Coronavirus Disease 2019 (COVID-19) pandemic has had a considerable impact on physical and psychosocial health (1). and is an emerging risk factor for chronic diseases such as hypertension, diabetes mellitus, cardiovascular disease, and chronic kidney disease (2), including debilitating post-acute sequelae of COVID-19 (3, 4). While COVID-19 adversely impacts physical health, a range of psychological issues has been linked to the pandemic as both direct and indirect impacts. The prevalence of psychological stress, insomnia, and psychological distress following COVID-19 has been reported to be between 20% and 30% globally (5). Similarly, in Nigeria, various studies have reported a range of psychological issues among Nigerians during the pandemic, including anxiety, depression, insomnia and inadequate social support (6–9). Risk factors associated with increased psychological distress during the pandemic include younger age group (≤40 years), female gender, previous mental health problems, unemployment, student status, and frequent exposure to social media or news related to COVID-19 (10).

Electronic health (eHealth) includes health-related services and information delivered or enhanced through the internet or related health technologies (11), including the capacity to evaluate health information obtained from electronic sources and use what is learned to address or resolve a health issue (12). The COVID-19 pandemic has increased global eHealth and mobile health (mHealth) usage alongside substantial increases in screen time (13). In Nigeria, the use of digital devices significantly increased during the COVID-19 pandemic (14). Nigeria has the largest mobile market in Africa, with 199.6 million mobile connections as of March 2022 (15); hence, mobile phones have been a resource for seeking health information in Nigeria as well as in many low and middle-income countries (16).

COVID-19 poses critical challenges to the utility of eHealth literacy, for which the World Health Organization and other agencies warned strongly against infodemics; “an overabundance of information and rapid spread of misleading and fabricated news, images, and videos, which, like the virus, is highly contagious, grows exponentially, and undermines public health measures and leads to unnecessary loss of life” (17). The exceptionally high volume and rapid evolution of COVID-19 pandemic-related information, with a proliferation of misinformation and disinformation, contributed to widespread public confusion and can have severe and lethal health and social consequences, further eroding trust in science (18). There have been speculations that these could contribute to increased anxiety, psychological stress, suicidal ideation, and worsened mental health (19). However, high eHealth literacy also offers opportunities for rapid dissemination of information and may contribute to assured safety and help people make better health-related decisions (20).

Healthy eHealth literacy and internet use may be linked to better psychological wellbeing. Previous reports have shown reports of a negative correlation between eHealth literacy and depression, insomnia, and post-traumatic disorder (21). Improving eHealth literacy has been recommended to address psychological distress (22). The mental health of Nigerians was adversely affected during the pandemic (9, 23). With the high internet and social media use in Nigeria, examining eHealth literacy during the COVID-19 pandemic and its contribution to psychological outcomes is important. This is vital to planning and preparedness for communication and mitigation strategies in future pandemics or crises. Hence, this study aimed to: assess the associations between eHealth literacy and psychological outcomes among Nigerians during the COVID-19 pandemic; examine the effect modification of age, gender, and geographic differences on these associations; and investigate residents’ preferences for future preparations.

We hypothesized that there would be no significant association between eHealth literacy and anxiety, depression, and fear of COVID-19, after adjusting for age, gender, education and employment.

We examined the association between eHealth literacy and psychological outcomes during the COVID-19 pandemic in Nigeria. Our study showed five key findings; first, majority of our participants have high eHealth literacy levels. Second, the prevalence of self-reported anxiety and depression is also substantial. Third, high eHealth literacy was associated with a lower likelihood of anxiety and depression, and fourth, there are age, gender, and geographical differences in the association between eHealth literacy and psychological outcomes. Finally, eHealth-related strategies such as medicine delivery, receiving health information through text messaging, and online courses were highlighted as important strategies for future pandemic preparedness (Figure 5). These findings have important implications for improving mental health services through digital technologies in Nigeria.

Our findings on high eHealth literacy can be explained by the increased mobile phone usage in Nigeria reported during the pandemic (14, 35). This is similar to the results from various countries that reported increased usage of mobile phones during the pandemic (36–38). Our results also show that participants with high eHealth literacy were more likely to be female, have at least a bachelor’s degree, be employed and live in the Southwestern region of the country. This is congruent with previous results conducted in Southwest, Nigeria, where women were shown to have a higher literacy level compared to men (39). This is similar to the results of a study conducted in Turkey which found that women had higher levels of eHealth literacy than men because they felt confident and more competent while searching for online information (40). This study found regional differences in eHealth literacy in Nigeria, where Southwest has higher eHealth literacy than other regions (39). This has also been reported in other studies and may reflect English educational attainment, English language proficiency, higher access to the internet and increased exposure to credible medical information that persons in this region have access to Kuyinu et al. (39).

The prevalence of self-reported anxiety and depression in this study aligns with previous studies that reported a range of psychological issues among Nigerians during the pandemic (6–9). This indicate the need for interventions to address psychological issues among this population. Similarly, as a high e-Health literacy was reported among participants in this study, mobile phones can be considered a platform to deliver such interventions, as evidence has revealed that psychological interventions delivered through mobile phones have beneficial psychological effects (41).

We found an association between higher eHealth literacy and lower odds of both depression and anxiety. Previous studies reported an inverse correlation between eHealth literacy and depression and that improving eHealth literacy may contribute to maintaining good psychological well-being (21, 22). Mental health services are severely sparse in Nigeria, and related stigma persists (42). Hence, it is likely that individuals are accessing online sources of mental well-being information, and this could be harnessed to help manage their anxiety and depression. There were no observed statistical associations between eHealth literacy and fear of COVID-19 in our study; this could be attributed to the country’s heightened public awareness of COVID-19 prevention (43). Additionally, persons with high eHealth literacy levels may be better equipped to access credible health information on COVID-19 and less susceptible to misinformation that may fuel fear and anxiety (44). The high mobile usage in Nigeria and eHealth literacy levels present a critical opportunity to advance mental health awareness and encourage mental health services in Nigeria (45). eHealth literacy-informed interventions may also be harnessed to address other health issues in Nigeria; these include verified information about infectious diseases; self-management of chronic disease through digital means (e.g., hypertension diagnosis and management training through an app). Leveraging high eHealth literacy for improving psychological outcomes in Nigeria could prove an important intervention opportunity.

There were age, gender and geographical differences in the association between eHealth literacy. Among women with high eHealth literacy, the likelihood of anxiety and depression was lower compared to men. This corroborated with other studies that have shown that being female, less than 75 years old and having a higher education are associated with eHealth literacy (22). Reasons for this disparity are unclear and could be explored in future studies. The regional differences observed in our results highlight the need for improving internet access for increased educational attainment and eHealth literacy interventions in other regions of the country outside of the Southwestern region. There was a high proportion of healthcare workers in our sample, and the high eHealth literacy in this group may be leveraged for advanced training of health workers, especially during crises and humanitarian situations.

Results from future pandemic strategies endorsed by participants further support the need for health technology-backed interventions in Nigeria. Medicine delivery, receiving health information through text messaging, online courses, food delivery, and receiving health information through social media were endorsed as strategies important to prepare for future pandemics and crises. These are mostly digital interventions that may significantly contribute to improving the health of Nigerians; partnerships between context experts like healthcare workers and digital content experts may further advance such interventions (45). It is important for these interventions to also cater to persons with lower educational attainment and low eHealth literacy. This may include providing health information through platforms like WhatsApp, which is more prevalent among persons with limited digital literacy in Nigeria. Rapid innovations in digital health technologies that improve healthcare access have shown high efficacy in high-income countries. However, access to these health technologies is not equitable globally, with LMICs like Nigeria experiencing global health disparities at a larger scale. Consequently, there is a need for reciprocal innovation, i.e., bidirectional, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings (46).

Our study should be interpreted in the context of these limitations. First, this was a cross-sectional design; hence, there was no temporality. Second, the survey was originally designed in Hong Kong and may not have initially included Nigeria in the original context; however, modifications were made to adapt certain survey items to the Nigerian context. Third, our study’s participants were mostly young adults from the Southwestern region, which may have contributed to the high level of eHealth literacy observed; hence, findings from this study might not be generalizable to Nigerians with low literacy, non-social media users and older adults. Fourth, the survey was administered digitally and may have excluded persons with limited digital literacy. Nevertheless, this study has some strengths. First, to our knowledge, this is one of the first studies to examine the associations between eHealth literacy and anxiety and depression in a Nigerian sample. In addition, we employed various recruitment strategies to ensure that participants from different regions of the country were represented in the sample.

Our findings have important implications for the development of interventions to address the scarcity of mental health services in Nigeria. The high eHealth literacy in Nigeria and high use of smartphones and mobile application makes the Nigerian environment suitable for digital health interventions. Participants-endorsed strategies for preparation for future pandemics are critical policy options that may inform healthcare policies. Strategies such as receiving credible health information through social media platforms. Future intervention strategies could leverage digital tools and platforms to provide remote mental health services and incorporate other chronic conditions. Given the critically low performance and ranking of the Nigeria health system (47, 48), these interventions have a high potential to strengthen the primary health care system, and guarantee access to care. An example could include implementing remote counseling and psychiatry services platforms using mobile apps, and telemedicine platforms, to improve access, availability, and utilization of healthcare services. Such strategies could be multi-pronged to address several conditions at once; for instance, such remote platforms could also include remote monitoring of cardiometabolic conditions (e.g., remote blood pressure monitoring), bi-directional messaging between providers and patients, etc. These digital tools should be co-designed and co-developed with patients, health care providers, health system leaders, policymakers and other stakeholders, and should prioritize simplicity in the design with considerations for persons experiencing barriers such as low eHealth literacy, limited broadband access or smartphones, etc. It is critical that digital interventions address health equity and not contribute to widening the digital divide. Importantly, there is a need for health policies that advance the implementation of telemedicine and digital health interventions in Nigeria and ensure equitable funding of health systems in the different regions of the country to improve access to health services.

In conclusion, our study showed high eHealth literacy among our sample of Nigerian adults. Self-reported prevalence of anxiety and depression is also considerably high in the face of prevalent economic and structural hardship and limited access to mental health services. High eHealth literacy was associated with psychological outcomes of anxiety and depression. eHealth literacy-informed interventions can be invested in to address several pressing health issues in Nigeria and prepare for future pandemics and health-related crises. The age, gender and regional differences observed present important intervention opportunities for interventions. Additionally, digital solutions focused on medicine delivery, receiving health information through text messaging, online courses, etc., are important health technology-backed intervention opportunities in Nigeria. The Nigerian environment may be suitable for digital health interventions to increase access to mental healthcare services due to the country’s high smartphone usage and eHealth literacy, as shown in this study’s result. Importantly, there is a need for health policies that promote the implementation of telemedicine and digital health interventions in Nigeria and guarantee equitable funding of health systems in the various regions of the country in order to enhance access to health services.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 20-272). The patients/participants provided their written informed consent to participate in this study.

EC, MH, KL, JW, and DF conceived the idea for the study and designed the study. OA, OAF, IF, JL, and OO contributed to recruitment and data collection. JL contributed to data collection and management. OO performed data analyses and visualizations for the country-specific data. OA, KA, OAF, and OO wrote the original draft. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.