Introduction
With the increasing number of older adults worldwide, attention to their mental and physical health issues is crucial. Health-related anxiety, a common mental health problem among older adults, can negatively affect their quality of life. Better access to and understanding of medical information can help reduce this anxiety. Health literacy is a key factor in enhancing an individual’s ability to access, understand, and use health information for health maintenance and disease prevention. In the digital age, e-health literacy becomes even more important as it empowers older adults to navigate online health resources effectively. The sense of coherence helps individuals perceive the world as comprehensible, manageable, and meaningful, potentially reducing health-related anxiety by improving their ability to handle life’s stresses. This study aims to assess the relationship of the sense of coherence and e-health literacy with health-related anxiety of older women in Richmond Hill, Ontario, Canada. It explores whether these factors can predict the health-related anxiety of older women, aiming to provide insights that could guide effective health interventions.

Methods & Materials
This cross-sectional study was conducted in Richmond Hill, Ontario, Canada, between February and July 2023. The study population consisted of approximately 4,700 women over 65 living in Richmond Hill, representing 6.8% of the city’s population. From this population, 350 were selected using a convenience sampling method, with the sample size determined based on Morgan and Krejcie’s table. Approximately 50 samples were selected from each region. Inclusion criteria were age >65 years, residing in Richmond Hill, ability to use the internet, and declaring written consent. Exclusion criteria were severe cognitive impairments or physical disabilities that could prevent the women from completing the questionnaires. The health anxiety inventory (HAI), the sense of coherence scale (SOCS), and the eHEALS were used for data collection. The questionnaires were administered in person at various locations, including nursing homes and local health centers. 
The SPSS software, version 27 was used for statistical analysis. Pearson’s correlation test was employed to assess the relationships between health anxiety, sense of coherence, and e-health literacy. Multiple linear regression was applied to determine the predictors of sense of health anxiety. Normality of data distribution was confirmed using the Kolmogorov-Smirnov test, and the homogeneity of variances was confirmed using Levene’s test. Statistical significance was set at 0.05, and results were presented at a 95% confidence interval. 

Results
The participants’ mean age was 71.43±5.62 years; 32.29% aged 65-70, 36.34% aged 71-75, and 31.37% aged ≥76. In terms of educational level, 39.71% had completed high school, 34.57% had a diploma or higher education, and 25.72% had education below high school. The mean HAI score was 20.45±4.56, indicating a moderate level of health anxiety. For the sense of coherence, the mean SOCS score was 45.67±5.78, indicating a moderately strong sense of coherence. The eHEALS score was 30.12±6.89, indicating a moderate e-health literacy.
The Pearson correlation test revealed a significant negative correlation between sense of coherence and health anxiety (r=-0.35, P=0.001). This finding suggests that a higher sense of coherence is associated with lower health anxiety, meaning that women with a stronger ability to view life as manageable, meaningful, and comprehensible are less likely to experience health-related anxiety. A stronger negative correlation was found between e-health literacy and health anxiety (r=-0.42, P<0.001). This implies that the older women with higher e-health literacy experience lower health anxiety.
Multiple linear regression model including sense of coherence and e-health literacy was statistically significant (F=4.89, P=0.003), and explained 22% of the variance in health anxiety (R²=0.20). E-health literacy had the stronger association with health anxiety, with a standardized beta coefficient of -0.42 (t=-7.89, P<0.001). This means that for every one-unit increase in e-health literacy, there was a corresponding 0.42-unit decrease in health anxiety. Sense of coherence also had a significant but slightly weaker effect, with a standardized beta coefficient of -0.35 (t=-7.00, P<0.001). Thus, for every one-unit increase in sense of coherence, health anxiety decreased by 0.35 units.

Conclusion
The study’s findings confirm that the sense of coherence and e-health literacy can significantly predict health anxiety among older women, with e-health literacy showing a slightly stronger association. These results highlight the importance of integrating a sense of coherence and e-health literacy into health interventions for older women to mitigate their health anxiety effectively. Targeted educational and psychological programs are recommended to increase the sense of coherence and e-health literacy of older women, thereby enhancing their quality of life and reducing health anxiety. 

Declaration of Interest
The authors declared no conflict of interest.

Ethical Considerations
Compliance with ethical guidelines
All participants provided informed consent after receiving explanations about the study objectives and methods. The study obtained ethical approval from the KMAN Research Institute, Ontario, Canada (Code: KEC.2023.6A4).

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors' contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all seniors who participated in this study.

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