Impact of patient empowerment on continuity of care needs in patients with stable COPD: the mediating role of eHealth literacy in a cross-sectional study from China

Abstract

Objective

To explore the relationships among continuity of care needs, patient empowerment and eHealth literacy in patients with stable chronic obstructive pulmonary disease (COPD), and to further identify the potential mediating role of eHealth literacy.

Design

Cross-sectional study.

Setting

A tertiary care hospital (Level 3A, the highest level in the Chinese hospital classification system) in Shanghai, China.

Participants

The study participants consisted of 219 patients with stable COPD who visited or underwent follow-up at the outpatient clinic between December 2023 and May 2024.

Outcome measures

The Continuity of Care Needs Questionnaire, COPD Patient Empowerment Evaluation Scale and eHealth Literacy Scale (eHEALS) were used to assess 219 patients with stable COPD. Univariate analysis, Pearson correlation analysis and mediation analysis were performed.

Results

The mean Continuity of Care Needs score was 24.17 (SD=2.74), with medication guidance needs being the highest-scoring domain. The COPD Patient Empowerment score was 84.37 (SD=11.58), and the eHEALS score was 23.37 (SD=6.06). Pearson correlation analysis showed that continuity of care needs were negatively correlated with patient empowerment (r=−0.930, 95% CI −0.946 to −0.910) and eHealth literacy (r=−0.976, 95% CI −0.982 to −0.969), while patient empowerment was positively correlated with eHealth literacy (r=0.919, 95% CI 0.895 to 0.937) (all p<0.001). Mediation analysis suggested that eHealth literacy partially mediated the relationship between patient empowerment and continuity of care needs, with an indirect effect of −0.169 (95% CI −0.247 to −0.091), accounting for 74.91% of the total effect. The direct effect was −0.051 (95% CI −0.067 to −0.035) and the total effect was −0.220 (95% CI −0.231 to −0.208).

Conclusions

Patients with stable COPD demonstrated high continuity of care needs, with eHealth literacy partially mediating the relationship between patient empowerment and continuity of care needs. Healthcare providers should consider patients’ eHealth literacy to enhance patient empowerment and develop personalised continuity of care strategies.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study used validated instruments with good internal consistency to assess patient empowerment, electronic health literacy and continuity of care needs among patients with stable chronic obstructive pulmonary disease.

• Mediation analysis with bootstrapping provided a structured approach to examine how electronic health literacy influences the relationship between patient empowerment and continuity of care needs.

• As a single centre, observational study based on self-reported data, the findings may be affected by recall bias and selection bias, and the cross-sectional nature prevents any conclusions about causality. Future longitudinal studies with larger, more diverse populations are needed to confirm these findings.

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible respiratory condition that remains a leading cause of morbidity and mortality globally, placing a significant burden on patients, families and healthcare systems.^{1 2} According to the WHO, COPD is projected to become the third leading cause of death worldwide by 2030.³ Despite significant advances in the diagnosis and treatment of COPD, its chronic nature often results in ongoing care needs that extend beyond acute management, particularly in patients during the stable phase of the disease.⁴ Stable COPD, characterised by a period without acute exacerbations, still requires ongoing management to prevent deterioration and improve quality of life.^{5 6} However, research has shown that patients with stable COPD often experience unmet care needs, particularly in areas of pulmonary rehabilitation instruction, lifestyle advice and post-discharge care.⁷ Addressing these needs is essential for achieving continuity of care, which is widely recognised as a cornerstone of effective chronic disease management.

Continuity of care refers to the delivery of consistent, coordinated and patient-centred care across different stages of a disease and care settings.⁸ For patients with chronic conditions such as COPD, it encompasses ongoing medical guidance, patient education, timely follow-ups and comprehensive support systems that empower individuals to manage their condition effectively.9,11 Some studies have shown that better continuity of care is associated with improved health outcomes, and patients with COPD with higher continuity of care have a significantly lower likelihood of avoidable hospitalisations.12,14 Therefore, identifying factors that influence continuity of care needs is of critical importance for clinicians and healthcare policymakers.

Patient empowerment has emerged as a key factor in improving outcomes for individuals with chronic diseases.¹⁵ Patient empowerment interventions are processes through which patients gain greater control over decisions and actions that affect their health.¹⁶ Empowered patients are more likely to adopt positive health behaviours, adhere to treatment regimens and communicate effectively with healthcare providers.¹⁷ In COPD management, patient empowerment can reduce dependency on healthcare services by enabling individuals to take greater control over their care.¹⁸ However, the relationship between patient empowerment and continuity of care needs has not been extensively explored, particularly in patients during the stable phase of COPD.

With the rapid development of digital technologies, eHealth literacy—the ability to locate, understand, evaluate and apply online health information—has gained increasing attention in chronic disease management.¹⁹ eHealth literacy plays a critical role in facilitating patients’ access to reliable information, enabling informed decision-making and improving communication with healthcare providers.²⁰ For patients with COPD, who often require ongoing education and self-management strategies, eHealth literacy may act as a bridge between patient empowerment and continuity of care needs.21,23 Patients with higher eHealth literacy are better equipped to navigate online resources, follow medical advice and address their unmet care needs.²⁴ Conversely, patients with limited eHealth literacy may struggle to benefit from digital health resources, exacerbating existing gaps in care.

Although previous studies have highlighted the importance of patient empowerment and eHealth literacy in chronic disease management, few studies have examined the specific relationships among these factors in the context of stable COPD.²⁵ In particular, there is a lack of evidence on the potential mediating role of eHealth literacy in the relationship between patient empowerment and continuity of care needs. Understanding these relationships is essential for developing targeted interventions that improve patient empowerment, enhance eHealth literacy and address unmet care needs in COPD management.

Therefore, this study aimed to: (1) assess the levels of continuity of care needs, patient empowerment and eHealth literacy among patients with stable COPD; (2) explore the relationships between patient empowerment, eHealth literacy and continuity of care needs; and (3) explore whether eHealth literacy mediates the relationship between patient empowerment and continuity of care needs. By elucidating these relationships, this study seeks to provide a scientific basis for designing interventions that enhance eHealth literacy and patient empowerment, thereby improving continuity of care and overall disease management in patients with stable COPD.

Methods

Study design, setting and participants

This was a cross-sectional study. A convenience sampling method was employed to recruit 219 patients with stable COPD who visited or underwent follow-up at the outpatient department of Shanghai Chest Hospital, a tertiary hospital (Level 3A, the highest level in the Chinese hospital classification system) in Shanghai between December 2023 and May 2024. The inclusion criteria were as follows: (1) diagnosis of stable COPD according to the Guidelines for the Diagnosis and Management of Chronic Obstructive Pulmonary Disease (2021 edition) issued by the Chinese Thoracic Society; (2) a history of symptomatic treatment or hospitalisation for COPD followed by a stable phase; (3) complete and accessible clinical data; and (4) provision of written informed consent and active participation in the study survey. The exclusion criteria were: (1) presence of other pulmonary diseases; (2) severe hepatic or renal dysfunction, or immune-related diseases; (3) severe cognitive impairment or disturbances of consciousness; and (4) inability to fully cooperate with researchers or withdrawal from the study midway.

Sample size calculation

A priori sample size calculation was performed using G*Power software (V.3.1). For a linear multiple regression model with two predictors (patient empowerment and eHealth literacy) to detect a medium effect size (f²=0.15) with 80% power and a 5% significance level, a minimum sample size of 107 was required. The final sample of 219 patients exceeded this requirement, ensuring adequate statistical power for mediation analysis.

Study measures

Demographic information of the study participants was collected, and three self-reported instruments were used: the Continuity of Care Needs Questionnaire, the COPD Patient Empowerment Evaluation Scale and the eHealth Literacy Scale (eHEALS). The questionnaires were administered by trained investigators in the outpatient clinic. The purpose of the study and the content of the instruments were explained to the participants face-to-face, emphasising the importance of providing truthful responses and ensuring the confidentiality of their personal information. After obtaining informed consent, the questionnaires were distributed and participants were guided on-site to complete them. The completed questionnaires were collected immediately, and their validity was carefully reviewed. Three invalid questionnaires (eg, all items marked with the same response or completion time less than 2 min) were excluded, resulting in 219 valid questionnaires with an effective response rate of 98.64%.

Demographic information

General information includes age, sex, marital status, education, work status, income and residence.

Continuity of Care Needs Questionnaire

The Continuity of Care Needs Questionnaire was adapted from the Chinese version of the Patient Continuity of Care Questionnaire to address the specific needs of patients with COPD.²⁶ To ensure its validity and reliability for our study population, we conducted a pilot test with 30 patients with stable COPD (not included in the final sample). Content validity was assessed by a panel of five experts (including two pulmonologists and one nursing professor), resulting in a Content Validity Index of 0.92. In our main study, the questionnaire demonstrated excellent internal consistency, with a Cronbach’s α coefficient of 0.880. Item-total correlations ranged from 0.45 to 0.72, all exceeding the recommended threshold of 0.30. It comprises six items covering the following domains: disease-related knowledge needs, medication guidance needs, nutritional and dietary guidance needs, exercise and physical activity guidance needs, follow-up and outpatient visit guidance needs and mental health guidance needs. Each item is rated on a 5-point Likert scale based on the level of need, ranging from 1 (‘not needed at all’) to 5 (‘very much needed’). The total score ranges from 6 to 30, with higher scores indicating greater continuity of care needs.

The COPD Patient Empowerment Evaluation Scale

The COPD Patient Empowerment Evaluation Scale used in this study was developed based on the patient empowerment in long-term conditions (PELC) scale.²⁷ PELC was created in 2013 by Nicola Small and colleagues at the University of Manchester to measure patient empowerment in chronic disease management within primary healthcare systems. Yanmei Wu from Yangtze University adapted this scale and tailored it to the characteristics of patients with COPD, resulting in the Chinese version of the COPD Patient Empowerment Evaluation Scale. This scale comprises 24 items across four dimensions: acquisition and understanding of disease knowledge, participation in decision-making, external support and self-management. A 5-point Likert scale is employed, with responses ranging from ‘strongly disagree’ to ‘strongly agree’, scored from 1 to 5. The total score ranges from 24 to 120, with higher scores reflecting greater patient empowerment. Validation with large sample sizes confirmed the scale’s reliability, with a Cronbach’s α coefficient of 0.890.

The eHealth Literacy Scale

The eHEALS was developed by Norman and Skinner at the University of Toronto.²⁸ Xu et al translated it into simplified Chinese and conducted validation and cultural adaptation.²⁹ eHEALS consists of eight items, which assess three areas: the ability to apply online health information and services, the ability to evaluate health information and decision-making ability. Responses are scored on a 5-point Likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’ (1–5 points). The total score ranges from 8 to 40, with higher scores indicating greater eHealth literacy. The scale has demonstrated excellent reliability, with a Cronbach’s α coefficient of 0.960.

Data analysis

Data was analysed using IBM SPSS V.27.0 software. Categorical data were described as frequencies and percentages (n (%)). The normality of continuous variables was assessed using the Shapiro-Wilk test. Descriptive statistics for normally distributed variables were presented as mean±SD, while non-normally distributed variables were reported as median (IQR). Univariate analysis was conducted using independent sample t-tests and one-way analysis of variance. Assumptions of linearity and homoscedasticity for the correlation and mediation analyses were inspected visually using scatter plots and plots of residuals versus predicted values, respectively. Multicollinearity was assessed using variance inflation factor (VIF); all VIF values were below 2, indicating no significant multicollinearity. Pearson correlation analysis was used to examine relationships between variables. Mediation analyses were performed and executed using the PROCESS macro of SPSS. The bootstrap method with 5000 resamples and a 95% CI was used to assess the direct, indirect and total impact of the model. The p value of <0.05 was considered statistically significant.

Patient and public involvement

None.

Results

Characteristics of participants

A total of 219 patients with stable COPD were enrolled in this study, of which 56.16% were male patients and 43.84% were female patients. The highest percentage of patients was in the age group of 51–65 years, followed by patients older than 65 years. As far as marital status was concerned, the majority (185 or 84.47%) were in a marital relationship and 15.53% of the patients were unmarried or divorced. In terms of education, most patients had high school and middle school education (32.88% and 30.59%, respectively). Due to the high average age of patients, 46.12% of patients retired, 36.99% were still working and 16.9% were unemployed. Patients with a monthly household income of US$3000 to US$6000 made up the majority (99 patients, 45.21%). In addition, the percentage of patients who were not living alone was greater than the percentage of patients living alone, and the percentage of patients living in urban areas was greater than the percentage of patients living in rural areas. Data regarding COPD-related hospitalisation in the past year, used as a proxy for disease severity, was available for all participants. Of these, 48 (21.9%) had at least one hospitalisation. See table 1 for more information.

Table 1. Univariate analysis of factors associated with continuity of care needs in patients with stable COPD (n=219).

Variables	n (%)	The score for continuity of care needs	t/F value	P value
Age
35–50 years old	53 (24.20)	22.51±2.93	47.144	<0.001
51–65 years old	97 (44.29)	23.57±2.39
>65 years old	69 (31.51)	26.30±1.42
Gender
Male	123 (56.16)	24.11±2.95	−0.424	0.672
Female	96 (43.84)	24.26±2.45
Marital
Unmarried or divorced	34 (15.53)	23.85±3.45	−0.743	0.458
Married	185 (84.47)	24.23±2.59
Educational attainment
Primary and below	43 (19.63)	22.26±2.86	13.875	<0.001
Junior high school	67 (30.59)	23.51±2.23
Senior high school	72 (32.88)	24.71±2.26
College and above	37 (16.90)	25.19±2.70
Operating state
Working (eg, in a job)	81 (36.99)	23.38±2.81	5.902	0.003
Unemployed	37 (16.90)	24.35±2.58
Retired	101 (46.12)	24.74±2.60
Monthly household income
<¥3000	26 (11.87)	22.92±2.76	21.815	<0.001
¥3000 to ¥6000	99 (45.21)	23.28±2.79
>¥6000	94 (42.92)	25.46±2.09
Living situation
Living alone	78 (35.62)	25.69±1.96	6.697	<0.001
Not living alone	141 (64.38)	23.33±2.75
Place of residence
Rural	78 (35.62)	23.91±2.88	−1.035	0.302
Urban	141 (64.38)	24.32±2.65
COPD-related hospitalisation in the past year
No	49 (22.37)	23.81±2.65	2.285	0.024
Yes	170 (77.63)	25.08±2.81

Note: P values are derived from independent samples t-tests (for dichotomous variables) or one-way ANOVA (for categorical variables with more than two groups).

ANOVA, analysis of variance.

Continuity of care needs, patient empowerment and eHealth literacy levels in patients with stable COPD

The Continuity of Care Needs scores for patients with stable COPD were M=24.17, SD=2.74, with the highest-scoring domain being medication guidance needs. The COPD PELC yielded a mean score of M=84.37, SD=11.58, while the eHEALS had a mean score of M=23.37, SD=6.06 (see table 2).

Table 2. Scores on dimensions of Continuity of Care Needs Questionnaire, COPD PELC and eHEALS in patients with stable COPD (n=219).

Variables	Number of items	Range of total score	Average score
Continuity of Care Needs Questionnaire	6	6–30	24.17±2.74
Disease-related knowledge needs	1	1–5	3.99±0.85
Medication guidance needs	1	1–5	5 (4, 5)
Nutritional and dietary guidance needs	1	1–5	4 (4, 5)
Exercise guidance needs	1	1–5	3.78±0.89
Follow-up and consultation guidance needs	1	1–5	4 (4, 5)
Mental health guidance needs	1	1–5	3.63±0.90
COPD PELC	24	24–120	84.37±11.58
Acquisition and understanding of disease knowledge	9	9–45	32 (29, 35)
Participation in decision-making	3	3–15	9.56±2.16
External support	6	6–30	21.84±3.08
Self-management	6	6–30	20.82±2.99
eHEALS	8	8–40	23.37±6.06
Ability to apply online health information and services	5	5–25	15 (13, 17)
Ability to evaluate health information	2	2–10	5.42±1.99
Ability to make decisions	1	1–5	2 (2, 3)

COPD, chronic obstructive pulmonary disease; eHEALS, eHealth Literacy Scale; PELC, patient empowerment in long-term conditions.

Correlation of continuity of care needs with patient empowerment and eHealth literacy in patients with stable COPD

Pearson correlation analysis revealed that continuity of care needs was negatively correlated with patient empowerment (r=−0.930, 95% CI −0.946 to −0.910) and eHealth literacy (r=−0.976, 95% CI −0.982 to −0.969). Additionally, a positive correlation was observed between patient empowerment and eHealth literacy (r=0.919, 95% CI 0.895 to 0.937) (see online supplemental table 1).

Mediating role and pathway analysis of eHealth literacy

Using continuity of care needs as the dependent variable, patient empowerment as the independent variable, and eHealth literacy as the mediating variable, we analysed the mediating effect of eHealth literacy on the relationship between patient empowerment and continuity of care needs in patients with stable COPD. The results of the mediation analysis are shown in table 3. eHealth literacy demonstrated a significant indirect effect, with an effect size of −0.169 and a 95% CI of (−0.247 to −0.091), which did not include zero, supporting the hypothesis of a significant mediation effect.

Table 3. Results of the mediation analysis of eHealth literacy on the relationship between patient empowerment and continuity of care needs (n=219).

Items	Unstandardised coefficient (B)	SE	P value	95% CI	Proportion of total effect (%)
Direct effect	−0.169	0.040	<0.001	−0.247 to −0.091	74.91
Indirect effect	−0.051	0.008	<0.001	−0.067 to −0.035	23.18
Total effect	−0.220	0.006	<0.001	−0.231 to −0.208	100

Note: the indirect effect represents the mediating effect of eHealth literacy. The direct effect is the effect of patient empowerment on continuity of care needs after controlling for eHealth literacy. The total effect is the sum of the direct and indirect effects.

The analysis indicated that eHealth literacy plays a crucial mediating role in the relationship between patient empowerment and continuity of care needs, accounting for 74.91% of the total effect. In the model, the direct effect of patient empowerment on continuity of care needs was −0.151 (95% CI −0.067 to −0.035), while the total effect was −0.220 (95% CI −0.231 to −0.208). These findings indicate that eHealth literacy partially mediates the relationship between patient empowerment and continuity of care needs, rather than serving as a full mediator (see figure 1). The path coefficients (unstandardised) are displayed on the mediation diagram.

Figure 1. Mediation model showing the role of electronic health literacy in the relationship between patient empowerment and continuity of care needs among patients with stable COPD. Path values represent unstandardised coefficients (B). Path a represents the association between patient empowerment and electronic health literacy; path b represents the association between electronic health literacy and continuity of care needs; path c represents the total effect of patient empowerment on continuity of care needs; and path c’ represents the direct effect of patient empowerment on continuity of care needs after inclusion of the mediator. COPD, chronic obstructive pulmonary disease.

Discussion

This study investigated the relationships among continuity of care needs, patient empowerment and eHealth literacy in patients with stable COPD, as well as the mediating role of eHealth literacy between patient empowerment and continuity of care needs. The findings provide valuable insights into the factors influencing continuity of care needs and offer valuable implications for clinical practice and policymaking.

The demographic results showed that 56.16% of patients with stable COPD were male and 43.84% were female. Most patients were aged between 51 and 65 years or older than 65, highlighting that COPD is an age-related chronic disease primarily affecting middle-aged and elderly populations.³⁰ The participants’ education levels were relatively low, with most having only middle school (30.59%) or high school education (32.88%), which may result in limited health knowledge and challenges in disease self-management, contributing to higher continuity of care needs.³¹ While direct measures of lung function (eg, forced expiratory volume in 1 s) were not available, we used a history of COPD-related hospitalisation as a clinical proxy for disease severity. The observed association between hospitalisation history and higher continuity of care needs aligns with the logical expectation that patients with more severe diseases have greater care requirements.

The results revealed that patients with stable COPD had relatively high continuity of care needs, with a mean score of 24.17 (SD=2.74). Among the six domains assessed, medication guidance needs received the highest scores. This finding highlights the critical importance of medication management for patients with COPD, even during the stable phase of the disease. Geng et al clearly reveal that despite China’s drive for an integrated healthcare system, patients lack personal awareness and experience of continuity of care, but this remains a key issue.³² Effective use of medications, such as bronchodilators and corticosteroids, is essential for controlling symptoms, maintaining pulmonary function and preventing exacerbations.^{33 34} However, the persistent high demand for medication guidance suggests a lack of sufficient patient education or follow-up support in clinical practice.³⁵ Similar findings have been reported in previous studies, emphasising the importance of targeted interventions to improve medication adherence and understanding in patients with chronic respiratory conditions.^{36 37} Clinical strategies, such as structured medication education programmes and personalised follow-up plans, could be implemented to address this unmet need.

The mean score for patient empowerment in this study was 84.37 (SD=11.58), indicating a moderate level of empowerment among the participants. Patient empowerment reflects an individual’s ability to acquire knowledge, make informed decisions and engage in self-management behaviours, all of which are crucial for managing chronic diseases like COPD.³⁸ Previous findings have shown that empowered patients tend to exhibit better self-care behaviours and health outcomes.³⁹ However, the moderate scores suggest that many patients may still lack confidence or knowledge in managing their condition effectively. This may be due to limited access to educational resources or insufficient support from healthcare providers. Programmes that emphasise patient education, shared decision-making and support systems tailored to COPD management can further enhance patient empowerment, ultimately improving continuity of care and health outcomes.⁴⁰

Our research findings indicate that eHealth literacy scores were also at a moderate level, with an average score of 23.37 (SD=6.06). While many patients with COPD can access digital health information, their ability to critically evaluate and effectively use such information remains limited.⁴¹ This limitation may hinder patients’ ability to make informed decisions, adhere to treatment regimens and manage their health proactively. Previous studies have also highlighted that low eHealth literacy is a barrier to achieving optimal chronic disease outcomes, particularly among older adults and individuals with lower education levels.^{42 43} To address this issue, healthcare providers should incorporate eHealth literacy training into patient education programmes, ensuring that patients are equipped with the skills necessary to navigate digital health resources effectively.

The Pearson correlation analysis demonstrated strong negative correlations between continuity of care needs and both patient empowerment (r=−0.930, p<0.001) and eHealth literacy (r=−0.976, p<0.001). These findings suggest that as patient empowerment and eHealth literacy improve, continuity of care needs decrease. Patients who feel empowered and possess higher eHealth literacy are better able to manage their health independently, access appropriate care resources and engage in effective communication with healthcare providers, thereby reducing their unmet care needs.^{44 45} This is consistent with prior research that highlights the importance of empowerment and health literacy in enabling patients to manage chronic diseases effectively.^{46 47} A significant positive correlation was observed between patient empowerment and eHealth literacy (r=0.919, p<0.001), indicating that higher levels of eHealth literacy are associated with greater patient empowerment. This relationship suggests that eHealth literacy plays a critical role in facilitating empowerment by enabling patients to access reliable health information, develop a deeper understanding of their condition and participate more actively in their care.^{25 48} This finding highlights the potential benefits of integrating digital health education into empowerment interventions to maximise their effectiveness.

The mediation analysis further suggested that eHealth literacy may play a significant mediating role in the relationship between patient empowerment and continuity of care needs. The indirect effect was −0.169 (95% CI −0.782 to −0.631), accounting for 74.91% of the total effect. This finding is consistent with the interpretation that while patient empowerment directly reduces continuity of care needs, a substantial portion of its impact is mediated through eHealth literacy. In other words, patients with higher levels of empowerment experience greater reductions in care needs when their eHealth literacy is also high. This result aligns with previous studies that have highlighted the mediating role of health literacy in chronic disease management.^{49 50} It highlights the potential importance of targeting eHealth literacy as a critical component of interventions designed to improve continuity of care. For chronic diseases such as COPD, where continuous monitoring, medication adherence and lifestyle adjustments are essential, eHealth literacy enables patients to better understand their condition, seek reliable information and use digital tools to support self-care.⁵¹ Researchers have suggested that digital healthcare innovation has faced rapid expansion and scaling in recent years.⁵²

Implications for practice and future interventions

Our findings on the mediating role of eHealth literacy offer concrete directions for developing targeted interventions. To address the high continuity of care needs, particularly in medication guidance, healthcare providers and policymakers should consider multifaceted strategies that synergistically enhance both patient empowerment and eHealth literacy. Concrete strategies could include: (1) Integrating eHealth literacy training into self-management programmes. For example, clinicians could guide patients on how to access and evaluate reliable online information about medication use or pulmonary rehabilitation, directly addressing their highest-scoring needs. (2) Using eHealth tools to facilitate empowerment. Prescribing specific, reputable mobile apps for medication reminders or using digital platforms for secure communication with healthcare providers can help empowered patients apply their knowledge and skills effectively.

In this model, eHealth literacy acts as a bridge, enabling patients to translate empowerment into actionable self-care, thereby reducing their unmet needs for ongoing guidance. Future studies should test the efficacy of such combined interventions.

Limitations

Several limitations should be acknowledged. First, the cross-sectional design precludes causal inferences, as the relationships identified cannot establish directionality or temporality. The observed mediation, while statistically significant, should be interpreted as a model that is consistent with the data rather than proof of causal pathways. Second, the study was conducted using a convenience sample from a single tertiary hospital, which may limit the generalisability of the findings to broader COPD populations. Third, the use of self-reported measures may introduce social desirability and recall bias, potentially inflating the observed correlations. Although we attempted to control for key demographic and clinical variables, residual confounding from unmeasured factors cannot be ruled out. Furthermore, the lack of spirometry data is a limitation, as it precludes a direct analysis of the relationship between objective lung function impairment and our variables of interest. Although we used hospitalisation history as a proxy, future studies should include direct physiological measures to confirm and extend our findings. Future research should employ longitudinal designs and include more diverse and representative samples to validate these findings and explore the long-term impact of interventions targeting empowerment and eHealth literacy.

Conclusion

In conclusion, this study demonstrates that patients with stable COPD have significant continuity of care needs, particularly in the area of medication guidance. Both patient empowerment and eHealth literacy are critical factors associated with reduced care needs, with eHealth literacy playing a substantial mediating role in the relationship between empowerment and continuity of care needs. Targeted interventions that enhance eHealth literacy and empowerment are essential for improving continuity of care and overall disease management in patients with COPD. Future research should further explore these relationships using longitudinal designs and evaluate the effectiveness of interventions in diverse patient populations.

Data availability statement

Data are available upon reasonable request.