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eHealth resources offer new opportunities for older adults to access health information online, connect with others with shared health interests, and manage their health. However, older adults often lack sufficient eHealth literacy to maximize their benefit from these resources.
This review evaluates the research design, methods, and findings of eHealth literacy interventions for older adults.
A systematic review of peer-reviewed research articles from 28 databases in 9 fields was carried out in January 2013. Four rounds of screening of articles in these databases resulted in a final sample of 23 articles.
Findings indicated a significant gap in the literature for eHealth literacy interventions evaluating health outcomes as the outcome of interest, a lack of theory-based interventions, and few studies applied high-quality research design.
Our findings emphasize the need for researchers to develop and assess theory-based interventions applying high-quality research design in eHealth literacy interventions targeting the older population.
Electronic health information plays a growing role in how individuals manage their health and interact with the health care system [
Problematically, older adults often lack the skills and knowledge necessary to use online health resources [
eHealth literacy interventions offer one solution for increasing older adults’ ability to access and use eHealth resources such as electronic health records, patient portals, online support groups, and self-management tools [
Health literacy is “the degree to which individuals [can] obtain, process, and understand basic health information and services needed to make appropriate health decisions” [
Building on the concept of health literacy, eHealth literacy emphasizes information and communication technologies’ (ICTs) growing role in health information. Examples of ICTs relevant to individuals’ health management include patient portals, telehealth systems, and online support systems. eHealth literacy requires a mix of health, information, scientific, media, computer, and Internet literacy [
In this new (but growing) field, few studies have yet developed and tested eHealth literacy specific theories. Rather, eHealth interventions often use learning theory to guide interventions (eg, Xie [
Older adults’ distinct characteristics may explain why learning theories have not generalized to eHealth literacy interventions. Cognitive aging examines age-related changes in cognition, such as reduced information processing speed or a diminished ability to coordinate and integrate information [
Diversity within the older population may also affect intervention outcomes. This diversity includes chronological age, along with race and ethnicity. Chronological age can range from 50 to over 100, while racial and ethnic minorities comprise 21% of the US population over age 65 [
A systematic review of eHealth literacy interventions for older adults can provide a foundation for improving intervention outcomes. A recent systematic review investigated health literacy interventions for older adults [
We address a significant gap in the literature by providing a more comprehensive review that includes eHealth literacy interventions with both computer literate and illiterate older adults. This approach is necessary because (1) many older adults lack computer literacy [
We performed four rounds of systematic selection in January 2013 to identify relevant articles: (1) database selection, (2) keyword search, (3) screening the titles and abstracts, and (4) screening the full text.
We conducted search queries with electronic databases accessible at the University of Texas at Austin. Database selection involved two steps. First, we identified academic fields pertinent to the literature review, resulting in a list of nine fields with a total of 159 databases (see
The following keywords were used to search the 28 selected databases: “health literacy” OR “eHealth literacy” OR “e-Health literacy” OR “information literacy” OR “computer literacy” AND “old* adult*” OR “senior*” OR “elder*” OR “aging” OR “ageing” OR “babyboomer*” OR “retiree*”.
To ensure an inclusive selection of results, we applied no additional limiting criteria in the second round. Due to differences among the 28 databases, the keywords were used to search the articles’ full text, abstract, or title. This process produced a total of 253 articles.
One author (IW) screened the titles and abstracts for the 253 articles to ensure each study included
1.
2. The study involved evaluation of an
3. The intervention must have focused on improving
One author (IW) reviewed the full text of the remaining 30 articles to confirm consistency with the three criteria applied to review article titles and abstracts during the third round. We eliminated another 7 articles in Round 4. Articles were eliminated for not reporting empirical data [
Four-round selection process.
The 23 articles were published between 2003 and 2013 and report results from 23 independent studies [
We identified several intervention strategies among the sampled studies, including collaborative learning and tailored intervention content. Collaborative learning “involves the construction of meaning through interaction with others and can be characterized by a joint commitment to a shared goal” [
Similarly, four studies (17%) tailored intervention content [
Interventions applying collaborative learning strategies significantly improved participants’ computer and Web knowledge and skill [
The sampled studies provided evidence for the effectiveness of eHealth literacy interventions for older adults. The studies that conducted RCTs all found significant improvement for outcome measures from pre- to post-intervention [
About half of the studies (12/23, 52%) applied no theoretical framework. The 11 studies that applied a theoretical framework drew on two fields: (1) health behavior (seven studies) and (2) education (4 studies). Of these 11 studies, 7 (30%) used health behavior theories: three studies (13%) used the Transtheoretical Model [
The studies used a variety of research designs, consistent with the broad selection criteria used in our searches. Just under half (11/23, 48%) used designs with pretest and posttest of a single condition [
Five studies (22%) used either the Test of Functional Health Literacy in Adults (TOFHLA) or the Short Test of Functional Literacy in Adults (S-TOFHLA) [
Sample size varied between 11 participants in a pilot study and 909 participants for an RCT (a notable outlier is Olson, Sabogal, and Perez [
Only seven studies (30%) reported data on participants’ income [
Ten studies (43%) targeted a specific health outcome or behavior as the outcome of interest, with health literacy serving as an independent variable [
Most (6/8) of the eHealth literacy interventions used instructional materials developed by the National Institute on Aging (NIA) of the National Institutes of Health (NIH) [
Fourteen studies (61%) occurred in informal learning settings (eg, public libraries or senior centers) [
eHealth literacy interventions can provide older adults with the skills and knowledge necessary to benefit from eHealth resources [
The sampled eHealth interventions were inconsistent with the clinical perspective in that none of the interventions included a health outcome as an outcome measure [
Similarly, developing and applying theory could enhance the quality of research on eHealth literacy interventions. Theory development advances emerging fields by shifting the research focus away from simply discovering new facts to explaining facts, predicting outcomes [
None of the sampled studies used an eHealth literacy-specific theoretical framework, such as the Lily model or Chan and Kaufman’s [
While the Lily model describes the skills and knowledge necessary for eHealth literacy, it includes no cognitive, social, or environmental variables and lacks empirical validation. The Chan and Kaufman [
Along with a lack of theory, poor research design makes evaluating intervention outcomes problematic. Consistent with recent health literacy reviews [
A notable distinction between health literacy and eHealth literacy appeared in the intervention materials. The health literacy interventions used various materials, including condition-specific materials, such as an ulcer pamphlet [
The studies examined in this systematic review included participants that varied considerably in age, but most of these studies did not report participants’ income, education, race, or ethnicity. Mean participant age ranged from 61-84 years, raising the question of whether interventions effective for the “younger” segment of the older population can generalize to the “oldest” old. The failure to report participants’ income or education is problematic given the low median income of older adults in the United States [
Tailoring offers a solution for addressing the influence of individual characteristics on health outcomes. While tailoring has been proven effective in health interventions [
This systematic literature review contains several limitations. The keyword search did not use a controlled vocabulary (eg, Medical Subject Headings, Cumulative Index to Nursing and Allied Health) and was restricted to the title, keywords, and abstract for each article. This inclusion criterion may have excluded studies that deal with aspects of eHealth literacy but do not contain these exact keywords we used. Only studies with full text written in English were included in the sample, which excluded articles in non-English journals. Also, this review did not include studies that may have contributed to the development of the eHealth literacy construct (that pre-dated it and thus did not use the exact terms to be included in our searches). Nonetheless, this review identified important gaps in the literature that require future research. These gaps include (1) What is the relationship between eHealth literacy and health outcomes for older adults?, (2) Which theoretical frameworks are effective for developing and assessing eHealth literacy interventions for older adults, and which are more effective than others in what context?, (3) What is the relationship between eHealth literacy interventions conducted in clinical settings and those conducted in informal learning settings, and what factors should be considered when implementing eHealth literacy interventions in clinical settings?, (4) What instructional materials best facilitate older adults’ improvements in their eHealth literacy, and how can materials stay current given ICTs’ rapid development?, and (5) Which individual characteristics, such as health literacy level, computer experience, or SES, should be considered in interventions to tailor the health content and delivery strategies?
This paper reports findings from a systematic review of 23 articles on health literacy interventions and eHealth literacy interventions for older adults drawn from 28 relevant databases in nine fields. The eHealth literacy interventions in the sampled articles used eHealth literacy as an outcome of interest, applied learning theories, and occurred in informal learning settings such as senior centers and public libraries. In contrast, health literacy interventions (that involved ICTs as a key aspect of their interventions) often targeted specific health outcomes, applied health behavior theories, and occurred in both informal learning and clinical settings. These results indicate a significant gap in the literature on eHealth literacy interventions that use health outcomes for outcome measures. Additionally, most of the studies used no theoretical framework, and only seven studies were RCTs. These results highlight a great need to develop and assess theory-based interventions applying high-quality research design.
Selected databases organized by field.
Database inclusion criteria.
Selected articles.
controlled before and after studies
cognitive theory of multimedia learning
information and communication technology
National Institutes of Health
randomized controlled trial
socioeconomic status
social interdependence theory
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG041284 (PI: Bo Xie). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
None declared.