Healthcare professionals agree that it is important for patients to have information about their health and make the assumption that having this knowledge will contribute to better health outcomes. On the basis of these beliefs, healthcare professionals have at the least supported, but in most cases implemented, the development of health information for patients and are constantly evaluating how this information is utilized (or not utilized) by individuals. In this article, the literature on seeking health information and sources of health information will be examined. This includes terminology, theoretical models, and research associated with health information utilization. The majority of recent research on health information has focused on utilizing the Internet; however, additional topics include sources of information sought by individuals with various health literacy levels, utilizing cancer information, and seeking information based on race, gender, and age.

Health Information-Seeking Behavior

One of the most frequently mentioned concepts in the literature on seeking health information is "health information-seeking behavior" (HISB; Lambert & Loiselle, 2007, p. 1006). The definitions of this concept are not explicit and are not unified into one dominant definition. The definition is often accepted as being obvious and how individuals obtain information is assumed. Currently HISB is broadly viewed as ways individuals obtain information about health, illness, health promotion, and risks to health. Usually the term HISB is shortened to "information-seeking behavior" with the "health" implied; however, a few authors use "health information seeking" or "information seeking." Most authors indicate that HISB involves specific strategies/actions to obtain information. The HISB has been investigated in the following contexts: dealing with health-threatening situations, making medical decisions, and pursuing behavior change and preventive behavior (Lambert & Loiselle, 2007).

Other terms are associated with HISB. The term consumer health information-seeking behavior is commonly used in social and behavioral sciences (e.g., library and information science, psychology) and health sciences and has grown in popularity along with the growth of the Internet as a source of health information (Baker & Pettigrew, 1999, p. 444). The use of this term is a bit controversial; on one hand, the term does not accurately describe the concept because health is not consumable in the sense of expendable, but it can also have economic and political implications (Stavri, 2001). Because of this debate, the phrase "Personal Health Information-Seeking" has been proposed as a more accurate descriptor for the process of seeking health information (Stavri, 2001, p. 1484). This term focuses on the individual seeking health information for personal use as opposed to professionals seeking information for patients. This is in accordance with the research on health information seeking, which strives to understand how individuals pursue health information (Stavri, 2001). However, for the purposes of this article, "HISB" will be utilized.

THEORIES AND MODELS

When examining a concept like HISB, the first step is to note observations/trends in the behaviors exhibited by individuals performing this activity. These observations/ trends are used to develop theories that are used to explain observations/trends and are tested in future research or inquiry. Baker and Pettigrew (1999) propose that three theories/models from psychology and sociology can help to explain HISB and provide the foundation for future research. Psychologist Miller has studied individuals seeking information when dealing with very stressful events and developed the coping with stress model. In this theory, individuals are either "monitors" who seek information to cope with stress or "blunters" who avoid information when faced with a stressful event. This theory can help explain the seeking (and nonseeking) behaviors of individuals.

The "strength of weak ties," proposed by Granovetter, is a framework that has arisen out of the sociological field and the social network theory (Baker & Pettigrew, 1999, p. 444). In this theory, social networks are composed of strong ties (e.g., family, close friends) and weak ties (e.g., distant friends, acquaintances). A tie is the relationship between the individual and the network member. Granovetter proposes that weak ties, more than strong ties, positively impact the movement of new resources and knowledge within a personal network. Individuals who have strong ties have a tendency to know the same information and have had similar experiences. An example would be family members who have the same knowledge about cancer prevention. In contrast, individuals with weak ties tend to share information that is not already known because they do not connect regularly and do not have the same experiences. For example, parents who form a social network at a children's event have and share different knowledge about cancer prevention. Thus, new information is shared between individuals in the network. After new information is brought into a social network, input from strong tie relationships influences what happens to the new information. Parents at the children's event bring the information back to family and close friends who provide their thoughts on the information and influence what the individual does with this information. Thus the social network theory, and specifically the strength of weak ties, helps to explain how information is acquired (Baker & Pettigrew, 1999).

Longo (2005, p. 192) proposed the "Expanded conceptual model of health information seeking behaviors and the use of information for health care decisions." This model is based upon the experiences and reports of patients themselves. The model examines the variables (contextual and personal) that influence information seeking and information use. Examples of contextual variables include health status (of the person for whom information is sought), healthcare structure and care delivery, for whom the information is being sought, and information environment factors. Personal variables include demographic and socioeconomic factors, personal and familial health history, genetics, education, culture, language, attitudes, and current health status.

These variables influence the individual as they actively or passively seek health information. During the active pursuit of information, the patient goes to known sources or finds new sources, attempts to access the information (may or may not be successful), chooses to use the information or not, and may or may not use the information to make healthcare decisions. For passive receipt of information, the individual receives information from various sources without actively pursuing and makes decisions about whether to use the information. The outcomes of this model include empowerment/ locus of control, satisfaction, activities of daily living, and health outcomes. This model provides knowledge about variables that impact actively or passively, seeking information and the decisions that individuals make when involved with health information to achieve the outcomes (Longo, 2005).

Research

Research involving HISB has heavily focused on the use of the Internet in recent years. In the studies, the Internet use is the thrust or at least one of the major sources of health information examined. A few studies broadly look at all sources of health information in a certain population; however, most studies look at Internet HISB because it relates to various populations such as cancer patients, parents, rural women, and geriatric individuals.

GENERAL

The National Assessment of Adult Literacy examined sources of health information utilized by individuals and the relationship between these sources and background variables such as health literacy (Kutner, Greenberg, Jin, & Paulsen, 2006). Those with below-basic health literacy were less likely to obtain health information from any written source such as books, magazines, newspapers, or brochures when compared with those with higher literacy levels. Those with below-basic and basic health literacy sought "a lot" of health information from television and radio. With each higher level of health literacy, a higher percentage of individuals sought health information from coworkers, family members, and friends. Overall, individuals with below-basic or basic health literacy sought information from less sources (written materials, TV, radio, healthcare professionals, and coworkers/friends/family) than those with higher health literacy (Kutner et al., 2006).

Wathen and Harris' (2007) qualitative study examines the experience of rural women in southwestern Ontario, Canada, seeking health information for chronic health concerns or acute medical problems. The study reveals that these women view health very broadly, and that seeking information is impacted by contextual factors (e.g., gender, rural living, and access to technology) that interface with health literacy, self-reliance, and the willingness of others (professional and nonprofessional) to provide support in relationships involving healthcare. The women often utilized other sources of health information before utilizing the healthcare provider; however, when using the Internet, the volume of information available was overwhelming at times. Because of poor relationships with and scarcity of physician healthcare providers, the women turned to other providers such as pharmacists (whom they find very helpful) and even veterinarians. The study concluded that electronic health information has some positive aspects for women living in rural communities and the increase in online health chats may provide the support needed. However, before electronic health services are developed, it is important for the communities being served to have input on what is needed.

Khoo, Bolt, Babl, Jury, and Goldman (2008) investigated the seeking of children's health information by parents in Melbourne, Australia. The study's goal was to identify sources of information and parents' trust in them and define the role of the Internet. Although parents used the Internet, they trusted and used traditional sources of health information, such as healthcare providers, much more than other sources. Parents stated that they value easier access to Internet sources that they trust.

CANCER

Three studies utilized the 2003 Health Information National Trends Survey (HINTS) to look at HISB among cancer patients. Ramanadhan and Viswanath (2006) attempted to develop a profile of nonseekers, those individuals with cancer who do not seek information beyond their healthcare professional. When compared with others, nonseekers came from the lowest economic and educational groups and scored lower on behaviors related to health prevention, attention to health in the media, and trust of mass media health information.

Tian and Robinson (2008) based their research on the media complementarity theory, which states that new media such as the Internet does not replace old media such as newspapers and TVs, but rather it complements or augments information obtained from those sources. In their study using the HINTS, they found that there was no difference between the uses of the Internet for younger and older cancer patients seeking information for themselves. However, older patients were less likely to use the Internet to seek health information for others and less likely to find incidental health information on the Internet. Older adults are not using the Internet in place of other traditional media channels, they use the Internet in addition to other media channels. Tian and Robinson concluded that older adult cancer patients need to be given written health information because they do not solely rely on the Internet for health information.

Rains (2007) used HINTS to examine whether trust in sources of health information (i.e., information-oriented media, entertainment-oriented media, family, doctor, and Web) was a better predictor of using the Web for health information than other factors (i.e., education, age, risk of contracting cancer, and attention to health information). The results showed that distrust in traditional sources was associated with increased use of the Web for health information, specifically distrust in healthcare provider and entertainment-oriented media. Also, distrust in information-oriented media increased the chances that an individual would turn to the Internet for health information first. Individuals who did not trust their healthcare provider were less likely to perceive the information they found online to be useful. Trust in one's family did not predict the use of online health information. Overall, the study demonstrated that trust is core to motivating individuals to use the Web as a source of health information and for the individual to find the information useful.

Zanchetta, Perreault, Kaszap, and Viens (2007) examined information strategies used by older men to understand and deal with prostate cancer. The results showed that men's functional health literacy was developed throughout their lives and supported by cultural and social resources. The following characteristics aided the men in developing "critical-information-seeking" (Zanchetta et al., 2007, p. 961): interest in education (learning), home reading, and supportive elementary education environments and families. The men used information networks to gain knowledge and support (emotional and spiritual). Health literacy level was not associated with specific information strategies.

Race/Culture

The cancer literature also examines HISB because it relates to race. Thompson, Cavazos-Rehg, Tate, and Gaier (2008) used data from the Cancer Information Service call data to investigate HISB of African Americans with cancer. When compared with other racial groups, African Americans sought less information on prevention and psychosocial support. African Americans' calls were likely to center on information on support services and medical referrals.

Several other studies have examined the HISB of specific racial/cultural groups. Two studies focused on African Americans, one specifically addressed the HISB of older adult women (Gollop, 1997; Morey, 2007). The studies took place in urban environments (Pittsburgh, PA, and Buffalo, NY). For both studies, the main source of health information identified by a great majority of participants is the health service professional (e.g., physician).

Gollop (1997) found that the older participants used several additional sources for health information, including TV, radio, magazines, family, and friends, but to a much lesser extent. Which source used was often dependent on the health concern; however, the most trusted source was the physician. Morey (2007) found that the Web was the second most used source of health information followed by other sources not identified in the study, that is, family, friends, TV, and magazines. However, all these sources were used much less than the healthcare professional. In addition, older participants were more likely to seek and obtain health information and rely on the healthcare professional more often than younger participants. In contrast, younger participants sought information on the Web more often than the older participants. Thus, the participants of these two studies, which were published 10 years apart, are very similar in HISB except for the use of the Web (which may be partially explained by the advances in technology in the last 10 years).

A review of the literature found two studies addressing the HISB of Hispanics; one study occurred in western Texas (Hsai, 1987) and the other in Los Angeles, CA (Cheong, 2007). Both studies demonstrated that Hispanics seek most health information from interpersonal network (i.e., family, friends), which has remained unchanged in the 20 years between both studies. The sources identified after interpersonal network vary on the basis of numerous factors (e.g., education, income, immigration generation, and literacy).

Hsai (1987) noted that many factors influenced HISB and that ultimately the best way to reach Hispanic individuals in west Texas was to provide health information in newspapers read by community leaders who would then spread the word through the interpersonal network because most individuals did not pay attention to mass media.

Cheong (2007) found that ethnically targeted television was a source used by participants secondary to the interpersonal network. Also, there is a significant difference in HISB between those who are insured and those who are uninsured. Those who are uninsured, first generation immigrants, and part of a lower socioeconomic group were more likely to use ethnically targeted television for health information. In comparison, the insured participants were more likely to use newspapers in English and mainstream television for health information. The difference in secondary sources of information may reflect the change in technology that opened up the opportunity for ethnically based television.

A study completed in Australia examined sources of health information in three different socioeconomic communities (Dart, Gallois, & Yellowlees, 2008). In all three communities, the physician was considered the most trusted, important, and preferred future source for information. The most significant difference between the communities was the current and preferred future use of the Internet. The university community considered the Internet an important current and future source of health information. The other most common sources of health information include family and friends, television, Internet, health pamphlets from doctors' office, and magazines (Dart et al., 2008).

INTERNET/COMPUTER USAGE

Recent HSIB research has focused solely on the use of the internet and computers (and no other sources) in relationship to various variables including age, race/ culture, literacy/health literacy, and web use. The relationships between these variables and the use of the internet/computer for HSIB are described in the next several sections.

Older Individuals

Research studies consistently show that older individuals do use the computer and Internet to seek information (Campbell, 2005; Campbell & Nolfi, 2005; Flynn, Smith, & Freese, 2006; Leung, Ko, Chan, Chi, & Chow, 2007; Lorence, Park, & Fox, 2006). Those who use the computer/ Internet for information were more likely to be individuals who attended workshops in which they were satisfied (Leung et al., 2007). For those who had Internet access at home, years of education and an openness-to-experience was related to Internet use for health information (Flynn et al., 2006). Older individuals use the Internet more for health information than younger individuals (Lorence et al., 2006). Older individuals who took more medications used the Internet more for health information (Campbell, 2005; Campbell & Nolfi, 2005; Flynn et al., 2006). However, two studies show that despite the use of the Internet, older individuals do not use the information from the Internet to change the way they participate in healthcare; when it comes to decision making, older individuals prefer a physician-centered model of care (Campbell, 2005; Campbell & Nolfi, 2005).

Race/Culture

Two studies involving Hispanics noted that Hispanics utilize the computer less than non-Hispanics and are less likely than non-Hispanics to seek information on the Internet (Lorence, Park, & Fox, 2006; Pena-Purcell, 2008). The use decreased in middle- and low-income households (Pena-Purcell, 2008). In addition, Hispanics who brought Internet information to physician visits felt that it led to worsened patient-physician relationship (Pena-Purcell, 2008). African Americans also utilize the Internet less than Caucasians (Lorence et al., 2006).

Other countries have also examined Internet usage for health information. In Croatia, the leading motivation for seeking information was the individual perceiving that he or she had insufficient information after seeing the physician (Delic, Polasek, & Kern, 2006). Most looked for information on a specific condition and half discussed the information found with their healthcare provider. In Sweden, women used the Internet more for healthcare information and the younger and middle-aged population used the computer more than the older population (Rahmqvist & Bara, 2007).

Literacy/Health Literacy

When examining the Web searching of low-literacy adults, it was noted that the study participants used sponsored Web site more than a search engine for heath information. In addition, participants used Web sites that have a reading level of grade 10 or higher, which inhibited optimal use (Birru et al., 2004). Donelle and Hoffman-Goetz (2008) completed a content analysis based on Nutbeam's model of health literacy of an online health chat room used by African American women in North America. Analysis showed that the reading level was below eighth grade and the chat provided information on social support, healthy behaviors, and motivation for political involvement.

Web Users

Research has focused on identifying individuals who use the Internet for health information. Ayers and Kronenfeld (2007) noted that those individuals with higher number of chronic health conditions utilize the Internet more than those with less health conditions. In addition, the more often an individual uses the Internet for health information, the more likely the person will change health behaviors. A study involving military combat veterans showed that accessing the Internet and using the Internet to seek health information varied by age and race (Schneiderman, Lincoln, Cubow, & Kang, 2004). Caucasians continue to use the Internet at a higher rate than non-Caucasians. However, the gap between groups based on age and race has decreased over time.

In a study involving three urban clinics, 53% of the participants use the Web or e-mail and of those, 63% use it for health information. Twenty-two percent relied on others to search the Web for them. Common Web areas searched include health/nutrition and physical illness. Those with less education and non-White used the Web less (Dickerson et al., 2004). More active Web users include diabetic patients and pregnant women, and the Web users were more likely to engage in discussions forums and health portals (Eriksson-Backa, 2003). Warner and Procaccino (2007) demonstrated that Web users versus non-Web users sought health information more often and used this information when communicating with medical professionals. Web users also utilized this information to influence medical decisions and reported a greater awareness of health resources whether it is Web based or some other format (e.g., print, multimedia). Web users did not find that seeking health information from any source was easier.

Health Orientation

With the invention of the computer/Internet/Web, HISB research has focused on the use of these mediums over the last 15-20 years. In addition, public initiatives have focused on the Internet to deliver larger quantities of health information to larger groups of individuals. However, as the research presented in this article has shown, the use of computers and the Internet has not resulted in all individuals receiving and understanding necessary heath information. Even patients who have access to large amounts of healthcare information chose not to use it. Thus, HISB is influenced by numerous factors, not just access to the Internet, race, age, income, or education. Research has been initiated and completed, which examines factors (beyond those just listed) having an impact on HISB. One of the most recent concepts introduced into the discussion on factors impacting HISB is "health orientation" (Dutta-Bergman, 2004b, p. 273).

Dutta-Bergman (2004b) (also in the literature as Dutta) has brought to the forefront of HISB the idea that those who seek health information are more health oriented. These individuals have a stronger interest in health as demonstrated through certain health behaviors and attitudes than those who do not seek health information (Dutta-Bergman, 2004a). In a study using the HealthStyle database, results showed that individuals who used the Internet for a large number of health purposes are typically more health oriented (Dutta-Bergman, 2004a). In another study, health-oriented individuals were more likely to seek health information from newspapers, magazines, the Internet, and interpersonal networks.

TV and radio are viewed as more passive media outlets for health information. Researchers make the assumption that these outlets are considered the primary source of health information for individuals who are less health oriented (Dutta-Bergman, 2004b). However, further investigation into the use of TV as a source of health information shows that those who gain the most from health information on the TV are those who are more health oriented. Thus, health orientation is the largest factor in determining what individuals learn from TV (Dutta, 2007).

Research also demonstrates that health consciousness positively predicts consumers' search for health information beyond their healthcare provider. Five activities have emerged as predictors of an individual's intent to search for health information beyond the healthcare provider. These activities include interpersonal communication, community participation, newspaper readership, magazine readership, and Internet usage (Dutta-Bergman, 2005).

Conclusion

A review of the literature about HISB shows that many factors influence where and how individuals seek health information. Based on observation and research, several theories/models have been proposed to explain HISB that demonstrate the factors that influence this process. For studies that investigated sources of health information beyond the Internet, the healthcare professional was cited as the most common and trusted source of information. The source of information sought most often after the healthcare professional was not consistent in different populations. In some groups such as the Hispanics, family and friends were the next source of health information after healthcare professionals. For others such as the younger population, the Internet was a source of information after the healthcare professional. Overall, Caucasians used the Internet for health information more than non-Caucasians. Those with less education/lower health literacy used the TV and radio as a secondary source of information.

Individuals seek health information from healthcare professionals and supplement this information with other sources such as the Internet, nonelectronic written material, TV, radio, and family/friends/coworkers. How supplemental sources are used and to what extent vary on the basis of many factors such as age, race, education, health literacy, and health status, to name a few. In addition, the use (of information gained from supplemental sources) in making medical decisions depends on the individual and is related to factors such as Internet usage, age, and trust in source of health information. Overall, older individuals make decisions solely based upon information provided by the healthcare professional more often than younger individuals, even though they have additional information from various sources.

As nurses, we need to be aware of where and how our patients seek health information to ensure that we are using effective methods to disseminate health information. Nurses also need to have knowledge about the health information patients use to make decisions. This awareness and knowledge guide the nurse in effectively educating patients and supporting their medical decision making.

REFERENCES