Are older Australians with chronic diseases online?
Abstract
Issue addressed
Health information can be easily and cheaply provided through the Internet. However, we do not know whether older adults, those people most likely to be living with a chronic disease, are online or whether they use the Internet to find health information.
Methods
In order to establish the proportion of older Australians online, the impact of their current health status and chronic disease diagnosis on Internet usage and whether they use the Internet to search for health information, a paper-based survey was developed and mailed to 9000 older adults, resident in New South Wales, Australia (response rate = 46.8% ).
Results
Results showed that many older Australians are online (52.3%) and that the majority who are use the Internet to find health information (68.5%). Respondents were more likely to use the Internet if they reported good health. The presence of most chronic diseases reduced use of the Internet; however, this was not the case for those reporting asthma, anxiety or sleep apnoea. Internet use decreased as the number of reported co-morbidities increased. However, once online, self-perceived overall health and number of chronic diseases did not affect use of the Internet to find health information.
Conclusions
This study is important as there is currently little information available about Internet use for health information by older Australians. Findings show that the provision of health information online has the potential to reinforce existing barriers created by the social determinants of health.
So what?
There is a role for the Internet in providing preventative, health promotion information, to older adults, who are already online and younger, computer literate audiences. However, practitioners need to consider the fact that this mode of delivery reinforces existing social divides; requires people to have Internet access and be both literate and e-literate.
1 INTRODUCTION
Older adults consume the greatest amount of health care resources, and are more likely than other age groups to have been diagnosed with a chronic disease, with approximately half of people aged 65–74 living with five or more chronic diseases.1 At an individual level, chronic disease impacts quality of life and can have wide reaching social and economic effects, making them the leading cause of illness, disability and death in Australia.2 In order to reduce their impact, positive self-management strategies can be employed to manage the chronic illness and minimise their consequences for the patient, their family and the health system, while health promotion messages can be used to prevent the development of chronic diseases.
The Internet provides an alternate channel of communication that can be used to deliver self-management and health promotion information. It offers flexible delivery of timely, up-to-date information.3 For providers, the development and launch of materials is relatively cheap and the Internet offers extensive reach. The content can be constantly updated and can be made engaging through inclusion of interactive components, such as video clips and quizzes. Furthermore, sites can be individually tailored to participants' needs allowing content to be adapted as personal and social circumstances change.4 From a user's perspective, accessing health information online is a relatively low cost activity that can be undertaken at a time and place that is convenient to them. Internet interventions have shown significant improvements in health outcomes, health knowledge, self-care, adherence to treatment and self-efficacy.3-9 Due to the burden of chronic disease in the population, older adults can potentially benefit most from access to online health information.
Although it is known that Internet adoption amongst older adults lags behind that of other age groups,10 there is a paucity of information on Internet use by older adults in Australia. Furthermore, while there is plenty of interest in providing online health information and Internet interventions to support chronic disease self-management, to date there has been little research looking at the viability of these solutions. We aimed to establish whether older Australians are online and whether they search the Internet for health information. Furthermore, we examined the relationship between current health status, including presence of chronic disease, and use of the Internet both for general and health information.
2 METHODS
A paper-based survey was developed to examine the health beliefs, behaviours and attitudes of older Australians towards asthma. Initially, think-aloud interviews11 were conducted with a convenience sample of 13 older adults to ensure the questions were interpreted correctly. Participants were asked to read the survey out loud, verbalising any thoughts they had about the survey questions, response options and the answers they gave. Interviews were conducted in participants' homes and were recorded. The researchers also made notes during each interview. Changes to both the design and content of the research tool were made as a result of the findings.
The survey was subsequently piloted with 118 respondents (115 valid responses). The respondents were accessed either through community groups, or when travelling on trains between two major cities in New South Wales (NSW), Australia. Respondents were offered a coffee voucher to acknowledge their time and effort.12 The final paper-based survey contained 79 items and was printed in 14-point font to allow for the deterioration of eyesight that often occurs as people age. Twelve items addressed demographic characteristics; including age, sex, highest level of education achieved and household income. Participants were asked to rate their health on a five-point scale (poor to excellent), and rate their health when compared to last year (much better to much worse). They were asked to indicate whether they had ever been told by a health professional that they had any of the following conditions: heart disease (described as angina/heart attack/heart failure), anxiety or panic attacks, arthritis, asthma, diabetes, emphysema, chronic obstructive pulmonary disorder (COPD), high blood pressure and sleep apnoea. A further 17 items asked about their use of the Internet. Ethics approval was obtained from the University's Human Research Ethics Committee; and consent was implied by return of the survey.
Nine thousand older adults were sent a package that included the survey, a letter explaining the research and a reply paid envelope. The sample was randomly selected by the Australian Electoral Commission (AEC) and consisted of people aged 55 years or over, equally divided between males and females and living in three distinct regions of NSW, Australia. In order to maximise the response rate, participants who completed and returned the survey were able to opt into a draw to win one of ten $100 gift vouchers.
Surveys were coded, allowing the contact details of participants who responded to be removed from the database. This allowed the implementation of an amended version of Dillman's tailored design method to maximise the response rate.13 Reminder postcards were sent out after three weeks, when receipt of completed surveys slowed down. A second copy of the survey package was sent out four weeks later.
After three months, 4131 surveys had been returned: surveys marked “no longer at this address” or completed by people less than 55 years were excluded, leaving 4060 eligible surveys (response rate = 46.8%). The data were entered into SPSS Statistics 17.0 by three researchers. Five percent of survey data was re-entered to check for accuracy (error rate = 0.175%). Pearson's chi-square test of contingencies were conducted to examine associations between personal demographics, and both general Internet use and use of the Internet to find health information. Direct logistic regressions were subsequently performed to predict use of a computer to access the Internet and use of the Internet to find health information.
3 RESULTS
3.1 Survey respondents
Table 1 presents respondents' demographics, their Internet use and online health information seeking behaviour. Over half the respondents reported being female (54.8%) and most were aged between 55-64 years (42.6%). The majority spoke English at home (93.6%), and just over one percent self-identified as being of Aboriginal or Torres Strait Islander origin. While more than a third of participants had completed tertiary education (35.7%), over half reported a household income of $40,000 or less (56%) and two-thirds reported being retired (66.1%).
| Proportion of respondents (n = 4066) | Percentage online (n = 2092) | Relationship between demographic variable and Internet use (P) | Percentage of those online looking for health information (n = 1426) | Relationship between demographic variable and using the Internet to find health information (P) | |
|---|---|---|---|---|---|
| Gender | .095 | .000 | |||
| Male | 1837; 45.2% | 975; 46.6% | 622; 43.6% | ||
| Female | 2228; 54.8% | 1117; 53.4% | 804; 56.4% | ||
| Age | .000 | .000 | |||
| 55-64 years | 1733;42.6% | 1249; 59.7% | 900; 63.1% | ||
| 65-74 years | 1344; 33.1% | 639; 30.5% | 417; 29.2% | ||
| 75 + years | 989; 24.3% | 204; 9.8% | 109; 7.6% | ||
| Education | .000 | .000 | |||
| No school/primary school | 245; 6.1% | 27; 1.2% | 13; 0.9% | ||
| Some secondary school | 1180; 29.4% | 416; 20% | 258; 18.1% | ||
| Completed secondary school | 1156; 28.8% | 537; 25.8% | 319; 22.4% | ||
| Completed tertiary studies | 1430; 35.7% | 1105; 53%% | 833; 58.5% | ||
| Employment status | .000 | .176 | |||
| Employed full-time | 680; 16.9% | 538; 25.9% | 385; 27.2% | ||
| Employed part-time/casual | 462; 11.5% | 346; 16.6% | 245; 17.3% | ||
| Unpaid/volunteering | 113; 2.8% | 62; 3% | 43; 3% | ||
| Looking for work | 51; 1.3% | 31; 1.5% | 20; 1.4% | ||
| Retired | 2653; 66.1% | 1069; 51.4% | 699; 49.4% | ||
| Self-employed | 55;1.4% | 33; 1.6% | 23; 1.6% | ||
| Income | .000 | .000 | |||
| <$40K | 2092; 56.0% | 891; 45% | 585; 43.1% | ||
| $40K-$80K | 787; 13.1% | 586; 29.6% | 417; 30.7% | ||
| >$80K | 412; 11.0% | 360; 18.2% | 281; 20.7% | ||
| Don't know/ did not answer | 445; 11.9% | 142; 7.2% | 77; 5.7% | ||
| Health rating | .000 | .090 | |||
| V.good/excellent | 1471; 36.7% | 968; 46.6% | 640; 45.2% | ||
| Good | 1675; 41.8% | 825; 39.7% | 585; 41.3% | ||
| Fair/poor | 865; 21.5% | 287; 13.8% | 191; 13.5% | ||
| Health compared to last year | .000 | .083 | |||
| Better/much better | 498; 12.4% | 300; 13.5% | 214; 15.2% | ||
| About the same | 3032; 75.8% | 1574; 75.9% | 1054; 74.6% | ||
| Worse/much worse | 471; 11.8% | 199; 9.6% | 145; 10.3% | ||
| Chronic disease | .000 | .547 | |||
| None | 819; 20.4% | 513;24.7% | 353; 25% | ||
| One | 1351; 33.6% | 751; 36.2% | 500; 35.4% | ||
| Two or more | 1847; 46.0% | 811; 39.1% | 560; 39.6% |
The majority of respondents reported that their health was good, very good or excellent (78.5%) and most thought that their health was the same as last year (75.8%). Only 20% did not report having a chronic disease, with nearly half reporting two or more chronic diseases (46%); high blood pressure and arthritis were the two most frequently reported diagnoses (46.7% and 44.5% respectively).
3.2 Internet use
Over half of all respondents had used a computer to access the Internet during the past 12 months (52.3%).
While Internet use decreased with increasing age, it was more likely among those who were employed, had completed tertiary studies and had a higher household income (Table 2). Sex was not associated with Internet use (Table 1).
| Chronic disease | Internet use | Internet use for health information | ||||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | P | n | % | P | |
| Angina | 450 | 11.2 | 160 | 36.4 | ≤.01 | 111 | 69.4 | .808 |
| Anxiety | 418 | 10.4 | 224 | 54.9 | .302 | 171 | 77.0 | .004 |
| Arthritis | 1796 | 44.5 | 824 | 46.8 | ≤.01 | 558 | 67.9 | .614 |
| Asthma | 646 | 16.1 | 329 | 53.5 | .581 | 228 | 69.5 | .658 |
| Diabetes | 574 | 14.3 | 246 | 43.5 | ≤.01 | 157 | 64.1 | .113 |
| Emphysema | 149 | 3.7 | 54 | 37.5 | ≤.01 | 35 | 66.0 | .694 |
| COPD | 97 | 2.4 | 37 | 39.4 | ≤.01 | 31 | 86.1 | .022 |
| High blood pressure | 1881 | 46.7 | 878 | 47.4 | ≤.01 | 602 | 69.0 | .664 |
| Sleep apnoea | 250 | 6.2 | 118 | 47.8 | .126 | 80 | 67.8 | .862 |
Respondents were more likely to use the Internet if they reported good, very good or excellent health and if their health was the same or better than last year (Table 1). Internet use deceased significantly as the number of co-morbidities increased (Table 1). A chronic disease diagnosis was significantly associated with less Internet use, except when a participant reported a diagnosis of anxiety, sleep apnoea or asthma (Table 1).
3.3 Internet user characteristics
Among the sub-group of respondents that used the Internet (n = 2092), most were long-term Internet users (68.5% reported using the Internet for more than five years) with high comfort levels (52.8% reported being quite or very comfortable with using the Internet). Most respondents accessed the Internet at home (83.3%) or in the workplace (30.9%). Most respondents had broadband access (84%) and reported spending between one and 5 hours online each week (49%). Internet Explorer was the most commonly used web browser (79%).
3.4 Internet use for health information
Over two-thirds of respondents, who reported using the Internet, had searched for health information (68.5%;n = 1426). Table 1 shows the proportion of health information seekers by demographic variables. Pearson's chi-square test of contingencies showed that people who had used the Internet to look for health information were significantly more likely to be younger, female, have completed tertiary education, and have a higher household income (Table 1). Current self-perceived overall health status, health status compared to last year and number of chronic diseases were not significantly associated with using the Internet to find health information (Table 1). The presence of specific chronic diseases did not affect respondents' use of the Internet to look for health information, with the exception of anxiety and COPD, both of which made this more likely (Table 2).
A logistic regression using six independent predictors was performed to predict use of the Internet to find health information. The predictors were sex, age, education level attained, household income, health rating and number of chronic diseases. A test of the full model distinguished between people online who search for health information and those who do not (χ2 (10, N = 2092) = 109.32, P = .000).The overall prediction success rate was 69.8%. The set of variables was also successful at identifying those respondents who had used the Internet to find health information (95.8%). According to the Wald criterion, the following variables made a significant contribution to the prediction: age category, 55-64 years (z = 13.15, P = .001); age category, 65-74 years (z = 12.99, P = .000); age category, 75 years and over (z = 6.43, P = .011); sex, female (z = 20.89, P = .000); education level attained, no school/primary school or some secondary school (z = 52.07, P = .000); education level attained, completed secondary school (z = 24.69, P = .000); education level attained, completed tertiary studies (z = 44.94, P = .000); very good or excellent health status (z = 7.447, P = .024); and income (z = 5.30, P = .021).
4 DISCUSSION
Our study demonstrates that older adults who are online are confident, long-term users who look for health information on the Internet. Perceived good health was associated with Internet use. Chronic disease diagnosis was associated with less Internet use for all diseases except anxiety, sleep apnoea and asthma. However, reported health status and chronic disease diagnosis did not negatively affect searching for health information amongst those who were online.
4.1 Internet use
Internet use was found to be slightly lower (52.3%) than the levels reported in other recent Australian studies: 62%12 and 68%.14 Our results suggest that younger respondents (55-64 years), with a tertiary education, a higher household income and a job were more likely to be online, which is consistent with findings from other studies.12-17 It is evident from these findings that a digital divide still exists when it comes to Internet use; therefore, caution should be shown when utilising this medium for health education delivery as it may serve to reproduce existing social divides.18 While other studies have reported that males are more likely to access the Internet, this was not replicated in our results.14, 19
There were high reported rates of broadband use (84%) among Internet users, which has previously been shown to predispose users to search for health information.20 This is likely to be due to the increased speed at which information can be viewed and the reduced cost of accessing information through broadband.
4.2 Internet use, health and chronic disease
Respondents who reported better health status were more likely to access the Internet than those who reported fair or poor health; this finding is in keeping with other research.17 It is unclear as to why this differential occurs, and further qualitative research is required to adequately address this question.
Eighty percent of respondents reported having at least one chronic disease, and 45.3% reported having between two and five chronic diseases. These rates are very similar to those reported elsewhere; 49.6% reported two or more co-morbidities.21 Internet use significantly decreased as the number of chronic diseases reported increased. Again, this is consistent with other research which found 81% of those without a chronic disease diagnosis were online compared to 62% of people who reported having a chronic disease22; suggesting that people with chronic disease are disproportionately offline.20, 22
It should be noted, that people who live in areas of low socioeconomic status are more likely to partake in risky health behaviours which lead to poorer chronic disease outcomes.23 Using the Internet to deliver health information about chronic diseases may not reach its target audience and may serve to reinforce existing social divides. Furthermore, qualitative research is needed to more fully understand the relationship between chronic illness, low socioeconomic status and Internet use. In the meantime, it may be more appropriate to utilise the Internet as a means of providing preventative, health promotion information, targeting younger, computer literate audiences.
4.3 Internet use for health information
Our study found that among respondents who used the Internet, 68.5% looked for health information This rate is considerably higher than rates found by other Australian studies conducted between 2006 and 2008 (16.2%-49%).14, 24 It is likely that this is due to people gaining Internet access over time. However, Internet use for health information (68.5%) was found to be similar to a recent, small study (64%).12 Like Internet use, rates of searching for health information decreased with increasing age; this is in accordance with other research.20, 25 Women were significantly more likely to search for health information than men, which again is consistent with other findings,14, 20, 26-28 but raises the question of how health practitioners can effectively use the Internet to target men.
The other social divides, high household income and tertiary education, that were seen to affect Internet use also affected use of the Internet to access health information; these results were again consistent with findings from other studies.20, 25, 27, 29 Again, caution is urged when using the Internet to deliver health information as it may reinforce existing social divides.18
4.4 Internet use for health information and chronic disease diagnosis
Self-perceived overall health status, health status compared to last year and number of chronic diseases did not affect the likelihood of a respondent using the Internet to access health information once they were online. Previous research findings are divided on the impact of health status on use of the Internet to find health information. Some studies have found that better self-reported health status or absence of chronic disease(s) equated to less online health information seeking14, 20, 30; other studies have found that health status has no impact16; and a third set of findings report that people with multiple chronic conditions are the most frequent users of the Internet for health information.31, 32 Our results show that the majority of older adults with Internet access look for health information online. This finding indicates that the Internet has the potential to support mainstream health services by providing online health information for older adults. However, in order for people to benefit from such information they need to have Internet access and computer skills as well as being both literate and e-literate.
Although the proportion of older adults online is expected to increase with time, it is worth noting that older adults may still have problems adopting new technologies.15 Furthermore, the physical changes experienced through ageing—including reduced visual and auditory acuity, declining motor skills and changes in cognitive processes can impact use of the Internet.15 These issues highlight the need for formative, user-centred, research when developing online resources for older adults to ensure that the target audience can effectively use the site.
This study had a number of strengths, including a large sampling frame and a high response rate. However, the low number of respondents that did not speak English at home was not representative of the population33; this anomaly can be attributed to the format of the tool – a lengthy survey in English. A further limitation was the use of self-report measures as answers can be subjective and some questions relied on participants' memories, which can be flawed, particularly in older age, affecting reliability.
There is currently a paucity of information around how and why Australians' use the Internet. While our results showed that the majority of respondents who used the Internet, looked for health information online, caution is urged when using this information as the numbers equated to just over one-third of respondents (35.6%; n = 1426). This highlights the need for additional, qualitative, research investigating the digital skills of older adults who are online and the reasons why a proportion of older Australians remain off-line. Furthermore, there is scope to investigate the type, function and frequency of health information searching across age groups, in order to understand the potential role of the Internet in providing health information and self-management support.
5 CONCLUSIONS
Although these results show that some older adults are online, these numbers are likely to increase as the population ages, due to exposure to computers in the workplace. It was found that those older Australians who were online often searched for health information. However, people with chronic diseases were more likely to be offline—with the exception of those with a diagnosis of asthma, anxiety and sleep apnoea. Therefore, the Internet may be best used to provide health promotion materials that will help to stall the development of chronic diseases. Furthermore, the provision of online health information has the potential to reinforce existing barriers created by the social demographic factors, and this impact needs to be carefully considered.
ACKNOWLEDGEMENTS
This project was funded by an Australian Research Council Linkage Grant (LP0990336), in partnership with Asthma Foundation New South Wales. The electoral roll data was supplied by the Australian Electoral Commission in conformity with sections 91(4 A)(e) and 91(2 A)(c) of the Commonwealth Electoral Act 1918 and regulation 10 of the Electoral and Referendum Regulations.
CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest in connection with this article.
