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International Journal of Medical Informatics (2004) 73, 503513

Information literacywhat it is about?


Literature review of the concept and the context
Kaija Saranto a,*, Evelyn J.S. Hovenga b,1

a
Department of Health Policy and Management, University of Kuopio, P.O. Box 1627, FIN-70211 Kuopio,
Finland
b
Faculty of Informatics and Communication, Central Queensland University, Rockhampton, Australia
Received 31 March 2003 ; received in revised form 21 October 2003; accepted 1 March 2004

KEYWORDS Summary Objectives: The use of IT in health care has merged advanced knowledge
Health informatics; and skills for health care professionals. Former studies indicate that basic skills in
Medical informatics; computer use are no more than comprehensive competencies to manage electroni-
Nursing informatics; cally stored information in health care. The purpose of this paper is to review the
Education;
literature focusing on the concept information literacy in the eld of health, nursing
and medical informatics. The target is to nd out how information literacy is dened,
Recommendations;
in what kind of context it is presented and who are the focus of interest. Methods:
Computer literacy;
An automated literature search was performed on-line to Medline and by using the
Information literacy; EndNote Bibliographic Software. All together the number of papers analyzed was 97
Computer skills; or 78% of the total literature search result. Results: The survey indicates that the con-
Information technology cept information literacy does not exist as such in the literature, but it can be found
literacy as a synonym to computer literacy or even more obscure concepts such as infor-
matics awareness or computer experience. The denitions of these concepts varied
considerably. A variety of descriptions of educational programs were also found, none
were based on the IMIA recommendations. Conclusions: In international cooperation
such as that of IMIA WG1, a wide range of efforts still needs to be carried out to com-
pile educational programmes in health informatics to enhance knowledge and skills
in computer use among health care professionals.
2004 Elsevier Ireland Ltd. All rights reserved.

1. Introduction informatics education for health care professionals


(http://www.imia.org/wg1). In their recommen-
Health informatics education has been a topic of dations IMIA WG1 has used a three dimensional
interest for the International Medical Informatics framework for educational needs that includes (1)
Association (IMIA) for many years. The Recom- professional in health care (IT user), (2) a type of
mendations on Education in Health and Medical specialization in health and medical informatics
Informatics by IMIA working group one (WG1) are (Health and Medical Informatics (HMI) Specialist
compiled to be used internationally as a basis for and (3) the stage of career progression for each.
The recommendations are classied into three
Corresponding knowledge/skill domain areas:
author.
E-mail addresses: kaija.saranto@uku. (K. Saranto),
e.hovenga@cqu.edu.au (E.J.S. Hovenga).
1. methodology and technology for the processing
1 Past chair, IMIA Health and Medical Informatics Education Work- of data, information and knowledge in medicine
ing Group. and health care;
1386-5056/$ see front matter 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijmedinf.2004.03.002
504 K. Saranto, E.J.S. Hovenga

2. medicine, health and biosciences, health system How is information literacy dened in recent pub-
organization; lications?
3. informatics/computer science, mathematics, Who are the focus of interest?
biometry.
Each domain has several learning and skill topics. In addition, attention was paid to the concept
Learning outcomes for each domain for all health of evidence based practice (EBP) as well as to the
care professionals in their role as IT users or HMI nationality of the authors.
Specialists, distinguish between introductory, inter-
mediate and advanced knowledge and skill. Infor-
mation literacy is one of the knowledge/skill topics 2. Material and methods
in the domain of Methodology and Technology for
the Processing of Data, Information and Knowledge 2.1. Sampling
in Medicine and Health Care. It focuses on library
classication and systematic health related termi- An electronic literature search was performed us-
nologies and their coding, as well as literature re- ing Medline (PubMed), Cumulative Index of Nurs-
trieval methods. For health professionals as IT users ing and Allied Health Literature (CINAHL) and Eric
the recommended level of knowledge and skills is databases. The search terms used were informa-
intermediate [1]. tion literacy, literacy and health, medical as well as
Many universities have also focused on informa- nursing informatics based on the review questions.
tion literacy demands from the librarys perspec- The search from Medline was made on-line us-
tive [2]. In addition the relationship between the ing EndNote Bibliographic Software. The keywords
concepts information literacy and computer or in- matched with 286 records and the search result
formation technology literacy in health care facili- was easy to explore further with the software
ties has emerged [3,4]. Information literacy can be options. The number of records in the PubMed
dened as an understanding and set of abilities search diminished once these were examined more
enabling individuals to recognize when information closely as all records with the terms nursing and
is needed and have the capacity to locate, eval- health informatics and information literacy were
uate and use effectively the needed information matched with and were duplicates of those found
[5]. Information technology literacy refers to a set using medical informatics and information literacy
of capabilities, knowledge and skills needed to use as the search terms. As well some of them were
information technology at a level appropriate to a duplicates to nursing and health informatics and
persons position, work environment and discipline medical informatics and literacy. The elimination
and the ability to continue to develop them into the of duplicates and records published before 1995
future [6]. Computer literacy has already existed was made automatically with the duplication op-
for many years in the literature [79] and the con- tion of the software. It was not possible to use the
tent of the concept has focused on basic knowledge on-line connection search of the Cinahl and Eric
and skills in computer use [10]. databases, thus the electronic databases of the lo-
Information retrieval from electronic resources cal library were used for searching. Records found
such as clinical and research databases is evident in the Cinahl database (n = 18) also had duplicates
for health care professionals. This requires both (n = 8) in PubMed searches. Due to the scarce num-
abilities and possibilities to access information as ber of records in the Cinahl database an additional
well as knowledge to recognize information needs search was made using the keywords information
and to assess the quality of the information. There literacy and nursing. Of those records (n = 7) two
is a demand to easily combine evidence-based re- had duplicates in former searches. There were only
search and clinical data in practice [11]. Thus not two records identied in the Eric database. How-
only the competencies of health care profession- ever, those papers were totally irrelevant to the
als, but also the availability of electronic databases subject. Obviously the scarcity of the number of
have to be taken in account. This paper reviews the the records in the educational database was due to
literature that focuses on the concept of informa- the Boolean operation search terms and nursing,
tion literacy. The purpose of the review was to an- health or medical. The resultant nal number of
swer the following questions: the papers to be examined was 125 (Table 1).

In what kind of publications have studies about 2.2. Content analysis


information literacy been published?
Within what context is information literacy pre- The inclusion criteria for the content analysis were
sented? that papers had to
Information literacywhat it is about? Literature review of the concept and the context 505

Table 1 No. of references found and total found to be useful


Search terms Medline via Published before 1995 19952001 Total
PubMed and number of
eliminated duplicates
Medical informatics and literacy 100 100
Medical informatics and information literacy 62 21 Hi-lit
13 Ni-lit
28 Mi-lit
Health informatics and literacy 48 11 Ni-lit 5
32 Mi-lit
Health informatics and information literacy 29 All included in Hi literacy
Nursing informatics and literacy 30 25 Mi-lit 5
Nursing informatics and Information literacy 19 All included in Ni literacy
Total 286 110
Search terms Cinahl via Published before 1995 and 19952001
ProQuest number of eliminated Total
duplicates
Medical informatics and literacy 1 1 Mi-lit
Medical informatics and information literacy 4 2 Mi-lit 2
Health informatics and literacy 2 1 Ni-lit 1
Health informatics and information literacy
Nursing informatics and literacy 11 4 Mi-lit 7
Nursing informatics and information literacy
Information literacy and nursing 7 2 Mi-lit 5
Total 25 15

(a) be written in English; and medical informatics. Beyond the content analy-
(b) be able to be retrieved electronically as full sis the concept was rst discovered in a publication
text or to be reached locally without an inter- in 1986.
national ordering procedure. The papers had been published mainly in jour-
nals (n = 55) and conference proceedings (n = 39).
The authors language abilities restricted the se- All in all papers were published in a variety of 28
lection of non-English papers, however only seven journals and seven different proceedings of which
papers published in languages other than English eight articles had been published in Medinfo95
were excluded from the sample. For a better cov- proceedings. The journals represented both health
erage available abstracts from readily available full informatics and health education elds. Only a few
text publications were also included in the content papers (n = 3) had been published as chapters in
analysis. All in all 65 papers and 32 abstracts (78% an edited book. The rst authors of the papers
out of 125 unique records identied) were included represented 19 countries. The two most common
for the analysis. As a rst step the papers and ab- countries were USA (n = 34) and Australia (n = 11)
stracts were identied on the basis of the review (Table 2). A total of 40 papers came from Europe.
questions. Then, an internal classication based on The countries represented the continent well.
each question was made. However, contributions from Asian countries were
missing.

3. Results 3.2. The context of information literacy

3.1. Type of publications where the papers The search identied papers describing:
have been published
(a) the content of health informatics education
The search strategy revealed that information lit- programmes or curriculum development in dif-
eracy is a relatively new concept in health, nursing ferent education levels and countries;
506 K. Saranto, E.J.S. Hovenga

Table 2 Context of information literacy among countries


Context of information Countries (N = 19)
literacy (papers n = 97a )
Australia Europe North America Others
Literacy assessment Australia (4), 12% Check Rebuplik, Croatia, Canada (2),
(n = 33) Denmark, Germany (2), USA (15), 52%
Ireland (2), Italy, Portugal,
Sweden, UK (2), 36%
Curriculum development Finland (2), Netherlands Canada (3),
(n = 11) (2), UK, 45% USA (3), 55%
Programme description Australia (7), 27% Finland, France, Ireland Canada, USA Lebanon, 4%
(n = 26) (2), Italy, Netherlands, (7), 31%
Romania (2), UK (2), 38%
Information system Germany, Italy, Canada, USA South Africa
implementation Netherlands, Romania, (9), 42% (2), 8%
(n = 24) Spain, Sweden (5), UK
(2), 50%
a
Three papers could not be categorized.

(b) assessment of computer skills and competen- basis of their references to be able to nd out if the
cies among health care professionals; IMIA recommendations for education (published in
(c) evaluation of information system implementa- 1998) had been considered. The recommendations
tion in health care; were not used as references in any of the papers.
(d) overviews of Electronic Patient Record (EPR) This is primarily due to the large number of ab-
development from technical as well as users stracts used for this review [32] where such a refer-
perspectives or IT (e.g. multimedia) education ence is unlikely. Many of the remaining papers were
integration. published prior to the publication of these guide-
lines.
The papers were classied on the basis of the The context of information literacy was also an-
following topics: (1) literacy assessment, (2) cur- alyzed with respect to countries of the authors
riculum development, (3) educational program (Table 2). Literacy assessment was of interest both
description, and (4) information system implemen- in Europe and USA. Curriculum development, pro-
tation issues (Table 3). The difference between gram description and information system imple-
curriculum development and educational program mentation were of most interest in Europe.
description seemed to be very slight. However
papers describing educational programs also had
information about the implementation of the pro- 3.3. The denition of the concept
gram. A frequent theme focused on the assessment information literacy
of information or computer literacy (n = 33). The
papers described many types of methods to assess The literature indicates a huge variety of deni-
computer skills both in education and in clinical tions of the concept information literacy. There
context [4,1243]. Education in health informat- were papers (n = 9) that totally lacked the concept
ics, i.e. papers describing informatics educational information literacy as well as papers (n = 31) that
programs (n = 26) [4469] and descriptions of cur- lacked the denition of the concept. Based on the
riculum development processes (n = 11) were also content analysis the concepts describing informa-
popular themes [7080]. There were also special tion literacy in the papers could be classied into
courses focusing on information retrieval skills three categories: (1) computer literacy or skills
[22,36,44,68,69]. The papers focused both on fac- (n = 33), (2) information literacy (n = 23), and
ulty issues and broadly on clinical aspects. The (3) informatics awareness or computer experience
category named Information system implementa- (n = 32). In some papers the denition could be
tion was also quite large (n = 23) [81103]. The derived from the context such as from objectives
most common topic of these papers was electronic of an educational program. Based on the denitions
patient records (EPR). Finally four papers proved they were classied into the categories.
to be irrelevant for the content analysis. The denition of computer literacy described
The papers focusing on curriculum development the basic or lowest level of computer use. The most
and educational programs were also analyzed on the frequent denition was connected to abilities to
Information literacywhat it is about? Literature review of the concept and the context 507

Table 3 Issues identied by number of references


Issues Comments and references n = 97a
1. Assessment of information Many types of assessment methods in n = 33
or computer literacy education or clinical context (refs.
[4,1243])
2. Description of educational Describing informatics educational n = 26
programs programs that included information
about program implementation (refs.
[4469])
3. Curriculum development Descriptions of curriculum n = 11
development processes (refs. [7080])
4. Information system Most common EPRs (refs. [81103]) n = 23
implementation
a
Four irrelevant references for the content analysis.

use computers that is basic computer skills such as engines and database searches. The denitions
knowledge of the on-and-off switch and how to use also highlight the management of clinical infor-
an application [38,58,74]. Furthermore these types mation within the health care applications [35,43,
of denitions contained different software skills 46,78].
such as word processing, spread sheet, or statistics The importance of positive attitudes towards
[24,53,56,76]. The computer device and the lim- computer use was also mentioned as a part of some
itations of computer use were also mentioned in denitions [4,24,31,32,39,42,53,5759,77]. Com-
the denitions [24,38,40]. puter literacy (n = 8), information literacy (n = 5),
The denition of information literacy consisting and informatics awareness (n = 3) were all con-
of basic computer skills as well as information re- nected to attitudes towards computer use. The
trieval abilities and communication skills was found concept evidence-based practice was also of inter-
in several papers [32,33,36,37,46,79]. Information est, it was connected to all these three information
literacy was regarded as awareness of literature, literacy categories [32,36,67,103].
the skills to locate, retrieve and evaluate, and The relationships between the denitions and
apply information in critical thinking and problem the denition categories in the analyzed papers
solving [67]. The concept information literacy are shown in the Table 4. Literacy assessment has a
was also seen as an abstract concept. Symbolically, strong relationship with both computer and infor-
it appears to represent the ability to use informa- mation literacy and program description strongly
tion, or possibly the possession of knowledge of relates to informatics awareness.
information [41].
The denitions of informatics awareness or 3.4. The focus group of interest
computer experience were connected to the pro-
fessional use of computers for example clinical The papers were also analyzed on the basis of ac-
informatics [15,28,54,55,63,74]. It contains items tors. The main interest group consisted of health
of computer and information literacy including soft- care professionals with different backgrounds
ware packages, e-mail, Internet as well as search (n = 22). In several publications both medical

Table 4 The relationship between denitions and the context of information literacy
Context of information Denition categories
literacy
Computer literacy (%) Information literacy (%) Informatics awareness (%)
Literacy assessment 49 48 25
Curriculum development 3 13 19
Programme description 15 30 40
Information system 33 9 16
implementation
N = 88a 100 100 100
a
Nine papers could not be categorized.
508 K. Saranto, E.J.S. Hovenga

(n = 16) and nursing (n = 12) students were of in- rected manually later. The possibility to use differ-
terest. The papers focused also on nurses (n = 9) or ent keywords and eliminate duplicate records was
physicians (n = 14) as well as on nurses and physi- useful. During the search process the options of the
cians (n = 1). Both students and educators were software, including the ability to create your own
also of interest: medical students and physicians libraries (databases) for different purposes, proved
(n = 18) and nurse students and their educators to be helpful for the content analysis. The created
(n = 9). In six papers consumers and patients were libraries were also rewarding during the writing pro-
of interest [30,76,91,92,96,102]. In four papers the cess.
expressions were so diffuse that the focus group The selected time period 19952001 can be criti-
could not been stated. A number of papers (n = 14) cized for several reasons. However before 1995 the
covered more than one type of actor. information literacy concept was most frequently
used by librarians. Advances in hospital information
systems and the use of electronic patient records
4. Discussion have made the concept important for health care
professionals.
4.1. The reliability and validity of the study
4.2. Implications for the future
The literature review can be criticized for several
reasons. The keywords used for sampling in this This study focused on the denitions of the con-
study operated well although information literacy cept information literacy. The results show that
is not a term in either the Medline or the Cinahl the- the concept is understood in a variety of ways.
saurus. Despite this decit, the term is used when On the basis of the content analysis the concept
indexing papers and could also be found in some ab- had three categories which proved to be hierar-
stracts. The term illiteracy could also have been a chical: computer literacy, information literacy and
search term. However, it was not used as our target informatics awareness or experience. All these
was to dene the concept information literacy. Both categories or levels have overlapping competen-
authors determined the procedure of the content cies, but also specic knowledge and skill areas.
analysis. The rst author then made the analysis. The concept computer literacy as dened in this
However the authors had several discussions during study had no connections to professional use of
the analysis process and the categories adopted for computers. The denitions mainly describe basic
the analysis were a joint decision based on a con- computer skills. The denitions of the concept
sensus agreement reached. were very broad and could be applied to any eld
The main decit of the study is the criteria used or profession. However, the existence of this basic
for the selection of papers for content analysis. Only skills level can be justied by the fact that there
papers that could be reached on-line as full text are still a large number of nurses and physicians
or internally by the local library where included in who lack skills in computer use [27,58,74]. This
the study. Therefore on-line abstracts were also de- makes it obvious that the teaching of basic com-
cided to be included in the analysis. However, the puter skills still needs to be included in educational
quality of the abstracts varied, which made it im- programs. The content analysis also indicates that
possible to classify the content of some abstracts. a huge variety of efforts are focused on informat-
All in all the variety of 97 papers (78%) from 19 ics education of health care professionals. The
countries indicates an international sampling. The content of the computer literacy concept relates
papers were published mainly in two types of publi- to the knowledge and skill domain, referred to
cations: journals and proceedings. The proceedings as informatics/computer science by the IMIA WG1
proved to be easily reached compared with the va- recommendations.
riety of international journals that made it impossi- The concept information literacy further de-
ble to reach many of them electronically or manu- scribes abilities in computer use and computer
ally from the local library. Moreover, multiplicity of literacy. Thus computer literacy appears to refer to
the journals highlights the importance of the topic. the basic ability to read and write using a computer.
It was also rewarding to nd that the number of full The use of networks and computer communication
texts available from electronic databases is increas- links to libraries were essential skill requirements.
ing. Medline was used as the main database, at the The concept was also connected to professional
same time it was the only one reached on-line. The use of computers regarding searches of electronic
bibliographic software proved to be very exible for databases. The concept evidence based practice
this on-line literature search although it did result in was connected to information literacy in some pa-
many incomplete references that needed to be cor- pers [36,67,103]. This category relates to the IMIA
Information literacywhat it is about? Literature review of the concept and the context 509

WG1 recommendations perspective of the concept ever terms like necessity, benets, values, need
itself. and others can be interpreted as descriptions of
The concept informatics awareness or experience positive attitudes.
was connected to professional use of computers,
information systems or EPR. As a conclusion of the
content analysis the term informatics awareness 5. Conclusion
was chosen for the name of the category as the
most advanced competency level. However in many Information literacy proved to be an ambiguous
denitions the concept knowledge management concept. This concept was given a variety of de-
was also mentioned. Knowledge management was nitions, which could be categorized into different
not used as a search term as this is seen as a higher educational levels. In the analyzed papers edu-
level concept requiring information literacy as a cation of health informatics appears to have an
pre-requisite. As stated in the literature the trans- active role among health care professionals and
formation from data to information and to knowl- students. The concept was described in connec-
edge is an essential part of the information manage- tion with literacy assessment, curriculum devel-
ment process [11,104,105]. This category relates opment and educational program description as
to IMIA WG1 recommendations learning outcomes well as information system implementation. Both
as a whole. The category had methodological, journals and conference proceedings seem to have
technological, organizational, as well as scientic an active role of disseminating research results of
aspects. health informatics education. Although IMIA WG1
None of the papers analyzed mentioned the IMIA has described the knowledge and skill learning
WG1 recommendations for teaching health infor- outcomes of education in its recommendations,
matics as a reference although they could be rec- these are not mentioned in terms of a framework
ognized from some of the papers. Due to the use for curriculum development or reference for the
of abstract and time period limitations previously described educational programs. Above all, the
mentioned it is not possible to reach any meaningful number of the papers focusing on health infor-
conclusion regarding this. In accordance with the matics programme descriptions reect that a lot
principles adopted for the recommendations, many of educational activities exist internationally. De-
of the educational programs focused on health spite the variable denitions, there appears to be
care professionals to be taught in homogenous or a general consensus that information literacy and
heterogeneous profession groups [48,50,51,74]. information technology literacy is a foundational
The need for alternative types of specialization educational outcome to be achieved by all health
in health and medical informatics was also recog- professionals.
nized, but only one paper described the health in-
formatics specialists level [80]. Although education
was seen as a continuum at different competency Acknowledgements
levels the respective stage of career progression
could be seen only in some of the program de- The authors want to express their gratitude to Cen-
scriptions [31,63,65,66]. Eight papers focused on tral Queensland University, Faculty of Informatics
educators. According to these papers there is still and Communication. The study has been conducted
the need for qualied teachers of health infor- during the rst authors Visiting Scholarship. With
matics and their education should be strengthened the kind help of the CQU Library staff the data
[32,63]. collection for the study, using an on-line literature
The IMIA recommendations distinguish knowl- search was exible and fast to conduct.
edge and skill levels within educational domains.
Most of the papers describe knowledge and skills as
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