E-health promotion for aging baby boomers in North ...

Review

E-health promotion for aging baby boomers in North America

Andrew V. Wister PhD E: [email protected] Department of Gerontology, Simon Fraser University Vancouver, BC V6B 5K3, Canada D. Sinden, A.V. Wister. E-health promotion for aging baby boomers in North America. Gerontechnology 2008; 7(3):271-278. This paper focuses on the use of the Internet for health information and behaviour change. Specifically, it examines and reviews the current trends and issues connected to baby boomers in Canada using the Internet for accessing health information. We explore their opportunities and limitations as a target generation for e-health; considerations in serving diverse populations; issues of health literacy; e-health tool design and motivational impact; barriers to reaching offline boomers and strategies to reduce these barriers; and review several common e-health tools. The unique characteristics of this generation, including their high internet utilization rates and desire for health information make them a prime target for e-health tools.

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Danielle Sinden MA candidate E: [email protected]

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Keywords: e-health, baby boomers, behaviour change, internet, Canada

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care systems through e-health promotion are enormous. The following paper will examine e-health tools involving the use of the Internet for health information and behavioural change. It will examine the current trends in using the Internet for accessing health information, issues of health literacy for baby boomers, considerations in serving diverse populations, e-health tool design and motivational impact, barriers to reaching offline boomers, as well as strategies to reduce these barriers.

w w w. g e r o n t e c h j o u r n a l . n e t

E-health strategies have become popular in recent years in disseminating health information, knowledge transfer, and for the implementation of health promotion (HP) programs. These have potential for HP efforts targeting baby boomers, defined as born between 1946 and 1965, for several reasons. First, baby boomers tend to have experience with computers and retrieving information using the Internet both in their leisure and work lives1. Second, the baby boomers are at a stage in their lives (aged 42-61 in 2007) at which point chronic illness and its prevention has begun to become important 2. Third, baby boomers have higher levels of education than previous generations, which allows them to use health knowledge to make lifestyle choices3. Innovative and efficacious webbased health promotion has the potential to improve the health status of the large baby boomer generation as it moves up the age escalator into the elder years. Thus, the potential cost savings to health

Baby boomers and e-health

Promoting healthy aging among populations that are aging necessitates consideration of the baby boom generation, given the size and placement of these age cohorts in the population structures of Canada, the US, Australia, and many European countries. In 2006, the baby boomer cohorts comprised 30% of all Canadians4.

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Similar bulges in the age structure can be found in many other countries. The fact that these large age cohorts are compressed into only twenty years of the age structure magnifies their potential influence on population health and health care utilization. The front edge of this generation will reach their 65th birthday in 2011, and by 2031, baby boomers will range in age between 66 and 85. As they continue to age, baby boomers will exert an enormous influence on the course of many key social, economic and health institutions in society. Specifically, over the next few decades this group will be moving into the ages at which the onset of disease occurs, as well as increases in age-specific mortality rates. Yet, persons in their 40s and 50s are in their mid-life stage when modifiable risk factors can be targeted with considerable benefits to individuals and society5. The baby boomers comprise a generation because they share particular characteristics that set them apart from previous and following ones. Clark has identified six distinguishing characteristics: they are more concerned about healthy lifestyles and healthy aging; they have an interest in self-help resources such as the Internet; they are demanding of convenience and good service; they want evidence of quality and expertise in their service; they don’t accept advice at face value; and they are more willing to try complementary therapies6. Also, baby-boomers value youthfulness and desire to slow the aging process, given that they were part of a youth culture during the early stages of their life course3. It is important to carefully consider these attributes when developing e-health tools, since they may be important in identifying potential motivating techniques and cues to action. For instance, baby boomers may be influenced by HP approaches that emphasize keeping one looking and feeling healthy. For older Americans in 2004, 64% of 5064 year-olds had access to the Internet at


home, and 70% had previously gone online7.In the United States there are approximately 23.6 million people who search for health information online and it is estimated that a majority of these are baby boomers8.In Canada, compared to older age groups, the baby boomers are much more likely to use the Internet in general, and to use it for health information, despite the fact that health information needs increase with age. In an analysis of the 2005 Canadian Internet Use Survey and the 2000 General Social Survey, it was found that baby boomers (using persons aged 35-44 as younger boomers and 45-54 as older boomers in 2000 and 2005) were more likely to have ever used the Internet compared to older adults (persons aged 65 and older) (84% for younger boomers and 74% for older boomers, compared to only 26% for persons aged 65+). They were also more likely to have used the Internet to find health information in the last 12 months (42% for younger boomers and 38% for older boomers, compared to 14% for 65+)9. Thus, the proportion of older adults who use the Internet is expected to increase dramatically in the coming years as the baby boomers age and their health needs increase7. Approximately 24% of health information gathered is from an Internet source, and the Internet has even surpassed television, magazines, books and newspapers7. Also, about 51% go online everyday. In addition, baby boomers will continue looking online for health information for their aging parents. About 60% of people 30 to 49 years olds and 54% of those aged 50 and older say that they go online to find health information for their family members8. Internet health promotion could potentially play a pivotal role in spreading health information to adjacent generations7.

Definitions and key applications

E-health is defined as the application of information and communications technologies in the health sector10,11. These are

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We now turn to a number of issues in the literature that are relevant for the development of e-health tools targeting baby boomers. The digital divide Individuals with the highest risk for poor health tend not to have access to the Internet10. We know that ethnic minorities, people with low income and education, and the elderly have the highest incidence of disease8. For example, while 33% of seniors have Internet access in the US, only 15% of seniors with incomes under $20,000 do so7. This is referred to as a digital divide8,10. There are many ways in which this divide can be reduced; however, it first requires an understanding of and appreciation for the characteristics and needs of the intended users of e-health promotion. More research is also needed


A comprehensive report of e-health tools by the US Department of Health and Human Services concludes that the research conducted to date on e-health tools has questionable generalizability, particularly because of selection bias10. People who participate in studies are usually required to have Internet access, which indicates higher income and education levels. They may also therefore be in better health. These biases could result in findings that may affect the broad applicability of the development, implementation and evaluation of e-health tools. For instance, this could result in tools being developed that are not appropriate for more diverse segments of the population.

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Evidence is accumulating for higher adherence rates in health promotion programs compared to traditional intervention delivery methods. For instance, an interactive online physical activity intervention has been shown to increase motivational readiness and the time performing the activity compared to a control group12. Users of Internet-based physical activity interventions have reported four key preference themes including: structure, interactivity, environmental context and content13. Overall, these researchers found that people prefer simple interactive features and information regarding local community opportunities.

to understand how to reach these people, as well as how to motivate, engage and ultimately support them in using e-health tools.

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As to the ease with which people are able to access information that is available, it may be necessary to conduct a needs assessment to determine what type of information the users need and want, and the strategies they use to locate desired information. For instance, as a disease progresses, patient information needs may change in relation to the level of difficulty in accessing the information10,14,15. Health literacy Health literacy refers to the capacity of individuals to get health information and use it to make decisions regarding their health10. Health literacy is important because of its influence on a person’s interpretation of health messages, their communication of health problems, their ability to participate in interventions, and the skills required to use the Internet to find health information. Health factors rience, health


becoming increasingly available with the emergence of new health technologies that are diverse and constantly evolving10. E-health tools afford consumers an opportunity to access many interactive functions connected to the concept of disease prevention and management: including health information, behaviour change and prevention support, health self-management tools, online communities, decision support and healthcare tools10.

literacy depends on a number of including one’s education, expeincome, and culture. Most online educational materials require at

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least a 10th grade reading understanding15. According to the International Adult Literacy Survey (IALS), the average reading level of Canadian adults is grade 8 or 916. Adults over the age of 55 account for 50% of Canadians with literacy problems16. In addition, almost 90 percent of adults over the age of 65 had health literacy scores below the level considered adequate17. If understanding of health material is limited, the individual may not correctly identify disease symptoms, or they may not follow medical or health promoting prescriptions properly. In fact, low-literacy adults are twice as likely to be hospitalized as people with high functional literacy15. Low health literacy is also associated with higher rates of cancer, mortality and lower quality of life16.Moreover, much of the information provided by health professionals tend to be overly technical, jargonfilled, dense, long and confusing10. It appears that there is not only a problem with health literacy, but a system-design problem in communicating health information. Cultural appropriateness Cultural dynamics of the target population entail language, norms and values, meaning of messages and information, health literacy, culturally-based community resources, and family and community dynamics. For instance, in Indo-Canadian families, the grandmother plays a central role in the transfer of information to other family members. Also, messaging of information may need to be different for distinct ethnic or racial groups. Given the cultural diversity in the US and Canada, this factor is likely to be a primary consideration in the design of e-health tools and other health promotion approaches3. Inclusive design Making the Internet accessible to people regardless of ability is central to the concept of universal or inclusive design. When it comes to using the Internet, people with disabilities face several challenges related


to their vision, hearing, cognitive and physical limitations. The universal design for learning (UDL) framework outlines potential barriers for people with disabilities, including: (i) content within the site, (ii) interaction and navigation of the site, and (iii) engagement with the site. The UDL suggests that the key to design should be providing alternatives, as opposed to aiming for a ‘one-size-fits-all’ solution18. If the needs of people with disabilities were taken into consideration in the design of information technology (IT) tools such as the Internet, it would be easier to use, resulting in more people being attracted to it, thereby increasing health promotion effectiveness. Furthermore, inaccessible technologies for persons with disabilities have negative economic, social, cultural and personal implications, in particular, limiting access to key health promotion information and cues to action19. Trust, accuracy, credibility and privacy Seniors are less trusting of health information on the Internet than other age groups7. Approximately 26% of seniors would trust the Internet to provide accurate health information. For people 50 to 64, trust in health information on the Internet is 58%. This is promising for e-health tools targeting the baby boomers, provided the content of the information is appropriate and accurate. So people have to be taught how to check the source of the information to make sure that it is safe and reliable7. Another barrier to getting people online is privacy of information. Approximately half of all online health consumers reported being more concerned about privacy on the Internet than personal privacy in general8. Part of educating people on how to use the Internet for health information should include teaching people to recognize sites as being “safe” based on the source so they will feel more comfortable offering personal information. Establishing quality control measures of websites by providing a health check symbol of certification for

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The importance of interactivity Interactivity is an important feature of successful web-based interventions. For example, in a website physical activity intervention, simple interactive features were preferred among users aged 18-6513. Similarly, interactive designs may be better than less interactive systems because they are more engaging, create higher expectations to exercise and increase self-perceptions of fitness20. An interactive Internet site for patients with congestive heart failure found that such a tool has the potential to improve quality of life21.

Disease focused?

Although a disease-based and a healthy lifestyle approach do not have to be mutually exclusive, they tend to be different in how they target individuals, and in their emphasis. A disease-focused approach typically begins by identifying individuals with a specific disease (for instance, cardiovascular disease, diabetes, arthritis) or a set of risk factors linked to that disease (high blood pressure, high cholesterol, smoking, inactivity, obesity) and developing e-health tools or other health promotion interventions tied specifically to reducing the risk of the disease, or management of the disease. A healthy lifestyle approach typically targets persons who can benefit from changes in preventive and health promoting behaviours, and therefore tends to address wider populations at various stages of their life course. In this context, health promotion is about optimizing a person’s health status, regardless of his/her current state of health22. Since people’s choices and experiences earlier in life affect outcomes later on2, the earlier people take care of their health, the better they will be in the long-run.


Indeed, it has also been shown that many people who search for health information tend to be healthy at the time of their search. Cain and colleagues found that 60% of those online are healthy and tend to search for information about wellness and preventive medicine; the other 40% are comprised of the chronically ill and their caregivers (35%), and the newly diagnosed (5%)8. The available e-health tools tend to be restricted to disease management or risk factor change (i.e. smoking cessation, diabetes management, weight-loss)10. Mechanisms for behaviour change The goal of e-health promotion is to increase people’s knowledge of their health issues, thereby changing their attitudes in an attempt to ultimately change their health behaviours, and thus, improve their health. A number of behavioural change theories3,23-26 have been developed over the years to explain how and why people engage in healthy or unhealthy behaviours. These social psychological approaches have moved from analyses of health behaviours at a particular point in time to studying what moves people through intention-behaviour transitions. The Transtheoretical Model (TM) is one of a family of social-psychological behavioural change models that was originally formulated to understand smoking cessation, other addictive behaviours, and exercise23-25. It assumes that individuals spiral through five progressive stages of change: from not thinking about changing behaviour, to thinking about changing, to preparing for change, and finally, to actually making and sustaining the behaviour. It is important for e-health promotion, since this model suggests that there may be a need to tailor programmatic efforts to align with an individual’s stage of change for particular healthy lifestyle behaviour. Research suggests that health promotion strategies using the Internet can have an effect on changing attitudes and beliefs pertaining to the benefits of healthy life-

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sites that meet regulated standards could be useful, such as the one used on food labels in the US and Canada.

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styles as well as improving actual health behaviours7,8,10, although more research is needed to ascertain the most effective methods of achieving these aims.


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Tailoring health information Tailoring e-health information and programs may include retrofitting the e-health tool according to individuals’ age, gender, ethnicity, health needs or readiness to change. Tailored web-based interventions have been shown to be more appreciated, more personally relevant, and can have a positive impact on a person’s intentions to change behaviour27. A tailored approach is also one way in which appropriateness of content can be improved. In several randomized controlled trials, e-health tools were tailored to users’ stage of readiness to change, and outcomes were found to be more positive for users who received such information compared to controls2730 . Tailored information has also been shown to be more satisfying, relevant to the situation, and more likely to result in discussion of the information31. Tailored messages are different from targeted messages in that they take behavioural predictors that occur at the individual level into consideration and thus enhance the effectiveness of the message. Targeted approaches aim to involve specific segments of the population and fall between a general population approach and a tailored approach where the user is assessed on an individual basis.

E-health tools

Here we will provide 16 of the more common e-health sites in Canada and the United States under one or more of the following categories: non-profit charitable, federal government affiliated, provincial government affiliated, or for-profit. Charitable organizations Some popular non-profit charitable organizations in Canada include the Arthritis Society, the Canadian Diabetes Asso-


ciation, the Heart and Stroke Foundation and the Osteoporosis Society. These websites all have something in common; they all provide information and tools that are exclusive to a particular disease or set of diseases. Many of these sites also have peer-support groups, quizzes, fact sheets, and information on programs and services offered in various provinces and communities. All of these sites, excluding the Diabetes Association, have tools that can be tailored to the individual. The information is provided and maintained through volunteers, professionals and consultants in multi-disciplinary groups representing clinicians, researchers and educators from the field. No evidence of an evaluation of the tools is available on these websites. Government affiliated The BC HealthGuide Program is an online self-care initiative of the British Columbia provincial government. The Canadian government organizations with online health tools include the Canadian Health Network and the Healthy Heart Kit; both affiliated with the Public Health Agency of Canada. The Canadian Health Network covers general health topics and targets everyone from children to seniors and aboriginal people. The Healthy Heart Kit is a risk management and patient education program for cardiovascular disease. This tool can be used by physicians to help their at-risk patients make healthy lifestyle changes. In the US, there are also several government affiliated websites with ehealth tools, including: HealthFinder.gov, MedlinePlus and the National Institute of Health. All of these tools are similar in that they target people of all ages who want to learn more about various aspects of their health. These tools do not have features that provide tailored information, except for HealthFinder.gov, where the assessments and calculators can provide information that is somewhat tailored to the individual. Since these are government

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For-profit organizations The for-profit websites with e-health tools are Health Status Internet Assessments, Health Tools Online, and WebMD. These websites cover a wide range of health topics. Health Status Internet Assessments offers interactive tools for other websites to purchase. Health Tools Online and MedlinePlus are for all types of health consumers who want to browse health topics. Health Tools Online is the only website in the table that provides tools that are tailored to the individual. Most of these sites are based on reviews of expert panel reviews; however, no evaluation of the information is available on these websites.

Conclusion

There is an increasing number of websites aimed to provide people with the tools they need to change their health behaviours through interventions, self-help programs, and mass amounts of information. Yet, the full potential of the Internet for health promotion has not been met, especially for the baby boomer generation. There is a References

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