Patient Education and Counseling 103 (2020) 15–32

Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review Article

Health information overload among health consumers: A scoping

review
Israa Khaleela,* , Barbara C. Wimmera , Gregory M. Petersona , Syed Tabish Razi Zaidia,b ,
Erin Roehrerc, Elizabeth Cummingsd , Kenneth Leea,e
a
Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Tasmania, Australia
b
School of Healthcare, Faculty of Medicine and Health, University of Leeds, West Yorkshire, United Kingdom
c
Discipline of ICT, School of Technology, Environments and Design, College of Sciences and Engineering, University of Tasmania, Tasmania, Australia
d
School of Health Sciences, Faculty of Health, University of Tasmania, Tasmania, Australia
e
Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Western Australia, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To examine and identify the scope of research addressing health information overload in
Received 3 December 2018 consumers.
Received in revised form 2 August 2019 Methods: In accordance with a published protocol, six electronic databases (PubMed, CINAHL, ERIC,
Accepted 4 August 2019
PsycINFO, Embase, and Scopus), reference lists of included articles, and grey literature (Google Advanced
Search and WorldCat) were searched. Articles in English were included, without any limit on the date of
Keywords: publication.
Health information
Results: Of the 69 records included for final analysis, 22 studies specifically examined health information
Information overload
Scoping review
overload, whereas the remainder peripherally discussed the concept alongside other concepts. The 22
Self-management studies focused on one or more of the following: 1) ways to measure health information overload (multi-
Patients item/single-item scales); 2) predictors of health information overload - these included low education
Consumers level, health literacy, and socioeconomic status; and 3) interventions to address information overload,
such as videotaped consultations or written materials. Cancer information overload was a popular topic
amongst studies that focused on information overload.
Conclusion: Based on the identified studies, there is a clear need for future studies that investigate health
information overload in consumers with chronic medical conditions other than cancer.
Practice Implications: This review is the initial step in facilitating future efforts to create health
information that do not overload consumers.
© 2019 Elsevier B.V. All rights reserved.

Contents

1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.1. Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.1. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2. Information sources and search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.6. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.1. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

* Corresponding author at: Division of Pharmacy, School of Medicine, College of

Health and Medicine, University of Tasmania, Private Bag 26, Pharmacy Building,
Churchill Ave, Hobart 7005, Tasmania, Australia.
E-mail address: israa.khaleel@utas.edu.au (I. Khaleel).

https://doi.org/10.1016/j.pec.2019.08.008
0738-3991/© 2019 Elsevier B.V. All rights reserved.
16 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

3.2. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.2.1. Studies that focused on health information overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.2.2. Studies that discussed information overload and expert opinion articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.3. Key findings of the studies that focused on health information overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.3.1. Measurement of health information overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.3.2. Predictors of information overload and other correlates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.3.3. Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4. Discussion and conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.1. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.1.1. Health literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.1.2. Education level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.3. Cognitive effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.4. Interventions and health information overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.5. Further research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.6. Strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.2. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.3. Practice implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Funding sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1. Background among patients. To our knowledge, and having performed a

Information overload can be defined as a state where the
volume of the information exceeds an individual's information
processing capacity [1]. The volume and complexity of health
information, either provided through traditional patient education
or gained through patients’ self-management efforts, can lead to
information overload among patients [2]. In the health context, the
expanding availability of relevant information over the last few
decades, especially through online sources, has exacerbated the
issue of health information overload [3].
Outcomes of psychological research suggest the cognitive
capacity for processing and recalling new information is limited,
and is influenced by various personal factors [4,5]. These include a
high level of anxiety [6], health motivation [7], and an individual's
knowledge base [8]. A review of the literature in the management
sciences identified several effects of information overload [9]. For
example, in terms of the effects on information processing and
behavior, people who experienced information overload were
more likely to be stressed and confused, to abstract information
with incorrect interpretations, ignore further information input,
and had reduced accuracy in decision-making.
A study of newly-diagnosed patients with coronary artery
disease, which examined the effects of information overload on
patients’ behavioral intentions, suggested that perceived informa-
tion overload had a direct negative impact on patients’ intention to
read self-management educational materials [10]. Furthermore, a
study on online health information behaviors found that informa-
tion overload impaired the active interaction and communication
between patients and their health care providers [11]. At a time
when patients are increasingly expected to play an active role in
their health care management, such as engaging in decision-
making and self-management [12], information overload can
impair this expected role.
In addition to the effects of information overload on informa-
tion processing and behavior, health information overload in
patients may result in many undesirable health consequences,
including the impact on psychological well-being [13]. More
specifically, two studies have identified an association between
information overload and negative emotional states, such as stress,
anxiety, and anger [13,14].
Despite relatively extensive literature on information overload
in other fields, there appears to be a paucity of research that
explores information overload in the health context, particularly
preliminary search, there are no systematic or scoping reviews on
health information overload in health consumers. Given the
increasing significance of health information and its potential
impact on patients’ decision-making and self-management, a
comprehensive scoping review of the available literature related to
this topic is needed to identify key areas that warrant further
exploration.
1.1. Aim
This scoping review aimed to identify and examine the available
literature regarding health information overload among health
consumers.
2. Method
This scoping review was conducted in accordance with a
published scoping review protocol [15]. The aim of a scoping
review is to identify the breadth and depth of evidence, as opposed
to the quality of evidence [16,17]. Given that scoping reviews are
suitable in instances where fields have not been expansively
reviewed [17], we felt this was the most suitable methodological
approach for the present study.
2.1. Eligibility criteria
In accordance with the aforementioned published protocol [15],
this scoping review included studies where health information
overload was specifically explored, measured, or peripherally
mentioned (within the context of other concepts) in consumers
who sought or received information relevant to the treatment/
management of health conditions. The minimum age of patients
for inclusion was 12 years, based on the categories stated by the
authors of the relevant articles. In recognition of the potential
difficulties in identifying whether health information is sought by a
patient or by lay consumers on behalf of a patient, we did not
differentiate patients from consumers who sought/received health
information on behalf of a patient. We have thus used the broader
term ‘health consumers.’
The exclusion criteria included health and information pro-
fessionals or students. Thus, studies that merely investigated the
professional role of health or information professionals/students in
the context of information overload were excluded. Studies that
 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32
investigated health-related effects of information overload in
consumers searching for, receiving or utilizing non-health related
information, were also excluded. Any articles published in
languages other than English were excluded. There were no
restrictions imposed on the included studies based on a
geographical area or date of publication.
2.2. Information sources and search strategy
A comprehensive literature search was conducted through
relevant online databases. A search strategy was developed and
refined with the assistance of two research librarians. This search
strategy adhered to the aforementioned published protocol [15],
and is presented below.
Step 1: An initial search, relevant to the topic of the scoping
review and limited to two online databases (PubMed, for medical
and health-related literature, and CINAHL, for allied health-related
literature), was conducted. The initial search terms/phrases were
subsequently modified to expand the range of the results. New
free-text terms and controlled vocabulary terms were identified in
the title, abstract, and author fields, and these were included in the
second step of the search.
Step 2: A targeted search was conducted on the 17th August
2018. In this step, the final search strategy was applied to the
following electronic databases: (a) PubMed, (b) CINAHL, (c) ERIC
Fig. 1. Flow diagram of study selection.
17
(for education-related literature), (d) PsycINFO (for psychology-
related literature), (e) Embase (for biomedical and clinical health-
related literature) and (f) Scopus (citation database of peer-
reviewed literature).
Boolean operators “OR” and “AND” were used among controlled
vocabulary terms and free-text terms. The controlled vocabulary
terms included the MeSH terms (Medical Subject Heading) in
PubMed and equivalents in the other databases, namely (a) MH
terms as a Major Heading in CINAHL, (b) DE terms (Descriptors) in
ERIC, (c) Index Terms in PsycINFO, and (d) Map Terms in EMBASE.
There was no option for using controlled vocabulary terms in
Scopus. The free-text terms included free-text word or phrases.
Proximity operators were applied to eliminate free-text terms
which provided zero results in the search. The proximity operators
were used in all the electronic databases except PubMed, as it does
not offer proximity searching. The final search strategy that was
conducted in the six electronic databases is illustrated in
Appendix A.
As per the published protocol [15], a limited grey literature
search was conducted through (a) Google advanced search and (b)
WorldCat Dissertations and Theses. The Google advanced search
was limited to the English language, and to three groups of
websites (.edu, .org, and .gov). The advanced search of WorldCat
was narrowed to the English language, and “health” and
“information overload” were searched as keywords. All the terms
 18
Table 1
Summary of the studies that focused on information overload.

Study (by Year of Country of Type of study Aim/purpose Population (includes What was done? (variables Key findings Gaps in the research/
author publication origin (experimental, sampling method/approach compared, intervention type, limitations
surname) review, and sample size if applicable) duration of intervention)
conceptual, etc.)
Obamiro 2018 Australia Quantitative To measure the level of Adult Australians, diagnosed A modified scale of CIO Health information overload The study depends on self-
et al. [33] online survey, knowledge in patient with AF, with AF and taking oral developed by Jensen et al. was was identified as a significant reported measurement
through and to assess the connection anticoagulant, were used to assess health predictor of poor oral
Facebook between patients’ anticoagulant recruited via Facebook. information overload in AF anticoagulant knowledge.
knowledge and the patient n = 386 patients. There was no
factors. intervention in this study
Compare the results of this
study with the results of
patients taking direct acting
anticoagulants
Obamiro 2018 Australia Secondary data To measure percentage of AF Adult Australians with AF A modified scale of cancer Information overload was one The modified health

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

et al. [34] analysis of patients with suboptimal who were taking oral information overload that of the significant negative information overload
quantitative adherence and to find out if the anticoagulants were developed by Jensen et al. was predictors of oral anticoagulant measure used for patients
online survey, patient-related factors are recruited through Facebook, used to assess health adherence with AF was not validated
through different according to the level n = 386 who aged 65 or less. information overload in AF
Facebook of AF patient adherence. patients. There was no
intervention in this study
Ramondt & 2018 USA Quantitative To adapt and validate CIO scale Adult participants fluent in Cancer information overload Level of education is a The participants were not
Ramírezb survey-based to measure diet information English or Spanish, n = 287 scale was adapted and validated significant predictor of diet randomly selected; this
[35] study overload, and to examine the to measure diet information information overload while age, could affect the
effectiveness of using 5 items overload, using 5 items scale sex and completing the survey generalizability of the study
scale instead of 8 items. instead of 8 items. There was no in Spanish were not significant findings.
intervention in this study predictor in this study.
Ross et al. 2018 USA Secondary data To assess the relationship Adult participants, n = 3052 The survey included numeracy Information overload was Only the subjective
[36] analysis of 2007 between the low numeracy and questions in addition to strongly associated with low assessment of numeracy
Health CIO, cancer knowledge and demographic questions, current numeracy that was represented (self-reported) was included
Information beliefs health condition, cancer beliefs by discomfort with medical
National Trends and health information sources. statistics, even after controlling
Survey (HINTS- Information overload was the sociodemographic factors.
3) measured by one question with
2 points either agree or disagree
Bol et al. [37] 2018 The Cross-sectional To test a model that explore the Old patients diagnosed with Perceived cognitive load was Recall the online cancer Perceived cognitive load
Netherlands online survey effect of chronological age and cancer, aged 65 years or measured by single item “How information is negatively was assessed by single item
age-related factors on the recall above were recruited from much effort did it take to study associated with perceived question regarding the
ability of online cancer different sources: 2 hospitals, the web content about RFA?” cognitive load required effort to process
information in older patients online panel of cancer the information
patients, and research
institute panel. n = 197
Pignatiello 2018 USA Randomized To evaluate the reliability and Adult participants, able to Participants were divided into 3 There was no significant The sample size was not
et al. [38] control trial to validity of the 8-item cognitive communicate in English and groups: control, participants difference between the two adequate to observed
evaluate the scale in health decision making are identified by the received information support types of decision support validity and reliability of the
reliability and by a person who are kin to a intensive care staff as the intervention, and participants intervention in relation to the scale
validity of the 8- patient in intensive care unit closest person to the patients received interactive avatar- cognitive load level.
item cognitive were recruited from four based intervention (INVOLVE)
scale for health units in one academic
decision making medical center. n = 62
Jensen et al. 2017 United Cross-sectional To explore the relationship Adults 50–75 years old. Cancer information seeking/ Cancer information seeking is The question items relating
[27] States study utilizing a between perceived CIO and Recruited via human scanning and cancer worry negatively associated with CIO. to cancer information
quantitative cancer worry, with information resources representatives were compared with CIO This association was weak/ seeking/scanning were not
questionnaire seeking/scanning from eight worksites (six There was no intervention. moderate, and regardless of age, comprehensive.
hospitals, two manufacturing gender, and educational level
plants).
n = 209
Jensen et al. 2017 United Experimental To examine whether the Adult participants recruited Participants read a version of High level of uncertainty and One source of stimuli (news
[25] States design amount and source of from 7 shopping malls in the one of four newspaper stories newspaper stories about articles) was used, while
uncertainty in news coverage of US midwest, age range 18-84 and then responded to a battery treatment created high state- there are many sources of
cancer research impacts three years. n = 880 of questions and then were based CIO. However, none of news information such as
outcomes: cancer fatalism, asked to answer questions these findings were statistically radio and television
nutritional backlash, and CIO relating to cancer fatalism, significant.
nutritional backlash, and state-
based cancer information
overload.
Swar et al. 2017 Korea and Quantitative To investigate the influence of Adult participants and Psychological ill-being, and Perceived information overload The results of the study can’t
[13] Israel survey-based online health information university students aged behavioral intention were is positively associated with be generalized to all
study overload on the psychological between 19-24 years, from compared to online health negative effects, depression population, because of the
ill-being of information seekers Korea and Israel who information overload. symptoms, anxiety and anger young age of the
and their behavior intention to reported using online health There was no intervention in traits. participants
continue the use of online information were recruited this study
health information search for the survey.
n = 380
Norton & 2017 Australia Two-stage 1) To investigate why primary Stage 1: Caregivers of Stage 1 was used to address Information overload was The results of the study can’t
Raciti [31] qualitative case caregivers wanted to create children between ages 1 to 5 gaps in the literature and focus interfering with primary be generalized to all

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

study utilizing eating behaviors with their very years were recruited for the questions for use in Stage 2; caregivers’ decision making, population because of the
convergent young children, and how they convergent interviews. findings in the literature and causing confusion and creating qualitative method design
interviews. did that 2) To explore how n = 16 from stage 1 were compared anxiety. The consequences of
information overload influences Stage 2: Primary caregivers of and contrasted with findings information overload were:
the creation efforts of primary the families with one or two from Stage 2. ineffective practices,
caregivers caregivers were recruited for There was no intervention in inconsistent pursuits.
in-depth interviews. n = 24 this study.
Chae [6] 2016 United Cross-sectional To identify causal pathways of Study 1: United States Trait anxiety and CIA were Trait anxiety and CIA were The focus was on CIO
States survey utilizing CIA, and to evaluate whether residents. compared to CIO. positively correlated to CIO without considering the
(Study 1) an online trait anxiety has a direct effect n = 384 There was no intervention in effect of cancer fatalism as a
and South quantitative on CIA and/or an indirect effect Study 2: was conducted in this study predictor of CIA
Korea questionnaire through CIO South Korea by 3 waves;
(Study 2) (n1 = 1130, n2 = 813,
n3 = 582)
Chae et al. 2016 United Cross-sectional To explore correlates of CIO. Sample 1: United States Trait anxiety, education and Trait anxiety positively Key variables of interest
[22] States survey utilizing Specifically, focusing on residents. active use of information from predicted CIO. Education and were measured using
(study 1) an online evaluating whether ability and n = 3959 media channels were compared active use of information from single-item measures
and South quantitative motivation to process cancer Sample 2: United States to CIO. media channels negatively
Korea questionnaire information were correlated undergraduate students. There was no intervention in predicted CIO
(Study 2) with CIO n = 309 this study
Sample 3: United States
residents.
n = 384
Sample 4: South Korean
residents.
n = 813
Crook et al. 2016 United Cross-sectional To understand what influences Adults with age range 18-75 Internet use, perceived Individuals who were Participants’ intention was
[24] States survey utilizing a people to share health were recruited from a knowledge of heart health, overloaded with heart evaluated rather than their
questionnaire information, and to evaluate the regional health care clinic in information sharing, attitude information negatively behavior
impact that sharing has on an central Texas toward healthy heart evaluated healthy heart
individual's behavioral n = 180 information, and behavioral information. Attitudes toward
intentions intentions were compared to heart information mediated the
information overload. relationship between
There was no intervention in information overload and
this study information sharing
Meppelink 2016 Netherlands Cross-sectional To investigates the mechanisms Adult respondents were The online survey was emailed 1- The results of study 1 Health literacy was assessed
et al. [39] quantitative through which health literacy recruited by a research to the participants, and it indicated a significant indirect through the short
online survey affected information recall and company PanelClix (ISO included questions about relationship between health assessment of health
website attitudes certified) and randomly gender, age, education level, literacy and information recall literacy in Dutch
selected for this study. For health-related internet use and through cognitive load. 2- The
self-report knowledge. results of study 2 showed that

19
 20
Table 1 (Continued)
Study (by Year of Country of Type of study Aim/purpose Population (includes What was done? (variables Key findings Gaps in the research/
author publication origin (experimental, sampling method/approach compared, intervention type, limitations
surname) review, and sample size if applicable) duration of intervention)
conceptual, etc.)
the first study n = 423. For the Perceived cognitive load was the influence of health literacy
second study n = 395. assessed through four items on website attitude was
with 7 point Likert scale. There mediated through cognitive
was no intervention in this load.
study
Jiang & 2016 United Secondary data To test a model that includes Adults participants, n = 2305 Motivation for health-related A greater motivation for health- The variance explained in
Beaudoin States analysis of cross- health-related Internet use, related Internet use
Internet use and health literacy health literacy, by the
[28] sectional mail motivation for health-related were compared to perceived significantly predicted a lower model, was low; this
survey data from Internet use, perceived health information overload. There perceived health information suggests other important
the HINTS information overload, and was no intervention in this overload. Greater health- constructs need to be
program. health literacy study related Internet use measured
significantly predicted a higher

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

perceived health information
overload. A higher perceived
health information overload
significantly predicted a lower
level of health literacy.
Liu & Kuo 2016 Taiwan Cross-sectional To explore if information Adult inpatients or their Pre-existing (SMEM) were Perceived information overload Participants restricted to
[10] study overload will prevent patients, caregivers, over 20 years old, provided to in-patients or of SMEM impacts on a number patients within specific
Face-to-face early diagnosed with coronary newly diagnosed with caregivers immediately prior to of Theory of Planned Behavior departments of a single
interviews artery disease, from reading coronary artery diseases discharge. constructs and has a direct hospital
using a educational materials for self- within a single acute Participants read the full SMEM impact on intention to use
structured care management. This study hospital. whilst awaiting discharge. SMEM.
questionnaire was underpinned by the Theory n = 106 60 min after reading they were Different SMEM relevant to
of Planned Behavior interviewed using a revised and educational levels may boost
translated pre-existing the use of SMEM
questionnaire.
Jensen et al. 2014 United Both study 1 and 1- To develop (Study 1) and Study 1: participants were Study 1: Prior screening Study 1: A valid 8-item cancer Neither studies used
[7] States 2 were cross- validate a multi-item measure employees from health care behavior, CIO, and other information overload scale was random sampling methods;
sectional survey of CIO (Studies 1 and 2). and manufacturing facilities psychosocial constructs were developed. as such, results of this may
studies utilizing 2- To examine if cancer at eight worksites with age correlated to the data of Study 2: The factor structure of not be nationally
questionnaires information overload and range 50–71 years. eighteen months of insurance the 8-item CIO scale developed representative.
fatalism are distinct concepts n = 209 claims data that related to in Study 1 was confirmed; CIO,
(Study 2). Study 2: Adults participants colonoscopy of the participants. preventive cancer fatalism, and
recruited from seven Study 2: Cancer fatalism were treatment cancer fatalism are
shopping malls, aged compared to CIO. There was no three distinct concepts.
between 50-71 years. intervention in this study
n = 399
Jensen et al. 2014 United Randomized To examine the effect of two Adult participants were There are two types of Individuals with greater CIO The effect of personal
[26] States controlled trial strategies (narrative, tailoring, recruited from one of 8 interventions: (a) web message were less likely to file a cancer (attitude/belief) on the
and in combination) on the worksites in Indiana with age provided to the participants screening claim. tailoring message was not
adherence to colorectal cancer range 50-75 years. after completing the survey, (b) Tailoring was effective at countered
screening n = 209 take home pamphlet. Four increasing screening behavior
message interventions were for those with higher overload
compared: stock (no tailoring,
no narrative), narrative (no
tailoring, narrative), tailored
(tailoring, no narrative), and
tailored narrative (tailoring and
narrative).
Niederdeppe 2014 United Study 1: This was Study 1: To evaluate the volume Study 1: There were no Participants in the experimental CIO and prevention fatalism The news stories used in the
et al. [30] States a content and the content of the news participants. group read stories about cancer were found to be separate study were more than a
analysis. coverage regarding cancer cause Study 2: Adult participants causes and cancer prevention. constructs. Exposure to decade older than when the
Study 2: and prevention that available in with age range 18- 95 years The control group read stories intervention that promotes study was conducted,
 Randomized local TV were recruited from a public unrelated to the topic. The reduced cancer risk behavior differences between local
controlled trial Study 2: To examine the effect of location in a small north- length of the stories in did not reduce CIO. TV and newspaper coverage
with a post- the identified factors in eastern city in the United experimental and control of cancer may be less
intervention reducing cancer risk States. groups were held constant. dramatic today.
only n = 601
questionnaire.
Chan &Huang 2013 United Secondary data To explore correlates of weight Data of 2007 Health Age, lower education, being Older age, lower education, The subjective overload
[23] States analysis management information Information National Trends single, unemployed, lower being single, unemployed, perception was evaluated
overload (HINTS) Survey were used in annual income, and the ethnic lower annual income, and regardless of the objective
this study. groups were compared to Hispanics and non-Hispanic assessment

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

n = 3311 weight management blacks were positively
information overload correlated with weight
management information
overload
Kim et al. 2007 United Secondary data To explore the predictors of CIO Adults, cancer information Socioeconomic features, health Significant predictors of Only one item was used to
[29] States analysis of the in cancer information seekers. seekers with age range communication and status, information overload: lower measure CIO
2003 Health between 35-64 years. were compared to information education level, greater
Information n = 3011 overload to explore the concerns of quality of
National Trends predictors. information, poorer search
Survey (HINTS) There was no intervention in expertise, and poorer cancer
this study. literacy.
Schommer 2001 United Experimental To examine the persons’ Adults, households. Participants were randomly The more depth and breadth of The use of videotape
et al. [32] States research design processing of prescription n = 477 allocated one of 12 conditions of information provided the less consultations provides only
(randomized medicine information by using presentations (52 study information overload one-way communication,
control trial) different prescription subjects in each group). experienced by the participants which may not be realistic
conditions Participants received a
videotape of a pharmacist
consultation with or without
written information
(experiment), and were then
asked to complete a mailed
questionnaire.

Cancer information avoidance = CIA, cancer information overload = CIO, self-management educational materials = SMEM, Atrial fibrillation = AF, radio frequency ablation = RFA.

21
22 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32
used for the grey literature search, as well as the final results, are
included in Appendix B.
Step 3: Reference lists of all the eligible articles and reports
were reviewed to identify any additional relevant studies.
Attempts were made to contact relevant authors to gain further
information, especially when published conference abstracts
without the full text were identified in our database search.
2.3. Study selection
Search results identified through electronic databases were
imported into Covidence [18], a web-based program for streamlining
the conduct of systematic reviews. Duplicates were removed from the
imported studies. Title/abstract screening (stage 1) and full-text
screening (stage 2) were used to determine if studies met the inclusion
criteria. Two members of the research team (IK and KL) completed the
first stage. Full-text studies were assessed for eligibility byall members
of the research team. Each stage of the screening was conducted by two
reviewers independently. A consensus decision was used to resolve
conflicts, when needed. The process for article selection is presented
using the PRISMA flow diagram template [19] in Fig. 1.
2.4. Data extraction
Data were extracted from the included studies based on the
template outlined in the scoping review protocol [15]. The
template included: (a) citation details, (b) country of origin, (c)
study population and sample size, (d) intervention type, com-
parators, and additional details, (e) key outcomes, and (f)
limitations. Study aims were also extracted, where relevant, in
recognition of the need to provide additional context during data
extraction and reporting. The extraction and presentation tables
were performed by IK and approved by the team (Tables 1 and 2).
2.5. Data synthesis
We used a combination of tabular approaches and narrative
integration for data synthesis [20]. A narrative approach to data
synthesis was chosen owing to the heterogeneity of the research
designs, foci, and quality of the included evidence. Tables were
used to summarize data extracted from the included studies, and a
narrative was provided to explain key findings from the tables.
2.6. Quality assessment
Quality evaluation was conducted only for randomized trials.
While quality evaluations are not typically performed in scoping
reviews, we conducted a quality evaluation for the five studies that
used interventions so as to provide readers with further context of
the need for further high-quality research in health information
overload among health consumers. The evaluation was performed
independently in pairs by members of the research team, using the
critical appraisal checklist of the Joanna Briggs Institute for
randomized controlled trials [21].
3. Results
3.1. Study selection
Overall, 15,059 records were retrieved. Of these records, 14,304
were identified from the six databases. Specifically, the records
were identified from PubMed (n = 1015), CINAHL (n = 1525), ERIC
(n = 66), PsycINFO (n = 868), EMBASE (n = 5682), and Scopus
(5148). An additional 755 records were identified through other
sources; namely, 80 records from grey literature and 675 records
from checking the reference lists of included articles. Following
the removal of the duplicates, 8,055 unique records remained.
After the abstract and full-text screening, 69 references were
deemed eligible for inclusion (Fig. 1). Of the 69 included
references, only 22 studies focused on health information
overload.
3.2. Study characteristics
The included studies/articles were subsequently divided
into two main groups: studies where the focus was on
health information overload (n = 22) and expert opinion
articles or studies where the focus was not on health
information overload, but health information overload was
discussed (n = 47).
3.2.1. Studies that focused on health information overload
Of the studies where the focus was on health information
overload (n = 22) [6,7,10,13,22–39], 13 were conducted in the
United States. Approximately half (n = 10) of the 22 studies focused
on the concept of cancer information overload (CIO). The other
studies had diverse topics, such as overload relating to overweight
information (n = 1), dietary information (n = 1), healthy heart
information (n = 1), anticoagulant medication (n = 2), self-educa-
tion materials (n = 1), health literacy and internet information
(n = 2), primary caregivers’ efforts in creating eating behaviors for
their children (n = 1), psychometric evaluation of cognitive load
scale (n = 1), psychological ill-being (n = 1), and processing
prescription drug information (n = 1). Most of the 22 studies were
published between 2014 and 2018 (n = 18). These studies used a
predominantly quantitative methodology (n = 21), with only one
qualitative study (Table 1).
Of the studies presented in Table 1, five were randomized
controlled trials [25,26,30,32,38]. We conducted a quality evalua-
tion for these studies, as summarised in Table 2.
3.2.2. Studies that discussed information overload and expert opinion
articles
This group included 47 records: empirical studies (n = 31),
expert opinion articles (n = 15), and a literature review (n = 1). The
31 studies that discussed information overload [40–70] were
published between 2000 and 2018, and mainly conducted in the
United States (n = 11) and Australia (n = 6). A large number of these
empirical studies were qualitative research (n = 20) (Table 3). The
expert opinion articles were published between 1988 and 2018,
and mainly in the United States [71–85] (Table 4). There was one
literature review [86]; this review suggested that information
overload occurs because of the failure to introduce an appropriate
filtering system to manage and evaluate health information for
health care practitioners and patients.
3.3. Key findings of the studies that focused on health information
overload
The results of the studies that focused on health information
overload are summarized in Table 1. The studies presented in
Table 1 focused on health information overload in three main
ways: measurement of health information overload (Section 3.3.1),
identification of predictors/correlates of health information
overload (Section 3.3.2), and the effect of interventions on health
information overload (Section 3.3.3).
3.3.1. Measurement of health information overload
Different approaches have been used to assess health information
overload. Several quantitative studies developed [7], adopted
[22,27,30] or adapted either a multi-item validated scale [33–35]
or a single-item scale [23,29,36,37] to measure the level of health
 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32 23

information overload. Most of the approaches to measure informa-
tion overload were either developed and validated specifically for
certain conditions, such as cancer [7], or adapted for a selective
source of information, such as online information [13].
In 2014, Jensen et al. [7] developed and validated an 8-item
(with a 4-point) scale (strongly disagree to strongly agree) that
predicted cancer information overload (CIO). Later, this scale was
adopted by Niederdeppe et al., Chae et al., and Jensen et al. to
measure CIO [22,27,30]. The CIO scale was adapted by Obamiro
et al. [33,34], and Ramondt and Ramírez [35] for use with atrial
fibrillation and diet information, respectively. Another newly-
designed scale with 6 items (4-point) was suggested by Jensen
et al. at 2017 to evaluate state-based CIO [25].
A single item was used to measure information overload in
studies that depended on secondary data analysis of the Health
Information National Trends Survey (HINTS) [23,29,36]. A 9-item
with 7 point-Likert scale (1 = very strongly disagree to 7 = very
strongly agree) was used to measure information overload in an
experimental study designed by Schommer et al. This scale
measured feelings of confusion, frustration, doubtfulness, anger,
and vulnerability in response to received information [32].
Two scales from other disciplines have been adapted to
measure health information overload in consumers. For example,
Swar et al. adapted three items out of a 7-item scale that had
been initially developed by Chen et al. to measure the effects of
information overload on consumers’ decisions in the internet
shopping environment. The adapted scale by Swar et al. [13]
included “When I accessed online information on the internet
related to a healthcare topic: (i) I could effectively handle all the
health related information found on the internet, (ii) I was
certain that the online information about that health related
topic fit my need well to make better decisions, and (iii) I had no
idea where to find online information about that particular
health related topic due to abundance of online information on
internet.” The response ranged from 1-strongly disagree to 5-
strongly agree [13]. Another example is a scale used by Crook
et al. [24]; it was a 4-item scale derived from the Stephens and
Rains tool that was intended to measure information overload in
the context of information and communication technology [87].
One of these 4-item was, “The information I received about
healthy heart behaviours was too much information for me to
process.”
Another approach to measuring information overload is
through assessing the cognitive load of processing health
information. For example, a single item was used to assess the
extent of cognitive effort of the participants [37]. Another study
used a validated 8-item scale to assess the effect of cognitive load
on decision-making [38].
One qualitative study relied on semi-structured interviews to
explore the impact of information overload. This study was
designed by Norton and Raciti [31] as two-stage convergent
interviews. The first stage explored the literature, while the second
stage aimed to explore the impacts of information overload on the
primary caregivers’ efforts in co-creating healthy eating behaviors
for their young children. In this study, information overload was
found to interfere with primary caregivers’ decision-making,
causing confusion and creating anxiety. This study identified
consequences of information overload: ineffective practices,
paradoxical pursuits (e.g., wanting a child to eat more but being
concerned about the child becoming overweight), under-appre-
ciation of long-term consequences, and the daily challenge of
establishing healthy eating behaviors [31].
3.3.2. Predictors of information overload and other correlates
Several predictors were detected in the studies that focused on
information overload. Factors positively associated with health
information overload included a low education level [6,23,29], low
health literacy [28,29], poor searching skills [29], greater concern
about the quality of information [29], low socioeconomic status
[28,29], and race (Hispanic and non-Hispanic black) [22,23]. Trait
anxiety was positively associated with information overload
[6,13,22], as were older age and lower confidence in seeking
health information [23]. Greater motivation for health-related
internet use [28], more in-depth information provided to the
consumers [32], screening behavior [26], and health information
scanning (passive receiving of information) [27] were negatively
associated with information overload. Cognitive effort was
reported to have a unique inverted U-shaped relationship with
information overload [32]. Participants initially preferred to
receive a large amount of health information and did not initially
report experiencing information overload. However, as the amount
of health information received began to exceed the individual's
information processing capacity, the participants then reported
experiencing overload.

Table 2
Quality Appraisal.

Critical appraisal checklist: randomized control trial Author/Year

Pignatiello Jensen et al. Jensen et al. Niederdeppe Schommer et al.

et al. (2018) (2017) [25] (2014) [26] et al. (2014)* (2001) [32]
[38] [30]
1- Was true randomization used for assignment of participants to treatment groups? Y Y Y U U
2-Was allocation to treatment groups concealed? Y U Y U Y
3. Were treatment groups similar at the baseline? Y U Y N Y
4. Were participants blind to treatment assignment? Y U Y U Y
5. Were those delivering treatment blind to treatment assignment? U U U U N
6. Were outcomes assessors blind to treatment assignment? U U U U Y
7. Were treatment groups treated identically other than the intervention of interest? Y Y Y Y Y
8. Was follow up complete and if not, were differences between groups in terms of their Y U N Y Y
follow up adequately described and analyzed?
9. Were participants analyzed in the groups to which they were randomized? U U Y U Y
10. Were outcomes measured in the same way for treatment groups? Y Y Y Y Y
11. Were outcomes measured in a reliable way? Y Y Y Y Y
12. Was appropriate statistical analysis used? Y U Y Y Y
13. Was the trial design appropriate, and any deviations from the standard RCT design Y Y Y Y Y
(individual randomization, parallel groups) accounted for in the conduct and analysis
of the trial?
Quality High Moderate High Moderate High

Y = Yes, N = No, U = Unclear, * = One part of Niederdeppe et al. article (the second study is a randomized control trial).
 24
Table 3
Summary of the studies that discussed information overload.

Study (by Year of Country of Type of study Aim/purpose Population (includes sampling What was done? (variables Key findings Gaps in the research/
author publication origin (experimental, method/approach and sample compared, intervention type, limitations
surname) review, conceptual, size if applicable) duration of intervention)
etc.)
Monaro et al. 2018 Australia Longitudinal To explore the hospital Adult patients or their families Participants were asked open- Information overload was Different languages
[67] qualitative semi- experience of patients and their were interviewed twice before ended questions to explore identified under the theme of and cultural
structured interviews families who need major and after the amputation. n = 42 their hospital experience of being confused by missed and backgrounds were
amputation because of critical major amputation because of mixed messages not assessed in this
limb ischemia critical limb ischemia study
Stenov et al. 2018 Denmark First study: To identify the approaches of Sample size of the first Descriptions were collected Information overload in The participants
[68] ethnographic health care providers that could study = 31 (21 patients with from the first study and patients was suggested by the were recruited from
fieldwork either help or prevent focusing type 2 diabetes and 10 health informed the development of author of the study as a result of two places (a
observation, second on the patient need in group care providers) the qualitative study to identify delivering large amount of hospital and
study: qualitative during type 2 diabetes Second study n = 10 (7 patients the approaches of health care information in short time primary care
semi-structured face- education program with type 2 diabetes and 3 providers that could either help center); this can

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

to-face interview health care providers) or prevent focusing on the affect the
with patients and patients’ needs in groups, generalizability of
HCP during type 2 diabetes the results
education programs
Koen et al. [69] 2018 South Africa Qualitative focus To investigate how nutrition Adult consumers who The participants completed a The author suggested that the The study included
group discussion information on the food completed grade 7 as a base survey; then they were consumers need simple only educated and
labelling could influence the minimum level of education asked open-ended questions to nutrition information, more urban consumers
consumer purchasing behavior, were recruited from grocery investigate how nutrition graphics and less information
why consumers read or avoid stores. n = 67. information on the food overload
this information, and what are labelling could influence their
the requirements of consumers purchasing behavior
regarding food labelling
Woodhart 2018 Australia Qualitative semi- To explore women's experience 10 inpatient women who were Women were asked to describe Information overload was Participants were
et al. [65] structured interview who transferred due to less than 32 gestational weeks their pregnancy and the described as one of the recruited from one
complication during or after were interviewed twice; face- circumstances that lead to the difficulties that women face maternity clinic
birth to-face at time of admission hospital admission during admission to hospital
then by phone after one month due to threat of premature
from the first interview. labour
Liang et al. 2018 Australia Qualitative semi- To explore the attitude and the Adult patients diagnosed with Patients with advanced cancer Information overload was Interviewing
[66] structured face-to- experience of advanced cancer NSCLC or melanoma able to were asked open-ended identified as a barrier of patients at different
face or telephone patients with somatic tumor communicate in English were questions to explore their understanding the tumor time from their
interviews screening recruited by 2 oncology centers attitude and experience with mutation screening diagnosis may cause
in New South Wales. n = 24 somatic tumor screening recall bias
Holtkamp 2018 The Qualitative semi- To explore the experience of Pregnant women with risk of Participants were asked open- Information overload was one Participants only
et al. [70] Netherlands structured interview pregnant women with the hemoglobinopathies, were ended questions to explore of the identified themes that able to speak Dutch
carrier screening for recruited from primary care their experience with the affected the hemoglobinopathy or English were
hemoglobinopathies midwives, n = 19. prenatal hemoglobinopathy carrier screening included.
carrier screening
Saab et al. [62] 2017 United Meta-narrative To explore the men seeking Participants in this systematic There was no intervention in Information overload was Grey literature
States systematic review behaviors in relation to review were men seeking this study reported as one of the barriers search and
prevention, screening and risk information for the prevention to men's information seeking dissertation were
reduction of cancer screening or risk reduction of behaviors excluded from this
colorectal or prostate cancer review
Borges & 2016 Germany Online survey base. 1- To identify the characteristics Adult German-speaking Participants completed online Information overload was The participants
Kubiak [43] The method was of type 1 diabetic patients who patients, self-reported survey to identify reported as a significant barrier had used different
guided by a model accept to use CGM diagnosed with type 1 diabetes characteristics of patients who to the continuous use of CGM. models of CGM (this
developed from 2- To compare the effects of at least for one year, aged 18 agreed to use continuous variable should
technology different level of CGM usage years and above. n = 111 glucose monitoring (CGM). have been
acceptance model experience on patients. There was no intervention controlled)
(TAM) and structural
equation modelling
(SEM).
Costello [46] 2016 United Qualitative study To analyze the effect of the Participants were recruited by Patients were asked open- Information overload was Because of the
States with grounded communication between the the researcher through a public ended questions to find the reported as one of many factors qualitative design of
theory approach CKD patients and the health online post on four CKD support effect of the communication that limits the patient-provider the study, the
care providers on the health group websites: 12 participants between the CKD patients and interaction. finding can’t be
information seeking behavior of (25-70 years) were interviewed the health care providers on the generalized to the
those patients. twice to give 24 interviews in health information seeking entire population of
total behavior of those patients. CKD patients.
There was no intervention
Davis & Jiang 2016 United Qualitative and To evaluate and analyze the Participants with age 18-69 The participants completed pre- Information overload was the The study was
[48] States quantitative data usability of three diabetic years were recruited through study demographic most important concern dependent on the
collection websites mainly concern about flyers and emails. n = 20 questionnaire and post-study experienced by the participants Internet; therefore,
type 2 and provide suggestions questionnaire to evaluate the with the three websites the finding might
to improve these websites usability of the websites. There change over the
was no intervention in this time
study
Gibson [54] 2016 United Qualitative study To examine the health-related US Parents (26-73 years) of The interview questions were Most of the participants The age variation of
States with grounded information seeking behavior of children with Down Syndrome adapted from the information reported experiencing the participants’
theory in-depth, parents of children with Down were recruited through emails horizon mapping survey of information overload at an early children affected
semi-structured syndrome, and to interpret the and local parents’ supportive Sonnenwald, Wildemuth, & stage of their children's the reliability of the

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

interview health information behavior groups on Facebook. n = 35 Harmon (2001) There was no diagnosis self-reported data
and needs intervention in this study
Badarau et al. 2015 Romania Qualitative, semi- To explore the factors and the The participants were selected This study was part of large Information overload was one Recall bias may have
[41] structure interviews possible strategies from the from 3 pediatric centers. project on role of children with of three limiting factors that influenced
perspective of the parents and n = 28 (18 parents of patients cancer in decision making. affected the communication participants’
the physicians for open with cancer, and 10 oncologists) There was no intervention between the parents and the responses
communication with the patients about their cancer
children about their cancer diagnosis
diagnosis
Brown et al. 2015 UK Cross-sectional, To describe the knowledge and Colorectal cancer survivor Participants were asked open- Based on framework analysis of The staff who were
[44] semi-structured awareness of long-term patients after one-year post- ended questions to depict the the qualitative data, responsible for
qualitative treatment and consequences in treatment, over 18 years, able to knowledge and awareness of information overload screening the
interviews colorectal cancer survivors communicate in English, long-term treatment and represented the common eligibility of
recruited from the nurse-led consequences. There was no barrier to patients’ education patients knew about
colorectal surgical clinic. n = 19 intervention the content of the
study; this could
introduce bias
Klerings et al. 2015 Austria literature review To explore the online health There was no intervention in Recommendations to solve The information
[86] information overload in this study health information overload overload, problems
patients, health care were proposed: (a) and suggested
practitioners, and systematic technological solutions, (b) solutions were
reviewers creation or adaption of specific mainly for online
content types, (c) improving use
health literacy, and (d)
strengthening the individuals’
intermediaries.
Delpassand 2015 United Qualitative semi- To explore the social experience Participants were recruited Phone interviews with open- Four out of six participants The study only
[49] States structured in-depth of patients diagnosed with rare from The Carcinoid Cancer ended question to explore the reported experiencing focused on patients
interview carcinoid cancer who used Foundation, diagnosed with social experience. There was no information overload because using Facebook, the
Facebook to obtain carcinoid cancer and users of intervention in this study of using Facebook. other social media
psychological support Facebook. n = 6 platforms were not
assessed
Fiksdal et al. 2014 United Qualitative study To explore the consumers’ Adult English-speaking The participants answered Information saturation and The study
[52] States conducted through 3 perception and understanding participants (22-73 years) were open-ended questions about subjective fatigue were the population was
focus groups of health-related activity recruited through flyers and their perception of health care main reasons for terminating limited to adult
searching online advertisements. information, the procedure of the online searching for health participants from
n = 19 searching for health information. one location
information online, how to use
health information and the
implications of health care

25
 26
Table 3 (Continued)
Study (by Year of Country of Type of study Aim/purpose Population (includes sampling What was done? (variables Key findings Gaps in the research/
author publication origin (experimental, method/approach and sample compared, intervention type, limitations
surname) review, conceptual, size if applicable) duration of intervention)
etc.)
information. There was no
intervention in this study
Gebele et al. 2014 Germany Online quantitative To explore the underlying Adult German citizens were Patient confusion model was Information overload reported The study did not
[53] survey causes of patient confusion, and recruited by Quota sampling developed and validated. There as a significant cause of focus on other
how information may affect the method. n = 198 (18-79 years) was no intervention in this patient's confusion sources of
behavioral intention to choose a study information other
health care provider. than the online
source
Ko et al. [58] 2014 United Secondary data To examine whether social n = 66 who completed the Participants were randomly A significant difference was This study was open
States analysis of previous cognitive theory and follow-up survey. Participants divided into two groups: noticed in intervention groups to self-selection bias
study The Pounds Off information processing theories were obese with BMI = 25- generic weight loss (control) (greater elaboration, greater
Digitally (POD) mediated the relationship 40 kg/m2. and podcast enhanced group information control and less

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

between podcast intervention (intervention). cognitive load)
and weight loss among
overweight individuals
Korzeniowska 2014 Poland The analyzed data The opinions of workers in n = 1012 adults working in The sample was obtained The study focused
The majority of the respondents
& Puchalski came from a Poland were demonstrated in companies and institution in through companies and reported feeling uncomfortableon the Internet as
[59] questionnaire-based, relation to the Internet and how Poland institution. Participants were with the health information the only source of
structured interview they used it for health asked questions about using the overload and they stated health information,
method information and related disease Internet to search for health and it did not
difficulty in identifying reliable
issues information. There was no sources of health information discuss other
intervention in this study channels of health
information
Barrera et al. 2013 Canada Grounded theory To explore the hope of the Parents of children with cancer- This study was a part of large Information overload was The sample was
[42] design, with parents of children who were resistance to treatment after 3 project that studied the parents’ reported as a negative outcome selected from one
prospectively recently diagnosed with cancer months of diagnosis. n = 35 hope. There was no intervention that challenged parental hope center
interviewing the resistant to treatment, and
participants identify parents’ perception of
hope in term of facilitators and
barriers
Feufel & Stahl 2012 Germany Qualitative crossover To observe the variation The participants recruited from Participants were randomly Less-skilled users reported The motivation
[51] study between the skilled and less the participant pool at the Max assigned to one of the 8 information overload as a main provided in the
skilled Web users searching for Planck Institute for Human different scenarios. These challenge for the Web use. scenarios could be
health information. The Development. n = 22 (n = 10 scenarios were about not relevant to all
assessment based on cognitive skilled and less than 30 years, information related to diseases the participants
strategies and attitude n = 12 less skilled, above 50 and symptoms, prescription
years) drugs, and medical tests.
Sessions lasted about
90 minutes.
Gray et al. [55] 2012 United Qualitative formative To assess patients Adults English-speaking Participants were asked open- Information overload was Different definitions
States semi-structured understanding and acceptance patients diagnosed with cancer ended questions to explore reported as one of the causes of of genetic tests
interview study of personalized medicine and (32- 86 year) their awareness and attitude the reluctance of undergoing might result in
widespread genetic testing n = 69 towards personalized medicine full genome sequencing test different attitudes
and genetic testing. There was or intentions
no intervention in this study
Hurley et al. 2012 United Qualitative study, in To elicit patient preferences Participants’ who were carrier An assessment of prior Participants reported feeling Participants
[56] States person interview regarding when and how they to BRCA1/2 mutation were knowledge regarding overloaded and stressed recruited from one
want to learn about the recruited from Cancer center. preimplantation genetic medical center
preimplantation genetic n = 98 diagnosis and prenatal
diagnosis diagnosis. After the tutorial, an
assessment was done to ensure
the participants understood the
information.
2012
Schulz et al. The Randomized trial To investigate the level of Participants were adults (19-64 Participants received a health Information overload and long The results
[64] Netherlands with two completion of a web-based years) living in the provinces of appraisal based on their period of time could be the depended on self-
experimental groups tailored intervention North-Brabant and Zeeland response to the Adult Health reasons behind the higher rate reports, which
addressing 5 lifestyle behaviors who previously participated in Monitor questionnaire, and of dropout in the simultaneous makes the results
the Adult Health Monitor study, then received tailored advice intervention susceptible to recall
had a valid e-mail address, and via an automated expert system bias
were computer/Internet (which selected advice from a
literate. n = 3473 large database)
Avery et al. 2011 United Qualitative study To determine the required Adult women from rural, urban The questions used in this study Confusion and information The effect of the
[40] States with 8 focus groups health information for women and reservation location, age followed the process of Krueger overload was one of 6 identified different ethnic
from different geographic and range 19-89 years, n = 87 and Casey (2000). There was no themes backgrounds among
ethnic groups, in order to intervention the women was not
establish a health education evaluated in the
program in the United States study
Jensen et al. 2011 United Quantitative web- To investigate the possible College students (17- 43 years) Participants received The outline of information All the participants
[57] States based survey relationship between cancer were recruited from a large manipulated cancer news in overload model was mentioned were university
research uncertainty's source Midwestern University. two ways: (1) the presence or in this study students with high
and presence in news coverage n = 1,082 absence of hedging, (2) the level of education.
with four outcomes. Namely: sources of hedging were either Therefore, the

I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

cancer fatalism, medical related to the primary results can’t be
skepticism, patient trust in scientists’ condition or generalized to the
medical professionals, and unaffiliated scientists’ condition whole population.
nutritional backlash
Lalor et al. [60] 2008 Ireland A longitudinal study To explore the information Participants were recruited Participants were asked open- It was reported that women The focus was only
with a ground theory seeking behavior of women from a maternity hospital. ended questions to explore the using blunting strategies on the psychological
design after antenatal diagnosis of fetal n = 42 women diagnosed with information seeking behavior of (avoiding information) became processing of
abnormality fetal abnormality and up to 3 women after antenatal distressed by information information seeking
months following birth diagnosis of fetal abnormality. overload behavior after the
There was no intervention in diagnosis
this study
Elliott [47] 2007 Australia Thesis with To evaluate the effect of breast Women with age ranged 22-87 The intervention based on Information overload was The family history
combination of cancer genetic counselling on years were recruited. n = 207 educational communication. suggested as a reason why most was not assessed in
qualitative and psychological distress, and There was no difference in of the women couldn’t the study
quantitative methods understanding the risk and psychological distress between understand the principal
importance of BRCA test the short term or long term information of the genetic test
waiting for counselling and the
early stage receiving
counselling
Tang & Lee 2006 Singapore The method was a To examine different Participants were recruited by Participants could choose the Information overload was The majority of the
[63] focus group, and 6 motivations, reasons and snowballing technique, discussion group that suited mentioned as a challenge for participants were
sessions were sources for online health participants were Internet them (e-health seeker or non- non-seekers who cannot cope highly educated
conducted: 3 for e- information between online users, well versed in English, seeker). There was no with the complexity of the e- (with a college
health seekers and 3 health information seeker and and 18 years or more. n = 38 intervention in this study health (non-seekers were degree) and this can
for non-seekers non-seekers internet users who prefer to use affect the results of
other sources for health the study
information other than the
Internet)
Edwards et al. 2005 UK Randomized To evaluate the effects of Participants were recruited by Additional medical information Information overload was The participants
[50] controlled trial with information presentation Diabetic UK website and provided to the each of the four reported by the participants. already had made
online based format on the patients’ decision printed newsletter versions. intervention groups. They request to simplify the their decision of
questionnaire making regarding the tight n = 508 information provided to them which kind of
control and usual treatment of treatment regimen
diabetes is better for them
before the study
Collins et al. 2001 Australia Qualitative, semi- To explore the reasons for using women were recruited, n = 207, The participants were asked to Information overload could be The family history
[45] structured interview. or avoiding genetic counselling age ranged 22- 87 years answer open-ended questions the reason why most of the was not assessed in
services and its benefits to the to find the reasons for using or women could not understand the study
families who used it avoiding genetic counselling the principal information of the
services and its benefits. There genetic test.
was no intervention

27
28 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32

Gaps in the research/

3.3.3. Interventions

One of the negative outcomes of The sample size was

Of the 22 studies that focused on health information overload,
five randomized controlled trials [25,26,30,32,38] measured the
limitations influence of interventions, either directly on health information
overload or on another variable related to it (Table 2). The

the course that reported in this small

procedures included providing educational information and then
collecting data only post-intervention, except for one study by

overwhelmed and frightened by

Jensen et al., in which pre-test and post-test data were collected
information overload, feeling

some information and even

[26]. The absence of baseline measurements in most of these
study was experiencing

studies was a methodological weakness.

Different types of interventions were used, such as modified
feeling depressed newspaper stories [25], written stories [30], a videotape of a
pharmacist consultation with or without written information [32],
Key findings

web messages, a take home pamphlet [26], and decision support

interventions [38]. However, most of these studies did not report a
significant effect of interventions in relation to the level of
information overload in consumers [25,26,30,38], apart from a
Participants were asked to give

experience during involvement

study by Schommer et al. [32]. This study examined individuals’

compared, intervention type,

in this course. There was no

What was done? (variables

processing of drug information under 12 different conditions. It

intervention in this study
duration of intervention)

their feedback on their

was found that providing participants with a higher level of

breadth (number of topics) and depth (profoundness per topic) of
information, up to a point, resulted in the individuals being less
likely to feel information overload.

4. Discussion and conclusion

4.1. Discussion
The only eligibility criteria were
Population (includes sampling
method/approach and sample

course. Participants (18-72

to attend the Take Control

The results of our scoping review indicate that CIO was the most
popular topic in the studies that focused on health information
overload in consumers, reflecting the seriousness of the condition,
size if applicable)

and the need to quickly assimilate relevant information. Moreover,

years). n = 26

several key findings that include correlates, predictors, interven-

tions and ways of measuring health information overload were
presented and discussed from mutiple perspectives.

4.1.1. Health literacy

outcomes of the Queensland's

Health literacy was identified by three studies as a correlate

educational support course
To prospectively assess the
positive and the negative

diagnosed with leukemia

with information overload [24,28,29]. However, there appears to

understanding, in those
(Take Control) through

be some conflicting evidence regarding the significance of the

evaluating patients’

relationship between health literacy and information overload. For

example, the results of a study by Crook et al. [24] showed that the
Aim/purpose

correlation between health literacy and information overload was

not significant. On the other hand, a study by Jiang and Beaudoin
[28] and another one by Kim et al. [29] reported that a higher
perceived health information overload significantly predicted a
Continuous glucose monitoring = CGM, chronic kidney disease = CKD.

lower level of health literacy. In these studies, health information

A prospective study
review, conceptual,

with a self-report

overload was measured using different approaches [24,28].

(experimental,

Additionally, the use of different health literacy assessment tools

Type of study

questionnaire

in these and other studies is a potential reason for the variation in

the correlation between health literacy and information overload,
etc.)

with a lack of consensus on the most appropriate health literacy

measurement tools [88]. There are numerous types of health
literacy scales that can be described as objective, subjective or
Country of

Australia

mixed measures, with different domains mainly in numeracy,

publication origin

prose and information seeking [89]. Thus, health literacy scales can
give different scores reflecting their different types of demands and
required skills [90–92]. Moreover, the small sample size of the
Crook et al. study [24] might not have been sufficient for the
Year of

2000

accurate determination of cross-sectional study outcomes in

Table 3 (Continued)

relation to the correlation between information overload and

health literacy. Overall, given the different approaches to health
McGrath [61]

literacy measurement, and the lack of consensus between the

Study (by

surname)

significance of the relationship between health literacy and health

author

information overload, further studies, utilizing larger, random

samples should be conducted.
 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32 29

Table 4
Summary of expert opinion articles that discussed information overload.

Study (by author Year of Country of Overall purpose of the expert opinion article
surname) publication origin
Kondylakis et al. 2018 Greece Create a high standard search engine based on cancer patients’ current profile to help them with extracting the
[85] relevant data and avoid online information overload.
Collins [76] 2015 United States Explore the possible ways to minimize the confusion and facilitate understanding the overwhelming information on
antioxidant, weight loss and low cancer risk diets
Van Velsen et al. 2013 Netherlands Suggest solutions for health information overload that affects consumers and health professionals
[82]
Tomaiuolo [81] 2012 United States “Medify” site was suggested as a solution for information overload in seekers of online health information
Norton [80] 2011 United States Suggest solutions for information overload in patients with amputated limb
Jones [77] 2010 United States Indicate how consumers feel overwhelmed with the flood of health information when they search for cancer health
information on the Internet
Walczak [83] 2009 United States Highlight the difference in information retrieval needs between health professionals and consumers
Kickbusch [78] 2008 Switzerland Evaluate the effects and the consequences of health literacy and information overload on the community
Whitelaw [84] 2008 The United Explore claims, rationality, and nature of exposure to information overload especially in the health field. Also,
Kingdom practical suggestions were offered
Burgess [73] 2006 The United Address the significant obstacles of using online health information that faces patients and their carers. Namely:
Kingdom information overload and information quality
Cohen [75] 2004 United States Emphasize the adverse effects of health information overload, and the need for doctors or pharmacists to assess this
information for consumers.
Christensen [74] 2000 Australia Information overload has been identified as one of the disadvantages of the Web when promoted for mental health,
from the view of practitioners and the community
Allen [72] 1999 United States Highlight the impacts of complicated HIV health information, and the patients’ desire to gather a lot of information
about their condition
Achterberg [71] 1988 United States Information overload was one of four main factors that affected learners’ readiness during a short period of one to
one interaction
Morris [79] 1998 The United Online search for HIV/AIDS resulted in an abundance of information
Kingdom

4.1.2. Education level individual information processing capacity, perceived information

Education was another identified correlate that has some
conflicting evidence regarding its association with health infor-
mation overload. An association between a higher level of
education and less information overload was reported in several
studies [6,23,27,29]. In contrast, a recent study by Ramondt and
Ramírez [35] identified higher level of education as a significant
predictor of diet information overload. In that study, more than
half of the participants were reported as Hispanic/Latino, one-fifth
of the participants completed the survey in Spanish, more than 20%
of the participants had below high school education level, and a
substantial number of participants were provided with nutrition
assistance services. These characteristics may explain the contra-
dictory finding of this study, as they could limit participants’
access, seeking and exposure to diet information, and consequent-
ly reduce the risk of information overload [93]. Thus, it appears
that there is an association between education level and
information overload.
4.1.3. Cognitive effort
Our scoping review identified several ways to measure
information overload. One way depends on assessing cognitive
effort of processing health information. In the literature, informa-
tion overload could be explained by the cognitive load theory. This
theory, proposed by John Sweller [1], refers to the limited cognitive
processing capacity of new information and connecting this
information with previous knowledge. This limited cognitive
capacity depends on various factors, such as complexity of
information, time available to process the information, and the
prior knowledge of individuals [1]. In our scoping review, there
were two studies that considered the amount of cognitive effort as
a direct indication of cognitive overload [37,38]; this suggests the
greater the cognitive effort required, the greater the likelihood of
experiencing cognitive or information overload. However, a third
study observed an inverted U-shaped relationship [32]; partic-
ipants initially preferred to receive a large amount of health
information, and did not experience information overload.
However, once this volume of information exceeded their
overload was reported. This initial response might have been a
result of the individuals’ tendency to reduce the feeling of
uncertainty that can accompany information overload [25].
Therefore, high cognitive effort at the initial response of receiving
a large amount of information was described to have a negative
correlation with information overload. However, information
overload was reported when individuals received more informa-
tion that required a doubled amount of cognitive effort and
exceeded the individuals’ processing capacity.
4.1.4. Interventions and health information overload
To mitigate health information overload, five studies were
identified that investigated interventions to address information
overload. The quality of these five studies ranged between
moderate [25,30] to high quality [26,32,38]. The interventions’
design in these five studies focused mainly on the format (web
message, printed materials, or videotaped information) and
amount of health information provided to participants, and
neglected the need to target the individuals themselves as well.
Based on a review conducted in information and communication
technology that aimed to enhance the skills to face information
overload, “training interventions” were implemented to tackle
information overload [94]. Thus, we suggest there is a need for
assessing more interventions that concentrate on the ability of
consumers to manage health information overload.
4.1.5. Further research
Despite the considerable number of included publications in
our scoping review (n = 69), only a small proportion of these
records specifically focused on health information overload
(n = 22). Given the fact that a large number of available studies
focused on CIO, the findings of such studies cannot be generalized
to all consumers with other chronic diseases. Thus, more studies
focusing on other common chronic diseases are essential.
In addition, the review identified only one qualitative study [31]
that focused on the experience of information overload, and this
study explored information overload in the context of parents
30 I. Khaleel et al. / Patient Education and Counseling 103 (2020) 15–32
creating healthy eating behaviors for young children. Further
qualitative studies are recommended to explore information
overload in other areas of health, and from the perspective of
patients, as opposed to the parents/carers of patients. The findings
of such studies would provide further insight into why patients
may experience information overload.
A study in human behavior and communication technology
reported that information overload resulted in psychological and
physical problems, such as stress and fatigue in consumers of social
media [95]. In the health sector, psychological burdens of health
information overload were empirically observed [13]. However,
the present review identified a lack of research that examined
other potential health consequences of health information
overload in consumers.
Creating a comprehensive understanding of the concept of
information overload helps in suggesting solutions that aim to
mitigate this issue. A small number of included records, such as
four expert opinion articles and a literature review [73,80–82,86],
have proposed some practical solutions for health information
overload. However, there is a need for robust studies examining
these potential solutions.
Given the concept of health information overload is relatively
underexplored at this stage, we decided to conduct a scoping
review that embraced an exploratory approach to map out the
available literature in this field, rather than an explanatory
approach that seeks to explain the theoretical underpinnings of
the phenomenon. However, we encourage future studies to adopt
theoretical explanatory models to specifically investigate potential
concepts and factors that may further explain the emergence of
health information overload.
Given the somewhat contradicting reported outcomes regarding
the effect of health literacy on health information overload, there is a
need for studies that more deeply explore the interconnection
between health literacy and health information overload in
consumers. Moreover, there is a need to explore the impact of this
association on the accuracy of decision-making, and subsequently on
health outcomes in consumers of health information.
4.1.6. Strengths and limitations
This is the first scoping review to identify the breadth of
evidence of health information overload in consumers. We believe
that our approach, including the broad inclusion criteria and
search strategy, facilitated the comprehensive identification of
research on the topic. Our review was also meticulously and
robustly conducted. Specifically, each stage of screening, identify-
ing, and evaluating the eligibility of the included records was
independently performed by two reviewers, and we adhered to a
published review protocol [15].
This scoping review has some limitations that need to be
acknowledged. Firstly, formal quality evaluation was not per-
formed for the majority of the identified records. However, it must
be noted that scoping reviews do not typically evaluate quality.
Secondly, only records published in English were included. This
means that a number of records relevant to this review may not
have been captured. Finally, there may be some studies, which
utilized other ways of expressing the term ‘information overload’.
These studies may not have been captured using our search
strategy. However, we are confident that we have included the
majority of relevant records given our broad and encompassing
search terms and search strategy.
4.2. Conclusion
Health information overload has received growing attention in
recent years, although our scoping review highlights that further
research is required. Specifically, there is a need to explore the concept
of health information overload in chronic conditions other than cancer,
as well as identify consequences of health information overload, and
rigorously evaluate potential solutions to address overload.
4.3. Practice implications
Our scoping review serves as an early attempt to grow the field
of health information overload research through highlighting the
areas that need further exploration, and identifying the available
approaches of measuring information overload. Outcomes of such
further research will help in 1) recognizing the extent of health
information overload in patients, to ensure that they are receiving
a suitable volume and format of information for effective self-
management purposes, and 2) informing the development of
solutions to address the issue of health information overload.
Funding sources
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgments
We would like to thank the University of Tasmania research
librarians (Michaela Venn, and Heather Mitchell) for their
assistance in developing the final search strategy. Israa Khaleel
was supported by an Australian Government Research Training
Program (RTP) Stipend and RTP Fee-offset Scholarship through the
University of Tasmania.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.pec.2019.08.008.
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