Avatar Customization, Social Presence, and eHealth Literacy: Understanding User Adoption of Virtual Hospitals for Public Health Innovation

HAORAN LI^1*Sijie Sun^1*Ruijie Zhang²Xiang Li³Yilu He^4*

• ¹Autonomous University of Barcelona, Barcelona, Spain
• ²Universidad Politecnica de Cartagena, Cartagena, Spain
• ³Sungkyunkwan University, Jongno-gu, Republic of Korea
• ⁴City University of Macau, Taipa, Macao, SAR China

Introduction: Global healthcare systems face escalating challenges due to an ageing population, an increasing illness burden, and significant shortages in the healthcare workforce. In this context, rapid advances in digitalisation and metaverse technologies have positioned virtual hospitals as a potentially transformative solution. However, research has largely focused on technological and clinical implementation, leaving open the question of how avatar-based design features and users' eHealth literacy jointly shape psychological experiences and adoption behaviours in virtual hospital environments. This study addressed this gap by examining whether avatar customisation, avatar identification, social presence, and eHealth literacy influence users' intention to use virtual hospitals. Methods: An online experiment was conducted with 415 participants recruited from an online panel. Participants were exposed to a virtual hospital scenario featuring varying levels of avatar customisation and then completed validated measures of avatar identification, social presence, eHealth literacy, and intention to use the virtual hospital. Results: Avatar customisation significantly increased users' intention to use the virtual hospital by enhancing their sense of presence and engagement. Avatar identification and social presence operated as sequential mediators: higher avatar customisation strengthened avatar identification, which in turn increased social presence, ultimately leading to greater usage intention. In addition, eHealth literacy moderated the effect of social presence on usage intention, such that this relationship was stronger among individuals with higher levels of eHealth literacy. Discussion: These findings suggest that avatar-based design and users' eHealth literacy jointly shape key psychological processes underlying the adoption of virtual hospitals. The results are consistent with and extend prior work on avatar identification and social presence by demonstrating their combined mediating role in a virtual healthcare context. The study offers practical implications for designing virtual hospital systems that foster identification and social presence, and it highlights the importance of supporting users' eHealth literacy. Future research could further explore these mechanisms in different cultural settings and with longitudinal designs.