\u003c/strong\u003e\u003cp\u003eThe use of a scenario-based interactive e-book will significantly improve nursing students\u0026rsquo; overall health literacy performance.\u003c/p\u003e\u003c/p\u003e"},{"header":"2 METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eThis study employed a quasi-experimental design with a two-group repeated measures approach and convenience sampling. Participants were fourth-year nursing students enrolled at a university in Taiwan. Classes were randomly assigned to either the experimental or control group. During the medical ethics course, the experimental group received an instructional intervention integrating the Health Literacy E-book into the regular curriculum, while the control group took the standard course without the e-book component.\u003c/p\u003e\u003cp\u003eTo minimize potential testing effects, both groups received a briefing on the study's purpose and procedures three weeks before the intervention, after which informed written consent was obtained from eligible and willing participants. Pre-test assessments using the Health Literacy Performance Scale were conducted prior to the course intervention, and the same scale was administered immediately after the intervention (post-test). Pre- and post-test data were paired for statistical analysis to evaluate the effectiveness of the intervention.\u003c/p\u003e\u003cp\u003eTo ensure equal access to educational resources, the control group received the Health Literacy E-book content after the study was completed, enabling all participants to benefit from the learning material.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Participants\u003c/h2\u003e\u003cp\u003eParticipants were recruited from fourth-year nursing students at a private university in Taiwan through convenience sampling. According to statistical principles, a medium effect size (f\u0026thinsp;=\u0026thinsp;0.25) was assumed, reflecting a moderate impact of the independent variable on the dependent variable, a value commonly used in experimental designs such as ANOVA [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. An a priori power analysis was performed using G*Power 3.1.9.7, with the statistical model set as F tests \u0026ndash; ANOVA: Repeated measures, within\u0026ndash;between interaction, an effect size of 0.25, a significance level (α) of 0.05, and a statistical power (1\u0026ndash;β) of 0.95. The required sample size was estimated at 54.\u003c/p\u003e\u003cp\u003eConsidering potential attrition and the course schedule, a total of 87 students from two classes enrolled in the Medical Ethics and Law course. One class (n\u0026thinsp;=\u0026thinsp;44) was assigned to the experimental group, and the other (n\u0026thinsp;=\u0026thinsp;43) to the control group. Both groups completed the pre-test before the intervention and the post-test immediately afterward.\u003c/p\u003e\u003cp\u003eIn the data collection process, 81 valid pre-test questionnaires were returned (43 from the experimental group and 38 from the control group), and 75 valid post-test questionnaires were collected (38 from the experimental group and 37 from the control group). Only students who completed both pre- and post-tests were included in the final analysis, resulting in 55 participants (28 in the experimental group and 27 in the control group), with an overall valid response rate of 63.2%. The mean age of participants was 22.91 years. Participant enrollment and assessment are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Experimental Context and E-Book Development\u003c/h2\u003e\u003cp\u003eTo improve nursing students\u0026rsquo; health literacy performance, this study aimed to help them recognize and assess patients\u0026rsquo; health literacy, explain medical information clearly, and promote positive nurse\u0026ndash;patient interactions. An interactive digital e-book was created as the teaching tool. The e-book included various interactive features designed to improve learning outcomes, such as audio and image playback, interactive multiple-choice questions, pop-up tips, and embedded clinical videos. These features were intended to strengthen students\u0026rsquo; ability to identify and respond to patient needs during clinical communication. To meet the 4A learning principles (anytime, anywhere, anyone, anyway) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and considering the time and cost involved in developing technology and learning resources, the e-book was developed in partnership with Hamastar Technology Co., Ltd., and delivered through its cloud-based \u003cb\u003eeBookHub\u0026trade;\u003c/b\u003e sharing platform.\u003c/p\u003e\u003cp\u003eThe content featured diverse and highly interactive instructional formats. Animated titles and content displays were used to quickly introduce and reinforce key concepts. Various interactive games\u0026mdash;such as multiple-choice questions, drag-and-drop activities, and masking sticker exercises\u0026mdash;were designed to increase engagement and enjoyment. Scenario-based comic strips, along with clinical scenario videos performed by cartoon characters or real actors, helped visualize abstract concepts and enhance learners\u0026rsquo; understanding and application of health literacy.\u003c/p\u003e\u003cp\u003eThe teaching content consisted of five main components:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAnimated Introduction to Health Literacy: Animation presenting the definition of health literacy, accompanied by scripted audio narration to promote initial understanding and motivation.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eComic Story Experience and Observation: Comic-based stories with guided audio narration to help students understand the needs of patients with low health literacy and appreciate the value of empathy and support.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eScenario Videos and Quizzes: Videos showing patients\u0026rsquo; communication challenges and misunderstandings, followed by brief quizzes to reinforce learning.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHealth Literacy Assessment and Clinical Awareness: Overview of common health literacy assessment tools and indicators of low health literacy, including clinical case quizzes to test the students\u0026rsquo; recognition and judgment skills.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSummary of Clinical Awareness and Strategies: Guidance on how nurses can detect and evaluate health literacy in clinical practice, a strategy summary, and scenario-based questions to consolidate practical application.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe Health Literacy E-book could be accessed via the \u003cb\u003eeBookHub\u0026trade;\u003c/b\u003e cloud bookshelf platform on web browsers or through the \u003cb\u003eeBookHub\u003c/b\u003e\u0026trade; mobile application for Android and iOS devices, enabling learning across multiple platforms and devices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Questionnaires\u003c/h2\u003e\u003cp\u003eTo assess the effectiveness of the \u003cem\u003eHealth Literacy E-book\u003c/em\u003e intervention, a structured questionnaire was used. The instrument consisted of two sections: (1) demographic information, including gender, age, comprehensive clinical nursing internship experience, and work experience in healthcare institutions, and (2) health literacy performance.\u003c/p\u003e\u003cp\u003eThe health literacy performance scale was adapted from the MMHLQ [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], with permission from the original author. Ten additional items were incorporated to reflect the dual role of nursing students as both users and providers of health literacy. The final scale comprised 26 items covering four domains: \u003cem\u003eobtaining\u003c/em\u003e, \u003cem\u003eunderstanding\u003c/em\u003e, \u003cem\u003eevaluating\u003c/em\u003e, and \u003cem\u003eapplying\u003c/em\u003e health information, as well as the practice of promoting patients\u0026rsquo; health literacy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEach item was rated on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;very difficult, 2\u0026thinsp;=\u0026thinsp;difficult, 3\u0026thinsp;=\u0026thinsp;easy, 4\u0026thinsp;=\u0026thinsp;very easy). Missing responses were considered missing data. The additional items were reviewed for content validity by a panel of five experts from various fields, including medicine, social sciences, health education, and health literacy, to ensure they were appropriate and clear. The revised instrument was then pilot-tested with 30 nursing students to evaluate reliability and validity. The scale showed excellent content validity (CVI\u0026thinsp;=\u0026thinsp;0.97) and high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.96), confirming its suitability for the main study.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eScale Items for Measuring Health Literacy Performance\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScale Item\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, finding knowledge about diseases is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, obtaining information about daily health care is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, searching for necessary health information on the internet is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, collecting additional information after receiving a health examination report is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, understanding the instructions on a medication bag is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, being able to care for a disease according to healthcare providers\u0026rsquo; instructions is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, understanding the explanations given by healthcare providers is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, being able to use medications according to the instructions on the medication bag is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, determining whether the obtained health information can solve a health problem is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, determining whether the obtained health information is suitable for me is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, determining whether the obtained health information is consistent with other information is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, judging whether online health information is trustworthy is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, applying health information to understand changes in my health condition is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, applying health information to prepare for facing a disease is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, applying health information to understand the results of a health examination is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFor me, applying health information to choose treatment methods is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, using the \u0026ldquo;Admission Nursing Assessment Form\u0026rdquo; to understand a patient\u0026rsquo;s health literacy level is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, observing a patient\u0026rsquo;s self-care ability through the teach-back method is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, helping a patient obtain medical information related to their diagnosed disease is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, helping a patient obtain necessary health or medical information unrelated to their diagnosed disease is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, assisting a patient in understanding medication bag instructions and using medications correctly is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, assisting a patient in interpreting the content of health education leaflets is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, assisting a patient in applying health information to analyze and select the appropriateness of different treatment options is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, assisting a patient in assessing further nursing care needs is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, guiding a patient to follow healthcare providers\u0026rsquo; instructions for self-health management is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf I were a nurse, helping a patient apply medical information to prepare for treatment is\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eResponse scale: 1\u0026thinsp;=\u0026thinsp;Very Difficult to 4\u0026thinsp;=\u0026thinsp;Very Easy\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Data Analysis\u003c/h2\u003e\u003cp\u003eAll data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Baseline characteristics between the experimental and control groups were compared using the Chi-square test to confirm group homogeneity. The distribution of background variables was similar across groups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05), indicating suitability for the subsequent intervention effect analyses.\u003c/p\u003e\u003cp\u003eTo examine the influence of background variables, including gender, comprehensive clinical nursing internship experience, and work experience in healthcare institutions, between-group comparisons were performed using independent samples t-tests.\u003c/p\u003e\u003cp\u003eBefore conducting the intervention effect analysis, the Shapiro\u0026ndash;Wilk test was used to check the normality of the data for each group at both measurement time points, considering the sample size (\u0026lt;\u0026thinsp;50 per group). Results showed that none of the variables broke the normality assumption (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05).\u003c/p\u003e\u003cp\u003eTo evaluate within-group changes in health literacy performance, paired-samples t-tests were conducted separately for the experimental and control groups. The primary analysis of intervention effectiveness was conducted using Generalized Estimating Equations (GEE), a statistical approach suitable for repeated measures data that accounts for both the \u0026ldquo;time\u0026rdquo; factor (pre-test vs. post-test), the \u0026ldquo;group\u0026rdquo; factor (experimental vs. control), and their interaction.\u003c/p\u003e\u003cp\u003eAlthough the GEE analysis did not produce a statistically significant interaction effect between time and group, supplementary analyses were performed following the recommendations of Wang et al. (2016)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. When the primary model does not show significant differences, especially with small samples, targeted comparisons at specific time points using t-tests with appropriate variance estimators can reveal meaningful trends. Therefore, independent samples t-tests were performed on the post-test data to further examine potential differences between groups. This supplementary analysis aimed to provide more precise comparisons and enhance the practical interpretability of the results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Ethical Considerations\u003c/h2\u003e\u003cp\u003eThis study was approved by the university\u0026rsquo;s Research Ethics Committee (Approval No. 202501HS020) and conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed of their right to withdraw from the study at any time without penalty. All data were anonymized and used solely for research purposes to ensure confidentiality.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Differences in Health Literacy Performance by Background Variables\u003c/h2\u003e\u003cp\u003eTo determine whether background variables affected participants\u0026rsquo; health literacy performance, the difference score (d) between post-test and pre-test results was calculated and examined using independent-samples t-tests for four variables: gender, age, comprehensive clinical nursing internship experience, and work experience in healthcare institutions. The analysis showed no significant differences by gender, internship experience, or work experience (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). In the control group, older students scored significantly lower than younger students (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.033), although this result should be interpreted cautiously due to the lack of an intervention and the brief interval between tests. Detailed results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBackground Variables and Health Literacy Performance\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eExperimental Group (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.03 (0.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.769\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.03 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.960\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06 (0.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.04 (0.18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05 (0.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.867\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.12 (0.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.033*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.04 (0.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.09 (0.34)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eInternship experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06 (0.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.04 (0.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.216\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.42 (-----)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.35 (-----)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWork experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.02 (0.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.595\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.04 (0.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e.128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.08 (0.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.12 (0.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Evaluation of the Effectiveness of Health Literacy Performance\u003c/h2\u003e\u003cp\u003ePaired-samples t-tests showed that the experimental group\u0026rsquo;s overall health literacy score increased significantly from pre-test to post-test (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), while the control group\u0026rsquo;s score decreased significantly during the same period (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The gain in the experimental group was associated with a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;\u0026asymp;\u0026thinsp;0.50), indicating a practically meaningful improvement in health literacy.\u003c/p\u003e\u003cp\u003eItem-level analysis showed that 14 out of 26 items in the experimental group improved significantly, especially in areas related to acquiring, interpreting, and applying health information in clinical settings. In contrast, most significant changes in the control group were declines in performance, mainly in patient-support tasks such as helping patients use health information to evaluate treatment options and interpret health education materials. Full item-level statistics are available in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNursing Students\u0026rsquo; Health Literacy Performance\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eExperimental Group (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-test Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-test Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePre-test Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePost-test Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.00 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.36 (0.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.027*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.93 (0.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.26 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.133\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.29 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.54 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.37 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.56 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.54 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.64 (0.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.52 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.63 (0.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.43 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.32 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.009*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.33 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.15 (0.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.50 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.71 (0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.011*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.48 (0.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.48 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.003*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.61 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.68 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.003*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.56 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.52 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.61 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.68 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.043*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.44 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.52 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.062\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.71 (0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.75 (0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.003*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.74 (0.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.63 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.36 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.46 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.22 (0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.15 (0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.015*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.25 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.50 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.342\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.00 (0.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.04 (0.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.25 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.57 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.93 (0.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.26 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.14 (0.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.43 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.039*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.70 (0.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.96 (0.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.003*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.29 (0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.50 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.011*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.04 (0.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.15 (0.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.345\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.32 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.43 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.007*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.00 (0.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.15 (0.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.50 (0.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.57 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.30 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.22 (0.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.18 (0.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.43 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.361\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.00 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.22 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.025*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.00 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.18 (0.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.032*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.93 (0.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.07 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.320\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.21 (0.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.25 (0.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.11 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.19 (0.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.389\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.18 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.29 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.005*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.15 (0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.11 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.436\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.11 (0.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.25 (0.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.04 (0.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.89 (0.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.024*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.32 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.50 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.41 (0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.30 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.86 (0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.46 (0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.005*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.67 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.26 (0.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.042*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.75 (0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.32 (0.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.007*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.59 (0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.07 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.75 (0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.32 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.70 (0.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.07 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.284\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.75 (0.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.32 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.017*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.59 (0.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.19 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.71 (0.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.36 (0.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.007*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.70 (0.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.07 (0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.359\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.41 (0.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.45 (0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.29 (0.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.24 (0.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Overall Effectiveness of the Teaching Intervention\u003c/h2\u003e\u003cp\u003eTo thoroughly assess the effectiveness of the intervention, a Generalized Estimating Equations (GEE) analysis was performed to examine the effects of time, group, and the time \u0026times; group interaction on the outcome variables, with age included as a continuous covariate (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This adjustment was made because the independent samples t-test results (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed that, among the four background variables examined, only age was significantly related to health literacy performance.\u003c/p\u003e\u003cp\u003eThe GEE analysis showed that neither the main effect of time nor the time \u0026times; group interaction was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05), indicating no meaningful differences between pre-test and post-test or among groups. However, after adjusting for age, the main effect of group was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015), suggesting the experimental group performed better than the control group overall.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNursing Students\u0026rsquo; Health Literacy Performance: GEE Analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026#120573;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStd. Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntercept\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[4.50, 98.14]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.032*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[-0.36, 3.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup (ref.=control group)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-6.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[-11.28, -1.24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.015*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime (ref.=pre-test)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[-3.61, 1.19]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.322\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime*Group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[-0.78, 5.88]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.134\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs a supplementary analysis, independent samples t-tests were conducted to compare the experimental and control groups at pre-test and post-test. At pre-test, the experimental group had a mean score of M\u0026thinsp;=\u0026thinsp;3.41 (SD\u0026thinsp;=\u0026thinsp;0.32, 95% CI [\u0026minus;\u0026thinsp;1.66, 7.99]) and the control group had M\u0026thinsp;=\u0026thinsp;3.29 (SD\u0026thinsp;=\u0026thinsp;0.37). Levene\u0026rsquo;s test indicated equal variances, F(1, 53)\u0026thinsp;=\u0026thinsp;0.056, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05. The independent samples t-test showed no significant difference between groups at baseline, t(53)\u0026thinsp;=\u0026thinsp;1.315, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05.\u003c/p\u003e\u003cp\u003eAt post-test, the experimental group\u0026rsquo;s mean score was M\u0026thinsp;=\u0026thinsp;3.45 (SD\u0026thinsp;=\u0026thinsp;0.39, 95% CI [0.41, 11.02]), which was significantly higher than the control group\u0026rsquo;s M\u0026thinsp;=\u0026thinsp;3.24 (SD\u0026thinsp;=\u0026thinsp;0.36), t(53)\u0026thinsp;=\u0026thinsp;2.159, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.035. The effect size was medium (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.56), indicating that the e-book intervention produced a meaningful short-term improvement in health literacy performance.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 DISCUSSION","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Interpretation of Key Findings\u003c/h2\u003e\u003cp\u003eThis study showed that nursing students performed better in health literacy tasks related to obtaining and applying health information, such as \u0026ldquo;assisting patients in interpreting health education leaflets,\u0026rdquo; \u0026ldquo;assessing patients\u0026rsquo; care needs,\u0026rdquo; and \u0026ldquo;using medication according to instructions.\u0026rdquo; However, their performance was noticeably lower in \u0026ldquo;evaluating the credibility of online health information\u0026rdquo; and \u0026ldquo;recognizing and assessing patients\u0026rsquo; health literacy\u0026rdquo; (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These findings are consistent with Ram\u0026oacute;n-Arbu\u0026eacute;s et al. (2023), who reported that although 57.4% of Spanish nursing students demonstrated adequate health literacy, their skills in evaluating information and making decisions needed improvement [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, Zhang et al. (2016) found that Chinese nursing students understood health information well but were less proficient in interacting with the healthcare system and critically evaluating information, highlighting the need to strengthen their critical appraisal skills [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComparable patterns have been observed internationally. For example, while 76.5% of Namibian nursing students exhibited adequate comprehension skills, only 3.9% could effectively translate this into practice [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In Iran, Nesari er al. (2019) also reported that registered nurses in Tehran struggled with using health literacy assessment tools and applying teach-back strategies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Comparison with Previous Studies\u003c/h2\u003e\u003cp\u003eAnalysis of background variables showed no significant differences in health literacy performance based on gender, internship experience, or work experience (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), aligning with previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Notably, in the control group, older students scored significantly lower than younger students (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.033), which matches Wittenberg (2018), who found that more experienced oncology nurses in the U.S. reported greater difficulty in assessing and identifying patients with low health literacy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Conversely, some studies have shown that health literacy improves with age and educational progress [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These differences could be due to the smaller sample size in the control group and the lack of educational intervention, or they might reflect different contextual factors influencing the relationship between age and health literacy. For example, Balmer et al. (2020) found that health literacy increased with age among nursing students in Pacific regions, but no such pattern was observed in Europe or Southeast Asia [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Implications for Nursing Education and Practice\u003c/h2\u003e\u003cp\u003eThe results highlight specific skill gaps among nursing students, especially in critical thinking and assessing patients\u0026rsquo; health literacy, confirming earlier findings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These gaps emphasize the need for nursing curricula to focus more on health literacy training, particularly in evaluating online health information and assessing patients\u0026rsquo; health literacy, to improve overall professional competence.\u003c/p\u003e\u003cp\u003eThe e-book intervention in this study significantly improved health literacy performance in the experimental group compared to the control group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.035), with a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.56). In nursing education, a medium effect size indicates that the intervention can meaningfully enhance learning within limited instructional time, especially in information evaluation and clinical application. This finding supports previous research that promotes incorporating digital materials, interactive tasks, and clinical scenarios into instructional design to improve students\u0026rsquo; ability to interpret and apply health information [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious studies have shown the benefits of interactive e-books in different settings. Wu et al. (2023) found that combining multimedia e-books with community health practicum significantly improved nursing students\u0026rsquo; information literacy and health communication skills [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Tseng et al. (2025) revealed that an interactive e-book with simulation and gamification improved medical students\u0026rsquo; learning results across three areas of health literacy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Chang et al. (2019) noted that interactive e-books were especially helpful for low-achieving students, helping to narrow performance gaps [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Chang et al. (2025) showed that digital materials could enhance knowledge and response strategies for sexual harassment prevention among new nurses [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Bulfone et al. (2024), in a systematic review, emphasized that educational interventions and simulation training can promote health literacy skills [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Educational Impact of the Intervention\u003c/h2\u003e\u003cp\u003eFurther analysis in this study showed that the e-book intervention significantly improved skills in obtaining and evaluating health information as well as in patient interaction. Notably, post-test improvements were observed in \u0026ldquo;evaluating the credibility of online health information,\u0026rdquo; \u0026ldquo;using admission nursing assessment forms to assess patients\u0026rsquo; health literacy,\u0026rdquo; \u0026ldquo;applying health information to understand changes in patient condition,\u0026rdquo; and \u0026ldquo;helping patients interpret medication instructions and use medications correctly.\u0026rdquo; These areas were identified as weaknesses before the intervention, indicating that the e-book effectively addressed these gaps. However, performance in \u0026ldquo;using teach-back to assess patients\u0026rsquo; healthcare ability\u0026rdquo; and \u0026ldquo;applying health information to interpret health check-up results\u0026rdquo; remained relatively weaker, although slight improvements were observed.\u003c/p\u003e\u003cp\u003eThe e-book was developed with scenario simulation and choice-based learning features to enhance learner engagement and clinical reasoning. Its interactive design and well-organized content effectively support learning, echoing findings from Tseng et al. (2025) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. These results support the wider adoption of e-book-based learning in nursing education and clinical training programs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Strengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study has several strengths. First, it employed a quasi-experimental design with both within-group and between-group comparisons, enhancing the validity of the findings. Second, the intervention was tailored to address specific skill gaps identified in prior research and incorporated interactive features designed to simulate clinical decision-making. Third, the study utilized a validated instrument (MMHLQ) with additional items developed and reviewed by multidisciplinary experts, ensuring content relevance and reliability.\u003c/p\u003e\u003cp\u003eHowever, certain limitations should be acknowledged. The study was conducted at a single private university in Taiwan, which may limit the generalizability of the findings to other cultural or educational settings. The sample size, especially in some subgroups (e.g., students without internship experience), was relatively small, possibly impacting the reliability of subgroup analyses. The follow-up period was limited to the immediate post-intervention stage; thus, the long-term retention of health literacy skills was not evaluated. Moreover, self-reported measures may be influenced by social desirability bias, and objective performance assessments in real clinical environments were not conducted.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Future Research\u003c/h2\u003e\u003cp\u003eFuture studies should adopt multi-center designs involving diverse nursing programs to improve the external validity of results. Larger, more balanced samples are necessary to better understand how demographic and experiential factors, especially age, influence health literacy outcomes. Long-term follow-up assessments are crucial to evaluate whether intervention effects are maintained over time. Additionally, incorporating objective performance-based measures, such as standardized patient encounters or observed structured clinical examinations (OSCEs), could provide a more thorough assessment of health literacy skills. Exploring the adaptability of interactive e-book interventions for other healthcare disciplines and in interprofessional education environments may also increase their reach and effectiveness.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 CONCLUSION","content":"\u003cp\u003eThis study showed that although nursing students generally demonstrated good health literacy skills, there were still gaps in higher-level abilities such as evaluating health information, integrating it into clinical decision-making, and assessing patients\u0026rsquo; health literacy. The interactive e-book intervention contributed to measurable short-term improvements in students\u0026rsquo; ability to understand and apply health information. These findings support the integration of scenario-based, interactive digital learning tools into nursing curricula as a feasible strategy to strengthen health literacy competencies and enhance patient-centered care.\u003c/p\u003e"},{"header":"6 RELEVANCE FOR CLINICAL PRACTICE","content":"\u003cp\u003eThe findings of this study indicate that incorporating scenario-based, interactive e-books into nursing education can meaningfully improve students\u0026rsquo; ability to obtain, interpret, and apply health information in clinical settings. By simulating realistic patient interactions and integrating multimedia learning tools, such interventions can better prepare nursing students to assess patients\u0026rsquo; health literacy and promote safe and effective self-care practices. The e-book approach can be integrated into pre-licensure curricula and in-service training, offering a flexible, scalable method to strengthen the health literacy competencies of both future and practicing nurses. In turn, this may contribute to higher quality, patient-centered care and better health outcomes across diverse healthcare environments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e This study was approved by the \u003cem\u003eNational Taiwan Normal University Research Ethics Committee\u003c/em\u003e (Approval No. 202501HS020; February 2025). Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analyzed during the current study are available from the first author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Interests:\u0026nbsp;\u003c/strong\u003eThe authors declared no potential conflicts of interest concerning to the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any external funding and was self-funded by the first author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: We sincerely thank Dr. Chiu-Lin Lai for her valuable guidance and technical support in developing the interactive e-book, particularly her expertise with the \u003cstrong\u003eeBookHub\u003c/strong\u003e\u003csup\u003eTM\u003c/sup\u003e platform.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePei-Ling Tseng\u003c/strong\u003e: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Visualization, Writing \u0026ndash; Original Draft.\u003cbr\u003e\u003cstrong\u003eChen-Yin Tung\u003c/strong\u003e: Conceptualization, Methodology, Supervision, Validation, Writing \u0026ndash; Review \u0026amp; Editing, Project Administration.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrach, C. and L.M. 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Yusuf, \u003cem\u003eThe roles of nurses in supporting health literacy: a scoping review.\u003c/em\u003e Frontiers in public health, 2023. \u003cstrong\u003e11\u003c/strong\u003e: p. 1022803.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Doherty, D., et al., \u003cem\u003eBarriers and solutions to online learning in medical education\u0026ndash;an integrative review.\u003c/em\u003e BMC medical education, 2018. \u003cstrong\u003e18\u003c/strong\u003e: p. 1-11.\u003c/li\u003e\n\u003cli\u003eBankar, M.N., et al., \u003cem\u003eThe Role of E-Content Development in Medical Teaching: How Far Have We Come?\u003c/em\u003e Cureus, 2023. \u003cstrong\u003e15\u003c/strong\u003e(8).\u003c/li\u003e\n\u003cli\u003eChang, T.-S., et al., \u003cem\u003eUse of an interactive multimedia e-book to improve nursing students\u0026rsquo;\u0026apos;sexual harassment prevention knowledge, prevention strategies, coping behavior, and learning motivation: A randomized controlled study.\u003c/em\u003e Nurse Education Today, 2021. \u003cstrong\u003e105\u003c/strong\u003e: p. 104883.\u003c/li\u003e\n\u003cli\u003eRegmi, K. and L. Jones, \u003cem\u003eA systematic review of the factors\u0026ndash;enablers and barriers\u0026ndash;affecting e-learning in health sciences education.\u003c/em\u003e BMC medical education, 2020. \u003cstrong\u003e20\u003c/strong\u003e: p. 1-18.\u003c/li\u003e\n\u003cli\u003ePickering, J.D. and B.J. Swinnerton, \u003cem\u003eExploring the dimensions of medical student engagement with technology‐enhanced learning resources and assessing the impact on assessment outcomes.\u003c/em\u003e Anatomical Sciences Education, 2019. \u003cstrong\u003e12\u003c/strong\u003e(2): p. 117-128.\u003c/li\u003e\n\u003cli\u003eWu, T.-T., et al., \u003cem\u003eApplication and analysis of a mobile E-Book system based on project-based learning in community health nursing practice courses.\u003c/em\u003e Journal of Educational Technology \u0026amp; Society, 2018. \u003cstrong\u003e21\u003c/strong\u003e(4): p. 143-156.\u003c/li\u003e\n\u003cli\u003eWu, T.-T., Y.-C. Lu, and Y.-M. Huang, \u003cem\u003eEffect of Multimedia E-Book Use on the Information Literacy of Nursing Students and Health Communication in Student-Led Large-and Small-Group Community Health Education Sessions.\u003c/em\u003e Sustainability, 2023. \u003cstrong\u003e15\u003c/strong\u003e(9): p. 7408.\u003c/li\u003e\n\u003cli\u003eYu, T.-Y., et al., \u003cem\u003eEffects of an Interactive e-Book on Enhancing Nursing Students\u0026apos; Knowledge, Confidence, and Learning Self-efficacy of Nursing Skills: A Randomized Controlled Trial.\u003c/em\u003e Nurse Educator, 2024. \u003cstrong\u003e49\u003c/strong\u003e(1): p. E20-E25.\u003c/li\u003e\n\u003cli\u003eMills, A., \u003cem\u003eImproving health literacy to support better health outcomes.\u003c/em\u003e Nursing Times, 2024. \u003cstrong\u003e120\u003c/strong\u003e(1): p. 26-29.\u003c/li\u003e\n\u003cli\u003eCohen, J., \u003cem\u003eStatistical power analysis for the behavioral sciences\u003c/em\u003e. 2013: routledge.\u003c/li\u003e\n\u003cli\u003eDong, Z.Y., et al., \u003cem\u003eSmart campus: definition, framework, technologies, and services.\u003c/em\u003e IET Smart Cities, 2020. \u003cstrong\u003e2\u003c/strong\u003e(1): p. 43-54.\u003c/li\u003e\n\u003cli\u003eWang, M., et al., \u003cem\u003eCovariance estimators for generalized estimating equations (GEE) in longitudinal analysis with small samples.\u003c/em\u003e Statistics in medicine, 2016. \u003cstrong\u003e35\u003c/strong\u003e(10): p. 1706-1721.\u003c/li\u003e\n\u003cli\u003eZhang, Y., et al., \u003cem\u003eExploring health literacy in medical university students of Chongqing, China: a cross-sectional study.\u003c/em\u003e PloS one, 2016. \u003cstrong\u003e11\u003c/strong\u003e(4): p. e0152547.\u003c/li\u003e\n\u003cli\u003eMunangatire, T., N. Tomas, and V. Mareka, \u003cem\u003eNursing students\u0026rsquo; understanding of health literacy and health practices: a cross-sectional study at a university in Namibia.\u003c/em\u003e BMC nursing, 2022. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 8.\u003c/li\u003e\n\u003cli\u003eAyaz-Alkaya, S. and H. Terzi, \u003cem\u003eInvestigation of health literacy and affecting factors of nursing students.\u003c/em\u003e Nurse Education in Practice, 2019. \u003cstrong\u003e34\u003c/strong\u003e: p. 31-35.\u003c/li\u003e\n\u003cli\u003eGonz\u0026aacute;lez-L\u0026oacute;pez, J.R. and M. de los Angeles Rodr\u0026iacute;guez-G\u0026aacute;zquez, \u003cem\u003eDo health literacy levels of nursing students change throughout the study programme? A cross-sectional study.\u003c/em\u003e BMJ open, 2022. \u003cstrong\u003e12\u003c/strong\u003e(1): p. e047712.\u003c/li\u003e\n\u003cli\u003eOzen, N., et al. \u003cem\u003eHealth literacy of nursing students and its effective factors\u003c/em\u003e. in \u003cem\u003eNursing forum\u003c/em\u003e. 2019. Wiley Online Library.\u003c/li\u003e\n\u003cli\u003eWittenberg, E., \u003cem\u003eHealth literacy: exploring nursing challenges to providing support and understanding.\u003c/em\u003e Number 1/February 2018, 2018. \u003cstrong\u003e22\u003c/strong\u003e(1): p. 53-61.\u003c/li\u003e\n\u003cli\u003eBalmer, D., et al., \u003cem\u003eNursing students and health literacy: The effect of region and programme level.\u003c/em\u003e Nurse education in practice, 2020. \u003cstrong\u003e42\u003c/strong\u003e: p. 102688.\u003c/li\u003e\n\u003cli\u003eChang, L., T.-T. Wu, and C.-Y. Su. \u003cem\u003eThe influence of interactive and non-interactive e-book on the learning effectiveness of high and low achievement nursing students\u003c/em\u003e. in \u003cem\u003eInternational conference on innovative technologies and learning\u003c/em\u003e. 2019. Springer.\u003c/li\u003e\n\u003cli\u003eChang, T.-S., et al., \u003cem\u003eEffectiveness of an e-book in enhancing knowledge, coping behaviors and preventive strategies for sexual harassment prevention among new nurses: A randomized controlled study.\u003c/em\u003e Nurse Education in Practice, 2025. \u003cstrong\u003e82\u003c/strong\u003e: p. 104198.\u003c/li\u003e\n\u003cli\u003eTseng, P.-L., et al., \u003cem\u003eThe effect of an interactive game-based e-book with simulative clinical scenarios on the health literacy competency among medical students in Taiwan.\u003c/em\u003e BMC Medical Education, 2025. \u003cstrong\u003e25\u003c/strong\u003e(1): p. 876.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Interactive E-Book, Health Literacy, Clinical Scenario, Nursing Students, Nursing Education","lastPublishedDoi":"10.21203/rs.3.rs-7532459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7532459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Health literacy is essential for safe and effective nursing practice, yet traditional teaching methods may not fully address students\u0026rsquo; needs. This study evaluated a scenario-based interactive e-book designed to enhance nursing students\u0026rsquo; health literacy performance.\u003c/p\u003e\u003cp\u003eMethods: A quasi-experimental design was conducted with 55 fourth-year nursing students from a Taiwanese university. Students were assigned to an experimental group (n\u0026thinsp;=\u0026thinsp;28) that received e-book instruction or a control group (n\u0026thinsp;=\u0026thinsp;27) that received traditional teaching. The 26-item Health Literacy Performance Scale, demonstrating strong validity and reliability, was administered before and after the intervention. For educational parity, the control group accessed the e-book after data collection.\u003c/p\u003e\u003cp\u003eResults: Generalized Estimating Equations revealed no significant effects of time or time \u0026times; group interaction. However, after adjusting for age, the main effect of group was significant (p\u0026thinsp;=\u0026thinsp;.015). Post hoc analysis showed that the experimental group scored higher on the post-test (p\u0026thinsp;=\u0026thinsp;.035), particularly in interpreting health education materials, assessing care needs, and correct medication use.\u003c/p\u003e\u003cp\u003eDiscussion: Findings indicate that the scenario-based e-book effectively improved nursing students\u0026rsquo; health literacy performance. This approach demonstrates practical value and suggests potential for broader application in nursing education to strengthen essential competencies.\u003c/p\u003e","manuscriptTitle":"Effectiveness of a Scenario-Based Interactive E-Book in Enhancing Nursing Students’ Health Literacy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-07 10:27:58","doi":"10.21203/rs.3.rs-7532459/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-09T23:07:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T03:23:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T11:56:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212992063149544754589076615564348078728","date":"2026-03-17T00:51:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59424655650538828037491383658424475836","date":"2026-02-25T16:10:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T03:00:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T11:12:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-06T06:54:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-06T06:53:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-09-04T05:39:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cea272b5-f139-4018-a42b-a3dd618af9f2","owner":[],"postedDate":"October 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:00:36+00:00","versionOfRecord":{"articleIdentity":"rs-7532459","link":"https://doi.org/10.1186/s12912-026-04715-8","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-04-30 15:57:33","publishedOnDateReadable":"April 30th, 2026"},"versionCreatedAt":"2025-10-07 10:27:58","video":"","vorDoi":"10.1186/s12912-026-04715-8","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04715-8","workflowStages":[]},"version":"v1","identity":"rs-7532459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7532459","identity":"rs-7532459","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}