ABSTRACT
Virtually 100% of American teens have access to the Internet either at home, school, libraries, or elsewhere, and the majority are using it daily. The Internet has become one of the most important vehicles to educate and inform young people about health and medical issues. However, many teens have limited searching skills or problems with literacy and other issues that may make it difficult for them to locate and understand authoritative information. Parents, teachers, school nurses, health professionals, librarians, and Web designers who impact teenagers' health knowledge and skill development in information seeking, health decision making, and health literacy should be aware of the issues in dealing with this unique group and should also be familiar with quality health resources on the Web.
HEALTH LITERACY ISSUES
eHealth literacy has become an important issue in recent years, as it becomes clear that many health consumers are at the low end where “health literacy” is defined as the “degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”1 At the same time, there is an enormous amount of online health resources that are freely and widely available to most Americans, either through home computers or computers located at schools, universities, the workplace, libraries, and community centers.
Healthy People 2010 is a comprehensive set of health objectives for the nation that is continually being revised. It includes several sections on the importance of health literacy to individual patients as well as the impact on the health care system. The discussion on health disparities indicates that health illiteracy is associated with poor health, an incomplete understanding of health problems and treatment, and a greater risk of hospitalization. For instance, the inability to read or understand prescription labels or medical instructions can directly lead to patient safety risks.Citation2 The chapter on Educational and Community-Based Programs specifically refers to the National Health Education Standards (NHES)3 as the baseline for teen health education. One NHES standard specifies that young people should be able to find, understand, and use health information and services, specifically on the Internet. It is particularly important that teens, who are in the process of developing lifelong health behaviors and habits, understand and use information to make better health decisions and avoid health-risk behaviors. This effort to both reach and teach adolescents needs to involve their parents and teachers as primary instructors, but also needs to include health professionals as sources of medical expertise, and librarians as guides and organizers of authoritative online resources and a collaborative resource for parents, teachers, and health professionals.
ADOLESCENT HEALTH LITERACY
From early childhood, parents and teachers are the primary sources for health information for most children and teens. Health professionals come in a distant third. However, since a number of parents themselves have only basic or below basic health literacy skills (an estimated 36% of all adults on a national survey), it would be difficult for them to instruct their children about health matters. In addition, the health of their own children might be impaired by parents who cannot understand, for example, vaccination instructions, newborn screening information, or asthma management programs. Yet it is clear that most medical information is still written far above the reading level of many poor, elderly, or disadvantaged minorities.Citation4 In addition, there is still a “digital divide” in terms of low income people having little or no access to the Internet and possibly lacking the skills for computer use.Citation5
Many adolescents are also deficient in their reading skills. According to the Alliance for Excellent Education, one-third of eighth graders do not read at a proficient level.Citation6 Illiteracy in reading has a significant influence on students' understanding of health information.Citation7 Despite teens' demonstrated familiarity with the Internet and computer usage in general, this literacy deficit can greatly impede their understanding of the resources they locate online. According to Norman, the essential skills for consumer health literacy are traditional literacy and numeracy (reading skills and understanding mathematical functions), media literacy (understanding media bias, perspective, or meaning), information literacy (ability to see connections between information from various sources, familiarity with libraries and library resources, ability to frame search questions effectively), computer literacy (using computers), science literacy (understanding of scientific knowledge, terminology, and the scientific method), and health literacy (understanding basic health terms, ability to follow medical instructions).Citation8 Modern teens generally excel in computer literacy (using computers) but may be deficient in several of these other areas. These are the knowledge and skills areas that can be affected by teachers, librarians, and health professionals.
Adolescents' needs differ from adults in that adolescents are generally healthier as far as disease risks overall but undergoing a time of great change in their lives due to their physical, emotional, and intellectual growth. Modern teens are probably no different than teens in preceding generations; however, the information that is available to them has greatly expanded, both for good and ill. Topics that consistently appear as the most requested subjects asked by teens on health Web sites include sex and sexuality, interpersonal relations, body issues, growth and development, diet and nutrition, exercise and fitness, substance abuse, and violence.9–15
Teens are comfortable on the Internet and use all of the social networking and interactive functions that are available, such as blogs, chat groups, MySpace, Facebook, and more. They use them for a variety of reasons, for instance, social and emotional support, relationship creation and maintenance, entertainment, help seeking, and information seeking.16–20 They can create their own virtual world without interference or supervision by adults. They can also investigate topics they consider embarrassing or that might arouse their parents' suspicions. However, in the wide-open Internet virtual world, teens are likely to come across poor quality health information, misinformation, pornography, sexual predators in chat rooms, and sites promoting anorexia, bulimia, self-cutting, and illegal drug use.21–25 Teens can even create their own methods of gathering and disseminating illegal information.Citation26
Since teens seem to easily take advantage of the best features of the Internet, for example, interactivity, customization, and multimedia formats, it would follow that authoritative health information providers would utilize these current methods to appeal to teens. Teenagers prefer gender-specific pages, and younger and older adolescents often have different interests. However, most teens enjoy games, quizzes, and interactive and personalized health check tools. These formats could be easily adapted to incorporate health information. Advantages would include more choices, access to personalized health information, information and services on demand, improved ability to disseminate information and update it quickly, and the ability to offer timely expert decision support.
Even if the health information on the Web is accurate, current, valid, appropriate, intelligible, and free of bias, if it cannot be found by searchers, then it is not doing much good. Several studies have been done on analyzing the searching skills displayed by adolescents looking for health information. The general consensus is that the majority (over 80%) use search engines (mostly Google and Yahoo), they select Web sites from within the first 10 hits and rarely go past the first page of results, and do not examine the pages they select very closely but go back to the search engine results if nothing appeared immediately. At times, the answers were within the sites they selected but were not apparent on the very first page, so were not found. Searchers often used only one word, such as HIV, to search Google with the resultant millions of hits, or they used the opposite and equally unsuccessful tactic of typing in too many words. Misspellings were common and were a major reason for not locating information. Many times the authors, sponsorship, authority, objectivity, or currency of the site were not checked. Eventually though, all the users came up with an answer.Citation27 Teens searching for a specific disease or condition fared somewhat better. It should also be remembered that teens who have or have had a chronic or life-threatening disease, such as diabetes, asthma, and cancer, often display a good understanding of their disease and are particularly interested in finding information, not only medical information but also access to medical expertise, social and emotional support groups, and other interactive forums.Citation28 29
REACHING AND TEACHING ADOLESCENTS
A scan of the current literature indicates that teenagers have unique needs regarding health information, and a very accepting attitude toward innovative and interactive methods to access health information. However, there is much work to do incorporating these research findings into practice. For instance, only recently have quick and easy teen-level health literacy assessment tools been developed.30–33 Using these tools could be a starting point toward understanding the health literacy of the targeted teen population, for health professionals, teachers, librarians, medical writers, and Web designers and content developers. Developing and promoting reliable sites such as MedlinePlus that are informative and easy to use is another area where librarians and consumer health educators, in particular, can have a great impact (see Appendix).34–36 However, it is clear that K-12 teachers are the ones who spend the most time with children and teens instructing them about health issues and seem to be the best conduits for health education.
ONLINE HEALTH INFORMATION IN K-12 EDUCATION
Besides parents, teachers are primary health instructors of most children and adolescents. In most states, the National Health Education Standards3 is used as the basis on which to establish state health education curriculum standards. However, within the broad area of “health education,” there seems to be several categories of teachers who cover health topics, which can make it difficult to target who teaches what subject. For instance, there are science teachers who cover life sciences, and in upper grades, specialize in biology, anatomy, and so forth. There are health education teachers who are often physical education instructors, and there are instructors in family and consumer sciences, which in Indiana covers nutrition, wellness, and child development.Citation37 In order to work with teachers effectively, librarians and consumer health specialists need to understand the methods by which health topics are taught in schools because interacting with teachers and keeping them current about reliable heath resources for their students is an important way to reach adolescents.
CONNECTING WITH SCIENCE TEACHERS
The medical librarians at the Indiana University School of Medicine (IUSM) have promoted the National Library of Medicine's (NLM) MedlinePlus and Indiana Go Local resources to various audiences throughout Indiana. It was apparent that one way to reach children and adolescents would be through the schools. School librarians/media specialists provide supplemental materials for enhancing classroom instruction, and the IUSM librarians felt that the approach to high school teachers should be through this channel. A presentation was made at the annual conference of the school media specialists, but the attendance was very poor and subsequently alternatives to this approach were considered. IUSM librarians arranged to exhibit and demonstrate the NLM consumer health online resources to science teachers. At the same time, a questionnaire was developed to query teachers about their knowledge and use of online health resources and their interaction with librarians. The Hoosier Association of Science Teachers (HASTI) meeting was identified as an ideal opportunity. The annual conference is the largest gathering of K-12 science teachers in Indiana, drawing approximately 2,000 science teachers covering all areas of science. Through an Exhibit Award from the National Library of Medicine's Greater Midwest Region (NLM/GMR), a demonstration station and display was created for the meeting. In addition, a short informal questionnaire was designed to survey teachers.
There were several objectives when designing the survey. Questions included the kinds of resources teachers use to supplement learning in the classroom aside from the required school texts. Additional questions included how much interaction occurs between teachers and their school media specialists, and if school media specialists and school media centers are a resource that teachers use. Another goal was to ascertain the teachers' level of familiarity with National Library of Medicine (NLM) resources, such as MedlinePlus <http://medlineplus.gov/>, as well as introducing those unfamiliar with NLM to other online resources for use in their classroom. Since the focus was on teachers and children using health resources at school, teachers were queried about whether Internet filters hindered access to online resources, since many schools use these filters to block objectionable content.
Survey Methodology
The goal was for a short survey that could be filled out in less than five minutes as teachers visited the exhibit booth. The number of questions was kept to ten to make sure they would fit on one sheet of paper and be easily and quickly answered. This meant revisiting the original objectives to make sure the questions were relevant and provided useful answers. The survey was pilot tested beforehand with several educators.
Initial questions concerned demographics (“What is the size of your school?”); some questions used a Likert Scale (“I actively help/assist students evaluate Web sites for authority, relevance, and currency”); some were multiple choice questions (“Where do your students find resources for doing reports or research?”); and some were free-form questions (“What online sources do you use for personal health information and classroom health information use?”). Other questions were checkbox choices that could be filled out quickly. Since only one laptop computer was available at the exhibit, paper surveys were used instead of an online form. To summarize the results, the survey was recreated online using SurveyMonkey <http://www.surveymonkey.com/>, and all of the responses were entered into the SurveyMonkey version of the survey for data analysis.
Survey Findings
For the different sizes of schools (n = 70), 10 teachers were at elementary schools, 13 were at middle schools, and 52 were at high schools. Some teachers taught at more than one school.
Students utilize different resources for writing reports and doing research, with varying degrees of usage. Google and other search engines were the resources used most often by students for doing reports (87%). After search engines, the most popular resources were textbooks/class handouts (81%), library online databases (70%), books from the school library (56%), and other resources in the classroom besides textbooks (49%) (see Table ). Whether via Google, another search engine, or library online databases, students are actively using online resources for their assignments.
TABLE 1. Resources Used by Students for Writing Reports or Doing Research
Generally, more than half of the teachers agreed that is it easy for students to find authoritative and credible science and medicine resources online (58%). However, about one-fifth disagreed about students being easily able to find credible resources (18%), and one-fourth were neutral (23%). This indicates that a number of teachers feel that credible resources on health may be a problem for many students.
Teachers were asked about their collaboration with media specialists working on health topics. Those teachers (56%) who always or often looked for ways to collaborate with their school media specialist utilized library services in the following ways:
their students use the library books and online resources (90%); | |||||
they teach in the library with the school media specialist (40%); | |||||
they teach research skills one-on-one with the school media specialist (37%). | |||||
For those who responded that they “always” collaborated with their school media specialist (n = 10), they “sometimes” or “never” had trouble finding authoritative/credible online resources for class. Although a small set, they recognized the benefit of having a school media specialist.
Teachers listed several different science and medicine Web sites for personal and instructional use. The HASTI exhibit highlighted different Web sites from the National Institutes of Health (NIH) and National Library of Medicine (NLM); however, teachers took the survey before they viewed the exhibit. More than half (52%) of the teachers listed their favorite information resources as the following Web sites: WebMD (47%), Centers for Disease Control (CDC) (14%), MEDLINE (11%), MedlinePlus (11%), NIH (11%), and Mayo Clinic (6%). Since MEDLINE, MedlinePlus, and NIH Web sites are all from the NIH, these sites' combined percentages totaled 33%. It is apparent that the heavily advertised (both on television and online) WebMD has an edge over the government Web sites in regard to familiarity.
Internet filtering can have a big impact on the ease of finding health information online. Of the teachers surveyed for this report, a majority (83%) felt that the school Internet filters interfered with their students' access to health topics. However, many teachers had created alternatives (workarounds) when students did have problems with filters. Of the 73% of teachers who had established alternatives for filtering problems, most directed their students to use their home computer, use the public library's computers, or switch their topic. It seems that it is still problematic for students to use general search engines to research health and medical topics.
The teachers who were surveyed appeared to already be working with students in four of the six areas of literacy (traditional literacy and numeracy, media literacy, computer literacy, and science literacy). However, in the areas of information literacy and health literacy, many teachers expressed a need for assistance or guidance, mainly because of time constraints. There is a need to provide guidelines and assistance for helping teachers address the problem of being unable to access and keep current with authoritative medical and health related information. One solution may be to add reliable Web sites, such as MedlinePlus, to the school library's list of acceptable online resources. One of the authors of this article conducted a project in 2005 to demonstrate MedlinePlus to school media specialists at 25 Indianapolis-area high schools. Since meeting with the school media specialists, many of the Indianapolis Public Schools (IPS) high schools worked with their information technology departments to include MedlinePlus as a reliable link through each library's Web site. In this example, the collaboration between medical librarians and teachers was highly effective in reducing technical barriers to authoritative health information.
RECOMMENDATIONS
Teachers have a number of ways to improve their own health literacy and knowledge of reliable resources and enhance their teaching efforts, both on their own and with the assistance of librarians.38–43 In schools, teachers, school nurses, and librarians, along with other health professionals, can seek to collaborate not only on health education but also on the health of the adolescents themselves.Citation44 Current teens are, after all, the first generation of “digital natives” to grow up in a Web-connected world. Like all adolescents, at this time of their lives they are forming their lifelong health habits and beliefs, their health decision-making and searching skills, and their risk-avoidance behaviors. Besides teachers and parents, it is also necessary for health professionals and librarians working in the health fields and/or health literacy area to see that the influence of the Internet and online health resources on this generation is a beneficial one.
The HASTI exhibit is funded by the National Library of Medicine <http://www.nlm.nih.gov> under contract NO1-LM-6-35003 with the University of Illinois at Chicago Library of the Health Sciences <http://www.uic.edu/depts./lib/lhsc/>.
Additional information
Notes on contributors
Elaine N. Skopelja
Elaine Noonan Skopelja, MALS, AHIP ([email protected]) is Liaison CoordinatorElizabeth C. Whipple
Beth Whipple, MLS ([email protected]) is Research InformationistPeggy Richwine
Peggy Richwine, MS, MLS, AHIP ([email protected]) is Outreach Services CoordinatorRelated Research Data
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APPENDIX
RECOMMENDED WEB SITES FOR ADOLESCENT HEALTH EDUCATION
Teachers
KidsHealth in the Classroom Available: <http://classroom.kidshealth.org/>. Accessed: November 30, 2007.
Resources for Science Teachers (High School) Available: <http://sis.nlm.nih.gov/enviro/resources_science_teachers.pdf>. Accessed: November 30, 2007.
Teens
Consumer Health for Kids and Teens Available: <http://nnlm.gov/outreach/consumer/chforkids.html>. Accessed: November 30, 2007.
Kids.gov: Health, Fitness & Safety (Grades 6–8) Available: <http://kids.gov/6_8/6_8_health_issues.shtml>. Accessed: November 30, 2007.
MedlinePlus: Children and Teenagers Topics Available: <http://www.nlm.nih.gov/medlineplus/childrenandteenagers.html>. Accessed: November 30, 2007.
Teens Only: DrGreene Available: <http://www.drgreene.org/body.cfm?id=54&requesttimeout=60&action=list>. Accessed: November 30, 2007.
TeensHealth: Teen Pages Available: <http://www.kidshealth.org/teen/>. Accessed: November 30, 2007.
Top Consumer Health Sites
Medical Library Association Top Ten Most Useful Web sites Available: <http://mlanet.org/resources/medspeak/topten.html>. Accessed: November 30, 2007.