Decoding e-health literacy among Palestinian adolescents: a qualitative study in the West bank | BMC Public Health

Study design

We conducted an exploratory qualitative study as this approach allowed us to dig deeper into the target group’s thoughts, feelings, and experiences around digital health. Rather than testing specific hypothesis, it enabled us to explore underlying behaviors, experiences and motivation within the specific social, cultural, or personal contexts of participants, seeking deeper meaning without aiming for wide generalization [15]. This method also offered flexibility in examining emerging themes, which is crucial in politically sensitive contexts where broader socio-political factors influence digital health behaviors [16].

The data was collected through seven semi-structured focus group discussions (FGDs). Due to the lively and interactive nature of conversations, adolescents were more open in sharing their experiences while listening to others, leading to richer insights. This method is also time and resource efficient. The group dynamic allowed us to uncover hidden norms and attitudes by observing participants’ agreements and or disagreements. Additionally, it facilitated authentic dialogue, enabling us to capture details that individual interviews might miss.

Study setting

The study was carried out in five governorates of the West Bank, oPt. following rigorous ethical measures detailed in the “Ethics Approval and Consent to participate section”. Participants were recruited from the northern (Jenin and Tulkarem), central (Ramallah), and southern (Bethlehem and Hebron) governorates. Selecting different districts across the West Bank was crucial for this study because each area is unique in its context. This includes not only infrastructure and economics, but also social attitudes and cultural norms. For example, larger cities like Ramallah have more developed infrastructure, with better access to health services. People in these areas tend to feel more comfortable discussing sensitive topics like health or gender openly. In contrast, districts like Tulkarem and Jenin face infrastructure, economic and political constraints, which influence adolescents’ perceptions of health and the digital world.

Moreover, we targeted participants from different rural and camp settings, where infrastructure and healthcare resources are limited and economic challenges are more sever. Socially, these areas are generally more conservative, making open discussions about things like sexual and reproductive health more difficult. By selecting such diverse districts, our study aimed to capture the realities on the ground and explore how differences in resources, infrastructure, and, especially, cultural attitudes shape adolescents’ experiences and perspectives. Ultimately, our findings reflect the true complexity and diversity of Palestinian society.

The data collection was conducted through the Palestinian Medical Relief Society (PMRS) youth centers, a key provider of community health and social services with deep roots across the oPt. These centers are strategically located in the areas we aimed to reach, ensuring accessibility for young people from cities, villages, or refugee camps. Additionally, PMRS youth centers were chosen for their broad reach, as they engage adolescents from diverse backgrounds and settings. These centers provide dedicated spaces for marginalized and vulnerable youth and are locally recognized as safe environments that foster open dialogue among young people. PMRS has built strong community trust, which enhances authentic participation in research activities. Additionally, PMRS actively involves community members in planning and implementing programs, ensuring their relevance and sustainability.

Sample and data collection

A purposive sampling approach was utilized to select a heterogenous sample of adolescents, to ensure maximum variation among adolescents aged 15–19 years old, for several evidence-based reasons. Older adolescents are more frequent users of the internet for health information [17]. Additionally, research indicates that e-health literacy levels are higher among students in higher grades, suggesting that older adolescents have stronger skills for navigating digital health resources [18]. Furthermore, they engage in behaviors that require higher health literacy [19]. Our inclusion criteria focused on adolescents aged 15–19 year from diverse backgrounds, including school attendees, university students, school dropouts, as well as both males and females from various places of residence; urban, rural, or camp settings. Seven face-to-face focus groups were conducted between January 18 and March 31, 2024, with a total of 52 adolescents. The PMRS Youth Center facilitated participants’ recruitment. First, we provided the Youth Centers with information on research objectives, recruitment strategies, and target sample via email. Then, the research team met with the coordinators to further explain the study, ensuring clarity and a thorough understanding of the recruitment process. Table 1 presents the characteristics of the focus groups.

Each focus group session was carefully planned to ensure a safe and convenient environments and timing for all participants and researchers, considering the sensitive and fragile political situation in the West Bank region. Data was collected by native Arabic-speaking researchers familiar with the Palestinian context. These researchers were coached and closely guided in qualitative research methods by the second author, an experienced nurse-midwife and qualitative researcher with expertise in reproductive and adolescent health in Palestine.

Each researcher took on specific roles: one took notes, another handled logistics, and a third, a young co-facilitator close in age to the participants, provided additional support as needed. For consistency, all FGDs were facilitated by the same facilitator (the first author) except for the final session. To mitigate potential gender barriers in data collection, a male researcher with long experience in the sexual and mental health field was specifically recruited and trained to lead a session with male participants.

All focus group discussions were audio-recorded, with two recording devices positioned and monitored for optimal sound quality. After each sessions notes were reviewed and reflections were documented. All the researchers were healthcare professionals, providing participants with the opportunity to ask about any health concerns before or during the sessions. There were no refusals or interruptions in participant withdrawals during the FGDs. Each session lasted between 60 and 90 min, allowing for dynamic discussions. The number of participants per session ranged from six to nine, ensuring diverse perspectives. The FGDs were structured to encourage open dialogue and active engagement among adolescents. To enhance participation, we complemented open-ended questions with two activities: an icebreaker to build rapport and a health information search activity to gain insight into participants’ online behavior. Throughout the discussions, we used probes and follow-up questions to explore responses in depth and clarify ambiguities. (See additional file 1).

Focus group discussions (FGD) guide

A FGD guide was prepared in Arabic language following an extensive literature review and drawing on researchers’ expertise in the context of Palestinian adolescents. The guide wasinformed by the e-health literacy framework (eHLF). We adopted the eHLF, which comprises of seven domains that provide a comprehensive perspective on the interaction between individuals and digital health systems [20]. Unlike previous models, the eHLF goes beyond traditional health and digital skills to include aspects such as active engagement and feeling safe in digital environments. Additionally, its applicability across micro, meso, and macro levels [14] makes it particularly well-suited for our exploratory study. This framework to guided our methodology and the development of the focus group discussion guide. The guide was reviewed and discussed by all authors to ensure clarity and alignment with the study objectives (see Additional file 1).

Our FGD included the following key topics: demographic details (age, location, school administration, internet access), internet usage patterns (where, when, how often, preferred devices and languages), and methods for searching health information. It explored the types of health information adolescents sought, their reasons for searching, and the impact on their daily lives. Additionally, the guide addressed available online resources, challenges in finding reliable health information, and the skills needed to navigate online health platforms effectively.

We conducted a pilot focus group at the PMRS Youth Center in Ramallah to assess the effectiveness of the focus group guide and session format. A total of nine adolescents from diverse backgrounds participated. The pilot session lasted one hour, followed by 30 min of feedback session where participants provided input on questions, activities, and overall flow. All feedback was carefully considered, and the guide was revised accordingly. Data from the pilot focus group were excluded from the final analysis.

Data analysis

All audio recordings were transcribed into Arabic verbatim. All participants in FDGs were anonymized. After transcription, each author independently reviewed, coded, analyzed the transcripts to formulate themes (investigator triangulation). The team met several times to discuss and refine these themes until reaching a consensus. This process was essential to enhance rigor, ensure trustworthiness, and minimize bias. Data were coded using MAXQDA software to organize transcripts and codes for better data visualization. We centralized data in a special Google Drive folder within a Gmail account created exclusively for this purpose, accessible only by the research team. We triangulated data from FGDs, researchers’ notes, and observations during the sessions. (See additional files 2 and 3).

Data were analyzed using Braun and Clarke’s (2006) six-step method for thematic analysis. We started by reading the first Arabic transcript while synchronizing it with our session notes to familiarize ourselves with the data. Next, we generated codes in Arabic based on reoccurring patterns, relevance, interesting features, and meaning. These codes were then collated into sub-themes, which further refined to identify the main themes. Each step was initially conducted individually, followed by multiple rounds of group review to ensure accuracy and coherence before finalizing the themes and their named. Lastly, representative quotes were selected to illustrate each theme [21]. Table 2 presents the focus group numbers, locations and characteristics of participants.

Researchers’ reflections

After extensive note-taking and in-depth discussions following each session and throughout all meetings, the researchers shared their impressions about the participants and the dynamics of the session. Firstly, it was unanimously agreed that participants faced challenges in expressing themselves, as evident from the lengthy sentences found in their thoughts, notes, and transcripts. This difficulty may stem from political trauma and a limited health-related vocabulary. Additionally, mixed group discussions were observed to be more dynamic, with individuals actively demonstrating knowledge and skills. Female groups were more engaged, while school-aged male groups were the least interactive. As a result, another session was conducted with a male facilitator, but the dynamics remained similar.

Some groups included participants who were familiar with each other or had previously taken part in similar group discussions as part of their activities at the youth center, were more dynamic, as they felt more comfortable sharing their perceptions. Additionally, there was a notable difference between the northern groups and those from the southern and central regions. The northern groups were more affected by ongoing fragile conditions and Israeli military incursions into their residential areas, which was particularly evident in discussions about health perceptions and the seriousness of problems. Regardless of geographic area, there was a clear distinction between school and university students. Interestingly, despite the small age difference, the university experience significantly influenced their internet usage and health experiences.

All researchers were healthcare professionals, with the first author having over ten years of experience in adolescent primary healthcare and health promotion. This expertise facilitated discussions, fostering greater trust and openness among participants. It also contributed to a broader perspective in data analysis, enriched by contextual knowledge. Bias was minimized through the diverse backgrounds of the research team, including younger researchers closer in age to adolescents, ensuring a range of perspectives.

Findings

Demographic characteristics of participants

A total of 52 adolescents participated in the FGDs across the northern, central, and southern regions of the West Bank. The group consisted of 28 males and 24 females, with 20 participants aged 15–17 years, and 32 aged 18–19 years. The participants were from diverse geographical areas: 23 from cities, 18 from villages, and 11 from camps. Table 3 presents demographic characteristics of the FGD participants.

Table 4 presents four main themes and ten subthemes that illustrate the adolescents’ journey in searching for health information. The four themes are: Adolescents’ knowledge and influencing factors; the internet, its platforms, and available resources; approaches and strategies for seeking health information online; and challenges and the impact of limited e-health literacy on adolescents.

Theme 1: adolescents’ knowledge and influencing factors

Theme 1 includes the keystones according to the participants’ recipe to reach out for online health information. There are three sub-themes: Adolescents’ perception of health and online seeking information, primary factors Influencing e-health literacy, and healthcare services and information resources.

Subtheme 1: adolescents’ perception of health and online seeking information

During discussions, many participants perceived health primarily as physical well-being and disease absence, with few including mental health.

“Health means not being sick, and being sick means being really unwell, like not being able to get out of bed. It’s not about simple things like headaches that don’t make me worry or seek answers.” (FG5, A Male, University Student, Tulkarem group).

Participants displayed varying levels of interests in seeking online health information, some actively searched for health-related topics, while others showed no interest. Adolescents primarily perceived the internet and technology as entertainment tools, while others emphasized their use for communication and searching for answers to any questions came to mind.

I search about puberty, and most immediate change in our live such as menstruation. There are always questions: like if it’s late, if it’s regular, when it started, what its symptoms are, what complications might arise, what the causes could be, and what pain management are available. I’m always into these topics. I search a lot about this” (FG6, Female, School Student, Jenin group).

During the health information search activity in the FGD, most participants highlighted topics such as physical exercise, back pain, and healthy diet. These topics were particularly mentioned by those who identified as having healthy lifestyles. Notably, females showed greater interest in skin and acne issues, while male participants focused more on smoking and drug abuse. Additionally, female participants openly discussed sexual and reproductive health, whereas male participants spoke less about these topics. When a few male participants did mention them, they tended to do so indirectly.

“Sometimes, individuals feel too shy to discuss these topics, so they turn to someone close in age or go online. Adolescents may encounter issues related to reproductive organs and fertility problems, or even topics like masturbation.” (FG 1, Male school student, Bethlehem group).

“The topics we focus on are diverse, including reasons for delayed menstruation, hormones in girls, pre-marital counseling, issues related to adolescence, and women’s bodies.” (FG2 Female University student, Bethlehem group).

Subtheme 2: primary factors influencing e-health literacy

Across all groups, discussions on socioeconomic factors shaped were central to e-health literacy. Age and educational background influenced adolescent’s ability to assess and validate online information. University students, particularly those in health-related fields, demonstrated more advanced skills compared to school-aged participants, some of whom reported difficulty distinguishing reliable information from misinformation.

“I mean. I search for health information because I study nursing in university. Now, of course I search more than before”. (FG4 Female university student, Ramallah group).

University and school students from the Ramallah focus group who attended private schools were more likely to search for information in English compared to their peers in other schools. Some participants from the northern region reported that, given the current escalated political situation, seeking healthcare or e-health services is perceived as “not an important priority”.

“It is not the right time for this, in such situations. I mean, in Palestine now, nobody has time to sit and search for minor health issues”. (FG 5, A male, School Student, Tulkarem group).

Gender differences and stereotypes emerged during the discussion, as both male and female participants mentioned the belief that girls tended to search more for skin and body-related topics. Additionally, participants perceived females as more skilled in internet us, with males viewing them as more exploratory in online searches. Gender also influenced how adolescents perceive and seek health information. Female participants demonstrate a more holistic approach to health, while most male participants primarily associated health with physical health. Furthermore, females were noted to be more proactive in asking questions and seeking health information compared to males. The design of online resources also played a significant role in how females validated health content, whereas most male participants appeared less attentive to this aspect.

“Girls are more interested in topics related to hair, skin, and body care”. ( FG7, A Male school student, from Ramallah group).

“Usually, we look for topics related to skincare or the changes that occur in our bodies during this period”. (FG2, A Female University Student, Bethlehem group).

Subtheme 3: healthcare services and information resources

Although most participants preferred visiting doctors or consulting pharmacists when facing health problems, many noted that they had not seen a doctor for a long time. Some participants mentioned that the severity of the health issue influenced their choice of health information resources.

“Although I prefer to visit the doctor if I need any health information, last time I visited a doctor was as a newborn maybe for vaccination”. (FG4, Female university student, Ramallah group).

Many participants also indicated that they often seek advice from their mothers, and the majority highlighted self-management strategies, such as using known herbals remedies such as mint, anise, chamomile and sage to manage health issue.

“And whenever I feel something strange happening to me or any change occurs, I ask my mom about it because she has lived through this period and maybe went through the same thing. I feel it’s good to ask my mom; she might know about this”. (FG 6, A female school student, Jenin group).

The majority of participants reported that the internet is not their primary source for seeking health information and services. Instead, they first consult relatives and peers. Even when they do search online, they verify the information by discussing it with family and friends.

“Why should I use the internet when my mother is always available to answer my questions?”. (FG1, A male student university, from Bethlehem group).

Theme 2: the internet, its platforms, and available resources

This theme explores the adolescents’ approach to seeking online health information. It includes two sub-themes: technology and internet usage and exposure and the characteristics of preferred online health resources.

Subtheme 1: internet usage and exposure

Adolescents reported starting to use the internet as early as 3 or 4 years old, often influenced by family members, particularly if their parents and siblings were interested in technology. Social media engagement typically began around 6th or 7th grade, with variation by region. Some participants mentioned spending long hours on screen, up to 14 h, while others use them only during their spare time. Device preferences varied, with some favoring laptops, especially for research or study, while others preferred smartphones, primarily using them for taking photos, chatting, gaming, and social media communication.

“I mostly use my phone, primarily for entertainment or communication, but when it comes to studying or conducting any research, I use my laptop and I can spend long time searching up to 14 hours”. (FG3, A male university student, Hebron Group).

Participants whose parents were employed in health sectors showed more motivation and curiosity to gain health information. They also reported a wider range of health topics compared to other participants. Exposure to health information in schools, particularly in biology classes, was more reported more reported by female participants than male participants. Additionally, the majority of participants reported that they seek online health information when experiencing a health problem. Some participants also mentioned that their search for health information was prompted by online exposure and the focus of social media platform algorithms, such as those on TikTok platform.

“Lately, I’ve been seeing videos about this medicine that helps you lose weight in a short period. I’m not interested in this topic, but because I keep seeing it, I’ve become curious “. (FG 2, A female university student, Bethlehem group).

Subtheme 2: adolescent’s preferences of online health resources

Participants’ views on preferred platforms shared some common characteristics. Many expressed a preference for interactive websites and multimedia platforms like TikTok and YouTube. They also mentioned avoiding long, detailed content, with only a few participants preferring more in-depth information.

“If I want to look up any information, I prefer searching on TikTok. It gives me quick information and videos from people who have experienced it, even if I don’t know exactly what to type. (FG4 Female university student, Ramallah group).

Some participants emphasized the importance of privacy features, such as the ability to ask questions anonymously. The majority preferred medically named websites and a memorable logo. Additionally, some reported that they do not favor websites overloaded with various colors and elements.

“Sometimes the font appears small, and sometimes it’s decorated. Once I received a decorated font that was confusing, and I couldn’t understand anything, which was frustrating”. (FG 2, A female university student, Bethlehem group).

Theme 3: approaches and strategies for seeking health information online

This theme explores adolescents’ strategies and approaches for seeking online health information. It includes two subthemes: e-health literacy skills and competencies, and approaches and strategies used for utilizing the internet and validating information online.

Subtheme 1: e-health literacy skills and competences

Opinions varied regarding the skills needed to navigate health information online. Some participants argued that internet searching requires minimal skills, while others reported basic skills like reading and writing. Additionally, some participants mentioned that these skills are not necessary for internet searches, given features like voice recognition and video content.

“I think at least, we should know how to phrase the words. And what words to use to reach the information when google it”. (FG 6, female school student, Jenin group).

Participants also reported searching skills such as knowing how to formulate a question, where and how to navigate search engines like Google, and how to use social media effectively. The majority emphasized the importance of differentiating between true and false information. Adolescents also noted that it is helpful to compare information and assess how it aligns with what they already know. Some mentioned that these skills are acquired through practice and experience.

“The skills we need include analysis, meaning I understand whether this written thing is based on something truly scientifically accurate or not”. (FG7 A male, School Student, Ramallah group).

Subtheme 2: approaches and strategies used for utilizing the internet and validating information online

When searching for health information, the majority of participants preferred using Google, while some turned to social media platforms or ChatGPT. They typically began by writing their questions, keywords, or detailed sentences, mostly in Arabic. A few participants mentioned downloading PDF books and then searching using keywords. Many Participants noted that they ignore spelling errors or typos due to the Google’s autocorrect feature.

“When I type, suggestions automatically appear from above, like corrections asking if I mean”. (FG6, Female school student, Jenin group).

Participants indicated that they typically read Google’s summary, as it provided information from multiple sources. Some clicked on listed websites for more details, while others checked the first three results to verify credibility. A few relied exclusively on one website. When encountering conflicting information, they sought a third source for verification. Some participants cited university and school projects as sources of knowledge on internet searching techniques. Despite these approaches and strategies, many participants expressed uncertainty about the reliability of their choices.

“I go to the primary sources related to what I’m looking for. I select about four or five sources to read and extract information from. This is how I maximize my learning”. (FG7, A male school student, Ramallah group).

“I read the summary on Google, then I open even more websites and check from multiple sources to find the common among them”. (FG2 Female University Student, Bethlehem group).

Participants discussed various methods to validate online information. Some relied on internationally recognized authors or institutions, such as universities or governmental bodies, to ensure credibility. A few participants explained that they read website feedback, with positive reviews enhancing their trust. Others mentioned using social indicators, such as views or comments to gauge credibility. Some participants highlighted comparing information with personal experiences and seeking validation from family to ensure it aligned with their expectations.

“For example, when I watch a video on YouTube about a specific topic, I look at the highest views or read people’s comments?” (FG7, a male school student, Ramallah group).

Participants mentioned verifying information with specialists or experienced individuals such as doctors, or even peers who tried it before, or applying it to their own lives, especially for diet and lifestyle advice. Notably, for some participants, the research process itself had a positive impact on their health.

“I ask a doctor or someone who has tried the thing and see the results. If it works for them, I’ll give it a try too, why not?”. (FG4, Female University Student, Ramallah group)

Theme 4: challenges, and impact of limited e-health literacy on adolescents

This theme presents the challenges, and impact of lack of e-health literacy on adolescents through two subthemes: information implications and impact on adolescents’ health, and challenges encountered by adolescents in e-health literacy.

Subtheme 1: information implications and impact on adolescents’ health

Upon completing their search for health information, adolescents exhibited various behaviors regarding the information they obtained. Some participants admitted to disregarding the information altogether, as their search was driven by curiosity rather than a genuine intention to apply the findings in their lives. Others, however, expressed a willingness to test the information on themselves first before recommending it to others, demonstrating a cautious approach to adoption.

” When I try the obtained information and understand it, and see it good, I may share it with friends”. (FG7, a male school student, Ramallah group).

Some participants mentioned seeking verification from specialists or individuals who had experienced similar situations. Additionally, some preferred to save resources for later review, while others expressed absorbed the information without taking immediate action.

“When I see a video, reel, or something I find helpful, I usually save it. As a result, I have a lot of saved materials. However, sometimes I don’t get around to revisit them”. (FG2, female university student, Bethlehem group).

Subtheme 2: challenges encountered by adolescents in e-health literacy

Participants cited their limited understanding of health matters and struggled with conducting searches, which hindered their ability to formulate queries and assess credibility of information. Additionally, some expressed concerns about anxiety, fearing negative psychological impacts from online health searches. Language barriers posed challenges for certain participants, although translation features helped mitigate this obstacle for others. Many noted the lack of online health platforms in Palestine, as well as difficulties in internet accessibility and restrictions imposed by service providers. Participants also reported limited access to educational opportunities and online health information among youth and adolescents due to economic constraints.

“It might create a psychological impact. I will start thinking about things that aren’t present, like a disease I don’t have. I start worrying about something that doesn’t exist”. (FG3, a female university student, Hebron group).

“Oh, there might be a lot of ads, and I might decide I don’t want to see the information anymore”. (FG 4, a Female university student, Ramallah group).