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Men with prostate cancer require ample information and support along the continuum of care, and eHealth is one way to meet such critical information and support needs. Currently, evidence about how age influences use and perceptions about prostate cancer eHealth information and support is lacking.
The aim of this paper is to explore use and perceptions about eHealth among men living with prostate cancer. Specifically, we aimed to analyze men with prostate cancer by age-specific cohorts to identify potential age-related differences in use and perceptions about prostate cancer eHealth information.
We used survey methodology to examine how men under 65 years old with prostate cancer differ from those aged 65 years old or older in use and perceptions about prostate cancer eHealth information and support (n=289).
We found that men in the younger cohort used the Internet more often to be informed about treatment options (
Men with prostate cancer have different information and support needs; our findings suggest that these needs might vary by age. Future research is needed to unravel age-related factors underlying these differences to be better able to tailor prostate cancer eHealth information to men’s information and support needs.
Men with prostate cancer often turn to the Internet to fulfill their information and support needs [
Although diagnosed more often in older adulthood, or at the median age of 66 years old [
To deepen the understanding of the reasons for using eHealth information and the perceived psychosocial effects of its use, this paper aims to explore use and perceptions about eHealth among younger and older men living with prostate cancer. We refer to younger and older individuals as men under 65 years old and men 65 years and older, respectively. These two age groups have been found worthy of separate analysis in several studies on adulthood development [
In 2013, nearly 80% of adults aged 45 to 64 years had Internet access compared to a little less than 60% of adults aged 65 and over [
When evaluating prostate cancer eHealth and age, it is important to consider that using the Internet does not necessarily mean that individuals find what they seek online or that they perceive the information in the same way. This is often referred to as eHealth literacy, the ability to seek, find, understand, and act on health information from electronic sources to solve a health problem [
Considering these age-related differences with respect to Internet use and experience, we expect that when compared to younger men with prostate cancer, older men in our study will use the Internet less frequently in general, as well as less frequently specifically for prostate cancer information and/or support (Hypothesis 1a [H1a]). We also expect that older men will have a more negative experience using the Internet in general and in relationship to prostate cancer information and/or support when compared to their younger counterparts (Hypothesis 1b [H1b]).
Prostate cancer eHealth is as varied as the challenges men with prostate cancer face. Examples include information about cancer staging and grading (Gleason score), available treatments, treatment decision-making tools (nomograms) [
Other manifestations of prostate cancer eHealth focus on opportunities to find support from others through online tools, such as online support groups [
Although eHealth resources for prostate cancer are abundantly available online, issues concerning the applicability of these eHealth resources across diverse audiences needs further investigation. Given the scarcity of prior work on the specific age-related differences in reasons for using prostate cancer eHealth, we propose the first research question (RQ1): Are there differences between younger and older men living with prostate cancer in reasons for using prostate cancer eHealth for information and support?
To date, there are few studies that have focused on the perceived psychosocial effects of using prostate cancer eHealth. Some researchers, such as Dickerson et al [
Not all aspects of prostate cancer eHealth are perceived as having positive effects on psychosocial health. Broom [
Given the lack of a body of research about a range of psychosocial effects of prostate cancer eHealth, consideration of the rigorous literature review of Bjørnes et al [
Since there is not currently a large body of research to support the effect of prostate cancer eHealth on psychosocial outcomes, investigating men’s perceptions may enhance understanding of the relationship between eHealth and coping. Since perceptions of prostate cancer eHealth might vary by age, the second research question (RQ2) is posed: Are there differences between younger and older men living with prostate cancer in how prostate cancer eHealth affects positive and negative psychosocial outcomes?
To evaluate use and perceptions of prostate cancer eHealth, survey methodology was used. An online questionnaire was designed using multiple types of response scales for closed-ended questions. For bounded continuous scales, Likert-type scale response anchors as described by Vagias [
To address the third domain, the work of Bjørnes et al [
Institutional Review Board (IRB) approval for this study was obtained from George Mason University and Inova Health System. Survey participants were recruited using nonprobability sampling methods, including voluntary and snowball sampling. After obtaining permission from website administrators, recruitment occurred through four online prostate cancer social networks—the “New” Prostate Cancer InfoLink Social Network, His Prostate Cancer, the Association of Cancer Online Forums Prostate Problems Mailing List, and a prostate cancer-related email list of Life with Cancer, Inova Health System. All respondents provided informed consent through the questionnaire before the study questions were displayed.
Sociodemographic characteristics included questions about age, race/ethnicity, and education level. Race/ethnicity included the answer options “African American/Black,” “Asian/Pacific Islander,” “Hispanic,” “Native American/Alaska Native,” “White,” and “Other”; multiple responses were allowed. Education level was measured using the answer options “high school or less,” “some college,” “college graduate (Bachelor’s degree),” and “graduate degree (Master’s degree or above).” Prostate cancer characteristics were assessed by asking about the amount of time since diagnosis and types of treatment. Time since diagnosis was assessed through the answer options “less than 1 year ago,” “1-2 years ago,” “3-4 years ago,” and “5 years ago or more.” For type of treatment, participants were asked to select all treatments they had received. They could select “prostatectomy,” “radiation (external beam),” “radiation (brachytherapy),” “proton beam therapy,” “hormone therapy,” “testicle removal,” “cryotherapy,” “chemotherapy,” and “watchful waiting.” Other types of treatment not provided as options could be typed in an “other (please specify)” comment field.
Internet measures included questions about men’s Internet behavior and experiences.
Participants were asked why they used eHealth for information and support. They were provided with 13 information categories to select from, such as “to learn more about staging and/or grading,” and five support categories, such as “to read/listen to other men’s personal prostate cancer stories.” Participants could select as many options as applied.
How the Internet influences psychosocial health was measured with 10 items, such as “I feel informed,” “I feel in control,” and “I feel lonely.” All items were provided with the answer options “more,” “less,” and “no effect.” Scores were assigned to each item by giving a +1 when the Internet had affected men with prostate cancer more, a 0 when the Internet had no effect, and a -1 when the Internet had affected them less. Principle Component Analysis (PCA) with varimax rotation distinguished two reliable components: one for the “positive” effects of eHealth (Eigenvalue [EV] = 1.62, explained variance = 24.23%, alpha = .70) and one for the “negative” effects of eHealth (EV = 3.59, explained variance = 27.92%, alpha = .83). Two sum scales were computed, one representing the positive effects of eHealth and one representing the negative effects of eHealth.
We used descriptives and chi-square statistics to present the sociodemographic and prostate cancer characteristics. To address the first research domain, we tested whether there were differences between men under 65 years old and men 65 years old and older in Internet behavior (H1a) and experiences (H1b). Analysis of variance (ANOVA) tests were conducted with age group as the independent variable and the seven Internet measures as dependent variables. For the purpose of investigating the second domain, we used chi-square statistics to examine the differences between men under 65 years old and men 65 years old and older in reasons for using eHealth information to address information and support needs (RQ1). To investigate the third and final domain, differences between men under 65 years old and men 65 years old and older in how prostate cancer eHealth impacts psychosocial indicators (RQ2) were examined using Kendall’s tau-b correlation coefficients. The relationships between age, Internet measures, and psychosocial indicators were further explored using the conditional process modeling program PROCESS, Model 4 [
A total of 402 respondents started the online survey, of which 382 completed the survey (completion rate = 95.0%). Another 93 participants out of 382 (24.3%) chose not to fill out their age, and therefore were excluded from the data as we were not able to analyze age differences in use and perceptions of eHealth information for this group. This resulted in 289 valid cases for data analysis. Our sample of men with prostate cancer were on average 64.91 years old (SD 8.34, range 40-89). Most participants were white (277/289, 95.8%), and almost half of them had a graduate degree (134/289, 46.4%). For analysis, the sample was divided into a cohort of younger men (40-64 years old, 144/289, 49.8%) and older men (≥ 65 years old, 145/289, 50.2%). Older men were more likely to be diagnosed five years ago or more (χ2
1= 13.3,
Personal and prostate cancer characteristics (n=289)a.
Characteristics | Younger men (< 65 years), |
Older men (≥ 65 years), |
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Number of men per age group, n (%) | 144 (49.8) | 145 (50.2) | |
Age in years, mean (SD) | 58.28 (4.62) | 71.49 (5.51)b | |
Age in years, range | 40-64 | 65-89 | |
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White | 135 (93.8) | 142 (97.9) |
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African American/Black | 4 (2.8) | 2 (1.4) |
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Asian/Pacific Islander | 2 (1.4) | 3 (2.1) |
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Hispanic | 2 (1.4) | 2 (1.4) |
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Native American/Alaska Native | 2 (1.4) | 0 (0) |
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High school or less | 8 (5.6) | 7 (4.8) |
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Some college | 28 (19.4) | 35 (24.1) |
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College graduate (Bachelor’s degree) | 43 (29.9) | 33 (22.8) |
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Graduate degree (Master’s degree or above) | 65 (45.1) | 69 (47.6) |
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Less than 1 year ago | 36 (25.0) | 16 (11.0)c |
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1-2 years ago | 40 (27.8) | 32 (22.1) |
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3-4 years ago | 36 (25.0) | 34 (23.4) |
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5 years ago or more | 32 (22.2) | 62 (42.8)b |
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Prostatectomy | 79 (54.9) | 47 (32.4)b |
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Hormone therapy | 41 (28.5) | 58 (40.0)d |
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Radiation—external beam | 39 (27.1) | 54 (37.2) |
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Watchful waiting/active surveillance | 25 (17.4) | 36 (24.8) |
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Chemotherapy | 11 (7.6) | 10 (6.9) |
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Radiation—brachytherapy (implants) | 10 (6.9) | 19 (13.1) |
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Proton beam therapy | 3 (2.1) | 7 (4.8) |
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Cryotherapy | 1 (0.7) | 4 (2.8) |
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Testicle removal | 0 (0) | 0 (0) |
aSome numbers do not add up to 100% due to missing data.
bDiffers significantly from younger men (
cDiffers significantly from younger men (
dDiffers significantly from younger men (
To describe our findings regarding the first research domain, we found that the two age groups significantly differed on the frequency of Internet use (H1a) (
Internet behavior and experiences among younger (< 65 years) and older (≥ 65 years) men with prostate cancer.
Internet behavior and experiencesa | Younger men (< 65 years), |
Older men (≥ 65 years), |
Internet use | 4.84 (0.39) | 4.74 (0.47)b |
Internet access | 4.60 (1.00) | 4.54 (0.88) |
Internet comfortc | 3.85 (0.39) | 3.72 (0.49)d |
Internet use for prostate cancer information | 3.78 (1.10) | 3.81 (1.09) |
Information-seeking difficulty | 2.57 (0.96) | 2.58 (0.88) |
Internet personal applicability | 3.67 (0.67) | 3.59 (0.66) |
Internet trust | 3.76 (0.66) | 3.68 (0.66) |
aAll measures were assessed using a 5-point Likert-type scale.
bDiffers significantly compared to younger men (
cLevel of comfort with the Internet was measured on a 4-point Likert scale.
dDiffers significantly compared to younger men (
The second domain investigated (RQ1) showed that the most frequently selected reasons to address information needs were to learn more about available treatments (255/289, 88.2%), to learn more about the effects of treatment (245/289, 84.8%), and to keep up to date with prostate cancer research (237/289, 82.0%). We found that men in the younger cohort used the Internet more often to be informed about treatment options (χ2
1= 4.4,
Reasons to use eHealth for information and support needs among younger (< 65 years) and older (≥ 65 years) men with prostate cancer.
Reasons to use eHealtha | Younger men (<65 years) |
Older men (≥65 years) |
To learn more about available treatments | 129 (89.6) | 126 (86.9) |
To learn more about the effects of treatment | 122 (84.7) | 123 (84.8) |
To keep up to date with prostate cancer research | 115 (79.9) | 122 (84.1) |
To learn more about recurrence of prostate cancer | 101 (70.1) | 98 (67.6) |
To be informed about treatment options | 114 (79.2) | 98 (67.6)b |
To know what questions to ask my doctor | 112 (77.8) | 101 (69.7) |
To learn more about staging and/or grading | 113 (78.5) | 93 (64.1)c |
To learn more about self-management | 79 (54.9) | 87 (60.0) |
To make sure what the doctor told me is correct | 66 (45.8) | 66 (45.5) |
To make a treatment decision using a website tool | 54 (37.5) | 53 (36.6) |
To check out my doctor’s reputation | 52 (36.1) | 44 (30.3) |
To get a second opinion | 39 (27.1) | 55 (37.9) |
To learn more about and/or enroll in a clinical trial | 41 (28.5) | 41 (28.3) |
To read/listen to other men’s prostate cancer stories | 96 (66.7) | 96 (66.2) |
To offer my personal prostate cancer story | 64 (44.4) | 72 (49.7) |
To get personal opinions to help decision making | 64 (44.4) | 71 (49.0) |
To get personal opinions to help address treatment effects | 58 (40.3) | 69 (47.6) |
To get emotional support and encouragement | 48 (33.3) | 22 (15.2)d |
aMore than one reason to use eHealth for information needs could be selected. Reasons are presented from most frequently selected reasons to least frequently selected reasons.
bPercentage differs significantly compared to younger men (
cPercentage differs significantly compared to younger men (
dPercentage differs significantly compared to younger men (
Examining the third and final domain (RQ2), we found that increasing age was positively related to negative psychosocial indictors, indicating that older men with prostate cancer were more likely to feel lonely, depressed, anxious, and scared as a result of using the Internet for prostate cancer eHealth than men in the younger cohort (tau-b=.17,
Factor loadings for psychosocial indicators.
Psychosocial indicatorsa | Component 1, |
Component 2, |
I feel in control |
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-.19 |
I feel like I can cope |
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-.33 |
I feel connected with others living with prostate cancer |
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-.02 |
I feel connected with my spouse/partner |
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.01 |
I feel confident about my treatment decision |
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-.23 |
I feel informed |
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-.09 |
I feel scared | -.08 |
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I feel depressed | -.13 |
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I feel lonely | -.10 |
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I feel anxious/stressed | -.26 |
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aNegatively phrased items were not reversely recoded as Principle Component Analysis (PCA) distinguished the same two scales and same factor loadings when using the negatively phrased items.
bItalic numbers indicate which items load onto which components.
Correlations between age, Internet measures, and psychosocial indicators.
Age, Internet measures, and psychosocial indicators | Correlations between age, Internet measures, and psychosocial indicators, |
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1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. |
1. Ageb | - |
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2. Positive dimensions | -.08 | - |
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3. Negative dimensions | .17c | -.31d | - |
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4. Internet use | -.12e | .16f | .04 | - |
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5. Internet access | -.12g | .07 | 0 | .33d | - |
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6. Internet comfort | -.16h | .10 | -.01 | .44d | .37i | - |
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7. Internet use for prostate cancer information | .01 | .14h | -.05 | .14h | .09 | .07 | - |
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8. Information-seeking difficultyj | 0 | -.12k | -.02 | -.05 | -.08 | -.13k | 0 | - |
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9. Internet personal applicability | -.04 | .15f | -.07 | .06 | .15h | .06 | .04 | -.32d | - |
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10. Internet trust | -.05 | .21d | -.11g | .03 | .13l | .09 | 0 | -.18i | .42d | - |
aCorrelation coefficients are Kendall’s tau-b coefficients for ordinal level variables.
bAge as dichotomous variable. Using the continuous variable of age resulted in the same results.
cThe correlation was significant (
dThe correlation was significant (
eThe correlation was significant (
fThe correlation was significant (
gThe correlation was significant (
hThe correlation was significant (
iThe correlation was significant (
jThe higher the score, the more difficult information seeking was perceived.
kThe correlation was significant (
lThe correlation was significant (
When further exploring the relationships between age, Internet measures, and psychosocial indicators, we found a significant negative mediated effect of age on the positive psychosocial dimension through Internet use. The model showed an insignificant direct effect of age on positive psychosocial indicators (
Mediation model: The effect of age on positive psychosocial indicators through Internet use. Unstandardized regression coefficients are presented. (a) Age as dichotomous variable. Using the continuous variable of age resulted in the mediation effect. (b) Significant at 95% CI -0.28 to 0. (c) P=.001.
Our findings show that there may be age-related differences in use and perceptions about prostate cancer eHealth information and support among men with prostate cancer. Perhaps most provocative, when men were asked how prostate cancer information and/or support found on the Internet affected them, men in the older cohort were more likely to report that it made them feel lonely, depressed, anxious/stressed, and scared, for example (negative psychosocial indicators). We also found significant positive associations between measures of Internet use and, for instance, feeling informed, in control, and confident about treatment decision (positive psychosocial indicators). Moreover, we found that Internet use mediated the association between age and the positive dimension of psychosocial indicators, which shows that greater use of the Internet among men in the younger cohort, in particular, appears to lead to a more positive psychosocial response to prostate cancer eHealth. That men in our younger cohort were significantly more likely to use the Internet and feel comfortable with using the Internet is consistent with findings from past investigations [
We also explored whether our two cohorts would differ in reasons for using prostate cancer eHealth. We found that, when compared to older men, men in the younger cohort used eHealth information significantly more to be informed about treatment options and to learn more about staging and/or grading. Additionally, younger men reported using communication for emotional support and encouragement significantly more often than older men. Although a significant difference in time since diagnosis between the cohorts might partially explain this finding—older men had a longer time since diagnosis—it is still worthy of attention. Dickerson et al [
Although our findings shed light on the fact that there may be age-related differences in the use of prostate cancer eHealth and perceptions about how it affects one’s psychosocial health, these results should be interpreted with caution. Since there was a significant difference between cohorts in time since diagnosis (longer time since diagnosis for the older cohort) and types of treatment regimens (greater frequency of hormone therapy over prostatectomy for the older cohort), our findings might have detected differences in use and perceptions based on time since diagnosis or treatment regimen. For example, men diagnosed longer ago may use certain features of eHealth less or more frequently, which was not measured in this study. Furthermore, treatment effects on psychosocial health, such as depression or anxiety, as well as baseline predispositions related to depression, anxiety, and coping ability may have influenced participants’ responses about the specific effect of eHealth on their psychosocial health. Finally, certain treatment effects, such as cognitive effects associated with hormone therapy, could have influenced findings related to use and perceptions of prostate cancer eHealth [
Other limitations of this study included those related to selection bias. While the sample was fairly representative of the prostate cancer population based on age distribution [
There are several implications of this study for future research and practice. As described by Harden et al [
Kreps [
analysis of variance
Eigenvalue
Hypothesis 1a
Hypothesis 1b
Institutional Review Board
Principle Component Analysis
research question 1
research question 2
The authors wish to thank Samira Hosseini, Selamawit Tesfaya, James Zabora, the facilitators of the prostate cancer support groups of Life with Cancer of Inova Health System, and the administrators of the “New” Prostate Cancer InfoLink Social Network, His Prostate Cancer website, and the Association of Cancer Online Forums Prostate Problems Mailing List for their assistance with data collection.
None declared.