Original Paper
Analysis of eHealth Search Perspectives Among Female College Students in the Health Professions Using Q Methodology
Michael Stellefson1, PhD; Bruce Hanik2, PhD; J. Don Chaney1, PhD; Bethany Tennant1
1Center for Digital Health and Wellness, Department of Health Education and Behavior, University of Florida, Gainesville, FL, United States
2Office of Health Informatics, Department of Health and Kinesiology, Texas A&M University, College Station, TX, United States
Michael Stellefson, PhD
Center for Digital Health and Wellness
Department of Health Education and Behavior
University of Florida
P.O. Box 118210
Gainesville, FL, 32611
United States
Phone: 1 352 294 1805
Fax: 1 352 392 1909
Email:
ABSTRACT
Background: The current ?Millennial Generation? of college students majoring in the health professions has unprecedented access to the Internet. Although some research has been initiated among medical professionals to investigate the cognitive basis for health information searches on the Internet, little is known about Internet search practices among health and medical professional students.Objective: To systematically identify health professional college student perspectives of personal eHealth search practices.
Methods: Q methodology was used to examine subjective perspectives regarding personal eHealth search practices among allied health students majoring in a health education degree program. Thirteen (n = 13) undergraduate students were interviewed about their attitudes and experiences conducting eHealth searches. From the interviews, 36 statements were used in a structured ranking task to identify clusters and determine which specific perceptions of eHealth search practices discriminated students into different groups. Scores on an objective measure of eHealth literacy were used to help categorize participant perspectives.
Results: Q-technique factor analysis of the rankings identified 3 clusters of respondents with differing views on eHealth searches that generally coincided with participants? objective eHealth literacy scores. The proficient resourceful students (pattern/structure coefficient range 0.56-0.80) described themselves as using multiple resources to obtain eHealth information, as opposed to simply relying on Internet search engines. The intermediate reluctant students (pattern/structure coefficient range 0.75-0.90) reported engaging only Internet search engines to locate eHealth information, citing undeveloped evaluation skills when considering sources of information located on the Internet. Both groups of advanced students reported not knowing how to use Boolean operators to conduct Internet health searches. The basic hubristic students (pattern/structure coefficient range 0.54-0.76) described themselves as independent procrastinators when searching for eHealth information. Interestingly, basic hubristic students represented the only cluster of participants to describe themselves as (1) having received instruction on using the Internet to conduct eHealth searches, and (2) possessing relative confidence when completing a search task.
Conclusions: Subjective perspectives of eHealth search practices differed among students possessing different levels of eHealth literacy. These multiple perspectives present both challenges and opportunities for empowering college students in the health professions to use the Internet to obtain and appraise evidence-based health information using the Internet.
(J Med Internet Res 2012;14(2):e60)
doi:10.2196/jmir.1969
KEYWORDS
eHealth literacy; college students; Q methodology; Internet search; health professionals; medical education
The Internet continues to be widely used to facilitate research and learning for health and medical information. Eight out of 10 Internet users look online for health information, making it the third most popular Web activity next to checking email and using search engines [1]. The pervasiveness of the Internet and the continued evolution of devices that employ Web-based technologies makes obtaining, processing, and understanding health information a critical competency area for medical professionals in training. Among medical professionals around the world, mobile information and communication technologies (eg, smartphones, iPads, and notebook computers) enable frequent Web 2.0 searches for health information [2-5]. Recent studies have highlighted limitations in measuring and evaluating the interchangeable and interrelated skills necessary for information gathering in the highly social Web 2.0 environment [6-8]. The ability to conduct an effective Internet search to locate health information is particularly important for health and medical professional students who represent an especially ?plugged in? subgroup of the future public health workforce. Approximately 76% of college students use the Internet frequently for research or homework, while 86% report spending at least some time on social networking sites each week [9]. Given the wealth of health and medical information that exists on the Internet, implementing evidence-based health and medical Internet searches becomes far more complex than simply entering a medical condition or health term into an Internet search engine (eg, Google or Bing) and clicking on the most prominent search result within the selected Web browser.
Obtaining health information using the Internet involves a variety of competencies that health information seekers generally lack [10,11], such as: (1) conducting both basic and advanced information searches; (2) applying Boolean operators to limit Internet search results; (3) differentiating between scholarly documents, authoritative sources, periodicals, and primary versus secondary sources of health information; and (4) comprehending ambiguous eHealth terminology.
Increasingly, health and medical professionals must use at least basic eHealth literacy skills to perform their job-related responsibilities [4,5]. ?eHealth literacy? refers to the ability of individuals to seek, understand, and evaluate health information from electronic resources and apply such knowledge to addressing or solving a health problem [12]. The construct reflects the composite of both analytic and context-specific skills that require cognitive-behavioral capabilities to work with technology, critically think about issues of media and science, and navigate through online decision-making resources. The literature has established the need to begin unraveling the basis for cognitive Internet search tasks among medical professionals, especially tasks that may be repeated over long periods of time [4,5,13]. Medical professionals are aware of the need to make evidence-based decisions using eHealth resources [4]; yet, they rarely make evaluative judgments regarding the sources of health and/or medical information they are consuming and habitually visit websites that are perceived to represent high levels of information quality, where cognitive authority is presumed to be high [13].
College students who are professionally trained in the health and medical professions should be taught the knowledge and skills necessary to conduct advanced eHealth information searches on the Internet. These search tasks are complemented by critical appraisals of both the information content and source [14]. The medical education community has recognized the important responsibility of fostering the use of eHealth technologies among future health professionals who will continue to work in the Internet age [15]. Although college students do not encounter the environmental, physical, and resource-related barriers associated with surfing the Internet [8], this population still reports an inability to find desired materials in the digital age [16]. Recent investigations have examined eHealth literacy among college students [14,17]. Stellefson and colleagues [14] conducted a systematic literature review of studies assessing eHealth literacy among college students and found that college students generally lack eHealth literacy skills. Few studies have examined the unique patterns and underlying reasons for college students? health information search behaviors on the Internet [18], which has led to an incomplete understanding of these tasks. The limited current understanding of eHealth literacy is especially disconcerting when considering the importance of Internet search capabilities among young people studying to become future health and medical professionals.
Hanik and Stellefson [17] attempted to fill the gap in this literature by investigating perceived and actual eHealth literacy among undergraduate health education students studying to become allied health professionals. Participants were asked to complete the Research Readiness Self-Assessment-Health (RRSA-h) [19] online assessment, which measures knowledge/skill sets necessary for performing eHealth searches on specific health and medical topics. The multi-part eHealth search task was operationally defined as: (1) making a determination into possible sources of quality health information; (2) conducting an actual health information search on the Internet; (3) evaluating the quality of the health information retrieved; and (4) answering questions following the analysis of health information that was located and evaluated. A total of 77 undergraduate students (88% female) completed this online assessment and earned subpar actual eHealth literacy test scores (mean overall ability score = 42.6%) [17] as compared to results from a previous study in a similar population [19]. However, it was noted that more advanced students (eg, juniors and seniors) had higher overall eHealth literacy than their younger counterparts did. Although the more senior level students exhibited higher levels of eHealth literacy, it could not be determined whether specific eHealth search attributes were qualitatively different among students possessing high versus low eHealth literacy. It was determined, however, that actual eHealth literacy was markedly inferior to ratings of perceived eHealth literacy [17].
In light of these preliminary research findings, it is important to better understand how personal eHealth search practices are perceived among health and medical professional students. These insights may provide a context for determining the types of characteristics that predict and explain eHealth literacy achievement within this population. The purpose of the current research study was to systematically identify health professional college student perspectives of eHealth search practices. The current study addressed three research questions in hopes of achieving this research aim:
1. How many clusters of health professional college students exist, given information about perceptions of personal eHealth search practices?
2. Which college students belong to the eHealth search clusters that emerge?
3. Which specific perceptions of personal eHealth search practices provide the basis for differentiating the clusters that emerge?
To systematically identify health professional college students? perspectives of their own eHealth search practices, Q methodology [20] was employed. The Q method is a systematic way to study subjectivity and it can be used to reveal various social perspectives that exist on a given topic [20-22]. The Q method fits under the broad umbrella of discourse analysis techniques, which constitutes a large category of research methods that systematically analyzes text-based statements in order to determine underlying patterns or meaning [22]. Within this analysis, individuals are clustered into different typologies based on how they describe themselves [23]. This method of inquiry can provide exceptional insight into how many types of people there are, which people belong to different groups, and which particular variables best differentiate types of people [24]. It also enables researchers to systematically explore a variety of perspectives about an issue to identify important areas that may overlap or differ among unique populations [25]. This methodology has been applied in various disciplines including general nursing research [26], clinical decision making among nurses [27,28], and health care informatics [29].
In Q-method research, participants are the independent variables and the text-based statements they are asked to evaluate are the subject of analysis. Participants are asked to systematically order (or ?Q sort?) text-based statements presented to them according to how those statements fit into their own belief system regarding how they believe themselves to be. After participants sort the text-based statements presented to them, the Q method seeks to identify patterns embedded within the Q sorts completed by different participants. Any existing patterns suggest intersubjective orderings of beliefs shared among participants, thus revealing social perspectives [22]. This research technique is valuable because it capitalizes on the strengths of both qualitative and quantitative research [30,31]. For more on the mechanics of Q methodology, the reader is directed to guideline tutorials published within the health and medical research literature [21,26,29].
In the context of the current study, it was hoped that the Q method would help detect any qualitative patterns within undergraduate health professional students asked to consider beliefs about their own personal eHealth search practices. Specifically, the researchers were interested in whether the intersubjective orderings of eHealth search beliefs were common among participants possessing distinct levels of eHealth literacy (eg, basic, intermediate, and proficient). To facilitate this analysis, the Q study protocol was split into three sequential steps: (1) development of the concourse, (2) facilitating the Q sort procedure, and (3) interpreting data from the Q sorts.
Concourse Development
In Q methodology, a ?concourse? is the list of statements that sufficiently represents the ?universe of viewpoints? about a topic [32]. To create a concourse of statements made by health professional students regarding attitudes and experiences conducting eHealth searches, a convenience sample of 42 health education majors were recruited from a large research institution in the southwestern United States. Traditional sampling principles and methods used in survey research are not of particular relevance to person sampling in Q methodology; thus, a pragmatic participant selection process was used [29]. Students were asked to respond to a set of statements meant to elicit responses about the students? personal experiences conducting eHealth searches. All statements were based on cognitive-behavioral constructs posited to be relational within the atomic components of thought theory (ACT) [33], which explains skill development as a process of encoding, strengthening, and proceduralizing declarative and procedural knowledge [34]. Declarative knowledge describes what one knows (eg, facts), whereas procedural knowledge describes whether individuals understand ?how to? complete tasks. Complex tasks, such as searching for eHealth information on the Internet, can be described as combinations of declarative and procedural knowledge put to work. The 12 open-ended statements that students were asked to respond to represented combinations of declarative and procedural knowledge necessary for locating and evaluating health information on the Internet.
The 12 statements informed by ACT were written on index cards, color coded, and numbered and each student was given corresponding index cards to write open-ended responses to each statement. For example, each student was asked to respond to the statement, ?List the source you use most when you search for health information on the Internet.? After all participants responded to each statement, 504 unique statements (42 students ? 12 statements) were generated. Repetitive responses were removed, and a literature review [14] informed the content validity of the 380 statements that were retained for the final concourse. The statements were edited for grammar and readability only to ensure face validity [26] and were grouped together into broad themes that emerged throughout the concourse by way of a constant comparison analysis [35]. To cultivate a greater sense of the most important concepts reported by participants, the number of times each code emerged (across each theme) was quantified to assess saturation within the statement pool. The four overarching identified themes were (frequency of emergent codes corresponding to each theme specified in parenthesis): educational experiences related to conducting eHealth searches (n = 111), confidence in ability to conduct eHealth searches (n = 99), knowledge about conducting eHealth searches (n = 87), and how students engaged the eHealth search process (n = 83).
Q Sort Procedure
After the final concourse was developed, a subset of 36 representative statements (known as a ?Q sample?) was selected to provide a miniature depiction of the larger concourse. This practice is suggested when using Fisher?s experimental design principles in Q methodology [36]. Each statement was randomly assigned a unique numerical identifier from 1 to 36 in order to reduce the probability that participants would recognize conceptually similar statements and cluster related statements together without cognitively processing each statement separately. Table 1 lists the 36 Q statements.
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