eHealth Literacy and Older Adults

Topics in Geriatric Rehabilitation • Volume 29, Number 2, 116–125 • Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/TGR.0b013e31827ec0bd eHealth Literacy and Older Adults A Review of Literature Gabriel R. Rios, MLIS Older adults with low health literacy are living to advanced ages, often with multiple chronic conditions. This review focuses on eHealth literacy, which is defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.” Sixteen articles spanning a 10-year period were reviewed and examined for study design, intervention, and outcomes. Systemic changes in our societies are needed to decrease problems associated with low eHealth literacy. Fundamental training in computer literacy and health literacy is also needed. Integrating eHealth with adequate health literacy is key to people’s ability to maintain their health, foster behavioral change, and utilize medical services effectively. Key words: eHealth, e-patient, health literacy, literacy, telemedicine, telehealth and mhealth. A ccording to the 2010 Census, 40.3 million people are older adults (65 years and older) in the United States, accounting for 13% of the total population. This age group is larger than that in any other decennial census, up from 31.2 million in 1990 and 35.0 million in 2000.1 Older adults are at increased risk for advanced illness and multimorbidity. In the United States, improved public health and medical treatments have led to more adults living to advanced ages, often with multiple chronic conditions. Among Medicare beneficiaries, more than half have 2 or more conditions and 24% have 4 or more comorbidities.2 The 2004 Institute of Medicine report, Health Literacy: A Prescription to End Confusion, defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”3 Expanding on this definition with the digital landscape, Norman and Skinner4 defined eHealth literacy Author Affiliation: Lister Hill Library of the Health Sciences, The University of Alabama at Birmingham. The author has no financial relationship/s or commercial interests that relate to the content of this article. Correspondence: Gabriel R. Rios, MLIS, Lister Hill Library of the Health Sciences, The University of Alabama at Birmingham, LHL 251, 1720 Second Ave S, Birmingham, AL 35294 ([email protected]). 116 www.topicsingeriatricrehabilitation.com as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.” This definition is focused on empowering the individual by enabling them to share in the health decision-making process, which is informed by resources obtained through information and communications technology (ICT). This review focuses on older adult health, information needs, and eHealth literacy. Given the increasing use of ICT from our patients, this area of research will become increasingly important to aid in patient understanding of self-care instructions. THE EHEALTH LITERACY LANDSCAPE The Internet and the Web have dramatically changed the way information is distributed to the public. With growing broadband and mobile usage, individuals have more access to information than ever.5 The Web has enabled health care providers to circumvent traditional methods of print health information distribution and has allowed people access to health information in mixed mediums such as text, animations, and videos. According to the 2011 report, the Social Life of Health Information, by the Pew Internet & American Life Project, 59% of all adults have used the Internet to look online for information topics related to a specific disease or treatment, share testimonials with others (34%), connect individuals to others with similar health conditions (18%), and rank health care provider and medical facility quality (15%).5 Pew has been tracking trends among Internet users for more than 10 years and more recently trends in eHealth. “eHealth” has been broadly defined as “health services and information delivered or enhanced through the Internet and related technologies.”6 The word “eHealth” has been used in a number of different ways since it appeared in scientific literature in the late 1990s.7 Other terms, such as “e-patient” and “telehealth,” are related to eHealth but have contributed to the ambiguity of a definition rather than providing clarification. Norman and Skinner purport that eHealth literacy is the combination of the 6 core skills (or literacies): traditional literacy, health literacy, information literacy, scientific literacy, media literacy, and computer literacy. A person does not need to have mastery in all of the 6 literacies, but a minimum competency across all the skills has been shown to be helpful in promoting eHealth literacy.4 April–June 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. REVIEW OF LITERATURE For the review of literature, the following key words and their variations were identified: literacy, health literacy, eHealth, e-patient, telemedicine, telehealth, and mhealth. The National Library of Medicine’s PubMed and Thomson Reuters’ Web of Science databases were used. The studies were limited to participants 65 years and older and English language. Telemedicine literature that did not focus on patient empowerment through ICT was excluded from consideration. Sixteen articles spanning a 10-year period (2002-2012) were identified to fit the criteria for the review. Telemedicine and eHealth Five studies were focused on traditional telemedicine approaches (provider-assisted videoconferencing) but had ICT components for the participants to learn lifelong self-care skills. The study by Kaufman et al8 in 2003 used a traditional telemedicine approach that specifically focused on older adults with a chronic condition (diabetes). The home-based ICT intervention provided a computer and medical equipment to measure glucose and blood pressure readings. The participants tested the intervention for usability and identified barriers to effective technology use. Reported barriers were related partially to the system complexity and partially to aspects of self-care such as monitoring one’s glucose and blood pressure values.8 Pevzner et al built on the 2003 study of Kaufman et al and concluded that older adults have to overcome multiple challenges when learning to effectively use ICT. Challenges caused by age-related decline included decreased perceptual motor skills, working memory limitations, and poorly designed interfaces.9 van den Brink et al10 investigated whether telemedicine could improve the quality of life for cancer patients. The patients in the intervention group were given access to an electronic health information support system for 6 weeks after discharge from the hospital where they had received care. The eHealth system enabled them to communicate with health care providers and peers, access information, and be monitored by medical personnel. The control group was given the standard of care that consisted of routine follow-up appointments in an outpatient clinic at 2 and 6 weeks after discharge. Although no statistically significant changes related to feelings of security were demonstrated between the groups, participants subjectively reported that they felt more secure being able to contact providers with a telehealth system.10 The study of Carter et al11 is a similar telemedicine intervention, but the intervention consisted of ICT that would empower patients to use a computer and medical equipment that recorded their biometric data and uploaded it for biweekly meetings with a telehealth nurse. The study participants also had access to an education module about their condition and a social networking module Topics in Geriatric Rehabilitation that allowed participants to interact by exchanging coping strategies and asking questions. The target population of this study was not specifically older adults, but the sample was skewed toward an older population. The anticipated outcomes of the intervention occurred, but the inadvertent outcomes could have a greater impact on an older adult population. Patients reported benefits beyond the measured outcomes including changing the patient’s view of the physician visits, developing a high level of comfort with the telehealth nurse, and increasing the accessibility of health care providers.11 The work of Tse et al12 updates the telehealth model with a focus both on eHealth literacy concepts and on older adults. This study describes the development, implementation, and evaluation of an eHealth program for older persons. The objective of the 4-week eHealth program was to improve older adults’ autonomous access to and use of health-related information in the form of physical exercise videography from a government-sponsored Web site. The study participants exhibited increased mastery of computer skills and interest in accessing Internet-based health information. This study proved to be an innovative way of using the Internet to search for health information and improve health promotion among community-dwelling older adults.12 Secondary data analyses Two studies performed secondary data analyses on data from the National Cancer Institute Health Information National Trends Survey (HINTS). The studies used the data from the 2005 and 2007 surveys differently. The 2010 study of Kim and Kwon13 used the 2005 HINTS results to create a profile of the cancer e-patient and compare cancer e-patients with other types of cancer information seekers. In general, cancer e-patients tended to be older than online seekers without cancer. There was little evidence that cancer e-patients had higher eHealth literacy than patients without cancer or offline cancer patients. Cancer e-patients used the Internet as a primary source of information, but they still preferred their physician.13 Lustria et al14 used the 2007 HINTS results to investigate the relationship of socioeconomic variables and the use of Web-based technologies for health information seeking, personal health information management, and patient-provider communication. Twenty-five percent of the survey respondents were older adults. The analysis indicated that older adults were more likely to have sought health information than young adults but were less likely than young adults to use the Internet to search for health information.14 Opinion surveys At least 5 of the studies used opinion surveys or interviews for participants to self-report eHealth literacy skills. The 2007 study of Wathen and Harris15 examined interviews www.topicsingeriatricrehabilitation.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 117 with 40 women (aged 20-82 years) living in rural medically underserved areas on their health information–seeking behaviors. Many women talked about their need to be heard and respected when they looked for health information for themselves or others. Several of the women’s stories showed clear evidence of their “push back” and resistance to treating their health issues. For this reason, an understanding of the needs of various types of users, and the role of information systems and professionals as part of the delivery system, is critical before developing delivery mechanisms for health information.15 Miller and West16 also conducted a survey that examined the degree to which health care consumers communicate through conventional, face-to-face consultation, telemedicine, or digital technology and the relationship between these means of communication and respondent characteristics. The results of the survey indicated that 31.1% are using ICT to search for health information online, 7.5% to make online medical purchase, and 4.6% to communicate with health personnel. Older individuals were significantly less likely to seek health care information online than younger individuals. Overall, the results indicated that individuals who use any one of the health ICT strategies were more likely to use the others.16 Dart and Gallois17 conducted a survey to determine whether the community’s attitudes toward components of a community eHealth strategy differ across 3 different socioeconomic groups. Researchers found a strong and widespread desire for a community-oriented eHealth strategy. However, survey respondents still wanted to receive health information in person from a health professional. Respondents of different socioeconomic status communities have different health information needs; therefore, any community eHealth strategy needs to reflect this diversity.17 The 2011 study of van Deursen and van Dijk18 focused on assessing how ready a sample of the general population is for eHealth. More specifically, 4 types of Internet skills (operational, formal, information, and strategic) were measured in a performance test in which participants had to complete health-related assignments on the Internet. Although the amount of online health-related information and services continues to expand, it is apparent that the general population lacks the skills necessary for eHealth. Two of the problem areas highlighted are the lack of information and strategic Internet skills, which, in the context of health, are very important. Despite common perceptions of Internet savvy youth, the younger generations did not score any better than older populations on informational and strategic Internet skills.18 The 2011 study by Takahashi et al19 measured the prevalence of Internet use for health-related information compared with other sources and examined the effects on user knowledge, attitudes, and activities. The prevalence of Internet use via personal computer for acquiring 118 www.topicsingeriatricrehabilitation.com health-related information was less than 25% among those surveyed, whereas the prevalence of Internet use via cell phone was 6%. Primarily younger people, people with higher education levels, and people with higher household incomes used the Internet via personal computer for acquiring health-related information. More than 66% of Internet users strongly agreed or agreed that Internet use “improved my understanding of symptoms, conditions, or treatments in which I was interested” (68.1%) and “affected the way I eat or exercise” (68.0%), whereas only 23% thought it “improved my ability to manage my health care needs without visiting a physician or other health care provider.”19 Moving toward a theoretical framework Given the emerging nature of the eHealth research, a theoretical framework will help determine what to measure and what statistical relationships to examine. Eysenbach and Kohler20 conducted the earliest eHealth observational study in this review. Their goal was to describe techniques for retrieval and appraisal used by consumers when they search for health information on the Internet through observation and in-depth interviews. The researchers found that the search techniques used by the participants were often inadequate; however, Internet users were still able to answer health information–related questions in an average of 5 minutes 42 seconds per question. Participants did assess the credibility of a Web site by the source, professional design, scientific or official touch, language, and ease of use. No participants checked any “about us” sections of Web sites, disclaimers, or disclosure statements.20 Chaffin and Maddux21 also conducted an observational study testing 2 Web sites wiÂth identical content, one with accessibility accommodations taken from a list published by the National Institute on Aging and one without, for usability with participants from 3 different age groups (30-64, 65-84, and 85⫹ years).22 There were significant differences in the 2 Web pages with regard to readable text, presentation of information, incorporating other media, and navigation, across all age groups; however, usability was especially important in the 85⫹ group.21 Chan and Kaufman23 built on the work by Norman and Skinner by proposing a theoretical and methodological framework for characterizing complexity of eHealth tasks. The framework integrated the 6 components of Norman and Skinner’s eHealth literacy model with Bloom’s taxonomy. The integration of these concepts can assist in the creation of eHealth instruments to assess eHealth competence, evaluate eHealth tools, and develop an eHealth curriculum. The growing use of social media services require that eHealth interventions be developed with a better understanding of how these services are utilized. The 2011 study of Xie24 examined the effects of a theorydriven eHealth literacy intervention for older adults. The April–June 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. www.topicsingeriatricrehabilitation.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Topics in Geriatric Rehabilitation TABLE Summary of Literature Review Author Research Question 11 Sample/Design Outcome Measures Findings Limitations Carter et al To determine whether Convenience sample of patients a provider-assisted, (African American with eighth-grade patient self-management literacy level), with an age range of telehealth intervention 36-74 y. Patients received laptop, creates access to quality wireless broadband, and health monitoring for the equipment. Telehealth nurses held medically underserved and biweekly videoconferences with leads to improved patient patients and discussed biometric outcomes. data and behavior changes. Lower hemoglobin A1c and BMI measurements than control group members Significant association in the intervention and achieving targeted hemoglobin A1c measures and BMI. This study shows that it is possible to design and deliver an effective telehealth intervention for African Americans with diabetes living in the inner city. The sample size was small. Sample is skewed toward older adults. Sample included those with eighthgrade reading level and higher, due to computer literacy. There are perhaps patients with lower literacy levels in need; however, the minimum literacy level was not met. Chaffin and Maddux21 To test 2 Web sites with identical content (one with accessibility accommodations and one without) for usability with participants from 3 different age groups Ninety participants were recruited; 30 from each age group (30-64, 65-84, and 85⫹ y). A 2 x 3, mixed analysis of variance was planned for the data analysis and a power analysis. Participants used a Likerttype scale to evaluate 2 healthrelated Web sites with the same content and different accessibility accommodations. Benefits of usability accommodations to all groups but especially to individuals 85 y or older There were significant differences in the usability of the 2 Web pages across all age groups; however, the “oldest group” rated the “no usability” site significantly lower than the others. The old and older age groups were not necessarily representative of their age groups, as they were highly educated and not of a low SES. There was also limited ethnic diversity. Chan and Kaufman23 To propose a theoretical and methodological framework for characterizing complexity of eHealth tasks, which can be used to diagnose and describe literacy barriers and inform the development of solution strategies. A convenience sample of 20 participants aged 18-65 y was recruited. Two existing theoretical models relevant to the analysis of eHealth literacy were adapted into a single framework to systematically categorize and describe task demands and user performance on tasks needed by health care consumers. Diagnosis and description of literacy barriers to inform the development of solution strategies The framework and analytic approach can serve as a platform to inform development of rigorous eHealth examination and design instruments and develop an eHealth curriculum. Small sample size. Usability, affordances, and resources available within specific technology tools were not considered. Motivations or attitudes toward technology were not taken into account. Dart and Gallois17 To determine whether the community’s attitudes toward components of a community eHealth strategy differ across 3 different socioeconomic groups. A total of 718 participants from 3 Health information Strong and widespread desire Only 4.3% of the participants different socioeconomic groups needs of different for a community-oriented were 65 y and older. were recruited: low SES (n ⫽ 262); SES communities eHealth strategy. Survey mid-SES (n ⫽ 256); and university respondents still wanted to students (n ⫽ 200). Survey receive health information questions were developed using a in person from a health pilot field study, and surveys were care professional. The placed in different SES communities. type of health information Surveys were collected and desired varied according to analyzed. the respondents SES. 119 (continues) 120 TABLE Summary of Literature Review (Continued) www.topicsingeriatricrehabilitation.com April–June 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Author Research Question Sample/Design Outcome Measures Findings Observations during Search techniques used by the retrieval the participants were often experiment suboptimal. Participants Transcripts of did assess the credibility of focus groups and a Web site by the source, interviews professional design, scientific or official touch, language, and ease of use. No participants checked any “about us” sections of Web sites, disclaimers, or disclosure statements. Limitations The sample size was small. Questions did not have any direct impact on the participants. Sample tested may not be representative. Eysenbach and Kohler20 To describe techniques for Twenty-one users in 2 focus groups retrieval and appraisal were recruited and observed while used by consumers when retrieving health information from they search for health the Web. information on the Internet. Kaufman et al8 To present a multifaceted A representative sample of 14 Ability to complete cognitive evaluation of the participants in the New York a representative IDEATel diabetes education City area and 11 participants in set of tasks that and telemedicine program Upstate New York was identified. were likely to be targeted at elderly diabetic Participants were asked a series among the most patients. of questions about their use of commonly used computers and experience with by patients diabetes. Researchers asked them to perform a series of tasks including measuring blood pressure, uploading results, accessing the Diabetes Manager Web page, reviewing patient data, and generating and interpreting a table of blood glucose results. Kim and Kwon13 To perform an empirical Secondary data analysis study of 1988 Participant data The study showed little SES may no longer be a clear investigation to (1) create a cancer information seekers identified examined in evidence that cancer indicator that distinguishes profile of cancer e-patients from the National Cancer Institute’s aggregate for soe-patients are more patients who access online and (2) compare and 2005 HINTS. ciodemographic competent online health health resources and those contrast cancer e-patients characteristics, information consumers who do not. The quality with other types of cancer use of social than either online seekers of the Internet sources information seekers in networks, without cancer or the e-patients actually visited terms of their use of, information offline cancer patients. and used for cancer preference for, and trust in competence, and Most e-patients used the information was not different types of cancer source selection Internet as their primary collected. information sources. source of information, yet their most preferred source was the physician. Barriers to effective home telemedicine use in this population that were in part related to dimensions of system complexity and in part related to essential competencies for selfmanagement of a chronic illness such as diabetes were identified. The methods used were specific to a diabetes telemedicine program. (continues) www.topicsingeriatricrehabilitation.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Topics in Geriatric Rehabilitation TABLE Summary of Literature Review (Continued) Author Research Question Sample/Design Outcome Measures Findings Limitations 121 Lustria et al14 To examine the 2007 HINTS Secondary data analysis study A total Socioeconomic The study finds that as gaps to investigate relationships of 3473 completed surveys and 109 characteristics, of computer ownership between a variety of partially completed surveys, with 868 rural vs urban and Internet access socioeconomic variables being completed by 63 y or older, residency, numerin America continue and the use of Web-based were reviewed. acy, and access to narrow, it will be technologies for health to the Internet increasingly important information seeking, analyzed along to track disparities in personal health information with personal adoption on a wider range management, and patienthealth information of variables beyond the provider communication. management and usual participants. patient-provider communication via the Internet Miller and West16 To examine the degree to which health care consumers communicate through conventional, face-to-face consultation, telemedicine, or digital technology and the relationship between these means of communication and respondent characteristics. This study is based on a national survey of 1428 adults 18 y or older in the continental 48 states. The limits placed on the HIT revolution by consumer usage and attitudes were examined. How often in the past year had respondents visited, called, or e-mailed a physician or other health care professional, visited a healthrelated Web site, or ordered prescription drugs or medical equipment online? Pevzner et al9 To develop a training protocol for elderly participants of a home telemedicine study grounded in prior usability research. The training aimed to reduce barriers in developing system mastery. A representative sample of 16 participants (aged 59-81 y) enrolled. Researchers identified a set of tasks needed to productively use the telemedicine system and the corresponding prerequisite skills and knowledge. How well Eight of the 16 patients The sample size was small. participants achieved benchmark completed performance levels (eg, auspecific tasks tonomous task completion) including (1) within the first 2 sessions. uploading Patients with higher literacy glucose and levels and greater dexterblood pressure ity exhibited a noticeable values, (2) Web increase in performance access, and (3) across a range of tasks. navigation of the Results indicate that even IDEATel Web site? after patients master motoric skills, forming coherent mental models remains a significant challenge. (continues) Further examination of trends in patient use of personal health records is needed. More comprehensive measures that take into account eHealth activities with potential predictor variables such as health literacy are needed. Few people are using digital Results derived from selftechnology to get informareports rather than actual tion, communicate with observation of behaviors. health personnel, or make Responses could also be online medical purchases. affected by recall bias or Less well-educated, lowerthe tendency of survey income individuals living in respondents to provide rural areas tend to use the socially desirable answers. health care Internet less than others. Overall, results indicate that individuals who used any one of the health communication strategies examined were more likely to use the others. 122 www.topicsingeriatricrehabilitation.com April–June 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. TABLE Summary of Literature Review (Continued) Author Research Question Sample/Design Takahashi et al19 To measure the prevalence of Internet use for health-related information compared with other sources and to examine the effects on user knowledge, attitudes, and activities with regard to Internet use for healthrelated information in Japan. The extent of use via personal computers and cell phones was examined. The study had a cross-sectional survey of a quasi-representative sample (N ⫽ 1200) of the Japanese general population aged 1579 y. Interviewers visited randomly selected households, requested that individuals fill out questionnaires. Internet use was classified into 4 types: (1) use of a Web browser via personal computer, (2) use of a Web browser via cell phone, (3) use of e-mail via personal computer, and (4) use of e-mail via cell phone. Tse et al12 To describe the development, This is an illustrative case study with implementation, and 30 older adult participants (9 men, evaluation of an eHealth 21 women, aged 65-80 y). The program for older persons. 4-wk eHealth program (1.5 h/wk) The objective of the 4-wk was held in the activity room of an eHealth program was elderly center with the objective of to improve older adults’ improving older adults’ autonomous autonomous access to access to and use of health-related and use of health-related information in the form of physical information in the form exercise videography from a of physical exercise government-sponsored Web site. videography from a government-sponsored Web site. Outcome Measures Findings Limitations Answers to the The prevalence of Internet Sample size was too small questions: use via personal computer to examine the details of “How often do for acquiring healthindividuals who access you use a Web related information was the Internet via cell phone. browser (or 23.8% (286/1200) No comparative Japanese e-mail) to acquire among those surveyed, studies or data for the information whereas the prevalence prevalence of Internet use or advice for via cell phone was 6% in Japan. health care via (n ⫽ 77). Primarily your personal younger people, people computer (or with higher education through your cell levels, and people with phone)? higher household incomes used personal computer for acquiring health-related information. Ability to operate The study demonstrated an computer innovative way of using and access the Internet to search for the Internet health information and Awareness and improve health promotion interest gained among communityusing a computer dwelling older adults. including the Computer skills, interest ability to answer in accessing health a set of questions information, and health and browse a knowledge gained were health-related found among the 30 Web site Ability participants. to apply the health knowledge acquired to perform suggested exercises for older people The sample size was small. Sample may not be representative of general population. (continues) www.topicsingeriatricrehabilitation.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Topics in Geriatric Rehabilitation TABLE Summary of Literature Review (Continued) Author Research Question Sample/Design Outcome Measures Findings Limitations 123 van den Brink To investigate whether et al10 telemedicine could be beneficial to the QOL of cancer patients. A prospective controlled trial of 229 Participant Although 5 of the 22 QOL patients (59 for the intervention group responses to parameters were positively and 170 for the control group) was 3 paper QOL influenced, there was no recruited from a tertiary university questionnaires: at effect on the 2 subscales hospital where they had undergone discharge, 6 wk of Feelings of Insecurity. surgery for head and neck cancer. after discharge, Subjective evaluation Intervention group was given access and 3 mo after showed that many patients to an electronic health information discharge stated that being able to support system for a period of 6 wk contact care providers starting at discharge from the hospital. through the telemedicine Using the system, patients could send system gave them a messages, access information, contact feeling of security. This peers, and be monitored at home. The study adds to the sparse control group was given the standard evidence that telemedicine of care, which included routine followmay also be beneficial up appointments in the outpatient for the QOL of cancer clinic at 2 and 6 wk after discharge. patients. The specific form of cancer the studied population suffered from may have influenced the QOL measurements. Participants were assigned to the control or intervention group on the basis of location rather than randomly. van Deursen and van Dijk18 To assess how ready a sample of the general population is for eHealth. More specifically, 4 types of Internet skills were measured in a performance test in which participants had to complete health-related assignments on the Internet. A total of 88 participants were randomly selected from a telephone directory. Each participant had assignments to complete, all with a specific answer. Assignments were operational, formal, informational, and strategic. Participants’ performances on assignments The general population lacks the skills to keep up with the amount of online health-related information and services. There seems to be the lack of information and strategic Internet skills, Younger generations did not score any better than older populations on informational and strategic Internet skills. Specific aspects of the participants’ skills were not considered. Internet use was limited to information retrieval (no communication skills were measured). Content creation and sharing were ignored. Wathen and Harris15 To describe interviews with 40 women living in a rural, medically underserved county in southwestern Ontario, Canada, who discussed their information-seeking experiences and the strategies used to find information about a chronic health concern or an acute medical problem. Using advertisements in local newspapers, advertising flyers, and word of mouth, 40 women were recruited to participate in a study about their health information– seeking experiences. A member of the rural community conducted semistructured interviews to determine women’s health information–seeking experiences. Responses to interview questions Many women talked about their need to be heard and respected when they looked for information about their health or on behalf of others. Several of the women’s stories showed clear evidence of their “push back” and resistance to the medicalization of their health issues. Generalizability of study due to the population studied (continues) www.topicsingeriatricrehabilitation.com Abbreviations: BMI, body mass index; HINTS, Health Information National Trends Survey; HIT, health information technology; QOL, quality of life; SES, socioeconomic status. Limitations Findings The eHealth literacy Findings may not be intervention tested in representative of the older this study, regardless population as a whole. of the specific learning Insufficient consideration method used, significantly for the inexperienced user improved knowledge, composition of the sample, skills, and eHealth literacy instructor differences, efficacy from pre- to and the ceiling effect. No postintervention. The consideration for the range intervention was positively of eHealth literacy skills perceived by participants going from easy to obtain and led to positive changes to requiring more effort to in their own health care. obtain. A total of 146 older adults aged 56-91 Knowledge y were recruited for this study and gains, skill assigned to the collaborative learning gains, efficacy, model or the individualistic learning attitudes, and model. Each class met 2 times per changes in week for 2 h each time. participation in own health care To examine the effects of a theory-driven eHealth literacy intervention for older adults. Xie24 Outcome Measures Sample/Design Research Question Author TABLE Summary of Literature Review (Continued) 124 study also investigated the relative benefits of different instructional methods (eg, individualistic vs collaborative learning) on older adults’ learning of health literacy knowledge and skills. The findings provide strong evidence that the eHealth literacy intervention tested in this study, significantly improved knowledge, skills, and eHealth literacy efficacy from pre- to postintervention. The specific learning method used did not make a difference. Participants positively perceived the study and felt it led to positive changes in their health care.24 RECOMMENDATIONS Access to health information and skills to effectively find and use information to solve health problems are key to increasing eHealth literacy. The Internet is the primary source of health information for most people.5 Yet, a significant digital divide still exists, as not all people, particularly older adults and those with lower incomes, have the access or the combination of technology skills to access, evaluate, and use online health resources to improve their eHealth literacy. On the basis of review findings, older adults with easy access to technology can potentially minimize barriers to adequate eHealth literacy whereas in the reverse situation, barriers for vulnerable populations can be intensified. Systemic changes in our societies are needed to decrease problems associated with low eHealth literacy. For example, recent federal programs have attempted to address the issue through funding opportunities. One of the funding priorities of the National Telecommunications and Information Administration’s Broadband Technology Opportunities Program emphasizes Sustainable Broadband Adoption.25 These projects focus on increasing broadband Internet usage and adoption among vulnerable populations where broadband technology traditionally has been underutilized. Many projects include digital literacy training and outreach campaigns to increase the relevance of broadband in people’s everyday lives. Fundamental training in computer literacy and health literacy is also needed. Several studies highlighted the need to further public education to facilitate health consumers’ ability to effectively find health information on the Internet and make use of such information. Not all people feel equally comfortable searching for online information. Privacy is a frequently cited concern.16 Using some of the models suggested in the literature, such as health information–seeking training for older adults held at community dwellings, public libraries, or community centers, would increase levels of eHealth literacy in older adults. The other side of this issue is to increase awareness of these eHealth literacy issues among health care providers. The provider-assisted telehealth studies have had great success. Exploring these interventions’ effects on care coordination and performing a cost-benefit analysis would illustrate viability of the telehealth model.11 April–June 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. eHealth is the use of emerging ICT, especially the Internet, to improve or enable health and health care. Integrating eHealth with adequate health literacy is key to people’s ability to maintain their health, foster behavioral change, and utilize medical services effectively (Table). References 1. Werner CA. The Older Population: 2010. Vol C2010BR-09. Suitland, MD: United States Census Bureau; 2011:1-19. 2. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269-2276. 3. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004. 4. Norman CD, Skinner HA. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res. 2006;8(2):e9. 5. Fox S. The Social Life of Health Information, 2011. Internet & American Life Project Web site. http://www.pewinternet.org/&/ media//Files/Reports/2011/PIP_Social_Life_of_Health_Info.pdf. Published 2011. Accessed January 12, 2012. 6. Eysenbach G. What is e-health? J Med Internet Res. 2001;3(2):E20. 7. Oh H, Rizo C, Enkin M, Jadad A. What is eHealth? A systematic review of published definitions. World Hosp Health Serv. 2005;41(1):32-40. 8. Kaufman DR, Starren J, Patel VL, et al. A cognitive framework for understanding barriers to the productive use of a diabetes home telemedicine system. AMIA Annu Symp Proc. 2003: 356-360. 9. Pevzner J, Kaufmann DR, Hilliman C, Shea S, Weinstock RS, Starren J. Developing computer skills and competencies in seniors. AMIA Annu Symp Proc. 2005:1078. 10. van den Brink JL, Moorman PW, de Boer MF, et al. Impact on quality of life of a telemedicine system supporting head and neck cancer patients: a controlled trial during the postoperative period at home. J Am Med Inform Assoc. 2007;14(2): 198-205. 11. Carter EL, Nunlee-Bland G, Callender C. A patient-centric, provider-assisted diabetes telehealth self-management intervention for urban minorities. Perspect Health Inf Manag. 2011;8:1b. Topics in Geriatric Rehabilitation 12. Tse MM, Choi KC, Leung RS. e-Health for older people: the use of technology in health promotion. Cyberpsychol Behav. 2008;11(4):475-479. 13. Kim K, Kwon N. Profile of e-patients: analysis of their cancer information-seeking from a national survey. J Health Commun. 2010;15(7):712-733. 14. Lustria ML, Smith SA, Hinnant CC. Exploring digital divides: an examination of eHealth technology use in health information seeking, communication and personal health information management in the USA. Health Informatics J. 2011;17(3):224-243. 15. Wathen CN, Harris RM. “I try to take care of it myself.” How rural women search for health information. Qual Health Res. 2007;17(5):639-651. 16. Miller EA, West DM. Where’s the revolution? Digital technology and health care in the internet age. J Health Polit Policy Law. 2009;34(2):261-284. 17. Dart JM, Gallois C. Community desires for an online health information strategy. Aust Health Rev. 2010;34(4):467-476. 18. van Deursen AJ, van Dijk JA. Internet skills performance tests: are people ready for eHealth? J Med Internet Res. 2011;13(2):e35. 19. Takahashi Y, Ohura T, Ishizaki T, et al. Internet use for healthrelated information via personal computers and cell phones in Japan: a cross-sectional population-based survey. J Med Internet Res. 2011;13(4):e110. 20. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the World Wide Web? Qualitative study using focus groups, usability tests, and indepth interviews. BMJ. 2002;324(7337):573-577. 21. Chaffin AJ, Maddux CD. Accessibility accommodations for older adults seeking e-health information. J Gerontol Nurs. 2007;33(3):6-12. 22. National Institute on Aging and National Library of Medicine. Making your Web site senior friendly: a checklist. http://www. nlm.nih.gov/pubs/checklist.pdf. Published 2002. Accessed March 12, 2012. 23. Chan CV, Kaufman DR. A framework for characterizing eHealth literacy demands and barriers. J Med Internet Res. 2011;13(4):e94. 24. Xie B. Effects of an eHealth literacy intervention for older adults. J Med Internet Res. 2011;13(4):e90. 25. National Telecommunications and Information Administration. Broadband Technology Opportunities Program (BTOP) Web site. http://www2.ntia.doc.gov/about. Accessed April 23, 2012. www.topicsingeriatricrehabilitation.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 125