How Do Adolescents Access Health Information? And Do They Ask Their Physicians?

How Do Adolescents Access Health Information? And Do They Ask Their Physicians?

 

George Ettel, III; Ian Nathanson, MD; Donna Ettel, PhD; Christine Wilson, PhD, ARNP; Paul Meola

Winter 2012 - Volume 16 Number 1

https://doi.org/10.7812/TPP/11-125

Abstract

Objective: To improve understanding about how high school students use electronic tools to obtain health information and how this information affects their behavior.
Design/Methods: Using a cross-sectional design, we administered an anonymous survey to high school students in grades 9 through 12 at a single private Catholic high school, inquiring about their use of electronic tools to obtain health information, topics of interest, sources used to obtain information, and modifications in their behavior based on that information. Descriptive statistics and multivariate analysis of variance were used to compare trends across grade levels.
Results: Of 705 students enrolled, 24.7% were either absent or chose not to participate in the survey. Of the remaining 531 students, 497 completed the surveys, for a response rate of 70.5% (497 of 705) and a participation rate of 93.6% (497 of 531). All students were comfortable using the Internet, and >90% used it at home and in school. Access to broadband applications averaged 95% at home and 80% at school. A significant proportion (0.66; p < 0.0001) of students reported that they trusted the information found online, and 22% (not significant) modified their behavior on the basis of the information they found. Forty-two percent searched for general health information, and 43% investigated specific medical conditions or disease states. Topics related to skin were researched significantly more than nutrition, birth control, and sexually transmitted diseases. Although a significant number of students (p < 0.05) reported conducting Email conversations related to health topics with their teachers, <5% had Email communications with physicians.
Conclusions: These data indicate that most high school students used the Internet and broadband applications at school and at home as resources for health care information. A significant number of students trusted the online information, and at nearly one-quarter subsequently modified their behavior. Students conducted Email conversations with teachers about health-related topics, but few students used this tool to communicate with their physicians. This information raises questions about design and implementation of strategies to provide adolescents access to appropriate health care information, including that provided by physicians.

Introduction

Adolescents seeking health information have available to them multiple sources, including physicians, families, schools, organized activities outside of school, the "street," and the Internet. As a result, adolescents may struggle to decide which sources provide them with information that is understandable and useful, particularly related to potentially risky health behaviors such as smoking, sexual behavior, drug use, and physical inactivity.

Evidence shows that the Internet serves as a major, if not primary, source of information for health-related issues for adolescents.1 It provides gateways and links to sources for information about effective preventive services and health care,2,3 and it can serve as a tool for an electronic support group.4 However, that adolescents find such information online does not ensure that they will practice healthy habits. For example, adolescents undergoing specific Internet-based interventions for weight loss or depression appeared to respond to treatment better than those using Internet-based health education alone, although the improvements appeared to decrease over time.5-8

Given the seeming prevalence of electronic communication among adolescents, it is safe to assume that they could find the means to obtain information using virtual sources or by direct electronic communication with others.

Physicians would seem to be a rich source of primary or secondary health information for teenagers, but adolescents do not appear to communicate much with physicians. One report showed that a majority of adolescents (70.9%) acknowledged 1 or more of 8 potential health risks, but relatively few (37%) actually talked with their physician about these.9 A survey of physicians practicing in Florida showed that only 14.4% to 20.4% of clinicians for children (general pediatricians, pediatric subspecialists, and family physicians) use Email to communicate with their patients.10 Although physicians recognize that an electronic medical record is an important tool that can integrate data about growth, development, patient safety, and changes in physiology and diseases,11,12 a variety of barriers preclude widespread use of such applications.13

We were interested in learning how and where high school students obtained health care information, the degree of trust they had regarding the health information found online, and how online health information influenced their behavior. We were also interested in learning what role their physicians had in their search for health care information. To study this, we developed a survey for high school students inquiring about their use of electronic communication tools to find health information.

Methods

We used a cross-sectional design to conduct an anonymous survey related to how students obtain health information using electronic tools. Initially, homeroom teachers hand-delivered a letter describing the purpose of the study and a questionnaire tracked by a 6-digit identifying code to students in grades 9 through 12 at a high school in the southeastern US. After collecting the questionnaires, we noted that numerous surveys had handwritten comments that we subsequently analyzed. Finally, a follow-up survey was administered to students enrolled in the medical program to further clarify the specific Web sites used.

According to school records, the school population consisted of 705 students (50.9% males) with a racial makeup that was 89.8% white and 4.1% black. The majority of students (88.1%) were Catholic, and 18.9% were from single-parent families. On the day the survey was distributed, 174 (24.7%) students either were absent or declined to participate, and no further information is available about this group. Of the remaining students, 497 of 531 (93.6%) completed the survey in about 30 minutes in the homeroom setting. Incomplete questionnaires were not included in the data analysis.
Students answered 32 questions that surveyed their 1) use of the Internet at home and at school, 2) access to broadband applications at home and at school, 3) comfort/ease with navigating the Internet, 4) ability to search for general health information and other topics related to specific medical conditions or diagnoses, 5) Email communication with physicians, and 6) behavior changes related to information obtained.

Statistical Analysis

Data were double-entered by separate researchers to ensure accuracy. Initially a multivariate analysis of variance was conducted to compare the four grade levels of students. For statistically significant findings, univariate analysis of variance was conducted for each of the survey items. The dependent variables were the students' knowledge and use of computers, the Internet, broadband applications, physician Email communication, and types of health information researched. All analyses were computed using SAS software (version 8.0; IBM, Cary, NC, USA), and significance was considered to be at the level of p < 0.05.

The Educational Pastoral Team, which reports to the school board of the diocese, approved this study.

Results

The response rate for this survey was 71%, with 497 of 705 surveys returned, and the participation rate was 93.6%. Of the completed surveys, 19.7% were from freshmen, 45.7% from sophomores, 16.1% from juniors, and 18.5% from seniors. On a five-point scale from poor to excellent, 66% of students rated their health status as very good to excellent. The remainder rated their health as good to fair, and no students considered their health to be poor.

All students reported that they were comfortable navigating the Internet. As shown in Figure 1, the overwhelming majority of students reported that they had ready access to the Internet and broadband applications both at home and at school. On average, a significant proportion of students (0.66) reported that they trust online information (p < 0.0001), and 22% (not significant) acknowledged that they changed their behavior on the basis of information found on the Internet. Forty-two percent of students used the Internet to search for general information related to health care. In addition, 43% reported searching for specific topics. Table 1 summarizes the proportion of students in each grade who searched the Web for specific health-related information and/or information about specific disease states. Students searched topics related to skin significantly more frequently than other topics (p < 0.05). Freshmen and seniors were more likely than sophomores and juniors to investigate this topic. Students reported researching sites related to wellness (activity and nutrition) and to sexuality (birth control and sexually transmitted diseases), although the percentage engaging in this activity was not statistically significant; fewer students searched for information about injuries.

More than 70% of students knew that physicians kept records about their health during visits, and 28% reported that their physicians used an electronic tool (computer or personal digital assistant) to record information at the time of the visit. The survey asked students if they Emailed their physicians. As shown in Figure 2, <5% of students engaged in Email correspondence with their physicians (not significant). In contrast, 38% of students conducted Email conversations related to health issues with their teachers (p < 0.001).

How Do Adolescents Access Health Information? And Do They Ask Their Physicians?

How Do Adolescents Access Health Information? And Do They Ask Their Physicians?

Discussion

Our results showed that a majority of high school students in grades 9 through 12 at a single school use the Internet both at home and at school (Figure 1), and they also use Email regularly. These findings are consistent with reports about other adolescents.14

Nearly half the students used the Internet to search for information related to specific health issues. As shown in Table 1, students sought information related to skin significantly more frequently than other topics. It is noteworthy that a substantial proportion of students sought information about birth control and sexually transmitted diseases. The reasons for this are not clear, but abstinence is the only method of birth control taught in this school as being acceptable. The most popular topics are similar to those reported by Borzekowski and Rickert, who also reported that sophomore students at a public high school in New York sought information from a range of other sources, such as books, clergy, friends and family, and clinics.15 Although the trend did not reach statistical significance, 22% of students reported modifying their behavior on the basis of their findings in online searches. It is unknown what the outcome of these changes in behavior were or whether they were sustained.

A significant number of students in this study trusted information found on the Internet, similar to what was found by previous studies.15 Although adolescents use the Internet as a source of information for health-related issues,1 questions remain about their ability to conduct thorough searches. Hansen et al reported that 69% of students could find a correct and useful answer to a health question but used trial-and-error approaches to find sites and did not necessarily consider the source of the content when searching.16 Similarly, Gray et al reported that adolescents had deficiencies in their health literacy skills.17 Richardson et al reported that as applications designed to block access to pornographic sites become more restrictive, they disproportionately block access to health information sites.17 This may not interfere with access to health sites if the pornography blocking is not restrictive, but as the degree of restriction increases, the number of health information sites blocked increases substantially, particularly sites related to sexuality. Therefore, limited sophistication in using search strings coupled with restrictive blocking applications could seriously impair students' access to accurate information that addresses their needs.

Given that adolescents use Email routinely for private and group communication, we asked them if they used this method to communicate with their physicians. Less than 5% of students, regardless of grade level, reported communicating by Email with their physicians. The reasons for this are unclear, but it does not appear to be because of trepidation, because a significant proportion of students regularly Email their teachers about health-related issues (Figure 2). This raises important questions about access to physicians for health information. In Sweden, people communicated electronically with family physicians using an Ask the Doctor Service. The service appeared to be generally well received, and questions often focused on previously diagnosed conditions.19 In the US, a variety of barriers to electronic communication between patients and physicians have been reported, including training, knowledge, confidentiality concerns, and attitudes of physicians.13 In Florida, pediatricians appear to lag behind their colleagues in the adoption of electronic tools, and less than one-fifth of clinicians of health care to children in Florida have Email conversations with their patients or parents.10

These data clearly show that physicians appear to be an underused source of vital information that affects children in critical stages of their lives. Thus, these findings raise questions about how to ensure that adolescents have access to health information that is accurate, understandable, and culturally sensitive. Ideally, a connected system of reliable and accurate electronic health care information would be valuable when addressing issues of health care quality, safety, education, and efficiency for adolescents.20,21 If physicians are to assume a major role in such a system by providing essential health information to adolescents, not only must they overcome their own deficiencies related to electronic technology but also, health care systems and payers must address issues of timeliness of informational exchanges, protection of conversations, parental involvement, and reimbursement.

This study has several limitations. We studied students from a single religion-affiliated high school whose students do not necessarily reflect the population at large. For this reason we are reluctant to imply that our findings are generalizable. However, one reason for selecting this particular school was to attempt to find the "best-case scenario" where participating students likely had ready access to the Internet, attended a school that limited teaching of certain subjects, and knew who their personal physician was. We did learn that these students clearly had ready access to virtual sites and the means to communicate electronically. We also learned that the school limited its teaching of birth control to abstinence. Because the survey was anonymous, we could not identify individual students or their personal physicians. Therefore, we do not know the willingness of the clinicians of these students to communicate by Email, but physicians practicing in this geographic region were included in the survey of Florida physicians.10

How Do Adolescents Access Health Information? And Do They Ask Their Physicians?

Conclusion

Adolescents have ready access to the Internet at home and at school and are comfortable using this tool to search for health information. They trust the information they find and tend to modify their behavior on the basis of that information. The real difficulty with obtaining health information from the Internet is that there are limited ways to determine whether the information is coming from a legitimate source or instead from an uninformed person with basic knowledge about building a Web site. "Researching" on the Internet by students often includes sites such as Wikipedia, an online encyclopedia that everyone is allowed to edit. It is unreasonable to expect adolescents to delve into peer-reviewed medical literature. Similarly, it is unreasonable for busy physicians to make themselves available whenever an adolescent has a question. We contend that it would be more effective if students and their physicians communicated asynchronously to enable students to find trustworthy information either directly from the physician or at physician-approved Web sites. For such communication to be successful, physicians must overcome several obstacles, including liability, billing, and ensuring that online conversations lead to the correct diagnosis and care plan.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgment

Katharine O'Moore-Klopf, ELS, of KOK Edit provided editorial assistance.

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