Surveys were distributed at the beginning and end of the five-week training session. The surveys were designed to capture baseline information about the participants, their experience using computers, and experience searching the Internet. To measure anxiety, the Computer Anxiety Subscale of the Computer Attitude Scale₃₈,₃₉, along with Busch's₄₀ computer efficacy scale were administered. The rationale for using these measures was to determine if levels of anxiety toward computers and feelings of self efficacy influenced participants use of the Internet to locate health related information. It was hoped that training older adults to use the Internet to find medical information would lower levels of anxiety, while increasing levels of efficacy and the desire to participate in one's health care.

In the fourth week of the seminar, a short questionnaire was administered which measured the frequency rate at which participants used the Internet outside of class to search for medical information.

A final questionnaire was sent to participants forty five days from the conclusion of the seminar. Each participant was asked to record how often they had used the Internet to locate health information and whether the seminar changed the role they played in their own health care.

A stratified sample was used to interview eight people at the conclusion of the training. These subjects were chosen due to the variation in their behavior during the training, i.e., some people had more trouble than others in learning the computer in general, others were comfortable with the computer, and others were inquisitive about how they could use the Internet to help them manage their own care. Questions were tailored to elicit as much information as possible regarding the outcome and satisfaction of the Internet training the subjects received. These included questions such as, “Before the seminar, what were your feelings toward the Internet”, “What are the barriers you have experienced in using the computer”, and “How do you think you can use the Internet to manage your health care?” Each interview was tape recorded and lasted approximately one hour.

Four surveys were completed by participants during this case study. A pre and post survey asking participants about their attitudes toward computers and Internet use was used at the beginning and end of the five week seminar. An Internet usage survey was completed at the beginning of the fourth week, and a final survey was sent out to participants forty-five days after they completed the seminar. Results from each questionnaire are discussed below.

These surveys were used to measure participants levels of anxiety toward computers and their levels of efficacy in terms of using a computer to locate medical information found on the Internet (N=28). The Computer Anxiety Subscale of the Computer Attitude Scale³⁸,³⁹ was used to measure participants level of anxiety. Busch's⁴⁰ computer efficacy scale was used to measure a person's efficacy when using a computer to perform certain tasks, such as using the Internet to locate health information.

Comparison of group pre and post scores indicated that instructing elderly adults how to use computers to find medical information lead to a reduction in anxiety levels and increased feelings of efficacy. See Table 1

Figure 1

Table 1: Computer Anxiety Scale

Participants feelings in their ability to find information on the Internet, rose from 59% to 80%. When it came to their confidence in finding information about their own health, the feeling of being confident rose from 51% to 69%. Finally, when asked about their confidence in using the Internet to manage their personal health care, the feeling of being confident rose from 29%-46%.

Figure 2

Table 2: Levels of Efficacy in Finding Internet Information

In addition to anxiety and efficacy levels, the pre and post questionnaires elicited information regarding participants' feelings toward using the Internet as a tool for locating health care information. At the conclusion of the seminar, 100% of the participants indicated they felt the Internet could be used to manage their health care, an increase of 25% from the pre-questionnaire. On the post questionnaire, 81% percent responded that they would be more comfortable taking a collaborative role in their health care. However, 48% indicated that they would use the Internet to manage their health care, while 44% stated that they did not know.

This survey was used to gather information regarding participants (N=28) use of the Internet to search for medical information outside of the seminar. Overall, 66% used the Internet to locate medical information an average of 2-3 times since the start of the seminar. Of that 66%, 56% had computers in their homes. The other 43% made use of computers located in a public library. It is important to note that individuals with computers at home used the Internet 3-4 more times than the other 43% to locate health related information. Of the 34% who did not use the computer outside of class, only two individuals had computers in their homes. Thus, whether an individual had a computer at home determined how often they used the Internet to find health related information.

Figure 3

Table 3: Internet Usage

This survey was completed by the participants (N=26) forty five days after completing the Internet seminar. Results showed that during that time, 58% (N=15) had used the Internet to look up health related information. Many of the participants used the Internet to look up information on topics as broad ranging as: colitis, thyroid, mental illness, drug information, prevention, hearing aids, cancer treatment, clinical trials, vitamins and heart conditions. Sixty-five percent of the participants reported having been to a health care professional since taking part in the Internet seminar. From that 65%, 59% engaged in activities that can be interpreted as having a more participatory or active role in their own health care. Participatory, defined as the elderly adult using the Internet to seek more information regarding their health problem, to discover alternative treatments, or to locate information to generate questions that were directed to their primary care physician. For example, one participant described how her use of the Internet made her more confident in asking questions of her health care provider. These questions ultimately lead to a change in her prescription drug medication. Another participant reported that he now takes more questions to his doctor based on the information found on the Internet.

Figure 4

Table 4: Final Survey

The primary reason for not engaging in participatory actitivities was access to a computer. For instance, one participant developed a balance problem along with a gastrointestinal disorder. Because he did not own a computer, his illness inhibited him from driving to the public library to research his problem. Two other participants, (a husband and wife team) developed health problems concurrently. The husband was already suffering from the effects of a stroke and was dependent on his wife to go to the library. When the wife broke her leg, both became house bound and where unable to reach the library to use the Internet to research their problems.

Interestingly, just because an elderly adult is confined to their home without Internet access, does not mean that they cannot get to medical information found on the Internet. One enterprising participant who was suffering from a severe bout of colitis sent an emissary to the library to locate information for her. This example speaks to the growing determination of many elderly to use the Internet to locate health information.

Each interview was transcribed by the author. To evaluate the interviews, transcripts of each interview was read and evaluated by three separate readers. From the evaluation process a codebook was developed which classified participant responses into twelve areas. These were then broken down into five specific themes. Those themes included: digital disparity, barriers, health beliefs, enticers and future potential.

This theme was characterized by the incongruity among participant emotions and feelings toward the computer and the Internet. Participant responses were overwhelmingly positive, but qualified by negative comments, “Yes, I enjoy using the computer about three times a day. However, if you are on the computer you cannot call anybody to ask for help. Because our phone is the only one—we only have one line coming in.” Only one participant stated that they did not enjoy using the computer, because it was “a great time waster.” This sentiment was echoed by another participant who although they liked using the computer, felt that one of the things that they “resented” was the amount of time it takes from doing other activities. The participant described how she could sit down at the computer at 1:00 o' clock and before long it was 3:00 o' clock, and she would feel that she got nothing accomplished.

This theme was characterized by responses that referred to any physical or cognitive obstacle which prevented or hindered the participant's ability or desire to learn the computer and the Internet to locate health information. Overall, a majority of the respondents felt they lacked the “technical skills” to use a computer, while a quarter of them felt that various technical problems, “you have to watch what key you hit . . .I hit the control key and it kind of frooze everything,” prevented them from using the computer optimally, and another others felt that they lacked adequate software skills, “I am always making little errors—like www. and then maybe I will have one letter too much or have the wrong colon.” Participants also cited lack of time, lack of resources, and certain cognitive skills (memory and organization) as significant barriers. “Fear. . . .Primarily, as I mentioned before—eh—fear that I couldn't absorb the information and it was beyond my comprehension . . .”

Half of the participants stated that prior to taking the seminar, they did not know what kind of information was available on the Internet, while the remaining participants cited fear, desocialization, anomie, and questions regarding authenticity of information as their primary emotions regarding Internet use

This theme refers to the participant's belief about the control they have over their health care. Participant health care beliefs could lie somewhere between an internal and external locus of control. For example, a participant with a paternalistic Primary Care Provider (PCP), in most cases, had an external locus of control, where they were willing to give complete control of their health care to some external source. Interview data suggest that patient/physician relationships varied widely, including patients who question their doctors, but ultimately follow their doctors' directions; and patients who react to their doctors' decisions by going online and investigating diagnoses, conditions and treatments. Two other types of relationships encountered identified patients who would only deal with physicians who agreed with their beliefs, “I try to choose doctors that I know agree with me”, and patients who had physicians receptive to a more open, participatory relationship.

When asked how their relationship with their primary care provider might change after being exposed to the Internet, most of the respondents believed that their behavior would change because they would be more willing to look up information before making a decision about their health care, “now when I am going to the doctor . . . I am going to research why I am seeing him in the first place.” Furthermore, participants believed that use of the Internet to find health related information allowed them to ask their physician more intelligent questions, therefore, putting them on a higher level of understanding in terms of their illness and the ramifications associated with different treatment options. This, participants believed, would allow them to have a “more detailed important discussion with their physician.”

This theme is typified by the Internet sites that participants experienced as interesting and useful. Participants expressed interest in further exploring the Internet as an information tool, “it's amazing how much information is available if you have the know how.”

Overall, the participants enjoyed using the computer and the Internet to stay in touch with other people, perform research, and use as a tool to look up news items or medical information. For non-health related topics, participants used various Internet sources to locate information on theater tickets, legal information, investment research, genealogy and recipes.

Participants discussed how they planned on using the Internet to manage their health care in the near future. Overall, participants felt the Internet was a good resource because it provided them with alternatives for their health care, enabled them to critique the qualifications of their provider, obtain important and factual information, and use as a source for quick up-dates to information on a health related topic. One participant went as far as to describe the sources available on the Internet as today's 800 numbers:

I think of web sites as the new 800 numbers. Before the Internet was big you would call an 800 number to get information about a disease or organization. Now everybody, every organization and disease has a web site that you can get the homepage and you see the linkage—you know you can go through the links and see what is available that way.

All of the participants responded that they would use the Internet to find information on physicians, health conditions, complications, treatments and medications. As a corollary, participants felt that the Internet provided them with the means to become a better, more informed patient who could ask their provider better questions. And asking better questions, they believed, would lead to better health outcomes.