REVIEW URRENT C OPINION
Adolescent health literacy and the Internet: challenges and opportunities Anuja V. Jain and David Bickham
Purpose of review Adolescents have increasingly turned to the Internet as a resource for insight into their health questions and concerns. However, the extent to which adolescents will benefit from using the Internet as a source for health information will be determined in great part by their level of media literacy and health literacy. The purpose of this review is to explore challenges that adolescents face when using the Internet to access health information and opportunities for intervention. Recent findings Adolescents must be able to access, understand, analyze, and evaluate health information on the Internet and then apply this information to make appropriate health decisions. Challenges faced by adolescents fall into the realm of functional literacy (e.g., not being able to spell a medical term needed in a search), critical literacy (e.g., not being able to differentiate accurate from inaccurate online health information), and, lastly, interactive literacy (e.g., translating online health information to appropriate health behaviors). Summary More research is needed in this field to better understand the challenges and to propose effective solutions. However, a multifaceted approach that engages policymakers, educators, healthcare providers, online health information providers, and parents may be positioned to make the largest impact. Keywords adolescent, health information, Internet, literacy
INTRODUCTION Over the last three decades, the Internet has become a seemingly endless information network heavily used by young consumers seeking resources, knowledge, and content from around the world. Ninetysix percent of young people spend, on an average, close to an hour daily online [1]. Given the perceived anonymity of the Internet, it is not surprising that adolescents have turned to this resource for insight into their health questions and concerns. Specifically, half of all young people aged 8–18 have looked for health information online [1], and, among 15–24-year-olds, three out of four individuals have searched for health information at least once [2 ]. The extent to which young people will benefit from using the Internet as a resource for health information will be determined in great part by their level of media and health literacy. At its core, media literacy is the ability to access, analyze, evaluate, and interact with information in a variety of forms – from print to video to the Internet [3 ]. Health literacy, on the other hand, is ‘the degree to which individuals have the capacity to obtain, process, and &&
&
understand basic health information and services needed to make appropriate health decisions’ [4]. Taken together and applied to online health content, in order to demonstrate both media and health literacy, coined health-related media literacy in this paper, adolescents must be able to access, understand, analyze, and evaluate health information on the Internet and then apply this information to make appropriate health decisions. This process presents challenges unique to adolescents and to the Internet. The aim of this article is to explore these challenges and to propose potential solutions.
ADOLESCENT ONLINE HEALTH-SEEKING BEHAVIOR To better understand the challenges adolescents face in becoming health-related media literate, it is Boston Children's Hospital, Boston, Massachusetts, USA Correspondence to Anuja V. Jain, MD, MEd, Boston Children's Hospital, 300 Longwood Avenue, House Officer Lounge, Boston, MA 02115, USA. Tel: +1 617 355 6000; e-mail: [email protected] Curr Opin Pediatr 2014, 26:435–439 DOI:10.1097/MOP.0000000000000119
1040-8703 ã 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent medicine
KEY POINTS Adolescents are using the Internet more than ever for accessing health information. Adolescents face many challenges related to health literacy when accessing health information. If an investment is made in the research and development of both adolescent health-related media literacy skills and appropriate and effective online information, then the Internet could be a very powerful health resource for these users.
examine the pages they select closely and often return to the search engine results if information was not readily accessible on the first website selected [6]. When reviewing sites, adolescents did not typically check for authors, sponsorships, authority, objectivity, or when the site was created [6]. In addition, adolescents have increasingly been adopting smartphones, resulting in increased mobile access to the Internet. According to the Pew Internet Research Study, approximately three out of four teens say they use mobile devices to access the Internet [7 ]. Furthermore, about 25% of all teens and about 50% of teen smartphone owners primarily use their cell phones to access the Internet [7 ]. In order to understand the characteristics of adolescent online health-seeking behavior described earlier, further examination of smartphone use must occur in the context of the health-related content found on the Internet. &&
&&
imperative to understand the ways in which adolescents are using the Internet for health information. Although reports vary, it has been estimated that as many young people as adults use the Internet for health information [5 ]. It appears to be one of the most common online activities for adolescents, with more young people using the Internet to find health information than for playing online games, downloading music, participating in a chat room, or checking sports scores [2 ]. The health topics most commonly searched are pregnancy, birth control, HIV, sexually transmitted diseases, specific wellknown illnesses (e.g., cancer or diabetes), weight loss or gain, drugs or alcohol, depression or mental illness, and violence [2 ]. Furthermore, among all online health seekers, 39% say that they have changed their personal behavior because of the health information they reviewed [2 ]. Although many young people are using the Internet for health information, this information was deemed less trustworthy than information obtained from other sources (Table 1) [2 ]. To find this information online, adolescents are most commonly using search engines, followed by incidentally coming across information through links or banner advertisements while surfing the Web, and, lastly, by going to particular websites [2 ]. When using a search engine, they select websites from within the first three hits 80% of the time and rarely go past the first page of results [6]. Researchers further report that teens often do not &
&&
&&
&&
&&
&&
Table 1. Percent of adolescents that trust the health information they receive from various sources Various sources
Percent of adolescents
Doctors
85%
Parents School
68% 66%
Television Internet
30% 17%
436
www.co-pediatrics.com
HEALTH-RELATED CONTENT ON THE INTERNET An analysis of the content of Internet health information available to and used by adolescents is useful in providing a better understanding of the challenges adolescents face as they strive to develop health-based media literacy. There are a number of categories of websites that often appear using search engines to find health information. These categories include commercial websites, academic websites, professional organization websites, government (federal, state, and local) websites, personal websites, interest group websites, question–answer websites, epidemiological data sets, chat rooms, social networking sites, and sites for rating doctors [8]. Such websites have different authors, goals, and funding sources. Researchers evaluating health-related websites found that 58% had no disclosure of authorship, 45% had no clear disclosure of sources, 93% had no disclosure of sponsorship, and 30% had no clear distinction between website content and advertising [9]. When evaluating the reliability of medical advice on the Internet to answer specific health-related questions, researchers found that 39% of websites gave correct information, 11% gave incorrect information, and 49% failed to answer the question [10]. Taken together, the accuracy of the content of online health information may contribute to the challenges that adolescents face in becoming health-related media literate.
STRENGTHS OF THE INTERNET FOR HEALTH INFORMATION Despite potential problems with the content of health-related websites, adolescents continue to Volume 26 Number 4 August 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent health literacy and the Internet Jain and Bickham
search online for health information. Researchers propose that adolescents may actively seek online health information to address specific health concerns for themselves or members of their social circle and to research topics for school health classes [11 ]. Craan and Oleske [8] expand on this by hypothesizing that adolescents may turn to online sites to gain social support from chat rooms, to respond to distrust in a provider’s or parent’s opinion, to avoid discomfort in discussing personal matters with providers or parents, to assist a friend or a relative, to supplement inadequate information from a provider, or to obtain information to a question that the adolescent forgot to ask while in a provider’s office. Livingstone [12] further noted that young people feel in control, confident, and empowered when searching for health information. Taken together, the strengths of the Internet as a health information source can be summarized into five themes: increased access to health information, increased user involvement, interactivity, tailored information, and anonymity or confidentiality [13]. Despite these strengths, adolescents’ ability to use the Internet to obtain accurate health information is limited because of the multiple health and media literacy challenges they face. &&
HEALTH-RELATED MEDIA LITERACY CHALLENGES When adolescents use the Internet to find health information, they are faced with demands placed upon their health-related media literacy. Users must be able to first locate a website that meets their needs by using appropriate search strategies. Next, they should critically evaluate the information to determine whether it is credible. Lastly, they must consider how such information applies to them to achieve desired health outcomes. All three of these steps require a high level of health-related media literacy. Nutbeam [14] divides this into functional literacy, critical literacy, and interactive literacy. Functional literacy is defined as the ability to have basic skills in reading and writing in order to function in everyday situations [14]. In the context of health-related media literacy, adolescents must have the language and comprehension skills to search for and understand the desired health information. According to the United States Department of Education, one-fourth of eighth graders are below basic proficiency for reading and 12% are below basic proficiency for writing [15]. It has been demonstrated that illiteracy has a significant influence on students’ understanding of health information [16]. Therefore, although teenagers may be familiar with the Internet and using computers, in general,
some may suffer a functional literacy deficit that could impede their understanding of the resources they find online. For example, limitations in functional literacy could result in difficulty in spelling of medical terms [17]. The Internet is text driven and most search engines accept only minor spelling deviations in the spelling of search terms. In addition, adolescents often have trouble understanding the vocabulary and medical jargon used in healthrelated content on the Internet [17]. Adolescents may struggle to articulate and then write questions describing symptoms when using a question-driven search engine [18]. Such deficits in functional health-related media literacy make it difficult for adolescents to search for and to utilize online health information effectively. Criticalliteracyisdefinedastheabilitytoanalyzeand useinformationtoexertgreatercontroloverlifeevents andsituations[14].Adolescentsoftenfinditdifficultto evaluate the accuracy of the information they find online [18]. They turn to online trusted brands, such as‘Yahoo’or‘MSN’,believingtheinformationiscrediblebecausethesitesareworldwide.Asdiscussed,when selectingsites,adolescentsdonotoftenreviewauthorship,sponsorships,authority,objectivity,orcurrency ofagivensitetoassesscredibility[6].Furthermore,they find it difficult to distinguish facts versus opinion and content versus advertising when researching health information [18]. Therefore, in addition to searching and locating online health information, adolescents also find it challenging to use critical health-related media literacy to choose the appropriate resources to guide their healthcare decisions. Interactive literacy is defined as the ability to extract information and derive meaning from different forms of communication and to apply new information to changing circumstances [14]. In the context of this article, interactive literacy describes the ability to apply the health information acquired from a website to achieve a desired health outcome. To date, there is no seminal work exploring how adolescents translate online health information into behavioral changes. However, it can be inferred that accessing unhelpful or inaccurate health information could lead to inappropriate health decisions. For example, if an adolescent determines that they do not have a sexually transmitted disease based on information found online, they may not seek following up with a healthcare provider.
OPPORTUNITIES FOR INTERVENTION In order to maximize the utility of online health information, concurrent improvements in adolescents’ health-related literacy skills and Internet health content are needed. There are multiple
1040-8703 ã 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
437
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent medicine
opportunities for intervention in both of these domains. A multifaceted approach that engages policymakers, educators, healthcare providers, online health information providers, and parents may be positioned to make the largest impact [18]. Advocates believe that stakeholders must first encourage and support adolescents in acknowledging and addressing the unique challenges that young people face while seeking online health information. Education campaigns could be developed to improve the variety of search strategies that adolescents use when seeking health information [19]. Researchers suggest guiding youth toward youth-oriented directories and search engines, recommending links to resources on the web pages of schools and libraries, teaching adolescents techniques for formulating and refining search terms, advising adolescents to be aware of potential search term misspellings based on surprising search results, and, finally, instructing young people on techniques for systemically exploring websites [19]. Healthcare providers and K-12 teachers may be best suited to provide this education in both formal and informal settings [20]. Other possible interventions include the creation of an online medical dictionary to assist in spelling medical terms, using ‘Frequently Asked Questions’ to make finding information easier while alleviating spelling barriers and challenges when creating search questions, and simplifying medical jargon on websites [18]. Borzekowski and Rickert [21 ] suggest taking advantage of the layered aspects of Internet sites to provide additional resources linked to the provided information. In addition, although general websites can serve as entry points, information specifically targeted to adolescent health needs could be provided in a separate and clearly marked link [21 ]. Other researchers have suggested creating tools for assessing a broad range of health information on the Internet in order to help adolescents develop critical evaluation skills [22]. Although several organizations have developed guidelines to evaluate healthcare websites in the realms of content, accuracy, disclosures, attribution, advertising, and design, these criteria have not been applied to a broad set of Internet sites [22]. The fundamental flaw with these guidelines is that the Internet has no central controlling authority and therefore sites are not required to have their content reviewed [23]. To address this issue, public health and educational organizations could sponsor adolescent health sites, ensuring that youth could retrieve health content that is reliable and current without worrying about being influenced by deceiving information and advertising [21 ]. Implementing such innovations is critical in ensuring that adolescents are able to maximize the benefits from online health information. &
&
&
438
www.co-pediatrics.com
CONCLUSION While many challenges exist when using online sources for health information, the Internet can be an extremely powerful tool for adolescents if an investment is made in the research and development of both health-related media literacy skills and appropriate and effective online resources for these users. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the period of review, have been highlighted as: & of special interest && of outstanding interest 1. Rideout V, Foehr UG, Roberts DF. Generation M2: media in the lives of 8-18 year-olds. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2010. 2. Kaiser Family Foundation. Generation Rx. com: how young people use the internet for health information. 2001. http://www.kff.org/entmedia/loader.cfm?url=/com&& monspot/security/getfile.cfm&PageID=13719. [Accessed 10 February 2014] This article describes in detail the frequency with which adolescents use the Internet for health information, what they search for, and where they search for it. Definitely a keystone article on this topic. 3. Center for Media Literacy. Media literacy: a definition and more. 2012. http://www.medialit.org/media-literacy-definition-and-more. [Accessed 10 & February 2014] This article defines in detail the definition of media literacy and is the framework upon which this topic was expolored in this review. 4. American Medical Association. Health literacy: report of the Council on Scientific Affairs. JAMA 1999; 281:552–557. 5. Fox S, Jones S. Generations online in 2009. 2009. http://www.pewinternet.org/ Reports/2009/Generations-Online-in-2009.aspx. [Accessed 10 February 2014] & This article describes the way in which different generations use the Internet as well as the similarities and differences between them. 6. Morahan-Martin JM. How internet users find, evaluate, and use online health information: across-cultural review. Cyberpsychol Behav 2004; 10:497–510. 7. The Pew Research Center. The Pew Research Center’s Internet & && American Life Project Teen/Parent Survey. 2011. http://www.pewinternet. org/Static-Pages/Trend-Data-(Teens)/Online-Activites-Total.aspx. [Accessed 10 February 2014] This article presents the most up-to-date demographics related to online use by teens. 8. Craan F, Oleske DM. Medical information and the internet: do you know what you are getting? J Med Syst 2002; 26:511–517. 9. Eysenbach G, Powell J, Kuss O, Sa E. Empirical studies assessing the quality of health information for consumers on the world wide web: a systemic review. JAMA 2002; 287:2691–2699. 10. Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010; 95:580–582. 11. Gray NJ, Klein JD, Noyce PR, et al. Health information-seeking behavior in adolescence: the place of the internet. Soc Sci Med 2005; 60:1467–1478. && A keystone article on the topic of adolescent health information-seeking behavior. 12. Livingstone S. Children and the internet: great expectations, challenging realities. Malden, MA: Polity Press; 2008. 13. Bell K. The strengths and limitations of the internet as a health information resource for adolescents. J Adolesc Health 2009; 44:520. 14. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15:259–267. 15. US Department of Education, Institute of Education Sciences, National Center for Education Statistics, National Assessment of Educational Progress. The Nation’s Report Card. 2009. http://nationsreportcard.gov/. [Accessed 10 February 2014] 16. Brown SL, Teufel JA, Birch DA. Early adolescents perception of health and health literacy. J Sch Health 2007; 77:7. 17. Gray NJ, Klein JD, Cantrill JA, Noyce PR. Adolescent girls’ use of the internet for health information: issues beyond access. J Med Syst 2002; 26:545–553.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent health literacy and the Internet Jain and Bickham 18. Gray NJ, Klein JD, Noyce PR, et al. The internet: a window on adolescent health literacy. J Adolesc Health 2005; 37:243. 19. Hansen DL, Derry HA, Resnick PJ, Richardson CR. Adolescents searching for health information on the internet: an observational study. J Med Internet Res 2003; 5:25. 20. Skopelja EN, Whipple EC, Richwine P. Reaching and teaching teens: adolescent health literacy and the internet. J Consumer Health Internet 2008; 12:105–118.
21. Borzekowski DL, Rickert VI. Adolescents, the internet, and health: issues of access and content. Appl Develop Psychol 2001; 22:49–59. & Discusses multiple challenges as well as opportunities for intervention related to adolescent online health-seeking behavior. 22. Clark EJ. Health care web sites: are they reliable? J Med Syst 2002; 26:519–528. 23. Kortum P, Edwards C, Richards-Kortum R. The impact of inaccurate internet health information in a secondary school learning environment. J Med Internet Res 2008; 10:17.
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www.co-pediatrics.com
439
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent health literacy and the Internet: challenges and opportunities Anuja V. Jain and David Bickham
Purpose of review Adolescents have increasingly turned to the Internet as a resource for insight into their health questions and concerns. However, the extent to which adolescents will benefit from using the Internet as a source for health information will be determined in great part by their level of media literacy and health literacy. The purpose of this review is to explore challenges that adolescents face when using the Internet to access health information and opportunities for intervention. Recent findings Adolescents must be able to access, understand, analyze, and evaluate health information on the Internet and then apply this information to make appropriate health decisions. Challenges faced by adolescents fall into the realm of functional literacy (e.g., not being able to spell a medical term needed in a search), critical literacy (e.g., not being able to differentiate accurate from inaccurate online health information), and, lastly, interactive literacy (e.g., translating online health information to appropriate health behaviors). Summary More research is needed in this field to better understand the challenges and to propose effective solutions. However, a multifaceted approach that engages policymakers, educators, healthcare providers, online health information providers, and parents may be positioned to make the largest impact. Keywords adolescent, health information, Internet, literacy
INTRODUCTION Over the last three decades, the Internet has become a seemingly endless information network heavily used by young consumers seeking resources, knowledge, and content from around the world. Ninetysix percent of young people spend, on an average, close to an hour daily online [1]. Given the perceived anonymity of the Internet, it is not surprising that adolescents have turned to this resource for insight into their health questions and concerns. Specifically, half of all young people aged 8–18 have looked for health information online [1], and, among 15–24-year-olds, three out of four individuals have searched for health information at least once [2 ]. The extent to which young people will benefit from using the Internet as a resource for health information will be determined in great part by their level of media and health literacy. At its core, media literacy is the ability to access, analyze, evaluate, and interact with information in a variety of forms – from print to video to the Internet [3 ]. Health literacy, on the other hand, is ‘the degree to which individuals have the capacity to obtain, process, and &&
&
understand basic health information and services needed to make appropriate health decisions’ [4]. Taken together and applied to online health content, in order to demonstrate both media and health literacy, coined health-related media literacy in this paper, adolescents must be able to access, understand, analyze, and evaluate health information on the Internet and then apply this information to make appropriate health decisions. This process presents challenges unique to adolescents and to the Internet. The aim of this article is to explore these challenges and to propose potential solutions.
ADOLESCENT ONLINE HEALTH-SEEKING BEHAVIOR To better understand the challenges adolescents face in becoming health-related media literate, it is Boston Children's Hospital, Boston, Massachusetts, USA Correspondence to Anuja V. Jain, MD, MEd, Boston Children's Hospital, 300 Longwood Avenue, House Officer Lounge, Boston, MA 02115, USA. Tel: +1 617 355 6000; e-mail: [email protected] Curr Opin Pediatr 2014, 26:435–439 DOI:10.1097/MOP.0000000000000119
1040-8703 ã 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent medicine
KEY POINTS Adolescents are using the Internet more than ever for accessing health information. Adolescents face many challenges related to health literacy when accessing health information. If an investment is made in the research and development of both adolescent health-related media literacy skills and appropriate and effective online information, then the Internet could be a very powerful health resource for these users.
examine the pages they select closely and often return to the search engine results if information was not readily accessible on the first website selected [6]. When reviewing sites, adolescents did not typically check for authors, sponsorships, authority, objectivity, or when the site was created [6]. In addition, adolescents have increasingly been adopting smartphones, resulting in increased mobile access to the Internet. According to the Pew Internet Research Study, approximately three out of four teens say they use mobile devices to access the Internet [7 ]. Furthermore, about 25% of all teens and about 50% of teen smartphone owners primarily use their cell phones to access the Internet [7 ]. In order to understand the characteristics of adolescent online health-seeking behavior described earlier, further examination of smartphone use must occur in the context of the health-related content found on the Internet. &&
&&
imperative to understand the ways in which adolescents are using the Internet for health information. Although reports vary, it has been estimated that as many young people as adults use the Internet for health information [5 ]. It appears to be one of the most common online activities for adolescents, with more young people using the Internet to find health information than for playing online games, downloading music, participating in a chat room, or checking sports scores [2 ]. The health topics most commonly searched are pregnancy, birth control, HIV, sexually transmitted diseases, specific wellknown illnesses (e.g., cancer or diabetes), weight loss or gain, drugs or alcohol, depression or mental illness, and violence [2 ]. Furthermore, among all online health seekers, 39% say that they have changed their personal behavior because of the health information they reviewed [2 ]. Although many young people are using the Internet for health information, this information was deemed less trustworthy than information obtained from other sources (Table 1) [2 ]. To find this information online, adolescents are most commonly using search engines, followed by incidentally coming across information through links or banner advertisements while surfing the Web, and, lastly, by going to particular websites [2 ]. When using a search engine, they select websites from within the first three hits 80% of the time and rarely go past the first page of results [6]. Researchers further report that teens often do not &
&&
&&
&&
&&
&&
Table 1. Percent of adolescents that trust the health information they receive from various sources Various sources
Percent of adolescents
Doctors
85%
Parents School
68% 66%
Television Internet
30% 17%
436
www.co-pediatrics.com
HEALTH-RELATED CONTENT ON THE INTERNET An analysis of the content of Internet health information available to and used by adolescents is useful in providing a better understanding of the challenges adolescents face as they strive to develop health-based media literacy. There are a number of categories of websites that often appear using search engines to find health information. These categories include commercial websites, academic websites, professional organization websites, government (federal, state, and local) websites, personal websites, interest group websites, question–answer websites, epidemiological data sets, chat rooms, social networking sites, and sites for rating doctors [8]. Such websites have different authors, goals, and funding sources. Researchers evaluating health-related websites found that 58% had no disclosure of authorship, 45% had no clear disclosure of sources, 93% had no disclosure of sponsorship, and 30% had no clear distinction between website content and advertising [9]. When evaluating the reliability of medical advice on the Internet to answer specific health-related questions, researchers found that 39% of websites gave correct information, 11% gave incorrect information, and 49% failed to answer the question [10]. Taken together, the accuracy of the content of online health information may contribute to the challenges that adolescents face in becoming health-related media literate.
STRENGTHS OF THE INTERNET FOR HEALTH INFORMATION Despite potential problems with the content of health-related websites, adolescents continue to Volume 26 Number 4 August 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent health literacy and the Internet Jain and Bickham
search online for health information. Researchers propose that adolescents may actively seek online health information to address specific health concerns for themselves or members of their social circle and to research topics for school health classes [11 ]. Craan and Oleske [8] expand on this by hypothesizing that adolescents may turn to online sites to gain social support from chat rooms, to respond to distrust in a provider’s or parent’s opinion, to avoid discomfort in discussing personal matters with providers or parents, to assist a friend or a relative, to supplement inadequate information from a provider, or to obtain information to a question that the adolescent forgot to ask while in a provider’s office. Livingstone [12] further noted that young people feel in control, confident, and empowered when searching for health information. Taken together, the strengths of the Internet as a health information source can be summarized into five themes: increased access to health information, increased user involvement, interactivity, tailored information, and anonymity or confidentiality [13]. Despite these strengths, adolescents’ ability to use the Internet to obtain accurate health information is limited because of the multiple health and media literacy challenges they face. &&
HEALTH-RELATED MEDIA LITERACY CHALLENGES When adolescents use the Internet to find health information, they are faced with demands placed upon their health-related media literacy. Users must be able to first locate a website that meets their needs by using appropriate search strategies. Next, they should critically evaluate the information to determine whether it is credible. Lastly, they must consider how such information applies to them to achieve desired health outcomes. All three of these steps require a high level of health-related media literacy. Nutbeam [14] divides this into functional literacy, critical literacy, and interactive literacy. Functional literacy is defined as the ability to have basic skills in reading and writing in order to function in everyday situations [14]. In the context of health-related media literacy, adolescents must have the language and comprehension skills to search for and understand the desired health information. According to the United States Department of Education, one-fourth of eighth graders are below basic proficiency for reading and 12% are below basic proficiency for writing [15]. It has been demonstrated that illiteracy has a significant influence on students’ understanding of health information [16]. Therefore, although teenagers may be familiar with the Internet and using computers, in general,
some may suffer a functional literacy deficit that could impede their understanding of the resources they find online. For example, limitations in functional literacy could result in difficulty in spelling of medical terms [17]. The Internet is text driven and most search engines accept only minor spelling deviations in the spelling of search terms. In addition, adolescents often have trouble understanding the vocabulary and medical jargon used in healthrelated content on the Internet [17]. Adolescents may struggle to articulate and then write questions describing symptoms when using a question-driven search engine [18]. Such deficits in functional health-related media literacy make it difficult for adolescents to search for and to utilize online health information effectively. Criticalliteracyisdefinedastheabilitytoanalyzeand useinformationtoexertgreatercontroloverlifeevents andsituations[14].Adolescentsoftenfinditdifficultto evaluate the accuracy of the information they find online [18]. They turn to online trusted brands, such as‘Yahoo’or‘MSN’,believingtheinformationiscrediblebecausethesitesareworldwide.Asdiscussed,when selectingsites,adolescentsdonotoftenreviewauthorship,sponsorships,authority,objectivity,orcurrency ofagivensitetoassesscredibility[6].Furthermore,they find it difficult to distinguish facts versus opinion and content versus advertising when researching health information [18]. Therefore, in addition to searching and locating online health information, adolescents also find it challenging to use critical health-related media literacy to choose the appropriate resources to guide their healthcare decisions. Interactive literacy is defined as the ability to extract information and derive meaning from different forms of communication and to apply new information to changing circumstances [14]. In the context of this article, interactive literacy describes the ability to apply the health information acquired from a website to achieve a desired health outcome. To date, there is no seminal work exploring how adolescents translate online health information into behavioral changes. However, it can be inferred that accessing unhelpful or inaccurate health information could lead to inappropriate health decisions. For example, if an adolescent determines that they do not have a sexually transmitted disease based on information found online, they may not seek following up with a healthcare provider.
OPPORTUNITIES FOR INTERVENTION In order to maximize the utility of online health information, concurrent improvements in adolescents’ health-related literacy skills and Internet health content are needed. There are multiple
1040-8703 ã 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-pediatrics.com
437
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent medicine
opportunities for intervention in both of these domains. A multifaceted approach that engages policymakers, educators, healthcare providers, online health information providers, and parents may be positioned to make the largest impact [18]. Advocates believe that stakeholders must first encourage and support adolescents in acknowledging and addressing the unique challenges that young people face while seeking online health information. Education campaigns could be developed to improve the variety of search strategies that adolescents use when seeking health information [19]. Researchers suggest guiding youth toward youth-oriented directories and search engines, recommending links to resources on the web pages of schools and libraries, teaching adolescents techniques for formulating and refining search terms, advising adolescents to be aware of potential search term misspellings based on surprising search results, and, finally, instructing young people on techniques for systemically exploring websites [19]. Healthcare providers and K-12 teachers may be best suited to provide this education in both formal and informal settings [20]. Other possible interventions include the creation of an online medical dictionary to assist in spelling medical terms, using ‘Frequently Asked Questions’ to make finding information easier while alleviating spelling barriers and challenges when creating search questions, and simplifying medical jargon on websites [18]. Borzekowski and Rickert [21 ] suggest taking advantage of the layered aspects of Internet sites to provide additional resources linked to the provided information. In addition, although general websites can serve as entry points, information specifically targeted to adolescent health needs could be provided in a separate and clearly marked link [21 ]. Other researchers have suggested creating tools for assessing a broad range of health information on the Internet in order to help adolescents develop critical evaluation skills [22]. Although several organizations have developed guidelines to evaluate healthcare websites in the realms of content, accuracy, disclosures, attribution, advertising, and design, these criteria have not been applied to a broad set of Internet sites [22]. The fundamental flaw with these guidelines is that the Internet has no central controlling authority and therefore sites are not required to have their content reviewed [23]. To address this issue, public health and educational organizations could sponsor adolescent health sites, ensuring that youth could retrieve health content that is reliable and current without worrying about being influenced by deceiving information and advertising [21 ]. Implementing such innovations is critical in ensuring that adolescents are able to maximize the benefits from online health information. &
&
&
438
www.co-pediatrics.com
CONCLUSION While many challenges exist when using online sources for health information, the Internet can be an extremely powerful tool for adolescents if an investment is made in the research and development of both health-related media literacy skills and appropriate and effective online resources for these users. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the period of review, have been highlighted as: & of special interest && of outstanding interest 1. Rideout V, Foehr UG, Roberts DF. Generation M2: media in the lives of 8-18 year-olds. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2010. 2. Kaiser Family Foundation. Generation Rx. com: how young people use the internet for health information. 2001. http://www.kff.org/entmedia/loader.cfm?url=/com&& monspot/security/getfile.cfm&PageID=13719. [Accessed 10 February 2014] This article describes in detail the frequency with which adolescents use the Internet for health information, what they search for, and where they search for it. Definitely a keystone article on this topic. 3. Center for Media Literacy. Media literacy: a definition and more. 2012. http://www.medialit.org/media-literacy-definition-and-more. [Accessed 10 & February 2014] This article defines in detail the definition of media literacy and is the framework upon which this topic was expolored in this review. 4. American Medical Association. Health literacy: report of the Council on Scientific Affairs. JAMA 1999; 281:552–557. 5. Fox S, Jones S. Generations online in 2009. 2009. http://www.pewinternet.org/ Reports/2009/Generations-Online-in-2009.aspx. [Accessed 10 February 2014] & This article describes the way in which different generations use the Internet as well as the similarities and differences between them. 6. Morahan-Martin JM. How internet users find, evaluate, and use online health information: across-cultural review. Cyberpsychol Behav 2004; 10:497–510. 7. The Pew Research Center. The Pew Research Center’s Internet & && American Life Project Teen/Parent Survey. 2011. http://www.pewinternet. org/Static-Pages/Trend-Data-(Teens)/Online-Activites-Total.aspx. [Accessed 10 February 2014] This article presents the most up-to-date demographics related to online use by teens. 8. Craan F, Oleske DM. Medical information and the internet: do you know what you are getting? J Med Syst 2002; 26:511–517. 9. Eysenbach G, Powell J, Kuss O, Sa E. Empirical studies assessing the quality of health information for consumers on the world wide web: a systemic review. JAMA 2002; 287:2691–2699. 10. Scullard P, Peacock C, Davies P. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010; 95:580–582. 11. Gray NJ, Klein JD, Noyce PR, et al. Health information-seeking behavior in adolescence: the place of the internet. Soc Sci Med 2005; 60:1467–1478. && A keystone article on the topic of adolescent health information-seeking behavior. 12. Livingstone S. Children and the internet: great expectations, challenging realities. Malden, MA: Polity Press; 2008. 13. Bell K. The strengths and limitations of the internet as a health information resource for adolescents. J Adolesc Health 2009; 44:520. 14. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000; 15:259–267. 15. US Department of Education, Institute of Education Sciences, National Center for Education Statistics, National Assessment of Educational Progress. The Nation’s Report Card. 2009. http://nationsreportcard.gov/. [Accessed 10 February 2014] 16. Brown SL, Teufel JA, Birch DA. Early adolescents perception of health and health literacy. J Sch Health 2007; 77:7. 17. Gray NJ, Klein JD, Cantrill JA, Noyce PR. Adolescent girls’ use of the internet for health information: issues beyond access. J Med Syst 2002; 26:545–553.
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Adolescent health literacy and the Internet Jain and Bickham 18. Gray NJ, Klein JD, Noyce PR, et al. The internet: a window on adolescent health literacy. J Adolesc Health 2005; 37:243. 19. Hansen DL, Derry HA, Resnick PJ, Richardson CR. Adolescents searching for health information on the internet: an observational study. J Med Internet Res 2003; 5:25. 20. Skopelja EN, Whipple EC, Richwine P. Reaching and teaching teens: adolescent health literacy and the internet. J Consumer Health Internet 2008; 12:105–118.
21. Borzekowski DL, Rickert VI. Adolescents, the internet, and health: issues of access and content. Appl Develop Psychol 2001; 22:49–59. & Discusses multiple challenges as well as opportunities for intervention related to adolescent online health-seeking behavior. 22. Clark EJ. Health care web sites: are they reliable? J Med Syst 2002; 26:519–528. 23. Kortum P, Edwards C, Richards-Kortum R. The impact of inaccurate internet health information in a secondary school learning environment. J Med Internet Res 2008; 10:17.
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