Introduction

Changes in connection with the transition to an information society are accompanied by variable problems related to a large extent to the increasing complexity of information and communication technologies (ICT), which exacerbates the risk of digital exclusion. The question of digital literacy is thus an increasingly discussed topic, especially in the context of economic growth and efforts to ensure the digital integration of population groups threatened by exclusion from the information society, which undoubtedly includes seniors (Skyba, 2017). The 2030 Agenda for Sustainable Development emphasizes the spread of ICT and global connectivity, which has great potential to accelerate progress in human activity, bridging the digital divide and developing a knowledge-based society (WHO, 2021).

A characteristic phenomenon of the demographic development in the Slovak Republic is the aging of the population, which is mainly the result of a significant long-term declining birth rate and the stabilization of mortality rates in recent years. It will be very important for seniors to participate in initiatives aimed at active and healthy aging, which will contribute to a healthier and better quality of life spent by people in the pensioner categories and to their long-term independence (MZ SR, 2022). Seniors, as a large group of the population, are at risk of digital exclusion also in relation to health and healthcare.

The increase in the area of ​​the so-called digital health poses the risk of deepening inequalities in the field of health. In its strategy, the World Health Organization - WHO (2021) recommends supporting global collaboration and advancing knowledge transfer on digital health, continuing to implement national digital health strategies, strengthening digital health governance at global, regional and national levels, and advocating for people-centred health systems that enable digital health. The development of digital health is related to digital health literacy, for the improvement of which specific strategies and interventions are needed in the population. The measures in the target group of seniors are particularly important, for which there may be significant barriers in the use of ICT and in accessing the Internet. Nurses can also participate in these measures, as the largest group of health workers working in various types of workplaces. Nurses in personal contact with seniors to whom they provide nursing care can carry out educational activities also with a focus on supporting digital health literacy using effective communication and cooperation with the senior's support persons. At the same time as promoting digital health literacy, the development of critical thinking in older people is also important.

Digital technologies are now an integral part of everyday life, and the world's population has never been more connected. Innovation, especially in the digital sphere, is taking place on an unprecedented scale. Nevertheless, their application to improve the health of the population remains largely untapped, and there is a huge scope for the use of digital health solutions. WHO draws attention to harnessing the potential of digital technologies and health innovations to accelerate the global achievement of health and well-being (WHO, 2024). In this context, the concept of digital health is coming to the fore. The digital health ecosystem includes:

  • eHealth management – national, regional and global eHealth coordination tools,
  • electronic health records – information about the health status of each patient recorded in digital format,
  • standards and interoperability – communication between different technologies and software applications, use of standards for efficient, accurate and reliable exchange and use of data,
  • telemedicine – provision of health services using ICT, especially where distance is an obstacle to receiving health care,
  • mHealth – medicine and public health supported by mobile devices such as mobile phones, patient monitoring devices and other wireless devices,
  • digital health literacy – a set of skills, knowledge and attitudes that a person needs to be able to develop functionally in the information society,
  • social networks – use of social networks to promote health,
  • big data – the use of non-conventional data for decision-making in the field of public health (EuroHealthNet, 2019).

Even in the conditions of the Slovak Republic, eHealth, telemedicine and telenursing interventions have been implemented in recent years. eHealth refers to electronic and computerized healthcare. In general, it is an electronic service and a service aimed at preventing diseases and preserving or restoring the health condition of the population. ICT is used for this, which is subordinate to diagnosis, treatment, preventive measures, monitoring and management in the field of health and healthy lifestyle. Telemedicine is considered a part of eHealth and means the combination of medical informatics and telecommunications, enabling in particular remote data transfer, consulting activities and remote provision of health and related services (e.g. in the field of psychology, education, etc.). The current terminology of telemedicine refers to ICT (Středa, Hána, 2016). Telenursing is defined as the use of ICT in the provision of nursing care "at a distance", that is, in the case where there is a large physical distance between the patient and the nurse (Slezáková et al., 2022). Full use of 21st century tools and innovations such as communication technologies (digital records, telemedicine and eHealth) and social media can contribute to better and more cost-effective care. An important principle is the perception of the patient as a partner while maintaining responsibility for the outcome of his treatment (MZ SR, 2022).

The digital transformation of healthcare means virtual care, remote patient monitoring, the use of artificial intelligence, the analysis of large data sets, the use of smart devices, the creation of a data platform and the use of tools enabling the exchange and storage of data and tools for remote sensing and data exchange, sharing relevant information within the framework of creating a health ecosystem. Digitization in healthcare has an impact on ensuring continuous care with the potential to improve health, improving medical diagnostics and treatment based on decisions in relation to available data, using the so-called digital therapy, clinical trial implementation, self-management of care and provision of person-centred care, as well as acquiring more evidence-based knowledge, skills and competences of healthcare professionals (WHO, 2021). A special area is the global trend of expansion of mobile applications to support health behavior in disease management, lifestyle modification and navigation in the healthcare industry (Levin-Zamir, Bertschi, 2019).

In connection with the ecosystem of digital health and its components, the necessity of developing not only digital literacy, but especially digital health literacy in connection with health is coming to the fore. Digital health literacy represents the ability to search, find, understand and evaluate health information from electronic sources and to apply the acquired knowledge to prevent or solve health problems (EuroHealthNet, 2019). Digital information is gaining more and more importance in society. Citizens' digital health literacy is a fundamental element for the successful introduction of electronic healthcare. Health literacy is the ability to find, understand, assess, and use information related to health care, prevention, or health promotion. This requires personal skills on the one hand and favorable framework conditions on the other, such as providing information in an understandable language. Using the Internet for this purpose requires additional skills (Official Journal of the European Union, 2019).

Health literacy is about communicating health information clearly and understanding it correctly. Health literacy is important at all points along the health care continuum – from well-being and health, through disease prevention and detection, to diagnosis and decision-making, as well as treatment and self-care (Osborne, 2018). According to the WHO, health literacy represents the cognitive and social skills that determine the motivation and ability of individuals to access, understand and use information in ways that promote and maintain good health (Parnell, 2015). Health literacy is currently considered one of the ways to prevent health problems and protect health, but also how to organize unexpected situations or problems related to health (Čakloš, Bóriková, 2020). Health skills also include understanding basic health information and knowing how to access information and use health services (Beňadiková et al., 2023). For seniors, it is the ability to understand instructions aimed at the implementation of preventive activities and cooperation in the treatment of diseases (Zrubáková, 2023).

Health literacy is also very important in old age and significantly affects curative and preventive care. However, at this stage of human life, it is associated with the greatest number of obstacles – changes in the aging process, the level of cognitive functions, the health status of the patient, socio-economic status, demographic characteristics (age, education, gender, etc.). The role of healthcare workers is to promote health literacy, help identify and eliminate risk factors preventing effective information acquisition, help overcome fear of digital media, and ensure data clarity. Health care and the provision of services depend on whether individuals are able not only to understand correctly, but above all to use the information provided by experts (Zrubáková, Magerčiaková, 2023).

The active involvement of seniors in the field of digitization overcomes the stereotypes in society's consciousness - the exclusion of seniors from the information society and the need to satisfy their needs and interests in the field of ICT. Especially young people and the middle generation are very actively involved in modern technologies, but digital literacy is at a lower level in the society of senior citizens, which means that it is a knowledge inequality - the so-called the "knowledge gap" that needs to be broken. The current information society, predicting the onset of the post-information society, as well as the active existence of seniors in it, in connection with the saturation of secondary needs and interests of seniors, requires an active approach to aging through education (lifelong education), e.g. informal education in the field of ICT. In this education, it is necessary to take into account that when acquiring competences in the sphere of modern technologies, a person at an older age has certain limitations in terms of the peculiarities of the seniority period, socio-economic status, but also educational opportunities. In this regard, counseling in the education of seniors can be an important facilitating factor, which will adequately guide the acquisition and management of the necessary competencies for working with modern ICT and their subsequent application when working with digital technologies. If a senior already has digital literacy, the range of possibilities for modern education through ICT is limitless for him (Mayer, Lenhardtová, 2017). When using the digital environment, more than half of seniors visit websites and more than a third follow social networks and discussion forums. Digitally savvy seniors also use electronic communication with their healthcare facility and health-oriented applications on their smartphone (ÚVZ SR, 2019).

Support for digital literacy and health literacy is also implemented in the strategic documents of the Slovak Republic. The development of these types of literacy has a significant impact on the level of digital health literacy. In the Strategic Health Care Framework for 2014-2030 (2013), Priority Area 1 focuses on the following areas: Investing in one's own health throughout the life cycle and creating opportunities for strengthening citizens' responsibility for health. Health promotion programs based on the principles of engaging people in activities that strengthen their mental and physical capacities represent an individual and social benefit (creating better conditions for a healthy lifestyle, improving health literacy, supporting independence, etc.).

The National Program for Active Aging 2021-2030 (2021) reports findings on older people's digital literacy and coping with modern communication tools and technologies in the digitized era. Digital literacy at a higher than basic level in Slovakia among persons under the age of 74 is comparable to the average of the European Union. Lagging is present only in people over 75 years old. The absence of digital literacy among older people can reduce their access to public resources and services, to the necessary information and tools for social participation, both in paid employment and in the implementation of a wide range of individually and socially beneficial activities. From the point of view of evaluating the prerequisites and capacities for active aging, based on comparative studies in Slovakia, the lower life expectancy of people, especially healthy life expectancy, appears to be risky for the future; lower representation of older people with higher education, but especially the lagging level of their digital literacy; the intensity of their personal social contacts also decreases with age, also in connection with the level of subjectively reported mental well-being. Prerequisite (context) parameters are projected into output parameters, i.e. j. into the experiences of older people with active aging. Based on the analysis carried out, the low level of digital literacy of older people can also be considered a risk factor in the future as a prerequisite for their access to quality employment, to information, goods and services, as well as to social contacts.

The National Digital Skills Strategy of the Slovak Republic and the Action Plan for the years 2023 – 2026 (2022) point to seniors as one of the population groups that lag behind the most in terms of digital skills in Slovakia. This fact was particularly evident during the COVID-19 pandemic, during which measures were defined that, in an attempt to limit personal contact between people, prevented many seniors from fully participating in social and economic life. The digital skills of seniors have their application and significance not only during the COVID-19 pandemic, but also in the perspective of the issue and support of active aging, i.e. the absence of digital literacy of older people can worsen their access to public resources, services, necessary information, social participation tools, in paid employment or in individually or socially beneficial activities of a wide range. From the point of view of the availability of digital technologies, especially low-income households with children and seniors lag behind. Therefore, it is important to design measures to improve digital inclusion.

The unavailability of publicly funded educational programs is a barrier to the development of digital skills, especially for seniors in the post-productive age. The share of people in the 65-74 age group with at least basic digital skills is also for this reason only 11%, while the EU average in the same age group is 24%. Up to one in four citizens aged 65-74 have low or no digital skills. Seniors also more often face barriers with regard to the availability of technologies not only for the development of digital skills, but for the overall use of digital tools. They also use the computer less: according to data from 2017, only 39% of seniors used a computer at least once in the last 12 months, which is 10% less than the EU average (National Digital Strategy..., 2022).

The importance of digital health literacy among seniors is multidimensional and can positively affect different areas in the health care context. Seniors can use ICT to:

  • searching for information about health and a healthy lifestyle, lay first aid,
  • searching for information about medicines - reading package leaflets in electronic form with the possibility of enlarging them,
  • watching instructional videos (e.g. wound care, ostomy care, feeding with various enteral nutrition alternatives, etc.),
  • listening to podcasts about health, watching professional discussions (discussion forums), seminars, etc.,
  • ordering examinations and preventive examinations,
  • searching for contacts at general practitioners' clinics and specialized clinics, following reviews of individual medical facilities (free choice of doctor and medical facility), consultations or electronic communication with a doctor, nurse, physiotherapist and other health workers,
  • sending e-mail messages with a request for an electronic prescription of medicines (chronic medication),
  • tracking the websites of individual medical facilities (e.g. provided medical services, office hours, reviews, etc.),
  • the use of mobile applications for health and life saving,
  • use of monitoring bracelets,
  • tracking and using the benefits of health insurance companies (websites, mobile applications),
  • monitoring and using the benefits of pharmacies (including a service aimed at home delivery of medicines), monitoring of electronic prescriptions for medicines, pharmaceuticals or medical devices,
  • tracking news (medical and compensatory aids and others),
  • monitoring the activities of clubs and self-help groups (e.g. pensioners' clubs, clubs for stomatics and others),
  • purchase of vitamin supplements, compensatory aids and other health products through the e-shop,
  • monitoring legislation related to health protection and health care,
  • monitoring news on the website of the Ministry of Health of the Slovak Republic related to health care,
  • use of social networks in relation to health and others.

Barriers for seniors in association with digital health literacy can generally be divided into somatic, psychological and socio-economic. Somatic barriers can include hand or body tremors or sensory disorders – vision and hearing disorders (Prashad, Chen, 2018). Among other physical obstacles, it can be the presence of a chronic disease or polymorbidity with annoying symptoms that prevent the use of ICT (eg immobility, pain, pressure ulcers, nausea, vomiting and others). The use of modern technologies and the level of digital health literacy among seniors can also be determined by nutritional disorders (malnutrition, dehydration), thermoregulation disorders, sleep disorders, the presence of dizziness, instability and falls, emptying disorders and other factors arising from the somatic side.

Mental barriers in relation to digital health literacy occurring in seniors are dementia, depression, delirium, memory disorders, maladaptive disorders, decline in mental performance, fatigue, slowing down of mental processes, deterioration of attention, changes in emotional reactions, personality changes and others.

Among the socio-economic determinants of digital health literacy among seniors are loneliness, a lower rate of social contacts, social isolation and lack of interest in social inclusion, inactivity, insufficient financial security, unsuitable living conditions and others.

Even though the group of seniors who used ICT during their productive life in connection with their work duties is currently expanding, their skills and erudition in this area were not based on formal education (informatics was not included in the school curriculum), but rather on self-study and spontaneous learning during real-life situations, or during short-term training when introducing ICT and various computer programs into practice. Seniors at an older age (over 70 years) had almost no experience of using ICT before retirement, and the most significant development in this area is evident in the last 20 years. Many of these seniors find it more difficult to adapt to changes, which also include the use of modern technologies, therefore, in terms of their current habits, they prefer information provided in the context of face-to-face contact and obtained from printed mass media and television rather than from the Internet. Above all, for this group of older people, it is necessary to implement not only activities for the development of digital literacy and digital health literacy at the national level, but also at the local level, and also in direct contact, for example, when providing health care. Nurses have an important position in this area as the most numerous group of health workers. As effective interventions by nurses in support of digital health literacy among seniors it is possible to use:

  • Educational activities - expanding knowledge and skills, supporting seniors in the use of ICT for the benefit of health - education using mobile devices, tablets and laptops - demonstration of the use of ICT, recommendation of electronic information resources in connection with health care, designing guidelines for health workers when working with seniors in connection with supporting their digital health literacy, cooperation with support persons for seniors, preparation of printed and electronic written educational materials for seniors and their support persons, compensatory aids when using ICT - e.g. in case of partial immobility of a senior, recommendation of various forms of lifelong education with a focus on the development of digital literacy - universities of the third age (UTV), national and local projects aimed at the development of digital literacy of seniors, socialization in communities, clubs and self-help groups of seniors.
  • Communication – using simple expressive language (without professional terminology) about the issue of using ICT and electronic information resources in connection with health and healthcare, active and patient listening, providing feedback, using verbal and non-verbal components of communication, using compensatory aids in communication (glasses, magnifying glass, hearing aid and others).
  • Participation in the lifelong education of seniors, including intergenerational education - nurses can also act as educators within the lifelong education of older people, for example through pensioners' clubs, universities of the third age and with the application of the so-called intergenerational education.
  • Cooperation with seniors' support persons and caregivers, with clubs and self-help groups of seniors - support for the use of ICT and the development of digital health literacy through cooperation with family members or other support persons of seniors, or with caregivers who participate in the daily care of an elderly person; participation in the activities of clubs and self-help groups bringing together seniors and their support persons - lectures, workshops and other activities with a focus on improving digital health literacy.
  • Multidisciplinary cooperation - cooperation of various categories of health and non-health workers (e.g. social workers) in supporting the development of knowledge and skills of seniors in the use of ICT for the benefit of health, familiarization with the benefits of using ICT and the Internet, adaptation of smart devices by seniors, information on available mobile applications for health, benefits of health insurance companies and their use, etc.

Nurses as a category of health workers working in various workplaces of ambulatory and institutional health care, as well as in social service facilities, can also effectively influence the development of critical thinking among seniors, which should be in the center of interest at the same time as the development of ICT and various information sources. Critical thinking means the ability to assess new information, which a person carefully and critically examines from several points of view, forms judgments, assesses the significance of new ideas and information for his own needs. It is a mental process that serves to acquire and evaluate information and find logical and objective conclusions (Štefková et al., 2023). The application of critical thinking among seniors is becoming more and more important, since a lot of unverified information and hoaxes also affect the field of health care.

Conclusion

The researches of the Institute for Public Affairs point to the fact that over a period of two decades, Slovakia has acquired the character of a digitally divided society. On one side stands the younger, more educated, more qualified, socially stronger and more urban part of the population. On the other hand, it is an older, less educated, low-skilled, socially weaker, or economically inactive and rural part of the population. More and more often, we encounter generational differences, which are the result of a mismatch between knowledge and skills when using computers, the Internet, electronic services, and the like. Different adaptation strategies, different level of digital skills, scope and form of their use thus create in society the so-called the digital divide (Velšic, 2023). Among the categories of individuals and groups that are threatened by the digital divide, among other social groups, seniors over the age of 65 may be the most affected (intergenerational digital divide). Measures for better digital inclusion should target children from disadvantaged backgrounds, adults with low levels of digital skills and seniors. The type of measures should vary depending on the characteristics of the target group. Just as the level and type of digital skills necessary for modern life vary depending on the age and individual needs of different groups, so do the types of barriers to their better digital inclusion. The state should therefore try to implement different types of policies and approach each target group individually (National Digital Strategy..., 2022).

Investing in programs that teach digital literacy to seniors can provide opportunities for lifelong learning and growth. Technologies can facilitate innovations that allow them to monitor and understand their own health and track their trajectories of healthy aging, enabling them to make better decisions about their own lives (WHO, 2020). Solving the issue of digital literacy of seniors and, in particular, digital health literacy is necessary at various levels - from the national or society-wide to the local level. It is here that the importance of the position of nurses in this area is indisputable.

Authors: PhDr. Mgr. Mariana Magerčiaková, PhD., MPH, MBA Catholic University in Ružomberok, Faculty of Health, Department of Nursing PhDr. Katarína Zrubáková, PhD. Catholic University in Ružomberok, Faculty of Health, Department of Nursing

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