Consumer use of the internet for health information:

Blackwell Science, LtdOxford, UKIJCInternational Journal of Consumer Studies1470-6431Blackwell Publishing Ltd, 2004282147153Original ArticleConsumer use of the internet for health informationG. Dolan et al. Consumer use of the internet for health information: a survey of primary care patients Gina Dolan, Rachel Iredale, Robert Williams and Jamal Ameen School of Care Sciences, University of Glamorgan, Pontypridd, UK Abstract Introduction An increasing number of patients use the internet to obtain information about health. Although some information is available about how health professionals use the internet, little is known about how patients utilize this information. Some patients may actively seek information to assume more responsibility for their health. However, others may feel obliged to do so because of failing confidence in health care provision. Health professionals have the potential to assist patients to make sense of health information from the internet; however, they may not necessarily welcome this role. This study aims to evaluate patients’ use of such information in a primary care setting. The sample consisted of adult patients (n = 851) from two general practice populations at different levels of the socio-economic spectrum in South Wales (UK). Patients were surveyed by questionnaire about the health information they use, including the internet. The majority of patients preferred to use their general practitioner as the main source of health information. The internet was jointly the second preferred source for information about an illness (6%). Just over half (51%) of patients in this study had access to the internet, of which about half use it to access health information. Just under a quarter (24%, n = 55) of health internet users had discussed information accessed from the internet during a subsequent consultation with a health professional. Of these, three-quarters felt more prepared and able to participate in decision-making about treatments. This study provides a greater understanding of how patients are making use of health-related information from the internet. These findings can be used to help prepare health care professionals for dealing appropriately with internet-informed patients. An increasing number of patients choose to adopt an active role in their health with the intention of becoming more involved in decisions about treatment and care.1 One concern of patients is that they are rarely consulted about their preferences or needs when information sources are being developed. There is evidence to suggest that many patients consider existing health information as too basic with a tendency to promote a paternalistic attitude.2 This evidence illustrates that the role of the patient may be underestimated in determining and fulfilling their health information needs. In recent years the use of electronic sources such as the internet has given patients the opportunity to access and use a wealth of information. However, little is known about why consumers choose particular information sources, or the extent to which some consumers are disadvantaged by limitations on choice, for example access to the internet. This paper explores the ways in which patients from primary care use health-related information from the internet, in two localities of different socio-economic status in Wales. Keywords Health information, consumers, internet, communication, primary care. Correspondence Gina Dolan, School of Care Sciences, University of Glamorgan, Pontypridd CF37 1DL, UK. E-mail: [email protected] © 2004 Blackwell Publishing Ltd Patient preferences for health information Research into patient preferences for information is limited and tends to centre on how effective these information sources are in providing patients with knowledge rather than focusing on which sources they prefer or whether their needs are met.3 However, a recent European survey investigating consumer use of health information from over 16 000 respondents revealed that the majority (45%) reported health care professionals as their main source of health information.4 Similarly, a smaller UK survey in 2002 of patients (n = 330) attending an ENT (Ear, Nose and Throat) clinic found that the majority of patients (64%) accessed their general practitioner (GP) for health information.5 Although there is now an extensive range of information available to International Journal of Consumer Studies, 28, 2, March 2004, pp147–153 147 Consumer use of the internet for health information • G. Dolan et al. patients, many still prefer to rely on their GP for information about health issues. Access to the internet Society is now faced with a digital divide, which has arisen from the income gap between those who have access to technologies and those who do not. The digital divide is not a new concept. As developments in information technology (IT) continue to progress, in turn the divide in access to technology also increases. A report of internet and IT use in the European Community refers to an ‘offline underclass’ as 28% of Europeans do not own a PC, digital television, games console or mobile phone.6 It is therefore important to consider whether electronic sources such as the internet are a valuable health resource for consumers, in order to determine whether those without access are disadvantaged. Consumer use of health information on the internet The internet has become an increasingly popular resource for consumers. It is no longer merely a source of information or communication, but offers a useful platform for consumers to conduct a variety of activities. E-mailing is still one of the most popular uses of the internet; however, a recent survey found that about half of consumers now actively use the internet to order tickets, goods or services.7 Consumer use of the internet to access information about health has also gained popularity. However, research in this area is still in its infancy. Although, in general, internet access varies, most surveys indicate that around half of users access health information. A recent telephone poll conducted in the USA revealed that 75% (n = 502) had internet access and of these 47% used it to access health information.8 It is interesting to note that nearly a third of these rarely used it for this purpose. There is less information about consumer use of the internet in the UK. One European survey reported that 29% of the online population in the UK had used the internet in the 3 months before the survey to search for health-related information.9 The European average in the same survey was slightly lower at 23%. A more 148 recent UK survey indicated that 57% of respondents had used the internet for health information during the year before the survey, which is the highest reported general health internet use in the UK to date.10 Consumer health information and the consultation The number of people who actively seek information about health from the internet is increasing at an exponential rate.8 This in turn has affected the ways in which patients act and are perceived by health professionals. An increasing number of patients bring in information that they have accessed from the internet for discussion in primary health care consultations.11 Such assertions are primarily reported from GPs’ experiences in consultations, rather than directly from patients. This clearly supports the move towards patients taking on a more active role in consultations. However, health care professionals may not encourage internet-informed patients which are perceived as a challenge to the traditional role of the GP.12 Quality of health information on the internet Information technology and consumer health informatics are integral parts of the modern concept of public health and national health care policies.13 The British government is committed to improving public participation in health care and enhancing shared decisionmaking, so that there is more equal partnership between patients and professionals.14 There are many advantages of using the internet, such as convenience of access and the potential for obtaining a variety of information about health and disease. However, there is a growing amount of evidence questioning the quality of health information on the internet.15 The internet is likely to remain an unregulated resource through which anyone can provide or access information. The internet has not only increased the possibility of patients accessing information intended for health care professionals, but may also put patients in a vulnerable position as they may encounter information which is unreliable, of poor quality, difficult to understand or may not even apply to their health care needs. In many cases, health internet users are patients seeking information about an existing health concern International Journal of Consumer Studies, 28, 2, March 2004, pp147–153 © 2004 Blackwell Publishing Ltd G. Dolan et al. • Consumer use of the internet for health information for which they are already consulting their health professional. For this reason and for the purpose of gaining the views of patients and health professionals from general practice, it was necessary to select the sample from primary care; the first level of contact with health services in the UK. A survey of the general population was likely to include many with either no health problem or interest, and would have required a considerably larger sample size, resources and time. and confidentiality. All participants were provided with written details of the study, explaining the purpose of the study and their commitments to the project. Ethical approval was obtained from the Bro Taf Local Research Ethics Committee which governs the area in which the two practices are located. The survey data were analysed with SPSS using descriptive statistics, chi-square (c2) goodness of fit and tests of independence. In tests of statistical significance, the significance level was set at P £ 0.05 (two tailed). Sample Results In the light of the above, adult patients, aged 18 years and above, attending two general practices in South Wales were approached to complete a survey during a 3-month period (October–December 2001). To address a potential digital divide the practices were selected from areas with different levels of deprivation. Practice 1 is located in an affluent area, ranked 826th (out of a possible 865) on the Welsh Index of Multiple Deprivation, and Practice 2 is in a more deprived area which is ranked the 11th most deprived in Wales.16 In order to adequately represent patients, a minimum of 5% from each practice was considered as the target sample. Patients were approached in the surgery waiting room to complete the survey. A total of 851 patients completed the questionnaire, which produced a response rate of 79%. There was a slightly higher response rate from Practice 1 than Practice 2 (84% and 72% respectively). Equal proportions (5%) were sampled from each practice. Practice 1 is a much larger practice and accounts for a higher number of patients in the sample. In order to account for uneven distribution of respondents, comparative studies of the data according to practice are conducted using percentages rather than raw frequencies to avoid any potential bias. Methods A questionnaire was designed focusing on: • • • preferences for health information sources; use of the internet for health-related information; and demographic information about age, gender and socio-economic status. The questionnaire was fairly brief and simple, and therefore self-completion was the most suitable mode of administration.17 The questionnaire can be obtained from the main author on request. Patients placed completed questionnaires in a sealed box, which assured anonymity, as they could not be linked to an individual patient. The study was conducted within an ethical framework based on the principles of informed consent, privacy © 2004 Blackwell Publishing Ltd Use of health information sources Patients were asked to indicate which sources of health information they had used during the previous 6 months. Overall, the doctor was found to be the most widely used source for any information about health. However, patients used different sources for information about a specific illness than for general health information. Health professionals were accessed most frequently as a source of health information, with the majority (80%, n = 677) accessing their doctor if they wanted information about a specific illness. This was followed by about a third using the pharmacist (36%, n = 303) and nurse (32%, n = 275). Table 1 shows that from a range of 16 health information sources, the majority of patients use these significantly more for information about an illness than for general health issues. Patients did, however, use media sources (see shading in Table 1) more for general health information than for an illness. In general, female patients used information sources International Journal of Consumer Studies, 28, 2, March 2004, pp147–153 149 Consumer use of the internet for health information • G. Dolan et al. Table 1 Comparison of the number of patients who use sources for information about an illness and for general health Source of Information Doctor** Pharmacist** Nurse** Friend/relative Magazines** Leaflets Books TV** Newspapers Internet** Journals* Telephone line** Radio Health visitor Midwife Other Information about an illness n (%) 677 303 274 251 229 226 184 181 177 162 124 80 69 55 35 15 (80) (36) (32) (30) (27) (27) (22) (21) (21) (19) (15) (9) (8) (7) (4) (2) General health information n (%) 230 122 134 211 360 204 161 259 223 99 83 12 99 47 26 13 (27) (14) (16) (25) (42) (24) (19) (30) (26) (12) (10) (1) (12) (6) (3) (2) *P £ 0.05; **P £ 0.01. more frequently than males during the previous 6 months. The biggest difference was displayed in the use of magazines with significantly more women (49%) than men (29%) using magazines for general health information (P = 0.03). Men only accessed the TV, radio, newspaper, doctor and nurse more than women in the past 6 months for information about an illness. However, these differences were not statistically significant. Preferences for health information sources Patients were also asked to indicate their preferred source of information. This was used to investigate any differences between their preferences and the sources they actually used. A large majority of patients (68%) preferred to use their doctor for information. The second most preferred source was the internet (6%). Although these figures are much lower than the use of their doctor, the internet was rated above the remaining potential sources of information. Access to the internet Just over half of the patients (51%, n = 426) had access 150 to the internet at the time of the survey. However, this was not evenly distributed between the two practices. Practice 1 (62%) had a significantly higher proportion of patients with internet access than Practice 2 (28%, P £ 0.01). Although access was evenly distributed according to gender (males 49%, females 52%), there were significant differences according to age. The greatest proportion of internet users was found in patients aged 22–44 which represents half of all internet users. Patients from the older age bands (aged 55+) had significantly less access to the internet (5%) than younger patients (P £ 0.01). Consumer use of health information on the internet Use of the internet for health information was similar in each practice with just over half of patients (52%, n = 220) accessing the health internet. There was little difference in use for health by gender (males = 50%, females = 54%). There were, however, significant differences according to age. Patients aged 24–54 were more than twice as likely (25%) to use the internet for health information than those aged 55 and above (10%, P £ 0.01). Usage also steadily increased with duration of access to the internet. Only a third of the least experienced users (defined in this study as having access for less then 6 months), had accessed health information, compared with 76% of those who had access for 5 years or more. The remaining internet users were asked to indicate reasons for not using the internet for health information. Most preferred to access health professionals (66%) or other sources of information (38%) than the internet. More surprisingly, only 7% did not trust the internet for health information. Internet information and the consultation Just under a quarter (24%, n = 55) of health internet users had discussed information during a consultation with a health professional. This information was accessed from the internet by patients before the consultation. The findings differed between practices with a higher proportion of internet users from Practice 1 (26%) who had discussed internet information during a consultation than those from Practice 2 (17%). Of these International Journal of Consumer Studies, 28, 2, March 2004, pp147–153 © 2004 Blackwell Publishing Ltd G. Dolan et al. • Consumer use of the internet for health information patients, most (76%) felt more prepared for a consultation by accessing the internet. The majority also felt able to participate more in decision-making (70%) when they discussed internet information. Only a small proportion (20%) had introduced information that was new to the health care professional or felt that the consultation time increased as a result of discussing internet information. Discussion The majority of patients use health professionals for information about an illness. This is not surprising as patients are more likely to rely on health professionals when concerned about an illness, as they may require information which is specific to their own needs. These findings are supported by recent surveys investigating consumer use of health information.4,5 However, patient access to the doctor (80%) was much higher in the current study. It is acknowledged that the patients in this study were those who were in contact with their health professionals. This study did not attempt to address consumers who may have accessed information to meet their health care needs in alternative ways. Evidently many patients prefer to rely on health professionals for health information. However, when consideration is given to the current resource constraints in the provision of primary care, it seems unlikely that all patients’ health information needs can be met by health professionals. An increasing number of patients are therefore likely to seek alternative sources of information such as the internet. In contrast, patients may feel more comfortable relying on informal sources such as magazines and the television for general information and do not feel the need to access health professionals. This may be because these sources are easily accessible and can be used in a more passive way. The internet was used more for information about specific illnesses than for general health. Searching for information about an illness is one of the most common internet uses when accessing health information.18,19 The internet can be used to carry out potentially complex searches from which the user may retrieve detailed information about an illness or condition. The internet may also contain up to date information about advances © 2004 Blackwell Publishing Ltd in diagnosis and treatment from experts from around the world. The findings revealed some gender differences in the use of health information. Men tend not to use health information sources as much and rely on media sources (with the exception of magazines) more than women. Health information can be accessed from these sources in passing without the need to actively seek information. This could suggest that men and women go about seeking health information in different ways. One possible explanation for this is that women usually assume responsibility for the health and well-being of their families and so are therefore more likely than men to actively seek health information in general.20,21 There were also considerable differences in access to the internet according to each practice. Far fewer patients from Practice 2 had access than those from Practice 1. Such differences are to be expected, as Practice 1 is situated in a more affluent area than Practice 2. Over the past few years, internet access has been made easier in terms of the technology available and the associated costs. Yet there are still many sectors of society who do not have access to this potentially valuable source of information. These findings therefore reinforce the evidence which suggests that there are differences in internet access according to socio-economic status.22 It is also likely that there may be differences in proficiency of using the internet according to socio-economic status, which also has implications concerning the users’ ability to access health information. This highlights the need for further research into the ways in which consumers use the health internet, which in turn will identify sectors of the population who may be disadvantaged as they do not have access or the skills to use the internet. If such inequalities are not addressed, it is conceivable that public health information on the internet will only be primarily accessed by the healthiest section of the population or the more affluent. Just over half of the patients from each practice used the internet for information about health. Figures reporting on use of the health internet tend to vary. They may refer to people who have used the internet at one point in time, or focus on those with more regular or sustained use. As a result there are limitations when comparing figures reported in the literature with the International Journal of Consumer Studies, 28, 2, March 2004, pp147–153 151 Consumer use of the internet for health information • G. Dolan et al. results of the current study as usage may not have been measured uniformly. Estimates in the UK range from as low as a third to as high as 57% of people using the internet for health.9,10 In comparison to these reported figures, use of the internet for health in this study seems to be fairly high. Most patients who had access to the internet but did not use it for health preferred to use health professionals or other sources of information. Few reported a lack of trust in the internet as a reason for non-use. This is surprising considering the concerns about the quality of health information amongst professionals/academics.23 Diaz et al. (2002)24 found similar levels of trust by patients using the internet with 62% (n = 168) rating internet information as ‘excellent’ or ‘very good’ and no respondents rating it as poor. Patients generally appear to be favourable about the internet and do not appear to be concerned about the potential limitations of inaccurate or irrelevant information. Of those who do access the internet for health, many appear to be discussing this information in consultations with health professionals. This is viewed in a very positive way by most patients who feel more in control and reported an improved consultation. Overall, patients seem to feel that their consultation appeared more selffocused. In contrast, health professionals describe many limitations of using internet information during a consultation. Although in principle they may welcome more informed patients, it is also viewed as a potential source of conflict for the patient–professional relationship as the health professional may feel challenged by the patient.25 Perhaps it is inevitable that the role of health professionals and their relationship with the patient will evolve in respect of interaction with the internet. It is perhaps more timely to reflect on how health professionals and patients can be guided in their use of internet health information. This issue will be addressed in a separate paper, in which patients and staff will be interviewed in depth to further investigate their use of health information, in particular, the use of the internet. Conclusions Current trends indicate that more and more patients are likely to use the internet as a source of health informa- 152 tion. Although use of the internet is not gender specific, age and social class are factors that have to be considered in the development of any guidelines or policies in the future. Health professionals have the potential to assist patients to make sense of health information from the internet; however, they may not necessarily welcome this role. There is now a need to examine in depth the ways in which sources such as the internet are used, and to consider the implications for future developments, in the provision of health information. Acknowledgements First of all we would like to thank the School of Care Sciences for supporting this study. 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