Question & Answer: What role do you think the World Wide Web will play in the future of health surveys?…..

To understand individual use of the internet and its impact on individuals, communities and societies is a challenge that is only beginning to be addressed. There are more than 580 million internet users world wide1, and over 16 million active users of the world-wide web in the UK. This is more than the estimated number of UK smokers yet little has been done to assess the potential health impact of the internet. New developments will lead to further growth in internet usage, and this medium is increasingly being employed for health information and healthcare delivery. Clinicians need to understand the possibilities of this technology, and to be aware of potential threats to health.

THE INTERNET AS A RESOURCE FOR HEALTH INFORMATION

One of the main uses of the internet is as an encyclopaedic information resource. Surveys consistently show that 60-80% of world-wide-web users have used it to obtain health information. The internet has the potential to educate and empower the health consumer, by providing information on health and health services and supporting self-help and patient choice. The ‘expert patient’ can only become expert if he or she can access and use information, and the internet can support the increasing role of consumers in their healthcare. Two-thirds of those using the internet to find health information claim it has some impact on their healthcare decisions. Consumers value the anonymity, convenience and quantity of information.

Many concerns have been raised about the quality of online consumer health information, and the possibility that poor information has detrimental effects on health. A systematic review of 79 studies investigating the quality of online health information revealed that the methodology and rigour of these studies varies widely, as do the findings. The information is often incomplete and sometimes inaccurate, although good quality material can be found. While consumers state that they pay heed to the credibility of internet sites, in practice little evaluation is carried out and users seldom remember the sites from which they retrieved information. The quality of internet information needs to be examined in the wider context of imperfect health information generally, and there is little reason to view the internet as radically different from other information sources. While there have been isolated case reports of individuals coming to harm from information on the internet, there is no systematic evidence that more harm arises from this medium than from others. DAERI (the Database of Adverse Events Related to the Internet) has been established at the University of Heidelberg to monitor this area. Perhaps the difference that the internet is making to consumer health information is one of quantity rather than one of quality. The quality of information has always varied; the internet has simply increased the quantity and the ease of access. Education of consumers or content producers may help reduce the spread of poor information.

The internet also supports professional health information. Clinicians are benefiting from increased access to evidence, policy and guidelines, and training and professional development. Health datasets, increasingly available online, will facilitate research.

THE INTERNET AS A MEDIUM FOR INTERACTION

It is the interactivity of the internet that possibly has the most profound impact on health and healthcare. The universal and pervasive e-mail is making fundamental changes to the way that people work. E-mail communication between doctors and patients is becoming part of medical practice—although a US survey suggests that doctors are reluctant to embrace this new medium until they are convinced it will save time or money (this is understandable, although impacts on effectiveness and quality might also be considered).

The revolution in communication and knowledge exchange between individuals is most evident in the phenomenon of virtual communities. In the health area, an example is support for people with HIV. Peer to peer support in virtual communities benefits from the absence of traditional barriers to access; and online anonymity can be helpful for those who have stigmatizing or embarrassing conditions. The international possibilities of virtual communities allow individuals with rare diseases to find peer support and allow all users to draw on a wide range of health perspectives and experience.

There are concerns that the lack of professional moderation or facilitation in most virtual communities may lead to inappropriate and disruptive use, or to the dissemination of inaccurate messages. (This applies, of course, to any forum where consumers meet face to face.) There are also concerns that participation in virtual communities may become addictive for some users. Problematic or addictive internet use is most commonly associated with the interactive functions of the internet—online shopping, gambling and chatrooms (especially sexual flirtation or ‘cybersex’). A syndrome of uncontrollable internet use to the detriment of other activities such as work or social life has been characterized. Other symptoms of addiction such as irritability and low mood when access is denied, or an increasing tolerance to the length of time spent online, may also be present. Data on incidence are lacking.

There has been speculation that internet use could lead to depression or social isolation. There is a need for high-quality research in this area, with carefully chosen control groups. The work to date suggests that there is no consistent major effect.

THE INTERNET AS A TOOL FOR THE DELIVERY OF HEALTHCARE

The internet is increasingly being used for healthcare delivery. Health promotion and education interventions have been successfully delivered online and there are early reports of psychological interventions via the internet. A randomized controlled trial showed that an e-mail discussion group had a positive effect on health status in people with chronic back pain. Specialties which have used telemedicine for remote diagnosis and asynchronous communication can now explore the enhanced possibilities of the internet—for example to provide ‘virtual outreach’ consultations in areas with poor access to conventional services.

The development of electronic patient records and the networking of primary and secondary care have the potential to improve the quality and efficiency of health services. The internet can also be used as a medium for health research—using online interviews, focus groups and quantitative survey methods.

SHIFTING THE BALANCE OF POWER

The internet is changing the balance of knowledge between healthcare professionals and the public, empowering patients to become more involved in healthcare decision-making and contributing to the deprofessionalization of medicine. The professional power of medicine is being challenged by the public availability of specialist knowledge, and by improved access to information on alternative approaches to healthcare, healthcare performance statistics, and consumer rights.

Many patients now bring internet printouts to the consultation, and benefits to patients are being reported. However ‘internet printout syndrome’ or ‘cyberchondria’ has generally been portrayed as a time-consuming affliction of the ‘worried well’. The internet offers the potential for patients to become more involved in their own care, learning about their condition, accessing and contributing to their online health record, and interacting with health services—for example using shared decision-making tools5. Clinicians can assist by recommending high-quality websites and listing these in information sheets.

THE INTERNET AND PUBLIC HEALTH

The advent of an internet-enabled ‘information society’ could have much broader consequences. For example, network access is supporting more home-working, which could impact on public health in many ways: decreased individual travel and increased commercial deliveries of goods may reduce traffic pollution and accidents, but may also reduce social interaction and physical exercise. Effects are to be expected on home life, productivity and energy consumption.

At present the internet is predominantly a computer-mediated tool, and there is a need to quantify its health impact with respect to ergonomic issues—for example, postural musculoskeletal disorders. In the future the internet will become more integrated with other technologies and this will need assessment. There is also a need for work around sustainability issues and computers—including the disposal of hardware and the myth of the ‘paperless’ office (now full of internet printouts).

The internet allows development of communities—explicit in chatroom format, but also implicit communities of individuals linking with each other through hypertext or e-mail connections. In this way the internet can support campaigning and democratization, giving users the means to organize socially and politically, and it can facilitate the working of communities of practice (such as public health networks). However, the ease of establishing such links, coupled with the anonymous nature of the internet, creates an environment where deviancy can flourish. A quarter of school-age children in a US survey reported having felt unsafe while online. The internet is used for the dissemination and display of offensive materials, and by paedophile rings.

ACCESS ISSUES: THE HAVE-NETS AND THE HAVE-NOTS

The term ‘digital divide’ has been coined to describe the gaps in access and understanding that may exclude certain groups from use of new digital technologies. As one might expect, the groups most at risk of digital exclusion are those that already have unequal access to health services and suffer health inequalities—for example, the poor, the homeless, those with limited formal education, disabled or elderly people and those in developing countries. Internet users tend to be young, affluent and employed. There are also digital divides by level of education, between rural and urban areas, and among certain ethnic minority groups.

The internet offers the possibility of reducing inequalities in health—through low-cost dissemination of consumer and professional information, remote delivery of health services, and removal of barriers to access. But care must be taken to ensure that differential access to new technology does not exacerbate existing inequalities in health. The World Health Organization has expressed concern at the digital divide between the developed and developing world and this has led to initiatives such as the Health Internetwork which aims to provide free access to resources such as biomedical publications.

CONCLUSIONS

The internet is having profound impacts on health and healthcare. It has the potential to improve the effective and efficient delivery of healthcare, empower and educate consumers, support decision-making, enable interaction between consumers and professionals, support the training and revalidation of professionals, and reduce inequalities in health. But there is a need for vigilance regarding new and emerging threats to health posed by the internet. Investigation of both positive and negative health impacts of this evolving technology must continue. As yet there has been little rigorous research on health effects of the internet. Work in this area must acknowledge the importance of the wider determinants of health: in addition to the more obvious direct effects, the impact of the internet on domains such as the economy, employment, the environment, and transport will all influence health and healthcare.