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Health and Cancer Information Seeking Practices and Preferences inPuerto Rico: Creating an Evidence Base for Cancer Communication EffortsGuillermo Tortolero-Lunaa; Lila J. Finney Ruttenb; Bradford W. Hessec; Terisa Davisd; Julie Kornfelde;Marta Sancheza; Richard P. Moserc; Ana Patricia Ortiza; Ruby A. Serrano-Rodríguezf; Kia Davisb

a University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico b SAIC, Inc. NationalCancer Institute, Frederick, Frederick, Maryland, USA c National Cancer Institute, Bethesda, Maryland,USA d Westat, Inc., Rockville, Maryland, USA e University of Miami, Miami, Florida, USA f PR-BRFSS,Puerto Rico Department of Health, San Juan, Puerto Rico

Online publication date: 10 December 2010

To cite this Article Tortolero-Luna, Guillermo , Finney Rutten, Lila J. , Hesse, Bradford W. , Davis, Terisa , Kornfeld, Julie ,Sanchez, Marta , Moser, Richard P. , Ortiz, Ana Patricia , Serrano-Rodríguez, Ruby A. and Davis, Kia(2010) 'Health andCancer Information Seeking Practices and Preferences in Puerto Rico: Creating an Evidence Base for CancerCommunication Efforts', Journal of Health Communication, 15: 1, 30 — 45To link to this Article: DOI: 10.1080/10810730.2010.522698URL: http://dx.doi.org/10.1080/10810730.2010.522698

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Health and Cancer Information Seeking Practicesand Preferences in Puerto Rico: Creating an

Evidence Base for Cancer Communication Efforts

GUILLERMO TORTOLERO-LUNA

University of Puerto Rico Comprehensive Cancer Center,San Juan, Puerto Rico

LILA J. FINNEY RUTTEN

SAIC, Inc. National Cancer Institute, Frederick, Frederick,Maryland, USA

BRADFORD W. HESSE

National Cancer Institute, Bethesda, Maryland, USA

TERISA DAVIS

Westat, Inc., Rockville, Maryland, USA

JULIE KORNFELD

University of Miami, Miami, Florida, USA

MARTA SANCHEZ


RICHARD P. MOSER

National Cancer Institute, Bethesda, Maryland, USA

ANA PATRICIA ORTIZ


RUBY A. SERRANO-RODRIGUEZ

PR-BRFSS, Puerto Rico Department of Health, San Juan, Puerto Rico

Address correspondence to Guillermo Tortolero-Luna, University of Puerto RicoComprehensive Cancer Center, Cancer Control and Population Sciences, PMB 711, 89 DeDiego Ave., San Juan, 00926 Puerto Rico. E-mail: [email protected]

Journal of Health Communication, 15:30–45, 2010Copyright # Taylor & Francis Group, LLCISSN: 1081-0730 print=1087-0415 onlineDOI: 10.1080/10810730.2010.522698

30

Downloaded By: [National Institutes of Health Library] At: 18:05 16 December 2010

KIA DAVIS

SAIC, Inc. National Cancer Institute, Frederick, Frederick,Maryland, USA

Effective communication around cancer control requires understanding ofpopulation information seeking practices and their cancer-relevant risk behaviors,attitudes, and knowledge. The Health Information National Trends Survey(HINTS) developed by the U.S. National Cancer Institute (NCI) provides surveil-lance of the nation’s investment in cancer communication tracking the effects of thechanging communication environment on cancer-related knowledge, attitudes, andbehaviors. TheUniversity ofPuertoRicoComprehensiveCancerCenter (UPRCCC),the Puerto Rico Behavioral Risk Factors Surveillance System (PRBRFSS), and theNCI implemented HINTS in Puerto Rico in 2009. In this article we describe thehealth and cancer information seeking behaviors, sources of information, trust ininformation sources, and experiences seeking information among the population ofPuerto Rico. A total of 639 (603 complete and 36 partially complete) interviewswere conducted. Nearly one-third of respondents had ever looked for informationabout health (32.9%) or about cancer (28.1%). The Internet was the most fre-quently reported source of information. College educated (odds ratio [OR]¼ 7.6)and females (OR¼ 2.8) were more likely to seek health information. Similarly, col-lege educated (OR¼ 5.4) and females (OR¼ 2.0) were more likely to seek cancerinformation. Only 32.7% of respondents had ever accessed the Internet, and collegeeducated were more likely to use it (OR¼ 12.2). Results provide insights into thehealth and cancer information seeking behaviors and experiences of the populationin Puerto Rico and contribute to the evidence base for cancer control planning on theisland.

Effective development and dissemination of cancer control messages to the publicrequires a firm understanding of individuals’ information seeking practices andpreferences, and cancer-relevant risk behaviors, attitudes, and knowledge(Nelson et al., 2004). The Health Information National Trends Survey (HINTS)was developed by the U.S. National Cancer Institute (NCI) as a mechanism forcollecting such data to inform effective health communication strategies acrosspopulations. Specifically, HINTS was developed to assess cancer-relevant beha-vior, such as prevention, screening, and treatment, in the population in orderto assess associations between key communication constructs and behavioraloutcomes and to monitor trends in the rapidly evolving health communicationlandscape.

One limitation of national-level HINTS datasets is that the sample sizes are notlarge enough to conduct state-level or more geographically local analyses. Toaddress this limitation, the NCI has been exploring possibilities for expandingHINTS data collection efforts beyond the NCI-sponsored national-level surveys.To this end, a demonstration project was conducted, utilizing existing BehavioralRisk Factor Surveillance System (BRFSS) infrastructure in Puerto Rico, to assessthe feasibility of adapting the national HINTS survey to local settings and to collectlocal data to inform cancer planning. Puerto Rico provided an opportunity toimplement HINTS outside the continental United States in a Hispanic Spanish-speaking population. The specific aims of the demonstration project were to identifyoperational issues with conducting a local HINTS data collection and to collect datafor use in scientific research and cancer control planning for Puerto Rico.

Health and Cancer Information Seeking Practices in Puerto Rico 31


https://www.researchgate.net/publication/228909860_The_Health_Information_National_Trends_Survey_HINTS_Development_Design_and_Dissemination?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx

Puerto Rico has a population of approximately 4 million and has the highestpopulation density of any state or territory (U.S. Census, 2009). The country isdivided into 78 municipalities or counties, with the highest concentration of popu-lation in the northeastern coastal region. Almost one-third of the population (29%)concentrates in the San Juan Metropolitan Area (SJMA), which consists of sevencounties, and approximately 40% of the population resides in 10 counties (U.S.Census, 2009). The median age of the population is 36.2 years, 52% are women,and 45% of the total population and 41% of families lived below the poverty lineas defined by Bishaw & Macartney (2010). The residents of Puerto Rico have amedian income that averages approximately 34% of the income of the residentsin the United States.

Cancer is the second cause of death in Puerto Rico, with over 10,000 casesdiagnosed and approximately 4,000 cancer-attributable deaths each year (Figueroa,De la Torre, Ortiz, Perez, & Torres, 2008). Approximately 5,569 men and 4,674women are diagnosed with cancer each year, and approximately 2,724 men and2,042 women die from cancer each year. In Puerto Rico, cancer is the second leadingcause of death, accounting for 16.6% of all deaths in 2004 (Puerto Rico Departmentof Health, 2004).

The University Puerto Rico Comprehensive Cancer Center (UPRCCC) is com-mitted to reducing the burden of cancer of the Puerto Rican population through amultidisciplinary approach of basic, clinical, epidemiological, and behavioral scienceresearch in cancer prevention and control; and delivering research-driven cancercare. The HINTS Puerto Rico provides an opportunity to better understand thecancer information and education needs of the population in Puerto Rico. In thisreport, we describe the health and cancer information seeking behaviors, sourcesof information, trust in information sources, and experiences seeking informationamong the population of Puerto Rico. In addition, we explore the role of sociodemo-graphic characteristics in information seeking and sources of information. To ourknowledge, this is the first study in Puerto Rico assessing the health and cancer infor-mation seeking behaviors, the use of Internet for seeking health information, and theexperience of seeking information in the island.

Methods

Data Collection and Response Rates

The UPRCCC, in collaboration with the PR-BRFSS; the NCI’s Cancer InformationService Coastal Region; Westat, Inc.; and the NCI; fielded the 2007 HINTS instru-ment in Puerto Rico. Data collection was conducted through the PR-BRFSStelephone research center using random digit dialing (RDD), computer assisted tele-phone interview (CATI). The interviews were conducted by experienced bilingualPuerto Rican interviewers.

Project-specific training, consisting of interviewer reference materials, interactivesessions, and dyad role plays, was conducted with specific attention to contact pro-cedures to maximize respondent cooperation. Interviewers were assigned to work onthe study during the Puerto Rico Department of Health telephone center operatinghours (9 a.m. to 9 p.m. on weekdays, 10 a.m. to 6 p.m. on Saturdays, and 1 p.m. to6 p.m. on Sundays). Interviews were conducted primarily in Spanish. If a respondenteither requested to complete the interview in English or if the interviewer determined

32 G. Tortolero-Luna et al.


that the respondent spoke only English, the case was transferred to a bilingual inter-viewer with a high level of English proficiency. The bilingual interviewers conductedinterviews in English or went back and forth between English and Spanish asnecessary.

Selected residential numbers participated in an initial screening interview to sel-ect an eligible person from the household for an extended interview.

The screening involved asking the respondent how many adults live in theirhousehold and discerning the number of telephones in the household. One adultper household was sampled for the extended interview using an algorithm designedto minimize intrusiveness. All screener refusals except for hostile refusals were con-tacted 3 days after their refusal to attempt refusal conversion.

If the screener contact was selected for the extended interview, the interviewerbegan the interview immediately upon completion of the screening. If someone elsein the household was selected, the interviewer asked to speak to that person toconduct the extended interview. If the extended respondent was unavailable, thetelephone center tried to conduct the extended interview at a different time and=oron a different day. All extended refusals except for hostile refusals were contacted3 days after their refusal to attempt refusal conversion. Only one stage of refusal con-version was attempted for both screeners and extended interviews—if a secondrefusal occurred, conversion efforts were ceased for that case.

Initial cooperation with both the screener and extended interview was very high,with 93% of respondents cooperating with the survey request. The field period forHINTS Puerto Rico was April 27 through June 28, 2009. A total of 603 completedinterviews were collected, and an additional 36 partially complete interviews werecollected, bringing the total to 639. The unweighted response rate for the screenerand extended interview was the same, 76.3%.

Sampling Design

A stratified sampling frame representing eight geographic regions of the Puerto RicoDepartment of Health was employed. These strata are also used as sampling stratafor the PR-BRFSS. Within each stratum, sampled phone numbers were selected withequal probability. Nonworking and nonresidential numbers were eliminated fromthe sample.

Instrument Development and Translation

The HINTS 2007 CATI instrument was built on the previous iterations of HINTS,with a goal of maintaining approximately 50% of the previous items. In addition tothe development of potential new questions, a review of all previously included ques-tions was conducted by working groups at NCI to determine their appropriatenessfor the 2007 instrument. Once a preliminary set of questions was identified, threerounds of cognitive testing were conducted. The cognitive interviews adhered to asemistructured protocol, with an interviewer asking selected questions and thenprobing respondents’ comprehension of the questions and observing any difficulties.Edits were made to the questions as indicated by the results of these interviews. Atotal of 27 cognitive interviews were conducted as part of the development of thefinal HINTS 2007 CATI instrument.



The HINTS 2007 instrument was translated into Spanish by a native Spanishspeaker with extensive experience in survey translation. Because HINTS 2007 is anational survey, the translation was developed to be as generic as possible so thatrespondents from any area of the Spanish-speaking world would easily understandthe questions. The initial translation then was reviewed by a different native Spanishspeaker for accuracy and clarity, with edits made as needed. For HINTS PuertoRico, the translation used for HINTS 2007 was carefully reviewed and edited for lan-guage appropriateness for the island population by the HINTS Puerto Rico team. Inaddition to reviewing the translation of the questions from HINTS 2007, the unspo-ken response options and interviewer directions were also translated into Spanish.This helped the Puerto Rican interviewers who conducted 100% of interviewscompletely in Spanish (vs. in the national HINTS where interviewers toggledbetween Spanish and English).

To ensure that the revised translation of the HINTS Puerto Rico survey wasunderstood by both interviewers and survey respondents, a small pilot test with 20participants (10 men and 10 women) was conducted over the phone using apaper=pencil version of the instrument. Edits were made to the translation basedon any difficulties encountered by either respondents or interviewers.

Measures

Health and Cancer Information Seeking and SourcesRespondents were asked the following questions about general health andcancer-specific information seeking: ‘‘Have you ever looked for information abouthealth or medical topics from any source?’’ and ‘‘Have you ever looked for cancerinformation from any source?’’ Those indicating they search for health or cancerinformation were asked to identify the source: ‘‘The most recent time you lookedfor information about health or medical topics, where did you go first?’’ Responseswere categorized in four groups: Internet, printed media, health care professionals,others (interpersonal, television, radio, telephone, health organizations, etc.).

Trust in Health Information SourcesTrust in health information sources was assessed by separate items asking respon-dents, ‘‘In general, how much would you trust information about health or medicaltopics from . . . doctor or health care providers; family or friends; radio; television;printed media; the Internet; government agencies; and charitable organizations.’’Respondents rated their level of trust for each source as a lot, some, a little, ornot at all.

Use of the Internet for HealthUse of the Internet and related behavior including buying medicine, participating ina support group, and emailing a healthcare provider was assessed. Responses werecoded as yes=no.

Sociodemographic CharacteristicsSociodemographic characteristics included age (18–34, 35–49, 50–64, and 65þ years),sex, education (less than high school, high school graduate, some college or technicalschool, and college graduate or more), ethnicity (Hispanic=non-Hispanic), place ofbirth (Puerto Rico, U.S. Mainland, Other), annual household income (<$15,000,



$15,000–24,999, $25,000–34,999, $35,000þ), marital status (married or living asmarried=not currently married), and employment status (currently employed=notcurrently employed).

Data Analysis

We used SUDAAN version 9.0.1 (Research Triangle Institute, Research TrianglePark, NC) to account for the complex sampling design used in HINTS and to incor-porate the jackknife replicate weights needed to compute accurate standard errors.All analyses were weighted to estimate standard errors of point estimates for thecomplex survey data. Data were weighted accordingly to control total estimates ofsex, age, education, and marital status from the American Community Survey

Table 1. Distribution of sociodemographic characteristics ofstudy participants (n¼ 639)

Sample n Weighted %

SexMale 189 46.3Female 450 53.7

Age18–34 81 31.935–49 115 27.950–64 194 21.465þ 249 18.7

EducationLess than high school 170 24.0High school graduate 147 27.8Some college (AA) 121 27.9College graduate (BA=BS) 162 20.3

EthnicityHispanic 595 98.9Non-Hispanic 8 1.1

Place of birthPuerto Rico 571 93.1Continental U.S. 18 3.1Other 14 3.8

Income<$15,000 170 36.9$15,000–$24,999 101 27.2$25,000–$34,999 43 14.4$35,000þ 76 21.5

Employment statusCurrently employed 165 40.8Not currently employed 433 59.2

Marital statusMarried or living as married 310 48.5Not currently married 293 51.5



(ACS) for Puerto Rico to provide representative estimates of the adult population inPuerto Rico. We calculated descriptive statistics for all variables included in thisanalysis. We conducted bivariate analysis between sociodemograhic characteristicsand the outcomes of interest (health and cancer information seeking, sources of healthinformation, and Internet use for health-related information) using the Pearsonchi square test. Finally, based on the results of the bivariate analysis, we conductedseparate multivariate logistic regression models for each of the outcomes of interest(health information seeking, cancer information seeking, and health-related use ofthe Internet) to estimate ORs and their 95% confidence intervals (CIs) for the associ-ation between sociodemographic characteristics and these behaviors.

Results

Sociodemographic Characteristics

Table 1 presents the unweighted sample size and weighted percentages of the HINTSPuerto Rico sample by sociodemographic characteristics. Of respondents, 98.9%self-identified as Hispanics; 93.1% were born in Puerto Rico. Approximately 54% ofrespondents were women, 40% were aged 50 and over, and 76% had high school orhigher level of education. Most participants (94%) had some form of healthcare

Table 2. Percentage (weighted) of health and cancer information seekers andsources of health and cancer information in Puerto Rico

Weightedpercent

Information seekingHave you ever looked for information about health or medical topicsfrom any source? (n¼ 639)Yes 32.9No 67.1

Have you ever looked for information about cancer from any source?(n¼ 639)Yes 28.1No 71.9

Sources of informationThe most recent time you looked for information on health or medicaltopics, where did you go first? (n¼ 219)Internet 56.4Printed materials 27.7Health care professionals 12.5Other 3.3

The most recent time you looked for cancer information, where did yougo first? (n¼ 181)Internet 47.0Printed materials 30.4Health care professionals 15.1Other 7.5



coverage, either the government run health program (40% of the population) or othertype of insurance. Among respondents who provided information on householdincome (61% of the sample), 65% reported household annual income below $25,000.

Health Information Seeking Behavior and Experiences

Population estimates for health and cancer information seeking behavior and experi-ences are summarized in Table 2. Nearly one-third of respondents (32.9%) reportedthat they had ever looked for information about health or medical topics. The mostfrequently reported source for health or medical information was the Internet(56.4%) followed by print media (27.7%). Similarly, 28.1% of respondents reportedhaving ever looked for cancer information, with the Internet (47.0%) and printedmedia (30.4%) being the most frequently identified information sources.

Respondents were asked to rate a series of statements to characterize their mostrecent search for health or medical information (see Table 3). While the majority of

Table 3. Reported experience of health information seekers in Puerto Rico

Based on the results of your most recent search for informationabout health or medical topics, how much do you agree ordisagree with the following statements? (n¼ 219)

Weightedpercent

It took a lot of effort to get the information you neededStrongly agree 7.5Agree 10.2Disagree 16.3Strongly disagree 66.0

You felt frustrated during your search for the informationStrongly agree 6.8Agree 4.3Disagree 17.0Strongly disagree 71.8

You were concerned about the quality of the informationStrongly agree 5.3Agree 14.5Disagree 23.4Strongly disagree 56.8

The information you found was hard to understandStrongly agree 4.5Agree 11.8Disagree 17.2Strongly disagree 66.6

Overall, how confident are you that you could get health-related advice orinformation if you needed it? (n¼ 629)Completely confident 26.8Very confident 39.0Somewhat confident 15.7A little confident 13.8Not at all confident 4.7



respondents were generally positive in their characterization of their informationseeking experiences, 17.7% agreed that it took a lot of effort to get the informationthat they needed; 11.1% agreed that they felt frustrated during their search; 19.8%agreed that they had concerns about information quality; and 16.3% agreed thatthe information they found was hard to understand.

Confidence in one’s ability to obtain necessary health or medical informationwas generally high, with 26.8% of respondents indicated that they were ‘‘completelyconfident’’ and 39.0% ‘‘very confident’’ they could obtain health-related informationor advice if they needed it.

Respondents were asked if they ever go on-line to access the Internet or WorldWide Web (Table 4). Respondents who indicated that they ever accessed the Internet(32.7%) were asked a series of questions about their health-related on-line activities.Among these respondents, 1.7% indicated that they had bought medicine or vitaminson-line, 9.1% participated in on-line support groups; and 7.6% communicated with adoctor or a doctor’s office.

Trust in Health Information Sources

Respondents rated their trust in several potential sources of health or medical infor-mation (Table 5). The most highly trusted sources were healthcare providers andgovernment health agencies, with a respective 76.5% and 47.7% of respondents indi-cating ‘‘a lot’’ of trust in these entities. The least trusted sources were the Internetand religious organizations, with a respective 27.0% and 18.0% of respondents indi-cating that they trusted these sources ‘‘not at all.’’

Factors Associated With Health and Cancer Information Seeking

Table 6 summarizes crosstabulation with chi square of sociodemographic variableswith health or medical information seeking, cancer information seeking, and access

Table 4. Percentage (weighted) of Internet users and Internet usage for health inPuerto Rico

Do you ever go on-line to access the Internet or World Wide Web, or to send orreceive e-mail? (n¼ 639)Yes 32.7No 67.3

Have you bought medicine or vitamins on-line? (n¼ 142)Yes 1.7No 98.3

Participated in an on-line support group for people with a similar health ormedical issue? (n¼ 142)Yes 9.1No 90.9

Used e-mail or the Internet to communicate with a doctor or a doctor’s office?(n¼ 142)Yes 7.6No 92.4



Table 5. Trust in sources of health and medical information

Weighted percent

Trust doctor (n¼ 638)A lot 76.5Somewhat 14.4A little 7.0Not at all 2.1

Trust family (n¼ 632)A lot 23.0Somewhat 34.0A little 30.2Not at all 12.8

Trust radio (n¼ 629)A lot 17.9Somewhat 33.8A little 34.2Not at all 14.1

Trust Internet (n¼ 594)A lot 24.4Somewhat 27.7A little 20.9Not at all 27.0

Trust TV (n¼ 633)A lot 24.5Somewhat 35.4A little 31.0Not at all 9.1

Trust magazines and newspapers (n¼ 632)A lot 22.8Somewhat 36.0A little 30.1Not at all 11.2

Trust government health agencies (n¼ 627)A lot 47.7Somewhat 25.2A little 20.1Not at all 7.0

Trust charitable organizations (n¼ 616)A lot 25.1Somewhat 33.6A little 27.6Not at all 13.7

Trust religious organizations (n¼ 625)A lot 22.2Somewhat 31.9A little 27.9Not at all 18.0



to the Internet. Education, income, age, and sex were significantly associated withhealth information seeking. Education, age, and sex were significantly associatedwith cancer information seeking. Age, education, income, and employment statuswere significantly associated with use of the Internet.

Variables significantly associated at the bivariate level with health and cancerinformation seeking or Internet access were entered into separate multivariate logis-tic regression models to identify independent associates. Because a large number ofrespondents did not wish to disclose their income, the income variable was notincluded in any of the multivariate analyses.

Table 6. Health and cancer information seeking and Internet use by sociodemo-graphic characteristics (weighted percent)

Sought healthinformation

Sought cancerinformation

Uses Internet orWWW

Weightedpercent

Weightedpercent

Weightedpercent

SexMale 22.6 20.7 35.1Female 41.8 34.5 30.7

p< .001 p< .01 p¼ .44Respondent age18–34 39.6 31.6 58.135–49 33.5 35.4 37.050–64 34.6 23.9 13.565þ 18.8 16.1 5.0

p< .001 p< .001 p< .0001EducationLess than high school 15.1 11.9 1.5High school graduate 21.9 16.7 23.8Some college (AA) 41.0 43.3 50.0College graduate (BA=BS) 56.4 41.1 59.9

p< .0001 p< .0001 p< .0001Income<$15,000 21.2 23.1 6.9$15,000–$24,999 32.0 18.6 28.2$25,000–$34,999 20.7 13.8 19.4$35,000þ 58.0 34.8 58.1

p< .01 p¼ .09 p< .01EmploymentCurrently employed 32.3 25.7 42.4Not currently employed 32.6 30.1 26.9

p¼ .95 p¼ .46 p< .05Marital statusMarried or living as married 28.5 27.0 26.8Not currently married 36.7 28.5 38.7

p¼ .16 p¼ .78 p¼ .07



Table 7 summarizes the results for the three logistic models. For both health andcancer information seeking, respondents with higher levels of education and femaleswere more likely to seek health information. Those with college or higher educationwere more likely to have sought health and cancer information; odds ratio(OR)¼ 7.6, 95% confidence interval (CI) 3.0–19.3 and OR¼ 5.4, 95% CI 1.8–14.1,respectively. Similarly, women were more likely than men to have sought health

Table 7. Multivariate logistic models

Health and cancer information seeking

Model 1 Model 2Sought healthinformation

Sought cancerinformation

OR (95% CI) OR (95% CI)

SexMale 1.0 1.0Female 2.8 (1.6–5.0) 2.0 (1.2–3.3)

Respondent Age18–34 1.0 1.035–49 0.7 (0.3–1.6) 1.3 (0.5–3.0)50–64 0.9 (0.4–1.9) 0.8 (0.4–1.8)65þ 0.7 (0.3–1.4) 0.9 (0.4–2.3)

EducationLess than high school 1.0 1.0High school graduate 1.7 (0.6–4.3) 1.5 (0.5–4.6)Some college (AA) 4.1 (1.8–9.0) 5.6 (2.1–15.2)College graduate (BA=BS) 7.6 (3.0–19.3) 5.4 (1.8–14.1)

Multivariate logistic model for Internet or WWW use

Testing parametersModel 3

Uses Internet or WWWOR (95% CI)

Respondent Age18–34 1.035–49 0.3 (0.1–0.7)50–64 0.1 (0.03–0.2)65þ 0.1 (0.02–0.2)

EducationHigh school graduate or less 1.0Some college (AA) 5.8 (1.7–19.6)College graduate (BA=BS) 12.2 (4.3–34.4)

EmploymentCurrently employed 1.0Not currently employed 1.1 (0.5–2.3)



information (OR¼ 2.8, 95% CI 1.6–5.0) and have sought cancer information(OR¼ 2.0, 95% CI 1.2–3.3; Table 7). Use of the Internet was also more likely amongthose with higher levels of education and those aged 18–34 years (Table 7). Respon-dents with some college or vocational training degree and those with college orhigher education were OR¼ 5.8 (95% CI 1.7–19.6) and OR¼ 12.2 (95% CI4.3–34.4) more likely to report having used the Internet. Compared with those aged18–34, older respondents (65þ years) were significantly less likely to report using theInternet (OR¼ 0.1, 95% CI 0.02–0.2).

Discussion

The primary aim of this investigation was to describe the implementation of HINTSin Puerto Rico and to examine health and cancer information seeking behaviors andexperiences among the population in Puerto Rico. To our knowledge, this is the firststudy in Puerto Rico assessing the health and cancer information seeking behaviors,use of Internet for health and information seeking, and experience seeking infor-mation in the island. Understanding the health information seeking behavior, theuse of different communication channels to obtain health and cancer information,and, in particular, the use of the Internet for health-related purposes is of greatrelevance given the rapid increase in the amount of information available, and itspotential to influence health behaviors, processes, and outcomes (Labert & Loiselle,2007; Rutten, Squiers, & Hesse, 2006; Viswanath, 2005).

Our results showed that approximately one-third of the adult population ofPuerto Rico has ever sought information on health in general or on cancer. The pro-portion of respondents in Puerto Rico who had ever looked for information abouthealth or medical topics from any source and had ever looked for information aboutcancer from any source was lower than that observed among respondents in theHINTS 2007 national (continental U.S.) sample (NCI, 2010). These findings areconsistent with previous studies that show that Hispanic populations are less likelyto be health information seekers (Rutten et al., 2006; Tortolero-Luna, 2006). Also,consistent with other studies, health information seeking and cancer informationseeking were strongly associated with sex and educational level (Rutten et al.,2006; Tortolero-Luna, 2006).

The most frequently identified source of health information in Puerto Rico wasthe Internet (56.4% of health information seekers and 47.0% of cancer informationseekers). This finding is consistent with the HINTS 2007 national sample (61.0% ofhealth information seekers and 54.8% of cancer information seekers; NCI, 2010).Based on the Pew Internet Project, 80% of Internet users have searched for infor-mation on at least one major health topic online (Fox, 2006). In HINTS PuertoRico, Internet health information seekers were more likely to be men, younger than50 years of age, and college graduates. These findings were consistent with data fromHINTS 2003 national samples (Hesse, 2005) and the results from the Pew InternetProject (Fox, 2006). The HINTS 2003 reported a higher percentage of Internet usersamong younger than age 65þ (64%) and college graduates (73%; Hesse, 2005). Simi-larly, the Pew Internet Project reported a higher percentage of Internet users amongthose younger than 50 years of age (57%) and those with more than high school edu-cation (62%; Fox, 2006). However contrary to HINTS Puerto Rico, in HINTS 2003and the Pew Internet Project women were more likely to report using the Internet forhealth purposes than men.



https://www.researchgate.net/publication/6876495_Relationship_between_English_Language_Use_and_Preferences_for_Involvement_in_Medical_Care_among_Hispanic_Women?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx


https://www.researchgate.net/publication/261773768_Online_Health_Search_2006?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx



https://www.researchgate.net/publication/7140196_Cancer-Related_Information_Seeking_Hints_from_the_2003_Health_Information_National_Trends_Survey_HINTS?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx




https://www.researchgate.net/publication/7426483_Trust_and_Sources_of_Health_Information_The_Impact_of_the_Internet_and_Its_Implications_for_Health_Care_Providers_Findings_From_the_First_Health_Information_National_Trends_Survey?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx



Our findings also suggest that while the Internet may serve as a first resource forhealth and cancer information seeking, physicians remain the most trusted source ofhealth information, followed by government health agencies. Thus, efforts to sup-port physicians in their role as information brokers, coupled with continued supportto government health agencies in the development and dissemination of health andcancer information are warranted.

Despite the importance of the Internet as a source of health and cancer infor-mation among information seekers, Internet penetration in Puerto Rico was relativelow, 32.7% compared with 68.5% reported in the HINTS 2007 national sample(NCI, 2010). Comparable rates of Internet users in Puerto Rico (25.2%) and theUnited States (74.1%) were reported by the Internet World Stats (Internet WorldStats, 2009). Use of the Internet was also more likely among those under age 35 yearsof age and those with higher levels of education. The sociodemographic differencesobserved in Internet use in Puerto Rico are similar to those identified among res-pondents to HINTS in the continental United States; however, overall Internet pen-etration appears to much lower on the island than in the continental United States(Atkinson, Saperstein, & Pleis, 2009; NCI, 2010). Therefore, the allocation ofresources to create greater access to on-line information has great potential forreaching a broad audience of consumers and giving them the necessary tools tobecome more engaged consumers of health information.

In addition to the low Internet penetration in Puerto Rico, only 24.4% of part-icipants reported trusting ‘‘a lot’’ the Internet as a source of medical and healthinformation. This finding is consistent with results from the HINTS 2005 nationalsample, which reported that 19% of all respondents and 25.4% of Hispanic respon-dents trusted the Internet as a source of health information (Rutten, Moser,Beckjord, Hesse, & Croyle, 2007). A small, but significant, percentage of thepopulation reported some difficulties with their last search for information includinghaving to exert a lot of effort, experiencing frustration, and having concerns aboutinformation quality and difficulty understanding information. Furthermore, nearlyone-third of respondents reported that they were only somewhat, a little, or not atall confident in their ability to obtain necessary health information. These findingssuggest the need for improvement in the information seeking experience of the popu-lation of Puerto Rico. Recognition of existing challenges with health informationseeking, including reported effort, frustration, concerns about information quality,and difficulty understanding information obtained provides a starting point forrevising existing resources and materials to be more consumer-friendly and access-ible. These data also point to disparities in cancer and health information seekingas well as Internet access. In particular, level of education appears to be a key factorassociated with seeking behavior and experience. Efforts to reach populations whoface additional barriers to information access due to lower levels of education andliteracy may include development of public service announcements for disseminationthrough population media such as television and radio.

The HINTS Puerto Rico has limitations inherent to the survey design,cross-sectional nature of the data, the use of RDD telephone methodology, andthe self-reported nature of the information; however, it provides data from a strati-fied representative sample from the eight geographic regions of the Puerto RicoDepartment of Health, a sample size large enough to conduct state-level analyses,and finding from HINTS in Puerto Rico that will inform cancer control planningefforts for the island.



https://www.researchgate.net/publication/24191161_Using_the_Internet_for_Health-Related_Activities_Findings_From_a_National_Probability_Sample?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx

Results from this analysis describe the health information seeking and communi-cation experience of Puerto Rico. In conclusion, implementation of HINTS inPuerto Rico demonstrates the feasibility of using existing survey infrastructure tocollect additional data and provides important insights into the health and cancerinformation seeking behaviors and experiences of the population in Puerto Rico.These data provide an evidence base for cancer and health communication effortsand can be incorporated into the cancer control plan for the island. The importanceof health communication on health outcomes, coupled with rapid changes in com-munication technology, underscore the importance of HINTS Puerto Rico data.Healthcare professionals, researchers, and policymakers may use HINTS PuertoRico data to understand differences in communication channels to obtain healthand cancer information, for developing models of health communication, and forprogram planning and evaluation.

References

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Hesse, B. W., Nelson, D. E., Kreps, G. L., Croyle, R. T., Arora, N. K., Rimer, B. K., &Viswanath, K. (2005). Trust and sources of health information: The impact of theInternet and its implications for health care providers: Findings from the first HealthInformation National Trends Survey. Archives of Internal Medicine, 165, 2618–2624.

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https://www.researchgate.net/publication/5917676_Health_Information-Seeking_Behavior?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx

https://www.researchgate.net/publication/5917676_Health_Information-Seeking_Behavior?el=1_x_8&enrichId=rgreq-6a27746b7810456f43f64b1f996c6a9c-XXX&enrichSource=Y292ZXJQYWdlOzQ5Njc5Njc2O0FTOjE3NTcxMzc3Njg0MDcwNEAxNDE4OTA0ODM3NzMx



















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