E-health literacy in older adults: an evolutionary concept analysis. — TEI-tagged view

Sun Ok JungpersName, Yoon Hee SonpersName, Eunju ChoipersName (2022date). “E-health literacy in older adults: an evolutionary concept analysis..” BMC Medical Informatics and Decision Makingtitle·j.

Object of study — the concept of e-health literacyterm·dom among older adultsterm·key

Research question — what the attributes, antecedentsterm and consequences of e-health literacyterm·dom in older adultsterm·key are

Contribution — three attributes of e-health literacyterm·dom in older adultsterm·key, with antecedentsterm, consequences and a definition

Full text — tagged

E-health literacyterm·dom in older adultsterm·key: an evolutionary concept analysisterm·key.

Abstract Internetterm·key technologies have become important for older adultsterm·key to not only seek, understand, and evaluate information on health management but also apply and share acquired knowledge. Despite the disparity in e-health literacyterm·dom among older adultsterm·key, which affects health outcomes, its conceptual definition has not been distinctly clarified in previous studies. This study aimed to analyse the concept of e-health literacyterm·dom among older adultsterm·key and to identify its contexts in the nursing field.

We identified concepts, attributes, antecedentsterm, and consequences of e-health literacyterm·dom in older adultsterm·key using Rodgers’ evolutionary approach to various fields of study, time, and cultural differences. A literature search was conducted using the National Assembly Library, Research Information Sharing Service, National Digital Science Library, DataBase Periodical Information Academic, PubMed, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, and Cochrane.

A total of 28 studies were included, and we categorised the following three attributes: active information seekingterm·key, two-way interactive communicationterm·key, and information utilization/sharing. The antecedentsterm included personal factors, health status, socioeconomic factors, cultural factors, and attitudes toward the Internetterm·key while the consequences included increased health interest, health behaviour promotion, and active decision-making.

As e-health literacyterm·dom in older adultsterm·key affects their health and quality of life, this study clarifies the concept and provides a conceptual framework for nursing practice and research. Further studies are needed to identify and expand the constantly evolving concept of e-health literacyterm·dom in older adultsterm·key.

Keywords: Aging, Concept analysisterm·key, E-healthterm·dom, Health literacyterm·dom Background Older adultsterm·key have a higher risk of disease and decline in physical function as they age; moreover, they may experience many acute and chronic problems requiring continuous management by various medical professionals in different environments [ 1 ]. In addition, the global life expectancy in 2019 was 73.4 years, and healthy life expectancy was 63.7 years [ 2 ]. In this context, older adultsterm·key likely prioritise a healthy life over a mere extension of their lifespan. Further, many older adultsterm·key seek health information to maintain their health and treat diseases. However, although health information is provided through various channels, it is difficult for older adultsterm·key to understand and manage their health using health information without proper guidelines or interventions because of its complexity [ 3 ]. Therefore, it is essential to understand the basic literacy related to health information of older adultsterm·key [ 4 ].

Since the 1990s, access to health information has increased due to developments in information and communication technologyterm·dom (ICTterm·dom) [ 5 ]. Moreover, since then, the terms ‘e-healthterm·dom’, ‘ehealthterm·dom’, and ‘electronic healthterm·dom’ have appeared in literature [ 6 ]. In the 2000s, electronic healthterm·dom (e-healthterm·dom) was defined as the use of emerging ICTterm·dom, especially the Internetterm·key, to improve or enable health and health care [ 6 ]. Today, e-healthterm·dom has been broadly expanded to include service contents, health care providers, health consumers, and systems [ 7 ]. Thus, the need for e-healthterm·dom using ICTterm·dom has increased [ 8 ], and the role of e-healthterm·dom information is becoming more important [ 9 ].

The growth in the community-dwelling older adultterm·key population and their expectations for patient-centred services have increased the need for the development and use of new information technologies [ 10 ]. Older adultsterm·key can now access health information using the Internetterm·key due to the wide availability of smartphones and tablets [ 11 ]. While older adultsterm·key started using the Internetterm·key later than younger generations, their usage is increasing rapidly with greater access to computers and the Internetterm·key [ 12 ]. Furthermore, health information technology use among older adultsterm·key in the United States of America has increased by about 19%, from 24.8% in 2009 to 43.9% in 2018 [ 13 ]. Given that the prevalence of health problems is higher in older adultsterm·key than in young adults, seeking and utilizing health information over the Internetterm·key can be particularly beneficial to them [ 14 ]. E-healthterm·dom information can increase access, especially for older people living in isolated rural communities [ 15 ]. Older adultsterm·key can use the Internetterm·key to help manage their health, such as making health-related decisions by searching for health information, communicating with medical professionals, seeking health services, and participating in health programs [ 9 ].

Early establishment of e-healthterm·dom mostly referred to health service and systems rather than the health of individuals [ 16 ]. Since 2010, due to the expansion of electronic healthterm·dom resources to websites, web-based applications, and mobile applications, an imbalance in access to health and medical resources has occurred. Health consumers who have difficulties accessing e-healthterm·dom information showed a marked difference in appropriate self-care and self-management of their conditions [ 17 ]. Therefore, older adultsterm·key should use the Internetterm·key to identify health information to manage, maintain, and improve their own health and health care [ 18 ].

The term ‘health literacyterm·dom’ was first used in the United States in 1974 to refer to guidelines for health education among students [ 19 ] and refers to an individual’s ability to obtain, process, and understand basic health information and services necessary to make appropriate health decisions [ 20 ]. Norman and Skinner [ 21 ] proposed an e-health literacyterm·dom model, defining e-health literacyterm·dom as the ability to seek, find, understand, and appraise health information from electronic sources. According to this model, e-health literacyterm·dom includes all aspects of traditional literacy and numeracy, media, computer, information, and science literacy, including traditional health literacyterm·dom [ 21 ]. With the further development of information, the field of e-healthterm·dom has been broadly expanded from service contents, providers, users, and other major systems, and the term ‘digital healthterm·dom’ has recently been widely used [ 22 ]. According to the WHO definition, digital healthterm·dom encompasses emerging fields such as big data, genomics, and the use of advanced computing science in artificial intelligence as well as mHealth and e-healthterm·dom. However, e-health literacyterm·dom is an important indicator of personal health technology utilization [ 23 ]. If the level of e-health literacyterm·dom is low, it is considered that it will be difficult to have digital healthterm·dom literacy. Therefore, in this study, rather than a technical approach, we would like to focus on e-health literacyterm·dom at the individual level to identify the determinants of the promotion of health management for older adultsterm·key and to provide a strategy to make good use of e-healthterm·dom resources.

Concept analysisterm·key of health literacyterm·dom was performed in order to clarify its meaning [ 24 ], particularly in older adultsterm·key [ 25 ]. Previous studies of e-health literacyterm·dom were initially conducted in the field of health information technology, such as electronic information records and decision-making systems [ 26 ]. Given the progress of electronic devices, studies have been conducted to evaluate health outcomes using mobile devices such as smartphones and tablets [ 27 ]. In addition, based on the concept of literacy, a tool to measure the e-health literacyterm·dom of the youth population was developed in 2006 [ 21 ], and a study successfully validated e-health literacyterm·dom of the elderly using this tool [ 14 ].

However, e-health literacyterm·dom is diverse by race, country, and culture of older adultsterm·key, and the level of e-health literacyterm·dom varies across countries, contents, strategies, training tools, and manuals of e-health literacyterm·dom interventions [ 28 ]. Previous studies have not yet been able to present advanced concepts, scope, or standards that reflect the rapidly changing characteristics of e-health literacyterm·dom, and the concept of e-health literacyterm·dom of older adultsterm·key reflecting their characteristics has not been defined. Moreover, as it is used interchangeably with terms such as ‘mHealth literacy’ and ‘digital healthterm·dom literacy’ [ 7 ], researchers apply different concepts and definitions [ 29 – 34 ]. This situation also raises questions about the reliability and validity of the study [ 35 ]. It is necessary, therefore, to clarify the concept of e-health literacyterm·dom by identifying the attributes, related concepts, and influencing factors of e-health literacyterm·dom among older adultsterm·key.

Clarifying the nature of changes in a dynamic manner through time and context is an important process in the development of useful and meaningful concepts in this field of study [ 36 ]. Identifying attributes of e-health literacyterm·dom in older adultsterm·key through multidisciplinary comparisons provides evidence for developing interventions for health promotion in the various nursing fields and, in turn, guides the direction of future research. As e-health literacyterm·dom in older adultsterm·key is affected by sociocultural and historical factors, such as age, the period of Internetterm·key dissemination, and the generalised environment, the concept of e-health literacyterm·dom should be defined through the evolutionary method proposed by Rodgers [ 36 ], which approaches concepts through context and an evolving point of view. E-healthterm·dom resources are constantly evolving and require ongoing adaptation by users [ 37 ]. Therefore, this study aims to provide basic data for future research by examining the literature on e-health literacyterm·dom in older adultsterm·key based on Rogers’ evolutionary method and identifying its properties, antecedentterm factors, and results in the literature.

Methods Design This study is a concept analysisterm·key of the attributes, antecedentsterm, and consequences of e-health literacyterm·dom in older adultsterm·key using Rodgers’ evolutionary method [ 36 ].

Researchers’ preparation This study was conducted by researchers with clinical experience with older adultsterm·key, with gerontological nurse certifications, who have submitted a thesis on older adultsterm·key, and who have written an article by conducting research related to health literacyterm·dom. Based on this understanding of older adultsterm·key, the literature on e-health literacyterm·dom among older adultsterm·key was searched and read repeatedly. In this process, we recognised the necessity of a concept analysisterm·key of e-health literacyterm·dom among older adultsterm·key. Accordingly, researchers attended a doctoral nursing theory development strategy class to acquire knowledge on concept analyses. Further, by reading Rodgers’ [ 36 ] literature related to evolutionary theory, we attempted to understand and analyse the philosophical background and analysis methods. In addition, the process was implemented with the advice of experts who had experience in concept analysisterm·key as well as those who were educated in nursing theory development.

Concept analysisterm·key process This study was sequentially analysed using the evolutionary concept analysisterm·key method suggested by Rodgers [ 36 ]; each step was repeatedly cycled and analysed until the concept became clear. The following steps were followed in the study: Identify the concept of interest and associated expressions (including surrogate termsterm).

Identify and select an appropriate realm (setting and sample) for data collection.

Collect relevant data (the attributes and contextual basis of the concept, including interdisciplinary, sociocultural, temporal, antecedentterm, and consequential occurrences) to identify variations.

Analyse data on the above characteristics of the concept.

Identify an exemplar of the concept, if appropriate.

Identify implications, hypotheses, and ideas for further development of the concept.

Identifying the concept of interest The literature was drawn from the time the concept of e-health literacyterm·dom first appeared until April 2021. For Korean literature, the National Assembly Library, Research Information Sharing Service, National Digital Science Library, and DataBase Periodical Information Academic were used. For English literature, PubMed, the Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, and Cochrane search engine were used. ‘E-health literacyterm·dom’ and ‘electronic healthterm·dom literacy’ were searched as keywords, and ‘computer/internetterm·key/mobile/online AND health literacyterm·dom’ were included to cover a wide range of literacy on devices. In addition, ‘older adultsterm·key/elderly/senior/baby boomer/retiree/pensioner’ were added to limit search results as a final outcome to identify the attributes, antecedentsterm, and consequences of e-health literacyterm·dom in older adultsterm·key. However, the age range of older adultsterm·key was not limited because it differed from study to study in extant literature.

Choosing the setting and sample To analyse the concept of e-health literacyterm·dom, quantitative and qualitative research was extensively considered, focusing on empirical studies. The inclusion and exclusion criteria were as follows.

Inclusion criteria Studies published from the time the concept first appeared until April 2021 Studies that further the understanding of the concept and attributes of e-health literacyterm·dom among older adultsterm·key Exclusion criteria Studies not targeting older adultsterm·key Studies on older adultsterm·key with certain diseases Studies not related to e-health literacyterm·dom Literature not published in either English or Korean Grey literature including books, materials, and pilot studies Literature for which no abstract or original text could be found Not suitable for the main research purpose Data analysis We organised selected literature using a matrix [ 38 ]. This structured analysing matrix was used to distinguish research fields, research purposes, research designs, inclusion of the concepts, and keywords. Moreover, to determine attributes of e-health literacyterm·dom, major questions including ‘What is e-health literacyterm·dom for older adultsterm·key?’ and ‘What are the characteristics and features of e-health literacyterm·dom of older adultsterm·key?’ were repeatedly discussed during regular meet-ups with researchers. In the matrix, articles with vague description in attributes were set aside, and some studies in other professional fields were also reappraised. Then, all antecedentsterm, attributes, and consequences were integrated with original results, and whether it was situation, event, or phenomenon was confirmed before and after the concept. In this process, analysed the attributes of the concept and the evidence of context strictly by asking opinions of other professionals about the categories of antecedentsterm, attributes, and consequences. To derive research results inductively, we attempted to find an adequate exemplar in qualitative study to identify the attributes applicable in reality.

Results Outcomes of searched literature The researchers (SJ, YS, and EC) extracted 5585 primary studies from the searched literature; 16 were in Korean, and 5569 were in English. Excluding 1323 duplicate studies, 91 studies were derived by screening the titles and abstracts according to the inclusion and exclusion criteria. After reading through the full text of 91 studies, discussions among researchers resulted in the exclusion of 63 studies based on the criteria above. Finally, 28 studies, consisting of 3 Korean and 25 English studies, were analysed in this study (Fig. 1 ).

Literature search flow Definition of e-health literacyterm·dom To understand the attributes of e-health literacyterm·dom in older adultsterm·key, we confirmed the definition of the term used in each study and identified how the term changed over time (Table 1 ). Early studies’ descriptions of the e-health literacyterm·dom of older people were similar to the existing definition of health literacyterm·dom, which includes the abilities to search, understand, and utilise health-related information. However, newer studies gradually reflected the development of information technologies and devices that affected older adultsterm·key’ ability to respond to health-related information. In addition, some definitions included the characteristics of older adultsterm·key and the manner in which they identify what they need from various media and reproduce or share such information rather than merely evaluating it. However, most recent studies have used the definition of Norman and Skinner [ 21 ], either by translating or quoting a part of the definition.

The definitions of e-health literacyterm·dom in older adultsterm·key Attributes Defining the attributes of a concept can help identify a real definition, which is necessary to understand the concept’s characteristics [ 23 ]. Moreover, defining attributes is fundamental to concept analysisterm·key as it provides the broadest insight into the concept [ 45 ]. In this study, we identified the attributes of the concept through the question, ‘What are the consistent characteristics of e-health literacyterm·dom in older adultsterm·key?’ The identified attributes of e-health literacyterm·dom in older adultsterm·key are active information seekingterm·key, two-way interactive communicationterm·key, and information utilization and sharing (Fig. 2 , Table 2 ).

Conceptual framework of e-Health literacyterm·dom in older adultsterm·key Antecedentsterm, attributes, consequences from literature Active information seekingterm·key Older adultsterm·key recognise the importance of health promotion, along with the need to identify health information [ 23 ]. They actively seek information using electronic media when they recognise its benefits for their wellbeing [ 50 ]. In other words, when they need the health information, they also identify how to obtain and actively seek it. Older adultsterm·key search for information online to solve health-related questions from various sources, ranging from professional websites to personal blogs [ 13 , 17 , 53 ].

Two-way interactive communicationterm·key Health-related information obtained through the Internetterm·key allows for real-time interactive communication using electronic media, which facilitates the understanding of various information [ 32 ]. This includes searching for information to understand what doctors say, formulating questions for medical professionals without hesitation, and communicating with health care providers [ 13 , 33 , 39 – 41 , 56 , 58 ]. In other words, older adultsterm·key play an active role in their health management, using two-way interaction to understand the information they receive [ 15 , 57 ]. Moreover, they check the necessary health needs in real time to self-manage the discovered information [ 32 ].

Information utilization/sharing Older adultsterm·key evaluate the information that they receive based on their understanding [ 50 ] and apply online knowledge to solve their own health problems [ 17 ]. In addition, information is constantly updated and modified after the searched knowledge is conveyed to online information providers or others seeking information [ 13 , 31 ]. This circulates in the desirable direction of participation as older adultsterm·key share and reproduce this health information among other older adultsterm·key online [ 13 , 44 ] rather than passively accepting and using it privately.

Antecedentsterm Antecedentsterm are events that occur prior to the concept [ 36 ]. They were classified into personal factors, health status, attitudes toward the Internetterm·key, and socioeconomic and cultural factors by reading the literature in view of the question, ‘What are the events that occur prior to e-health literacyterm·dom?’ (Fig. 2 , Table 2 ).

Personal factors Prior literature confirms the effect of personal characteristics of older adultsterm·key on e-health literacyterm·dom. We found that the younger the age [ 41 , 44 ] and the higher the level of health literacyterm·dom were [ 15 , 41 , 44 ], the more positive was the effect on e-health literacyterm·dom. In addition, e-health literacyterm·dom was high in those who personally had prior experience with Internetterm·key use [ 30 , 31 , 41 , 48 ] or Internetterm·key instruction [ 29 , 41 ]. However, those who lacked computer skills [ 15 , 41 ] and experienced difficulty in accessing the Internetterm·key for health knowledge [ 15 , 29 , 48 ] had low e-health literacyterm·dom.

Health status As aging progresses, older adultsterm·key may experience loss of vision, hearing, and mobility [ 15 , 30 ]; further, their cognitive function and language ability may decline [ 30 , 55 ]. Thus, the individual health status of older adultsterm·key [ 13 , 17 , 34 ] is a key factor influencing e-health literacyterm·dom.

Attitudes toward the internetterm·key Attitudes toward the Internetterm·key influenced e-health literacyterm·dom in older adultsterm·key. The absence of computer anxiety [ 23 , 39 , 41 , 44 , 50 ], higher computer confidence [ 44 ], and computer self-efficacy [ 31 , 39 , 41 , 50 ] enhanced e-health literacyterm·dom among older adultsterm·key.

Socioeconomic factors Studies reveal that higher income [ 30 , 46 ] resulted in having a higher number of devices [ 44 ]; further, the higher the education level was [ 32 , 52 ], the higher was the level of e-health literacyterm·dom. Older adultsterm·key with high incomes were more likely to have many electronic devices. Moreover, the higher the educational attainment among older adultsterm·key, the more likely they were to have basic literacy, thus requiring limited assistance in using computers. In addition, if older adultsterm·key were married [ 44 , 52 ] and had social support [ 53 ], they were able to receive help with computer use [ 30 ], which resulted in high e-health literacyterm·dom.

Cultural factors Perceived usefulness of and trust in e-healthterm·dom information [ 15 , 23 , 29 , 30 , 40 , 43 ] improved e-health literacyterm·dom. Moreover, older adultsterm·key who had experienced historical events such as war, baby boom, and economic development [ 29 ] confirmed that these cultural factors affect the level of education and, consequently, e-health literacyterm·dom.

Consequences Consequences of the concept refer to events or phenomena after the concept occurs [ 36 ]. We identified the consequences through the question, ‘What is the consequential occurrence of e-health literacyterm·dom in older adultsterm·key?’ In doing so, we derived the consequences of increased health interest, health behaviour promotion, and active decision-making (Fig. 2 , Table 2 ).

Increased health interest E-health literacyterm·dom in older adultsterm·key increases interest in health and enhances knowledge and expectations of health care [ 29 , 50 ]. It induces health information pursuit, confidence in Internetterm·key health information [ 50 , 51 ], and a positive attitude [ 17 ]. These circumstances may lead to an increased health interest [ 43 ].

Health behaviour promotion The ability to apply the acquired knowledge to address and solve health-related problems can be increased by e-health literacyterm·dom among older adultsterm·key, which can ultimately improve their health status. These behaviours include managing chronic disease [ 31 ], changing lifestyle [ 33 ], and improving their self-management abilities [ 15 ]. However, older adultsterm·key with lower e-health literacyterm·dom not only lack information but also experience medical inequalities in relation to the availability of health resources [ 52 ]. Moreover, another study found that enhancing coping ability for stressful situations increases older adultsterm·key’ understanding of medication usage [ 58 ], and identifying behaviours for disease prevention and health maintenance [ 43 , 50 ] could ultimately improve their overall quality of life [ 46 , 50 ].

Active decision-making The process of accurately recognizing one’s health status by using electronic healthterm·dom resources allows older adultsterm·key to actively make treatment-related decisions. E-health literacyterm·dom helps older adultsterm·key in determining which health care provider to choose [ 58 ] while enabling them to understand and complement the staff’s decisions [ 58 ], thereby strengthening the communication between service provider and user [ 15 ]. Moreover, it encourages older adultsterm·key to actively participate in the treatment process [ 17 , 46 ], thus inducing positive changes in the treatment process [ 46 ].

Related concepts and surrogate termsterm Identifying a variety of related concepts or surrogate termsterm is crucial to the interactive development of concepts [ 36 ]. Surrogate termsterm are means of expressing a concept other than the word or expression selected by the researcher to focus the study [ 36 ]. Surrogate termsterm must be identified to some extent before beginning formal analysis [ 36 ]. Surrogate termsterm checked before the official analysis were ‘mHealth literacy’ and ‘digital healthterm·dom literacy’, and it was confirmed that they were used interchangeably with ‘e-health literacyterm·dom’. E-health literacyterm·dom is a key attribute of these concepts, and, in this study, only the literature focusing on e-health literacyterm·dom was extracted. We identified such terms in each paper. Especially in South Korea, the phrases ‘ ability to understand Internetterm·key health information ’ and ‘ Internetterm·key health information literacy ’ have been frequently used as surrogate termsterm.

In this study, Related concepts that contain some important properties of the concept or are similar but not identical to the concept were described as well as how they are connected to the concept network surrounding the concept [ 36 ]. The attributes of concepts were different from those of e-health literacyterm·dom or contained only some parts of the attributes. For example, older adultsterm·key’ ‘ access to health information usability and accessibility ’ [ 34 ] or ‘ digital access to health information ’ [ 29 , 31 ] was used to describe the ability to access information through the Internetterm·key. In addition, ‘ online health information seeking ’ [ 31 , 48 , 55 , 57 ] was conceptually described as the process of searching for information. Moreover, the concepts for older adultsterm·key’ acceptance of information were developed and used. They included ‘ acceptance and use of health information technology ’ [ 13 , 30 , 31 ] and ‘ Internet-based interactivity information ’ [ 33 ]. The concept of ‘ computer literacy ’ [ 32 ] appeared with the development of electronic devices. Therefore, it is important to clearly distinguish attributes in each concept as they influence the conceptual development of e-health literacyterm·dom.

Model case According to Rogers [ 36 ], this analysis method was performed inductively; thus, in order to verify the concept of the study, it was necessary to confirm the actual example and apply the attributes, antecedentsterm, and consequences to present them. Therefore, in this study, the use of Internetterm·key media in situations of need in older adultsterm·key was presented as a model case [ 58 ]: When my wife had ovarian cancer, I became relatively knowledgeable about it. When we went to a surgeon, I asked the surgeon some questions and determined very quickly that I knew more about it than he did, and we just walked out. I went to the web, and I looked it up.... I found the list of names of the top-rated oncologists in the area, and the same way with the top-rated medical centres.... As a result, we talked with the top doctors at one of the top centres in this area. When I was growing up, you went to the doctor, did what he said, and took the medicine he gave you, and just believe; don’t ask questions, just do it.... Things are done a little bit differently these days. In the past, doctors were accepted on faith, but now, you could have a dialog with a doctor.

Discussion This study aimed to analyse e-health literacyterm·dom using an evolutionary approach to identify the definition of e-health literacyterm·dom while demonstrating the contextual flow of antecedentsterm and consequences. The results showed that e-health literacyterm·dom includes attributes such as active information seekingterm·key, two-way interactive communicationterm·key, and information utilization and sharing. Characteristics related to personal factors, health status, attitudes toward the Internetterm·key, socioeconomic factors, and cultural factors of older adultsterm·key were identified as antecedentsterm of e-health literacyterm·dom. As a result, we found that e-health literacyterm·dom enhanced health care interest, promoted health behaviour, and induced active decision-making in older adultsterm·key, which ultimately improved their quality of life.

Principal results First, from personal factors, the e-health literacyterm·dom of young adults increased with age [ 41 , 44 ], but the e-health literacyterm·dom of older adultsterm·key decreased with age [ 59 ]. As noted in the previous literature, this is likely because older adultsterm·key are more likely to experience vision and hearing loss [ 15 , 49 ], decline in cognitive ability [ 15 ], and decreased individual health status [ 41 , 43 ].

In addition, previous studies noted that higher levels of health literacyterm·dom in older adultsterm·key result in greater acquisition of e-health literacyterm·dom [ 30 , 46 ], which is a concept that includes the various abilities required to control health-related problems in daily life [ 60 ]. This suggests that promoting health status allows older adultsterm·key to explore and utilise health-related information through electronic devices. Older adultsterm·key’ attitudes toward the Internetterm·key are also an important factor in e-health literacyterm·dom; these include computer anxiety, computer self-efficiency, computer confidence, and other types of preferred sources. Further, prior experience with Internetterm·key use and instruction, increased frequency of Internetterm·key use, and familiarity with online media use can reduce difficulties related to computer skills and internetterm·key access [ 15 ]. It is thus necessary for researchers to study and policymakers to develop interventions to increase older adultsterm·key’ confidence and self-efficiency in electronic media use, reduce fear of Internetterm·key and computer use, and increase accessibility.

Socioeconomic factors suggest that, as in previous studies, older adultsterm·key with higher social status, educational backgrounds [ 32 , 53 ], economic conditions, and marriage status and social support [ 46 ] have relatively high levels of e-health literacyterm·dom. As e-health literacyterm·dom is influenced by educational attainment [ 55 ], affecting older adultsterm·key’ cognitive ability to understand, assess, and apply their knowledge, it is important to approach individual older adultsterm·key based on their education levels [ 61 ]. In addition, those with higher incomes are more likely to own or have access to electronic devices, while, on the other hand, older adultsterm·key with lower incomes have less opportunity to access electronic healthterm·dom information [ 30 ]. The presence of marriage and social support in older adultsterm·key’ lives also affects e-health literacyterm·dom as family and other social relationships can help them use electronic media to search for information on their own [ 44 ]. This suggests that older adultsterm·key who live alone or isolated may be vulnerable in their ability to understand and utilise e-healthterm·dom resources due to the absence of support around them, indicating that public healthcare approaches should be applied to remove this inequity.

Cultural factors indicate that older adultsterm·key perceive their health conditions and start to seek useful e-healthterm·dom information, which is influenced by environmental factors, such as the region, country, and culture in which the individuals live [ 61 ]. In particular, as older adultsterm·key have many restrictions regarding movement around their residential areas, cultural factors can play an important role in recognizing online health information [ 29 ]. In addition, when applying the concept, historical background must be considered as it can also affect e-health literacyterm·dom. For example, people born in the 1950s, who were not educated due to the Korean War, had relatively low literacy levels, which had a negative impact on their current levels of e-health literacyterm·dom as older adultsterm·key [ 29 ].

From the attributes of e-health literacyterm·dom in this study, active information seekingterm·key refers to the act of exploring using electronic media for health information. It is based on the need for and perception of finding health information that would be beneficial to older adultsterm·key’ health [ 55 ].

In modern society, the growing interest in health and active health care of older adultsterm·key has evolved into a form of interaction with experts or others through various media. This has moved away from a unilateral process of information acceptance and affords an opportunity for older adultsterm·key to choose what they utilise and share with others on their own [ 9 ]. After all, among physical and technical limitations of older adultsterm·key, only literacy levels were assessed in early studies; real-time information exchange has given online communication an important role in recent studies [ 15 ]. Older adultsterm·key may direct their queries to health professionals when they are unable to understand health information on the Internetterm·key through the Internetterm·key community and mobile applications. They actively exchange their knowledge and experiences with adults from other regions, genders, and age groups without space–time constraints. In addition, instead of meeting health professionals to obtain limited information, online real-time hospital appointments, consultations, and medical results confirmation by themselves have become available [ 32 ].

In the process of accessing the dynamic nature of the Internetterm·key, older adultsterm·key can have abundant information to apply to health-related problems. Additionally, from that experience, they gain self-belief in evaluating online health content [ 50 ]. Reproducing information by continuously sharing and updating information can have a positive impact on other older adultsterm·key as well as promoting their own health [ 44 ]. However, this diverse and continuous process of e-health literacyterm·dom may vary depending on the different Internetterm·key technology environments in each country [ 28 ]. While older adultsterm·key need to acquire the ability to select accurate and appropriate information from the abundant information that is indiscriminately shared online, standards for information can also vary depending on attitudes or social conventions.

As Internetterm·key use continues to increase, it is important to approach and apply intervention through the concepts to improve e-health literacyterm·dom in older adultsterm·key [ 18 ]. As some individuals have difficulty accessing and utilising health information due to personal capacities, training on new skills should be provided at the individual level for better health outcomes [ 62 ]. In addition, identifying the factors that promote and inhibit e-health literacyterm·dom in older adultsterm·key and implementing effective interventions to improve their abilities will contribute to diminishing the gap in health literacyterm·dom [ 54 ].

This study indicated that older adultsterm·key, who previously solved their health problems passively and had insufficient opportunities to gain health information, now maintain a more active life by interacting and sharing information with others in the common context of health promotion. In addition, older adultsterm·key with high e-health literacyterm·dom have increased interest in health and are aware of how to maintain their health or prevent disease through health-related information on the Internetterm·key. Therefore, it is expected that e-health literacyterm·dom of older adultsterm·key will be improved if nursing care is provided using antecedentsterm identified in this study. We propose to develop tools and intervention programs for older adultsterm·key that reflect the attributes of e-health literacyterm·dom identified in this study. Furthermore, practical interventions such as the development of educational programs based on multidisciplinary convergence are required. This study is significant in that it provides basic data necessary for providing nursing care to increase the e-health literacyterm·dom of older adultsterm·key.

Limitations The limitations of this study are as follows. First, the age boundaries of older adultsterm·key are unclear as each study defined age groups according to the population’s sociocultural context. Therefore, one should be cautious while generalizing the findings of this study. Second, our study was aimed at older adultsterm·key in general; follow-up research is needed to identify the attributes of older adultsterm·key with certain diseases as well as the changes in the information available on the Internetterm·key. Finally, as this study analysed concepts according to the contextual and temporal trends that have occurred so far, it is necessary to apply the evolutionary concept analysisterm·key method to continuously identify and extend the changing attributes of e-health literacyterm·dom in the future.

Conclusions This study is a concept analysisterm·key that confirms the meaning and attributes of e-health literacyterm·dom among older adultsterm·key using the evolutionary method to derive a conceptual definition of e-health literacyterm·dom for older adultsterm·key. The main attributes identified in this study were active information seekingterm·key, two-way interactive communicationterm·key, and information utilization and sharing; moreover, we confirmed that these attributes were organically related. Therefore, e-health literacyterm·dom of older adultsterm·key can be defined as actively searching for necessary health information using electronic media, exchanging real-time information, and promoting one’s own health by utilizing and sharing it. Therefore, based on these research results regarding e-health literacyterm·dom, follow-up studies on measurement development and additional research are needed to reveal changes in concepts that evolve with the development of electronic resources in the future.

Acknowledgements We acknowledge Prof. D.Y. JungpersName for her critical comments in the development of this manuscript.

Abbreviations Information and communication technologyterm·dom Electronic healthterm·dom Authors' contributions All authors contributed to the conceptualization and design of this study. SJ, YS, and EC conceptualised the theme; screened previous articles; and abstracted attributes, antecedentsterm, and consequences for the analysis. In addition, all authors critically reviewed and commented on the draft manuscript and contributed to editing the final version. All authors read and approved the final manuscript.

Funding Not applicable.

Availability of data and materials Not applicable.

Declarations Ethics approval and consent to participate Not applicable.

Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests.

Footnotes Contributor Information Sun Ok JungpersName, Email: okijung1@naver.com.

Yoon Hee SonpersName, Email: kityuni21@gmail.com.

Eunju ChoipersName, Email: celestial_@naver.com.

References Associated Data Data Availability Statement Not applicable.