This article was downloaded by: [University of Chicago Library]On: 05 October 2014, At: 20:24Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

The Serials Librarian: From the PrintedPage to the Digital AgePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wser20

Health Information Literacy and theElderly: Has the Internet Had an Impact?Kristen M. Hallows aa School of Library and Information Science, Kent State University ,Kent , Ohio , USAPublished online: 11 Jul 2013.

To cite this article: Kristen M. Hallows (2013) Health Information Literacy and the Elderly: Has theInternet Had an Impact?, The Serials Librarian: From the Printed Page to the Digital Age, 65:1, 39-55,DOI: 10.1080/0361526X.2013.781978

To link to this article: http://dx.doi.org/10.1080/0361526X.2013.781978

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

The Serials Librarian, 65:39–55, 2013Published with license by Taylor & FrancisISSN: 0361-526X print/1541-1095 onlineDOI: 10.1080/0361526X.2013.781978

VOICES OF THE FUTUREEdited by Rick Block

Health Information Literacy and the Elderly:Has the Internet Had an Impact?

KRISTEN M. HALLOWSSchool of Library and Information Science, Kent State University, Kent, Ohio, USA

The objective of the literature review was to determine whetherthe existence of the Internet has had a significant impact onhealth information literacy among the elderly in developed nations.Results were truly mixed, which led to the conclusion that, despiteits worldwide acceptance and usage, the Internet has not hadan all-encompassing influence on the ability of seniors to makeinformed health decisions, which is the ultimate product of goodhealth information literacy.

KEYWORDS health information literacy, senior, elderly, Internet,digital divide

INTRODUCTION

Around the world, older adults are quickly growing in number. As they age,they tend to become more interested in maintaining good health or manag-ing a chronic condition. The Internet has become an increasingly populardestination for health information, yet older adults have consistently beenleast likely to use the Internet. Is this a purely academic puzzle, or is there acause for concern?

© Kristen M. HallowsThis article was written in partial fulfillment of Information Needs, Seeking and Use

taught by Yin Zhang at Kent State School of Library and Information Science.Address correspondence to Kristen M. Hallows, MLIS, School of Library and Information

Science, Kent State University, 314 University Library, Kent, OH 44242, USA. E-mail:khallows@kent.edu

39

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

40 K. M. Hallows

The object of this literature review is to determine whether the Internethas had an impact on the health information literacy of online seniors sinceits acceptance as a mainstream source of health information. For these pur-poses, it will be estimated that the Internet had officially become a widelyaccepted source of health information by the year 2000; at the beginningof the 21st century, more than 70,000 websites provided health information,and over 50 million people sought it online.1

Many researchers define seniors as those who are 65 years of age andolder; some place individuals as young as 50 into this category, which maybe oversimplified at best and inappropriate at worst.2 “Differences in ability”are likely when grouping adults in their 50s with adults in their 70s or 80s.3

Because such variance exists, this literature review will loosely define seniorsas those over age 65, but every attempt will be made to interweave thenuances encountered within this diverse sector. The terms seniors, olderadults, and the elderly will be used interchangeably.

Originally, this literature review was to be limited to English-speakingcountries; however, it was discovered that similarities exist among devel-oped nations regardless of official language(s). Considerable research on theinformation-seeking behavior of older populations has been conducted invarious parts of the world including the United States, Germany, Finland,and Australia.

First, trends in senior Internet usage since the beginning of the newmillennium will be examined. Afterward, focus will shift to health informa-tion literacy and the tendency among seniors to view health providers aspreferred sources of health information. Next, the effectiveness of computertraining for this demographic will be investigated. Additional variables thatexert influence on health information literacy among the elderly will follow.Finally, there will be a brief description of the oldest old, which is an areagreatly in need of further research.

METHODS

Throughout October and November 2012, all EBSCO databases weresearched from 1998 to 2012. A combination of the following search termswas used: Internet, elderly, seniors, information behavior, and health infor-mation literacy. The search was limited to English language publications.Relevance was determined by a review of the abstract for each articleretrieved. When a relevant article was identified, related articles were locatedusing Science Citation Index Expanded (ISI Web of Science).

Original research articles that addressed the specific influence of theInternet or a computer-based service, such as an electronic health record(EHR), on health information literacy among elderly participants wereincluded. At a minimum, articles had to investigate seniors’ use of the

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 41

Internet—preferably to obtain health information. Articles that explored useof the Internet in younger populations and those that did not mentionInternet use were excluded. Database searches, in addition to the cross-checking of citations, yielded 60 articles, and 37 were selected for reviewbased on the previously mentioned eligibility criteria.

RESULTS

Wired Seniors

A 2001 study by James Merrell was conducted at a time when senior attitudestoward the Internet had never been explored. Merrell states, “seniors havehad little exposure to computers, much less the most recent online servicesmade available by the Internet.” The majority of participants (over 87%)reported having absolutely no experience with the Internet. Informationalsites pertaining to news, travel, and art museums were visited most often;others were “rarely visited.”4

The Pew Internet & American Life Project has provided periodic snap-shots of senior Internet usage in the United States over the past twelve years.In September 2001, a report was released that bore the title and subtitle,“Wired Seniors: A Fervent Few, Inspired by Family Ties.” At that time, seniorcitizens made up 13% of the United States population but just 4% of the pop-ulation using the Internet. Very little research had investigated what seniorswere doing online; however, a burning question was why more of themweren’t utilizing the vast resources available on the Internet. E-mail was byfar the most popular activity among online seniors; searching for health andmedical information shared fourth place with browsing “just for fun” andweather updates. Interestingly, the study found that “Internet connectivitydrops precipitously after the age of 55.”5

Conversely, Morrell, Mayhorn, and Bennett found that accessing healthinformation was actually among the most desired online activities for olderadults along with e-mail and travel for pleasure.6 In 2004, Pew reportedthat the number of seniors age 65 or older who use the Internet had risen byabout eight million since 2000. Further, 66% had looked for health or medicalinformation online at some point by the end of 2003—a growth rate of 25%since 2000. Understandably, online seniors were also found to be muchmore likely than other users to have used the Internet to get informationabout Medicare and Medicaid. However, it is important to note that thisstudy acknowledged the many “off-line seniors” who were “far removedfrom the Internet.”7 Put differently, there were still many seniors whose dailylife simply did not involve Internet use.

A 2009 Pew report found that older Internet users were “significantlymore likely” than their younger counterparts to look online for health infor-mation, which was the third most popular online activity among seniors

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

42 K. M. Hallows

age 73 and older after e-mail and online search.8 Interestingly, a Pewreport released the following year announced that the act of searching forhealth information, which was previously the “primary domain” of seniors,was now the third most popular online activity for all users 18 and over.As with the 2004 Pew study, the fact that “non-internet users” exist is alsorecognized.9

The most recent Pew report, released in June 2012, includes the subtitle“For the first time, half of adults ages 65 and older are online.” As of April2012, over half (53%) of American seniors used the Internet or e-mail. Thereport states that these gains are “significant” after “several years of very littlegrowth among this group.” Also significant is the finding that once online,most seniors make Internet use a daily part of their lives. E-mail contin-ues to be very popular among seniors; as of August 2011, 86% of onlineseniors used it. However, after age 75, Internet use drops significantly.10

Unfortunately, this report does not specifically delve into seniors’ onlinehealth information–seeking behavior.

The preceding studies strongly indicate that Internet use among seniorshas become increasingly common since the beginning of the 21st century.They also present evidence that seniors who use the Internet are using itto satisfy their health information needs. However, the health informationliteracy of online seniors has not yet been addressed. What impact, if any,has the Internet had over the last 12 years?

Health Information Literacy

Health information literacy (HIL) is defined by the Medical LibraryAssociation as “the set of abilities needed to: recognize a health informationneed; identify likely information sources and use them to retrieve relevantinformation; assess the quality of the information and its applicability to aspecific situation; and analyze, understand, and use the information to makegood health decisions.”11

Numerous studies identify health information as a very popular topicof interest among online seniors. Campbell and Wabby revealed through acase study that elderly people who received Internet instruction used theinformation retrieved to take a more active role in their own healthcare.Specifically, 65% reported a visit to a healthcare professional since the train-ing was received; of that 65%, most (59%) participated more actively intheir healthcare by seeking more information on the Internet about theirhealth problem, discovering alternative treatments, and locating informa-tion to develop questions for their primary care physician. One participantreported that information found on the Internet bolstered her confidenceto ask questions of her healthcare provider, which led to a change in herprescription.12 This is significant because elderly people have been found tohesitate to question their providers.13

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 43

On the contrary, Campbell found that seniors were willing to use theInternet, but familiarity with Internet resources did not lead to significantusage or changes in participation in their own healthcare. When asked if theirlevels of participation had changed since being introduced to the Internet,most (63.5%) said yes, and of those who had seen a healthcare provider dur-ing a six-month period, 75% indicated that they had played a “collaborativerole” and worked together with their doctor to make decisions. However,when asked about such activities as using the Internet to develop ques-tions to ask a physician before a visit, the majority of participants indicatedthat they had not done this; when asked whether they possessed a set ofmedical websites used to gather health information, fewer than half (48.1%)said yes.14

In the previously mentioned study by Campbell and Wabby, the fore-most reason for not taking a more participatory role in one’s own healthcarewas lack of computer access. Two additional studies found that lack of accessto health information on the Internet was an issue among the elderly.15,16

However, Peter Millward argued that lack of skills, not access, leads to lackof interest among older adults; more specifically, the author reasons thatseniors may indicate lack of interest when the actual problem is fear due tothe inability to use the resource.17 This possibility is supported by the findingof Feufel and Stahl that poorly skilled participants in both age groups (under30 and over 50) doubted the quality of information found online primarilybecause they doubted their skills; they were easily distracted by unrelatedinformation, and they searched to confirm their preconceived opinions, suchas “vaccinations are harmful.”18

In their study, Capel et al. stated that the percentage of people over65 years of age in the United Kingdom who had used the Internet was“slowly rising,” but it was found that the “Internet does not form a major com-ponent of older people’s information seeking behaviour.”19 Reasons citedinclude physical and/or cognitive impairments, but also considered was thelow quality (i.e., inaccuracy) of some health information on the Internet.

The inconsistent findings of these studies suggest that the Internet’sinfluence on health information literacy among older adults could be deter-mined by factors other than access. The remainder of this literature reviewwill attempt to identify them.

Provider Preference

Anne Aula found that access to computers and the Internet, while essential, isnot always a sufficient motivator for their use. This study’s participants werenot interested in looking for health information on the Internet because theyeither did not have a health problem or wished to consult their physician.20

The latter is an example of the “paternalistic” view that Campbell noted manyseniors hold in regard to their healthcare.21

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

44 K. M. Hallows

This preference for health professionals as a source of healthinformation may not be ideal because access to these providers usuallyrequires an office visit. Kristina Eriksson-Backa found that “despite usinga broad range of information sources in their daily lives, the elderly respon-dents in this study reported a fairly narrow range in their preference forsources of health-related information.”22 Yates et al. found that medical prac-titioners were trusted “most highly,” followed by friends and support groups.This study also described the two largest barriers to Internet use for seniors:dubious accuracy and the overwhelming amount of information. Even so,some seniors used the Internet as a “yardstick” against which a doctor’sadvice could be measured.23

Although medical providers are clearly a preferred source, a numberof obstacles have been documented, such as lack of time with the providerand confusion caused by contradictory information.24 Further, it has beenfound that between 40 and 80% of information provided by practitionersis forgotten immediately because of factors including age-related memoryfunction and anxiety;25 as such, authoritative websites would appear to be ahelpful resource following an encounter with a provider.

McMillan and Macias state that older adults are accessing health infor-mation online, but access is “not universal” among them; that is, differenttypes of information are sought in different ways. Individual health situation,sources of health information, and relationships with medical professionalscan impact online health information seeking. The authors found distinctgroups of older online Americans:

● Power users (experienced with the Internet and personal computers)● Well-to-do users (high education, high income, and overall good health)● Older men

Two additional categories were identified for attitudes toward health:

● Health traditionalists (tend to give physicians greater control in the doctor–patient relationship)

● Health technologists (heavy users of the Internet for health information)

It is plausible that power users are also health technologists; both groupsused “multiple Internet health resources to a much greater extent than [did]other online seniors,” and they identified many online sources as being ofhigh quality. Older men, on the other hand, tended to be health traditionalistsand used few online resources, which they were inclined to view as lowquality. Interestingly, the well-to-do group appeared to be neither healthtraditionalists nor health technologists. They were found to be unmotivatedby online health information seeking; instead, they used the Internet for

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 45

interpersonal communication. They are probably either a very diverse group,or perhaps they are somewhere in the middle of the spectrum. Also possiblyrelevant was the fact that this group reported good overall health.26

Taha, Sharit, and Czaja provide an intriguing finding: Older Internetusers tended to use it in place of more traditional sources such as magazinesor newspapers to get much of the same information. They found that thosewho did not use the Internet were just as satisfied with the health informationthey found as those who searched online. Interestingly, nonusers were foundto be more likely to make decisions about their healthcare based on informa-tion found offline than users (who have access to so much more informationon the Internet). The authors postulate that Internet users may not be aslikely to make decisions based on initial information because searching formore information is relatively easy; Macias and McMillan had found thataccessible information was “often not considered to be reliable or of highquality.”27 Or, print sources may be more familiar to this group. Remarkably,users and nonusers identified health professionals and pharmacists as thesources used “most of the time” or “always,” indicating deference to, if notpreference for, health professionals.28

Eriksson-Backa defined health information literacy as “the abilities torecognize a need for health information, to identify and use likely informa-tion sources, and to evaluate, understand, and use the information in orderto make good health decisions.” The author found that health informationliteracy was stronger in some areas than in others. Nearly 80% could identifyinformation needs, and sources were easily identified, though the sourceschosen were “one-sided” in that there was a clear preference for physiciansand other health professionals. Over half had access to a computer, and ofthose who had access, over 72% used the computer to search the Internet.29

The primary focus of this study was on libraries as an information source,so there was no further investigation of the search for health information onthe Internet.

How Effective is Training?

It is nearly impossible to discuss the older population’s use of the Internetwithout mentioning the so-called digital divide, a concept that emerged inthe late 1980s. It was feared that older Americans would miss out on theinformation revolution, as computers were not part of most of their lives.30

The digital divide has been described as a problem of access;31,32 however,as this literature review has already suggested, it is debatable whether accessis the solitary problem or solution.

Numerous studies have shown that computer training for seniors isan effective way to increase knowledge and skill in using computers andretrieving health information online.33–36 Chu et al. provided the followingdefinitions of concepts vital to this discussion:

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

46 K. M. Hallows

● Computer anxiety is “the fear or apprehension individuals feel when theyuse computers or when they consider the possibility of computer use.”

● Computer confidence is the “ability to use or learn to use a computer,”and it is inversely related to computer anxiety.

● Computer self-efficacy “refers to individuals’ perception of their abilityto successfully perform a computing task and their intentions for futureuse of computers.”37

Computer self-efficacy has been found to be related to enrollment in com-puter courses.38 Chu et al. found that a decrease in computer anxiety wasmaintained for six weeks after their training program. An increase in com-puter confidence and computer self-efficacy (as related to health informationretrieval) also remained when participants were interviewed six weeks afterthe completion of the study. Further, 95% reported higher confidence in“exploring and evaluating” health information online.39

Various studies have revealed unequivocally that not only is mere accessnot enough to create competent computer users, but also that training shouldbe tailored to the elderly.40–43 Bakaev et al. found two conditions that mustbe met in order for seniors to engage technology:

● The existence of a practical task to do with a computer or the Internet and● The discrediting of the pervasive yet false beliefs that computers are (a)

too complicated and (b) not for seniors.44

In their discussion of electronic personal health records, which have recentlyemerged as tools to manage one’s often scattered health records in the UnitedStates healthcare system, Kim et al. note that even though participants wereprovided with computers, Internet access, and personal assistance, participa-tion rate was relatively disappointing. Almost half used the system on onlyone day. Of interest was the fact that most (80%) user activities happenedwhen graduate students or housing staff were there to assist. The authorsstate that such “high dependency was mainly due to the limited physical andcognitive abilities and technophobia (i.e., computer anxiety) . . . ”45

Also interesting is the fact that at least two studies have found that lan-guage can be an insurmountable obstacle.46,47 From both of these studies,it can be inferred that it is essential to be able to access health infor-mation in one’s own language. Kim et al. discovered that none of theirRussian-speaking residents participated despite the fact that interpreters wereavailable.48 This is an important point for native English speakers to consider,as most Internet content is in English.

Finally, Aula warns that instruction inappropriate for the elderly can becounterproductive. Older adults may be embarrassed to ask for help for fearof asking “stupid” questions. Basic computer courses may also be conducted

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 47

at a speed too fast for elderly students, and they may contain perplexingjargon.49 A negative experience can lead to longstanding negative attitudestoward computers, as discussed later.

In summary, it appears that training is effective. However, there alsoappears to be an irksome reality that has appeared: High computer anxi-ety and low computer confidence and self-efficacy tend to preclude seniorsfrom seeking training, yet exposure to and instruction in computer use areapparently the only definite ways to reduce computer anxiety and increasecomputer confidence and self-efficacy. The question appears to be “Howcan we encourage seniors to take computer training so they can confidentlymake use of all the Internet has to offer?”

Further Complexity

Not only are not all seniors online, but also there is great diversity in infor-mation behavior among the group that uses the Internet. It appears that theavailability of the Internet has influenced the health information literacy ofsome online seniors but not for all, which suggests that even more variablesmust wield influence. One of them may be educational attainment. Meischkeet al. found that education is a “significant variable” in predicting health infor-mation seeking from the Internet. Further, seniors with a family history of acondition were more likely to exert the effort required to search the Internetfor desired health information.50 Eriksson-Backa et al. found that educationwas virtually the only factor that was related to differences in health informa-tion literacy. They found that age had no substantial relationship, and genderwas only related to confidence in the ability to use obtained information.51

Conversely, Taha, Sharit, and Czaja found that there were “no signifi-cant differences” in level of education among Internet users and nonusers.The authors also found no major difference in health status. The two groupsonly displayed differences in level of comfort with and interest in computers;not surprisingly, participants who used the Internet were more comfortableusing computers, felt more confident when using them, and were more inter-ested in learning about computers than the individuals in the nonuser group.It should be noted that a significant portion of participants (44%) learned touse the Internet by attending a class, and nearly half (48%) indicated thatthey had used the Internet in the past year to find health information.52 Itcan be construed that interest is a precondition and that such interest canbe stymied by things like inexperience and lack of confidence, which canescalate into fear.

In keeping with the leitmotif of the literature review, education couldbe one of many factors. In a broad study conducted by Czaja et al., theobject was to determine whether such differences in demographics, atti-tudes, and abilities predict technology and computer use. Use of the Internetwas found to be predicted by education, age, ethnicity, fluid intelligence,53

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

48 K. M. Hallows

crystallized intelligence,54 and computer anxiety. The strongest predictorswere ethnicity, fluid intelligence, and computer anxiety. Ethnicity was per-haps the least expected predictor; however, unlike the younger (18–39) andmiddle aged (40–59) groups, the older (60–91) group was mostly (81%)white;55 consequently, ethnicity may not be as much of a factor among thisgroup.

Fluid intelligence may deserve more attention as a possible factor, asit has been well documented that fluid intelligence declines with age.56

Czaja et al. found that their sample of older adults was “healthy and fairlywell educated,” but “significant age differences in computer and Web use”persisted.

One of the interesting findings regarding cognitive ability is includedbelow:

The younger adults performed better than did the middle-aged adults,who performed better than did the older adults, on the perceptual speed,memory, fluid intelligence, and psychomotor speed factors. For the crys-tallized intelligence factor, older adults outperformed both younger adultsand middle-aged adults, who did not differ from each other.57

Especially interesting is the finding that the older and middle-aged adultshad lower computer self-efficacy and more computer anxiety than youngeradults even though a large percentage reported having experience with com-puters. This finding is intriguing because studies cited in the previous sectionindicate that computer experience usually results in higher self-efficacy andlower anxiety. The issue here may be the varying definition of “experience.”Each person may use different programs and have different levels of success,which tends to enhance confidence.

Further, quantity of experience is one thing, but Aula urges readersto consider quality as well. The author found that deleterious first expe-riences with computers can produce long lasting negative attitudes. Someparticipants did have experience with computers in their working life;however, those experiences were negative, and the resulting attitudes per-sisted for decades! Due to the fast pace of technology, the systems theyused were vastly different from those used today, and they may havebeen used for a “very limited purpose.” Further, when these early sys-tems malfunctioned, developers may have placed undue blame on usererror (a situation not uncommon today). Consider the experience of oneparticipant:

We got computers at work in the 90s. Although I did not have a computerat that time, they told me at the office that I must not touch the comput-ers because I could break them. This left me a feeling of fear towardscomputers that only ceased when I took the first course last year.58

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 49

The comprehensive study by Czaja et al. found that attitudes and cognitiveabilities “simultaneously” predict computer use; in addition, there were otherdynamics such as age, health variables, and previous experience with com-puters. The authors speculate about a number of different factors includingperceived need and effort required to learn a new technology; the latter hasbeen shown to be greater among older people. Regrettably, differences influid intelligence make it even less likely that older adults will embrace—andmake the effort to learn—new technology, which is continuously changingand evolving.59

Sharit et al. conducted a study involving a younger-old group(60–70) and an older-old group (71–85) with a younger group (18–39) forcomparison. Participants were presented with realistic search problemsinvolving health and well-being that varied in complexity. This study isostensibly the only one to recognize that while the benefits of Internet useare clearly worth pursuing, online information-seeking places considerabledemands on the searcher’s cognitive abilities. As the authors state, “for manyolder adults who possess limited knowledge concerning the Internet andsearch engine processes and who may also exhibit declines in cognitive abil-ities, Web-based information seeking can be an intimidating and frustratingexperience.”60

Knowledge of the Internet was found to be necessary; however, it wasnot enough on its own to explain information-seeking performance. In thewords of the authors, “although having good knowledge was found to bestrongly related to effective information seeking . . . other factors besidesknowledge had an impact on information seeking.”61 These “other factors”were reasoning, working memory (i.e., short-term memory), and perceptualspeed. Thus, a combination of knowledge and cognitive abilities is requiredfor successful information seeking.

Interestingly, knowledge and working memory were important predic-tors of performance on complex problems; for simple ones, reasoning abilitywas found to be the only significant predictor. So, as the problems becamemore complex, performance became more dependent on both knowledge ofthe Internet and cognitive abilities. Given the amount of health informationon the Internet and the inherently complex nature of some health issues, itis easy to see how a user must come prepared in order to make use of sucha resource.

The following quotes from the study by Manafo and Wong illustrate thecontrast between delightful accessibility . . .

. . . It’s just easy, it’s marvelous, it’s the best thing in the world. I thinkback to when I was in my 20s and nothing was available and you couldn’tget information and you couldn’t get any information from your doctor,let alone [the Internet]. I used to go to the library and read things andthen I’d go home and look up words I didn’t know from there and then

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

50 K. M. Hallows

I bought a medical dictionary so that I could transfer the words and, youknow, figure it out like that.62

. . . and incapacitating overload:

I’ve been sorry I’ve had the Internet many times . . . too much informationand I don’t know where I’m getting it from . . . I keep thinking I’mmisusing this somehow because it’s not providing me with any help.63

If this literature review has revealed anything, it is that any one factorshould not be considered in isolation. It may also be helpful to consider theextreme variance in wealth among older people who have retired. Perhapsas expected, those who have less wealth are less likely to purchase newtechnology. Additionally, the impact of generational influences cannot beignored. Czaja et al. provide a thought-provoking point:

Today’s older adults have matured in a time when computer technologywas introduced, and their relative low use of computers probably reflectsa form of cohort-specific obsolescence rather than developmental changein effective use of these types of systems. One implication of this viewis that, as they grow older, today’s younger adults are likely to havevery different patterns of prior experience with, and attitudes toward,computer technology.64

Clearly, the literature presents a mixed bag of answers. The Internet is notan easy thing to use, particularly for seniors. A recurring theme is that someolder adults see the Internet as a welcomed conduit of accessibility to infor-mation; others see it as information overload and therefore a deterrent toinformation seeking. Some see it as a supplement to a trusted doctor’s advice;others believe it is simply too much for a layperson to assimilate.

The Oldest Old

As mentioned in the introduction, seniors are typically described as those65 years of age and older; within this group, considerable differences inability exist. Williamson and Asla state that people in the period of lifedescribed as the “fourth age” (85 years of age and older) may be impededby a relatively rapid decline in cognitive abilities, and they may have dif-ficulty with fundamental tasks such as turning on the computer. Further,people with Alzheimer’s disease and related dementias may lose the abilityto type,65 which precludes the use of a computer regardless of the availabilityof Internet access.

It is the information-seeking behavior of the oldest old that Asla et al.describe as most in need of additional research. They cite the following threereasons to support this assertion:

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 51

● The oldest old are the fastest growing segment among older people,● There is a lack of information behavior research involving this specific age

group, and● Evidence suggests that age may be more of a factor for this age group than

for the younger aged.

With a touch of weltschmerz, the authors cite a study that found that “nearlyall the oldest old show evidence of ‘significant cultural decreases in physicalhealth, certain cognitive abilities, and significant other networks.’” Asla et al.note that friends are not a major source of information for the very olddue to the fact that few are likely to be living; also, isolation results fromdeteriorating health. Such differences have an impact on new learning andinformation-seeking behavior. To date, the oldest old and the Internet remainlargely uninvestigated.66

DISCUSSION

Are the contradictory findings discussed in this literature review best left tothe academics, or is the Internet vital to the health information literacy of asegment of the population that tends to need it the most? A recurring senti-ment in nearly every scholarly article was that missing out on the Internet issuch an unacceptable condition that remedies must be instituted, namelyeducational initiatives. Given the undeniable potential benefits to healthinformation literacy, such a view seems perfectly reasonable. However, thisinvestigation has revealed that the concept that a portion of this demographicmay be managing its healthcare without the Internet is barely addressed inthe literature. Such an idea is understandably foreign in a society whoseinformation needs, seeking, and use have unquestionably been transformedby the Internet, but perhaps it is one that could be explored further.

The answer to the question of whether the Internet has influencedhealth information literacy among the elderly appears to be “somewhat.”There is conflicting evidence that educational level, access to technology,and previous computer experience spur Internet use. Attitude toward aninformation source has been shown to be relevant; some seniors have skillsand access and still view their doctor as the definitive source of health infor-mation. How can the Internet influence the health information literacy of theelderly if it is not included in their repertoire of sources, which the aforemen-tioned studies indicate has not changed greatly since the Internet became agenerally accepted—albeit flawed—source of health information?

Perhaps the best answer to the question is that the Internet has had animpact on the health information literacy of some seniors in some ways butnot all seniors in all ways. Specifically, some may use the Internet to identifylikely information sources after recognizing a health information need andthen use those sources to retrieve relevant information. More experienced

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

52 K. M. Hallows

Internet users may also be very proficient with the assessment of qualityof information and its applicability to a specific situation, but those withless exposure to the Internet or less education may not be as skilled in thisarea. The fifth tenet of health information literacy, the ability to analyze,understand, and use information to make good health decisions, may alsovary by individual; however, it is suggested that the availability of a wealth ofinformation, while of irregular validity and reliability, can increase the healthinformation literacy of those who are exposed to and interested in it.

Even so, age cannot be discounted as a factor; as Hanson stated, theage-related obstacles in the current older generation will not disappear inthe next.67 Put differently, those who are technology savvy today will oneday become “old,” and they too will be confronted by technology with whichthey are unfamiliar. Palsdottir also questioned whether coming elderly gener-ations, while accustomed to the Internet, will be able to adapt and learn howto use new technology.68 These uncertainties suggest that research opportu-nities in this area will continue into the future, as older people are our “futureselves.”69

REFERENCES AND NOTES

1. R. J. W. Cline and K. M. Haynes, “Consumer Health Information Seeking on theInternet: The State of the Art,” Health Education Research Theory & Practice 16,no. 6 (2001): 671.

2. Ages 60–65 have been the milestones for retirement eligibility in the UnitedStates since Social Security was established in 1935; as such, this age range hasbeen widely accepted as the point at which a person becomes “old.” However,someone in the United States who retires today with the same life expectancyof a 65-year-old at the time of Social Security’s inception would be celebratingthat retirement at the age of 80 [Terryl Asla, Kirsty Williamson, and John Mills,“The Role of Information in Successful Aging: The Case for a Research Focuson the Oldest Old,” Library & Information Science Research 28 (2006): 51].It can be inferred from these realities alone that our traditional understandingof being old has itself become antiquated and out of date. Quite simply, today’sseniors are “living longer and living better” [Elizabeth Manafo and Sharon Wong,“Exploring Older Adults’ Health Information Seeking Behaviors,” Journal ofNutrition Education and Behavior 44, no. 1 (2012): 85].

3. Vicki L. Hanson, “Age and Web Access: The Next Generation,” Proceedingsof the 2009 International Cross-Disciplinary Conference on Web Accessibility(W4A): 7–15. http://dl.acm.org/citation.cfm?id=1535658 (accessed November2012).

4. James T. Merrell, “Seniors in Cyberspace: The Determinants and Consequencesof Empowered Internet Use Among Senior Citizens.” (doctoral dissertation,University of Southern California, 2001).

5. Susannah Fox, “Wired Seniors,” Pew Internet & American Life Project(2001): 12. http://www.pewinternet.org/Reports/2001/Wired-Seniors/Summary-of-Findings/Findings.aspx (accessed November 2012).

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 53

6. Roger W. Morrell, Christopher B. Mayhorn, and Joan Bennett, “A Survey ofWorld Wide Web Use in Middle-Aged and Older Adults,” Human Factors, 42,no. 2 (2000).

7. Susannah Fox, “Older Americans and the Internet,” Pew Internet & AmericanLife Project (2004): 3. http://pewinternet.org/Reports/2004/Older-Americans-and-the-Internet.aspx (accessed November 2012).

8. Sydney Jones and Susannah Fox, “Generations Online in 2009,” Pew Internet& American Life Project (2009). http://www.pewinternet.org/Reports/2009/Generations-Online-in-2009.aspx (accessed November 2012).

9. Kathryn Zickuhr, “Generations 2010,” Pew Internet & American LifeProject (2010). http://www.pewinternet.org/Reports/2010/Generations-2010.aspx (accessed November 2012).

10. Kathryn Zickuhr and Mary Madden, “Older Adults and Internet Use,” PewInternet & American Life Project (2012). http://www.pewinternet.org/Reports/2012/Older-adults-and-internet-use.aspx (accessed November 2012).

11. Medical Library Association, “Definition of Health Information Literacy” (2003).www.mlanet.org/resources/healthlit/define.html (accessed November 2012).

12. Robert J. Campbell and James Wabby, “The Elderly and the Internet: A CaseStudy,” Internet Journal of Health 3, no. 1 (2003): 1–11.

13. Kristina Eriksson-Backa, “Access to Health Information: Perceptions of BarriersAmong Elderly in a Language Minority,” Information Research 13, no. 4 (2008):paper 368.

14. Robert J. Campbell, “Consumer Informatics: Elderly Persons and the Internet,”Perspectives in Health Information Management 2, no. 2 (2005): 3.

15. Morrell, Mayhorn, and Bennett, “A Survey of World Wide Web Use.”16. Daniel P. Lorence and Heeyoung Park, “New Technology and Old Habits: The

Role of Age as a Technology Chasm,” Technology and Health Care 14 (2006):180.

17. Peter Millward, “The ‘Grey Digital Divide’: Perception, Exclusion and Barriersof Access to the Internet for Older People,” First Monday 8, no. 7 (2003).

18. Markus A. Feufel and S. Frederica Stahl, “What Do Web-Use Skill DifferencesImply for Online Health Information Searches?” Journal of Medical InternetResearch 14, no. 3 (2012): e87. doi: 10.2196/jmir.2051

19. Sue Capel et al., “Access to Information and Support for Health: Some PotentialIssues and Solutions for an Ageing Population,” Health Informatics Journal 13,no. 4 (2007): 250.

20. Anne Aula, “User Study on Older Adults’ Use of the Web and Search Engines,”Universal Access in the Information Society 4 (2005): 72.

21. Campbell, “Consumer Informatics.”22. Eriksson-Backa, “Access to Health Information.”23. Christine Yates et al., “Health Information Literacy: Exploring Health Information

Use by Older Australians Within Everyday Life,” Library Trends 60, no. 3 (2012):472.

24. Eriksson-Backa, “Access to Health Information.”25. Roy P. C. Kessels, “Patients’ Memory for Medical Information,” Journal of the

Royal Society of Medicine 96 (2003): 219.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

54 K. M. Hallows

26. Sally J. McMillan and Wendy Macias, “Strengthening the Safety Net for OnlineSeniors: Factors Influencing Differences in Health Information Seeking AmongOlder Internet Users,” Journal of Health Communication 13 (2008): 778–792.

27. Wendy Macias and Sally McMillan, “The Return of the House Call: The Roleof Internet-Based Interactivity in Bringing Health Information Home to OlderAdults,” Health Communication 23 (2008): 34–44.

28. Jessica Taha, Joseph Sharit, and Sara Czaja, “Use of and Satisfaction WithSources of Health Information Among Older Internet Users and Nonusers,” TheGerontologist 49, no. 5 (2009): 671.

29. Kristina Eriksson-Backa, “Elderly People, Health Information, and Libraries: ASmall-Scale Study on Seniors in a Language Minority,” Libri 60 (2010): 185.

30. Asla, Williamson, and Mills, “The Role of Information in Successful Aging.”31. Hendrika Meischke et al., “Do Older Adults Use the Internet for Information on

Heart Attacks? Results From a Survey of Seniors in King County, Washington,”Heart & Lung 34, no. 1 (2005): 3–12.

32. Robert J. Campbell and David A. Nolfi, “Teaching Elderly Adults to Use theInternet to Access Health Care Information: Before-After Study,” Journal ofMedical Internet Research 7, no. 2 (2005): e19.

33. Merrell, “Seniors in Cyberspace.”34. Campbell and Wabby, “The Elderly and the Internet.”35. Adeline Chu et al., “‘Partnering With Seniors for Better Health’: Computer

Use and Internet Health Information Retrieval Among Older Adults in a LowSocioeconomic Community,” Journal of the Medical Library Association 97,no. 1 (2009): 13.

36. Bo Xie, “Effects of an eHealth Literacy Intervention for Older Adults,” Journalof Medical Internet Research 13, no. 4 (2011): e90. doi: 10.2196/jmir.1880

37. Chu et al., “‘Partnering With Seniors for Better Health.’”38. Yixin Zhang and Sue Espinoza, “Relationships Among Computer Self-Efficacy,

Attitudes Toward Computers, and Desirability of Learning Computing Skills,”Journal of Research on Computing In Education 30, no. 4 (1998): 420.

39. Chu et al., “‘Partnering With Seniors for Better Health.’”40. Millward, “The ‘Grey Digital Divide.’”41. Aula, “User Study on Older Adults.”42. Maxim Bakaev, Vladimir Ponomarev, and Larisa Prokhorova, “E-Learning

and Elder People: Barriers and Benefits,” Computational Technologies inElectrical and Electronics Engineering (2008). SIBIRCON 2008. IEEE Region8 International Conference.

43. Eung-Hun Kim et al., “Challenges to Using an Electronic Personal Health Recordby a Low-Income Elderly Population,” Journal of Medical Internet Research 11,no. 4 (2009): e44.

44. Bakaev et al., “E-learning and Elder People.”45. Kim et al., “Challenges to Using an Electronic Personal Health Record.”46. Ibid.47. Eriksson-Backa, “Access to Health Information.”48. Kim et al., “Challenges to Using an Electronic Personal Health Record.”49. Aula, “User Study on Older Adults.”50. Meischke et al., “Do Older Adults Use the Internet for Information on Heart

Attacks?”

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4

Health Information Literacy and the Elderly 55

51. Kristina Eriksson-Backa et al., “Health Information Literacy in Everyday Life: AStudy of Finns Aged 65–79 Years,” Health Informatics Journal 18, no. 2 (2012):90.

52. Taha, Sharit, and Czaja, “Use of and Satisfaction With Sources of HealthInformation.”

53. Fluid intelligence is “reflected not by what you know but rather how well yousolve novel problems” [John Jonides et al., “Building Better Brains,” ScientificAmerican Mind (2012).].

54. Crystallized intelligence refers to “learned knowledge and experience” [Sophievon Stumm and Ian J. Deary, “Typical Intellectual Engagement and Cognition inthe Ninth Decade of Life: The Lothian Birth Cohort 1921,” Psychology & Aging27, no. 3 (2012): 761. doi:10.1037/a0026527].

55. Sara J. Czaja et al., “Factors Predicting the Use of Technology: Findings Fromthe Center for Research and Education on Aging and Technology Enhancement(CREATE),” Psychology and Aging 21, no. 2 (2006): 333–352.

56. Michael Witthöft et al., “Adult Age Differences in Inhibitory Processes andTheir Predictive Validity for Fluid Intelligence,” Aging, Neuropsychology, andCognition 16 (2009): 133.

57. Czaja et al., “Factors Predicting the Use of Technology,” 337.58. Aula, “User Study on Older Adults,” 71.59. Czaja et al., “Factors Predicting the Use of Technology.”60. Joseph Sharit et al., “Investigating the Roles of Knowledge and Cognitive

Abilities in Older Adult Information Seeking on the Web,” ACM Transactionson Computer-Human Interaction 15, no. 1 (2008): 19.

61. Ibid., 20.62. Manafo and Wong, “Exploring Older Adults’ Health Information Seeking

Behaviors,” 86.63. Ibid.64. Czaja et al., “Factors Predicting the Use of Technology,” 349.65. Kirsty Williamson and Terryl Asla, “Information Behavior of People in the Fourth

Age: Implications for the Conceptualization of Information Literacy,” Libraryand Information Science Research 31 (2009): 81.

66. Asla, Williamson, and Mills, “The Role of Information in Successful Aging.”67. Hanson, “Age and Web Access.”68. Agusta Palsdottir, “Opportunistic Discovery of Information by Elderly Icelanders

and Their Relatives,” Information Research 16, no. 3 (2011): paper 485.69. Aula, “User Study on Older Adults.”

Dow

nloa

ded

by [

Uni

vers

ity o

f C

hica

go L

ibra

ry]

at 2

0:24

05

Oct

ober

201

4