Do Elderly People Enjoy the Fruits of Estonia’s e-Health System?

Marianne Paimre

Institute of Digital Tehnology, Tallinn University, Narva Road 25, Tallinn, Estonia

Keywords: e-Governance, e-Health, Digital Health Care System, Senior Citizens, Digital Divide, Health Information,

Health Information Behaviour, Estonia.

Abstract: The article focuses on the ability of senior citizens to use the highly acclaimed Estonian e-health system.

Estonians are heavy internet users and are known for their innovative e-solutions in the world. E-health is a

prime example of such state-of-the-art programmes set out to improve public health. The people who need

health related information the most are the elderly. But do they have access to the internet and can they find

relevant information and cope with e-health solutions? Acquiring a computer or subscribing to internet service

could present a major financial challenge for them. A pilot study, which is the initial step to a more

comprehensive research, revealed based on a focus group interview and in-depths interviews with seniors that

elderly often lack the skills and experience necessary to search for online health information as well as cope

with e-health solutions. Thus, the wholesome public image of Estonia’s e-success seems not to always

correspond to the reality. This paper puts the much-appreciated IT solution into a broader perspective and,

instead of the lavishly praised e-health applications, focuses on outlining the serious drawbacks of the digital

divide and exclusion of seniors from the digital services.

1 INTRODUCTION

Estonia, sometimes called the “European Silicon

Valley”, is often referred to as one of the most

advanced countries in the field of information

technology in the world where citizens have digital

access to all public services including legal,

education, and other Governmental Services (E-

Estonia, 2015; Bau, 2017). A prime example of such

state-of-the-art programmes of the Estonian e-

Government is e-Health: an electronic healthcare

system closely linking health databases to other

government systems and offering online access to

healthcare services. But can all Estonians, including

the elderly, benefit from it?

Digital healthcare services are particularly

important in the context of population ageing. This is

especially relevant to the Baltic states with declining

fertility rates and shrinking population. Estonia,

which is the northernmost and smaller of the Baltic

States, has a population of just over a million. The

share of senior (65+) citizens in Estonia is about

European average (19%) and, what’s even more

positive, is that they work longer and are better

educated than their European peers (Eurostat, 2018).

The sad side is that their participation in society is

meagre and their health is poor (Liiva, 2015).

The e-health system could play a vital role here

by enabling the elderly to make a doctor’s

appointment online, to obtain digital prescriptions

and to access their health data e.g. referrals and test

results. However, given the fact that Estonia registers

by far the worst results in the EU when it comes to

old-age poverty (Tambur, 2017), acquiring a

computer or subscribing to internet service could

present a major financial challenge for them. The

European Commission has repeatedly drawn

attention to the problem that about 40% of people

aged 65 and over are at the risk of poverty in Estonia

(European Commission, 2018).

The ones who need health related information and

the e-health care services most are the senior citizens.

Thus, it is imperative to study whether and how they

can employ the e-health programme and other online

resources offering health related information. The

question arises whether the elderly have access to the

necessary IT-solutions (computer, the internet) to

fully utilise the e-health and other e-systems, and

secondly, if they have no prior experience with

computers and the internet, then how can they make

the most of such e-services (i.e. are they willing and

230

Paimre, M.

Do Elderly People Enjoy the Fruits of Estonia’s e-Health System?.

DOI: 10.5220/0007726202300237

In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 230-237

ISBN: 978-989-758-368-1

 2019 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

competent enough to handle and benefit from the

system?)

Due to the under-representation of the elderly

among computer users, surveys using online surveys

cannot be considered sufficient (Ainsaar & Soidla,

2018). Thus, besides quantitative approach,

qualitative approach should be used to receive more

information from this age group. Even though digital

issues are very important to Estonia, it is somewhat

surprising that there is less academic research in this

field. There is lack of qualitative studies focusing on

digital gap in e-government issues. This study

attempts to diminish the gap.

The article focuses on the ability and willingness

of Estonian senior citizens to use the highly

acclaimed Estonian e-health system. First, the article

provides a short overview of Estonia’s e-health

system and the use of internet by elderly on the basis

of literature and previous research. Secondly, a pilot

study was carried out using methods of in-depth

interviewing and a focus group interviewing to reveal

Estonian seniors’ willingness and problems to use the

Internet as source of health information and the e-

health system.

It is necessary to study how elderly people feel

about the contemporary e-systems as e-health to make

this kind of systems more effective.

The rest of the article is organized so that the

following section will give a brief overview of the e-

Estonia and its e-services including e-health system

followed by a short introduction about exclusion of

Estonian elderly in e-services. As follows, methods

used of the qualitative pilot study will be introduced.

The paper ends with the results and summary.

2 ESTONIA’S E-GOVERNMENT

AND THE E-HEALTH SYSTEM

Estonia, the country that gave birth to Skype and

where internet usage among citizens’ amounts to 89%,

has ambitious plans with respect to digitization (Eesti

Statistika, 2018a; Lufkin, 2017). Since the 1990s, the

small nation has been striving towards a 100%

digitized society by putting even its entire government

online (Lufkin, 2017). Thus, no wonder it is sometimes

said that Estonia is seeking to create an ideal

information society posing a model for other countries

for how a government can successfully move of its

services to an online platform (Connectedhealth, 2017;

e-Estonia, 2015; Digital agenda, 2014).

Its IT success stories are e-solutions, which speed

up inter-agency procedures and increase

opportunities for communication between the citizen

and the state (Minifacts, 2017). When Estonia started

building its information society about two decades

ago, there was no digital data being collected about

Estonian citizens. The general population did not

have neither the Internet nor the devices which to use

it (e-Estonia, 2015). But today, Estonian citizens can

complete state and municipal services online in

minutes (Vabariigi Valitsus, 2018; Jaffe, 2016).

E-Estonia is the initiative of Estonian government

to facilitate citizen interactions with the state using

electronic solutions (E-Estonia, 2015; Björklund,

2016). The e-government should be understood as

part of the general investment in high technology that

followed reestablishment of Estonia as an

independent state at the end of the 1990s (Kitsing,

2011). E-government has been well suited to the

Estonian transition from a former communist republic

into a modern democratic European state (Kalvet,

2012; Kitsing, 2010).

E-government is being introduced because the

digital tools are at hand and because politicians and

public administrators see the possible gains in terms

of efficiency (Björklund, 2016). E-government has

been developed through close cooperation between

private and public interests, with the banking sector

in particular leading the way (Kitsing, 2011).

Favorable economic developments made the

investments in informational infrastructure possible

but launching e-government was also in line with the

process of strengthening democracy after a long

period of extraneous authoritarian rule (Runnel et al,

2009; Kalvet, 2007).

E-government entails digitalization of

governmental records and national data as well

communication between the government, public

administration, and citizens (Estonian Information,

2006). Launched in 1997, it’s let citizens file taxes

online since 2000 (95% of Estonians file taxes online).

E-services created under this initiative include as well

e-voting, e-tax board, e-business, e-banking, e-ticket,

e-school, university via internet, the e-governance

academy, as well as the release of several mobile

applications (Vabariigi Valitsus, 2018). It also allows

Estonians to obtain medical prescriptions and test

results (e-Estonia, 2015). The e-health is a digital

service created under the initiative of e-Estonia, and

it is aimed to improve public health by offering new

preventive measures and increasing the awareness of

patients (Estonian e-health, 2015). The measurable

goals of Estonian e-health strategy include the

reduction of the incidences of diseases, preventable

hospital visits and repeat treatment, and more

Do Elderly People Enjoy the Fruits of Estonia’s e-Health System?

231

effective time management by medical personnel

(eHealth, 2017).

The government, hospitals, doctors and patients -

all are hoped to benefit from the e-health system (e-

Estonia, 2015). 95% of health data is digitized in

Estonia, 99% of prescriptions are digital (eHealth,

2017). Each person who has visited a medical doctor

has an online e-health record that ca be tracked. The

health information is kept secure identified by the

electronic ID-card. It is accessible to authorised

individuals. KSI Blockchain technology is being used

for the system to mitigate internal threats to the

system and to ensure data integrity (eHealth, 2017).

To fulfil all its goals, high quality of source data

and the capabilities of secondary use of data are of

critical importance. An information system not

corresponding to the expectations of users or non-

optimized data acquisition and collection of low-

quality data may influence all the goals for which the

data are collected. Also, those may hinder the

achievement of the goals for which the patient has

given their consent, and which also includes

secondary use of data. The focus area also includes

increasing of the competence of health care

professionals to process data (skills and knowledge)

to collect and enter high-quality health information

(Estonian, 2015).

3 ELDERLY PEOPLE LEFT

BEHIND FROM E-SUCCESS

One should be delighted that the range of e-services

is becoming so diverse in Estonia. However, there is

a vast number of people who will suffer a kind of

information blackout (TNS EMOR, 2014). Estonia’s

strive towards a digital society teeming with e-

services could present a serious challenge for older

Estonians, because they can’t use e-services due to

lack of access or skills, or they simply do not own a

computer (TNS EMOR, 2014).

Statistics reflect that less than a half of people

aged 65 and over are at the risk of poverty in Estonia

(European Commission, 2018). In the third quarter of

2018, the average monthly retirement pension was

only € 448 (Eesti Statistika, 2018) in Estonia while

for example the German and Swedish seniors enjoy

much better life (Eurostat, 2017, 2018, 2018a).

Considering the differences in purchasing power, the

average old-age pension in Estonia is about 3 times

lower than in the above-mentioned countries

(Eurostat, 2019).

With respect to Internet usage information

technology devices, Statistics Estonia collects only

data among Estonian residents up to 74 years old

(Eesti Satistika, 2018a). Thus, the elderly citizens

have been left out and there is no adequate

information on their health information seeking

behaviour and usage of e-health system. Probably it

is assumed that they use Internet less than other age

groups. However, as noted by Estonian Chancellor of

Justice, acquiring updated data about elderly cannot

be considered less important (Chancellor of Justice,

2018). There is no good reason to distinguish 75-year-

olds and older people from the rest of the population

when collecting Internet usage data. For these

reasons, the Chancellor of Justice advises the

Statistical Office to also collect Internet usage data

from people older than 74 years of age.

Thus, it could be supposed that there is a

substantial number of older Estonians who have never

used a computer and a very modest share of those

with advanced computer skills. Also middle-aged

Estonians i.e. aged 50 to 64, lag behind in comparison

with their European counterparts. Apparently, more

than 10% of the people belonging to this age group

have never used a computer. Despite the fact that the

share of internet users among 65–74-years-olds have

increased, the digital divide between the youngest

(16–24-year-olds) and the oldest (65–74-year-olds)

age group is 46 percentage points (Statistics, 2017).

Thus, the frequently launched e-services are not

actually accessible to those who need them the most.

The chancellor of justice has noted that Internet

access is taken for granted by most people in Estonia

and this service can already be considered a main

necessity (Chancellor of Justice, 2018). Computer

skills training and Internet usage is associated with

quality of life and well-being for the elderly. This can

be a significant tool for supporting the elderly when

solving issues associated with living arrangements

(Chancellor of Justice, 2018). For instance, to avoid

social isolation, solve practical issues, and in case of

reduced mobility, encourages life-long learning and

cultural participation (Ainsaar and Soidla, 2018).

To diminish the digital divide between elderly

people and younger generations, EUR 7.2 million has

been set aside in the state budget for 2017–2020. It is

hoped that more extensive use of the Internet may

help to increase seniors’ quality of life. The objective

this plan is to increase the percentage of Internet users

among the entire population by 2020, from the current

89% to 95%. The means for this include digital

literacy and other training as well as raising

awareness.

ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health

232

4 LITERATURE REVIEW

Many scholars in the world have focused on digital

divide with respect to Internet use by elderly on

medical purposes. For example, some researchers

have focused on personal traits of senior citizen when

using e-health system. In Germany, a study analyzed

how individual characteristics shape elderly's

perceptions and behaviour in using e-health

(Rockmann and Gevald (2015). Since modern

technologies become increasingly complex, elderly's

mental models on how technology works might not

be supported. The authors focused on how individual

characteristics shape elderly's perceptions and

behaviour in using e-health. They proposed a research

model in order to understand how personality traits

determine perceptions and behaviour of elderly’s

health-related Internet use. According to them,

computer self-efficacy (CSE) and outcome

expectations regarding internet-based health

information act as primary determinants of

individual’s intention to use eHealth offerings. They

argued as well that the five broad personality traits

directly affect elderly’s CSE.

Vancea and Solé-Casals from Chile and Spain

examined the potentialities of new informatics

developments in generating solutions to better

address elderly people’s daily-life, especially those

with chronic illness and/or low autonomy. The

authors attempted to propose a research agenda, by

exposing various strengths and weaknesses of

eHealth innovations for elderly, mainly grounded in

secondary sources analysis (Vancea and Solé-Casals,

2016).

Wu and Li from the School of Information

Management, Wuhan University (China) explored

the behavioural patterns of Chinese elderly when

searching for online health information. A controlled

user experiment was conducted to understand how

Chinese elderly people search for online health

information. 20 elderly people completed three search

tasks based on three different health information

seeking contexts. The outcomes indicated that

education and familiarity with Internet searching

were found to significantly affect task performance.

Health, Internet search experience, and information

credibility influenced the decision to seek for

information online. Primary challenges were lack of

technical skills, internet search skills, and medical

knowledge (Wu and Li ,2016).

Tennant and colleagues focused on information

seeking behaviour among the US older generation.

They studied factors that influenced e-health literacy

among baby boomers and older adults. The authors

explored the extent to which sociodemographic

characteristics, social determinants, and electronic

device use influenced e-health literacy and use of

Web 2.0 for health information. The results revealed

that being younger and possessing more education

was associated with greater e-health literacy. Females

and those highly educated, particularly at the post

graduate level, reported greater use of Web 2.0 for

health information. They stressed the need for more

in-depth surveys and interviews among more diverse

groups (Tennant et al, 2015).

Thus, the issue of elderly people using Internet for

retrieving health information and e-health system has

arisen interest among scholars. In Estonia, some

researchers have been done with respect to people’s

satisfaction with e-services (TNS EMOR, 2014).

However, no studies have been conducted focused on

health information behaviour of senior citizens (74+).

Thus, the author of the article hopes to shed more

light over this important issue with this study.

5 METHODS

In this qualitative pilot study, five in-depth interviews

(three females and two male pensioner) and a focus

group (FG) interview with seniors were carried out at

the Haabersti Social Centre in Tallinn in May 2018.

All the participants were older than 74 years of age.

First, in-depth interviews (Boyce and Neale,

2006) conducted on the 25

May 2018 provided me

some relevant information about pensioners’ usage of

the internet and information technology and their

online health behaviour. Second, the focus group

(FG) interview (Better Evaluation, 2011) enabled me

to obtain more detail information on the same issues.

The FG interview was conducted on the 28

May

2018 and lasted 1 hour.

The respondents (12) of the FG interview

regularly participated in an arts and crafts class and a

sport club for seniors of which 7 were females and 5

males.

The author of the article was interested in the

following aspects:

• Do they have access to the internet and

computers? If not, then why?

• Where do they usually obtain information

related to health and diseases?

• Have they used internet to retrieve

information on health issues? If not, then

why?

Do Elderly People Enjoy the Fruits of Estonia’s e-Health System?

233

• Have they heard about e-health system?

• Have they used this system?

• How do they estimate their health

conditions?

• Have they used some other e-government

systems (e-voting, e-tax board, e-banking, e-

ticket or any other)? If no, then why?

• If yes, then are they satisfied with these

systems?

• If they have used the internet to retrieve

health related information, then what

difficulties and problems they have

encountered?

• If they haven’t use internet yet, are they

interested in becoming familiar with internet

and computers?

• Whether or not they would like to attend

courses on internet?

Interviews and the FG interview were analysed with

a software program MXQDA designed for qualitative

research. Major themes and related discourses were

identified.

6 OUTCOMES

The interviews revealed that the elderly have rare

exposure to the internet. Traditional face-to-face

communication or discussions with friends over the

phone is allegedly more convenient for them. They

know, of course, that the internet offers lot of health

information and they have heard about the e-health

system. However, they prefer to obtain information

related to diseases from their medical doctors.

The FG interviews further revealed that poor

economic conditions really prevent pensioners from

using information technology. As they lack

experiences with internet and IT-devices, they really

do not know how to use them. Following discourses

emerged.

“The economic circumstances are one reason why

we do not use the internet”. Even though the FG

participants did not express major concerns about

their economic situation (presumably due to certain

self-restraint), only 3 of them reported to have access

to a computer, 2 had personal computers at home and

one had a tablet given as a gift by their children, one

gentleman had a smart-phone. According to this male

pensioner (83):

“If my pension was higher, I would probably buy a

computer myself. My daughter gave me her old smart

phone, but I never use it to go online. I use it only for

answering incoming calls and calling to my daughter

mainly or my doctor. … I think all the ideas with respect to

the e-health and so on are good, but you know, if you

haven’t got a computer, then you don’t know how to use the

computer and then all the e-health systems are of no use to

you. …. In truth, I also do not use e-banking facilities. This

stuff is all for people younger than me….”

“Internet is an entertainment for younger

generations.” Internet was not considered a source

for retrieving any hard information, but rather a

gadget for younger generations for seeking

entertainment. According to a lady (75):

“Once I switched the computer on, and it seemed to me

that I saw some porn on the screen. I quickly shut it down

again…. If I need some health information, I can ask my

family doctor. She is very kind. “

Seeking health information from the internet was

rated as part of the youth lifestyle. Surprisingly it

turned out that pensioners have almost no interest in

the internet. One interviewee stated (female, 80):

“Children bought me a tablet, but I almost never use it.

I think this device can be used for fun, but to be honest, I

have better things to do. … Why should I look for health

information using this option? I never do that”.

Another lady (84) noted: “I don’t think I need any

means of IT or internet for that matter. This is something

for the younger generations. When my great-grandchildren

visit me, then all they do is fiddle with their cell phones.

“The adequate health information can be obtained

only from medical doctors”. For seniors, health

information on the internet environment meant

mainly information on alternative medicine, thus

considered not reliable. For them, traditional

medicine was the only acceptable framework for

health issues and the only well-established setting

where to voice their health concerns was a private

consultation with their doctor. A lady (79) pointed out

that:

“Listen, we have survived the Soviet time, thus, we are

strong enough not to believe all kind of rubbish. …. All

these miracle supplements and gemstones, this stuff is for

younger people and they obtain all the information from the

internet. They believe in it, it's for them, it's business … If

I need some information about my health conditions and

diseases, I will ask my doctor of course”.

They claimed not to believe as well questionable

medical stories disseminated by the mass media.

They considered alternative medicine to be

ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health

234

something that fascinates the younger people whom

they believed to be somewhat naïve and weak.

“My children assist me in coping with the e-health

system”. Seniors admitted that if they wanted to find

some information online, then their children or

grandchildren would show them how to conduct the

searches and assist them. A gentleman (76):

“I do not own a computer, but my children do. If I need

some information, then my daughter, for example, can find

this for me on the Internet. Actually, as I recall, I have never

needed it”.

A lady (76) noted: “I sometime use the system with

the help of my daughter. Simply to see what the doctor has

put down there e.g. the results of my blood tests or

screenings and other medical procedures. And I know it is

possible to book a doctor’s appointment online, but I

haven’t done it just yet”.

“We have a lot more to do than search the internet

for health information”. Surprisingly, the elderly

claimed that health is important to them, but they

prefer other topics. They said that they do not like to

complain about their diseases, rather they try to focus

on more positive and cheerful topics such as

grandchildren, cooking, handicraft, TV shows. A

joyful lady (77) noted:

“If I want to discuss my health issues with somebody, I

can always call my friends. In fact, we prefer to converse

about more joyful things. It seems to me that it's not a good

idea to bemoan all the time. If I have a problem, then I

quickly go to the doctor.”

The elderly participated in the FG admitted the

decline in their health conditions, but they said they

do not like to fill their daily routine with health

concerns and complaining. The participants liked to

contrast themselves with the younger generation.

Having survived the Soviet era, they regarded

themselves as strong enough to cope with their old

age problems as well.

Thus, in addition to the economic difficulties,

number of other factors were highlighted during the

FG interview with respect to the low use of the

internet. IT-devices information technology was

interpreted as a part of the youth lifestyle.

Elderly liked to confront themselves to young

people, who were considered weak and naive.

Excessive use of internet and smart devices was

considered a characteristic of young people and

suitable for them. It may therefore be thought that the

state-run IT courses would not be of particular

interest to them.

Limitations of the Study. First, the results shed light

on only a small part of Estonian pensioners. Second,

the elderly people in the group were not very talkative

about their economic conditions and difficulties, only

5 pensioners were willing to openly elaborate on such

matters in the group. Thus, the majority of the focus

group participants were rather reluctant to speak

about their difficulties, health conditions and their

health information seeking practices as well. This can

be explained by the fact that complaining is not a

good tone for this age group. When conducting the

following FG interviews in the other social centres

questions should be better formulated. Pensioners of

diverse social backgrounds and nationalities should

be integrated to the study.

7 SUMMARY

Digital healthcare services are especially important in

the context of population ageing. Estonia, the former

Soviet Republic that has developed rapidly over the

last decades, is often praised for its e-government

solutions including e-health. However, not everyone

enjoys Estonia's success in information technology.

Especially older people are left behind due to

economic deprivation or lack of skills.

The pilot study, which is the first step in the

second doctoral thesis of the author which is oriented

to study patterns of online health information

behaviour of Estonians, revealed that the elderly, in

addition to the economic disadvantage, are reluctant

to use computers and traditional communication.

They contrast themselves with young people, who

they think spend too much time in internet

entertainment environments and who trust alternative

medicine. With respect to health problems, they

believe in their doctor rather than searching internet.

However, with the help of their children, the e-health

system is sometimes used to obtain medical

prescriptions and test results.

The study contributed to the suspicion that the

wholesome public image of Estonia’s e-success not

always corresponds to the reality. Fortunately, the

first steps have been taken nationally to eliminate the

digital divide, for example, the government has

allocated millions to teach the elderly to use the

internet and IT tools.

The author of the article hopes to provide some

new insights on elderly's health information

behaviour. In the future, the author is going to

integrate all the other aspects influencing seniors’

online health information behaviour to her study. This

information could help to understand given age-group

Do Elderly People Enjoy the Fruits of Estonia’s e-Health System?

235

better which could be necessary in order diminish

information gap in the society. As a next step, it is

necessary to repeat FG interviews in some other

social centres in Estonia. Second, a quantitative study

should be conducted to reveal additional aspects

regarding health information behaviour of Estonian

elderly and to obtain data on the basis of which more

firm conclusions could be drawn.

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