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The Internet and Health Communication: Experiences and Expectations

Editor: Ronald E. Rice, James E. Katz
Publisher: Thousand Oaks, CA: Sage, 2001
Review Published: February 2003

 REVIEW 1: Kathleen M. Golden

In The Internet and Health Communication: Experiences and Expectations, Ronald E. Rice and James E. Katz present a volume of essays that covers how the Internet is emerging in an already challenging discipline: health communication. The editors claim that the book is not a "how-to" manual but, "instead, an attempt by academics for academics, students, researchers, and health professionals to explore the communication issues related to the consequences the Internet is having on health care as well as the way the experiences of health care are affecting the use of the Internet" (xiv).

This book pursues what Rice and Katz see as a "gap" in the extant literature as to how individuals actually use the Internet. The volume is framed with two overarching tasks: 1) what has worked or failed historically and 2) where does health care and the Internet go from here to solve those problems from the past.

The book is divided into five major parts. Each attempts to address the major components of the marriage between health care and the burgeoning Internet.

The book opens with Part I, "An Overview of Experiences and Expectations," two chapters that overview the major issues. Rice (Chapter 1) outlines the key areas of concern to Internet Health Care (IHC): usage of web sites, mailing lists, communities, newsgroups, and health communication. The reader is oriented to the wide morass of information on the Internet that is sometimes reliable, often contradictory, and many times inaccurate.

Robert Mittman and Mary Cain (Chapter 2) discuss the driving forces behind the various Internet applications and present barriers to "the implementation and diffusion of health care applications on the Internet (47). One strength of this chapter is the authors' forecast for the next five years. They believe growth will occur in the following areas:
  1. Consumer health information services -- search engines, rating systems, online prescription drug sales
  2. Online support groups for patients and caregivers -- empowerment of patients, but resistance from physicians
  3. Health care provider information services -- medical journal reprints, continuing medical education (CME)
  4. Provider-patient email -- some direct contact with physicians, but online frequently asked questions (FAQs)
  5. Communication infrastructure and transaction services -- claims processing, telemedicine claims
  6. Electronic medical records -- vendor development, more fragmentation (61-72).
Part II of the book, "Sources of and Experiences with Online Medical Information," moves to studies of sources of and online experiences with the medical information. Philip M. Napoli reviews the literature on consumer use of medical information from electronic and paper media. In his comparison of Internet-based information with more traditional media such as mass communication and interpersonal communication, he outlines three distinct models of health information seeking:
  • synergy model -- suggests that people learn of a particular health topic from mass media but other forms of media are consulted for additional information and support.
  • the Comprehensive Model of Information Seeking (CMIS) -- combines the health belief model, uses and gratifications research, and media exposure and appraisal
  • the sense-making approach -- examines the consumer's social construction of meaning.
In Chapter 4, through survey data in a nationwide study, the authors examine the quality of health care information and referrals to physicians. In the other study (Chapter 5), conducted in New Jersey, survey data revealed the use of the Internet for professional purposes. Findings in the nationwide study suggest 41% of those sampled (n=800) reported that they had "looked for medical information on the Internet" (101). Those accessing information do so multiple times: 23% (10 or more times), 16% (5-9 times), 22% (3-4 times). Most (73%) discussed information with others. Of those, 50% reported that it was with doctors or health professionals. Finally, 33% found the Internet highly valuable, while 61% found it somewhat valuable.

In the New Jersey study, the authors' objectives were to assess the level of physician usage, their attitude toward the Internet and its impact, identify users and nonusers, and discuss the accuracy of Internet health care information (Aspden, Katz, and Bemis, 109).

Three-fifths of physicians were found to use the Internet for professional purposes. The types of information accessed were: bibliographic databases, medical journals, email, information from providers, website of the Medical Society of New Jersey, discussion groups, and other sources (110). More than half of the physicians found that the Internet had a moderate or better impact on their work (111).

An interesting finding was that nonusers of the Internet and users agree that professional interaction with patients with Internet information is more productive (65% -- users, 46% -- nonusers) (111). Physicians did find that much of the information on the Internet was untrustworthy (58% -- agreed or strongly agreed). Physicians believed that they need to be proactive about patient use of the Internet and, as a result, they felt that they should be offered Internet training.

Perhaps the most insightful chapter, by June Anigbogu and Rice (Chapter 6), is an ethnographic case study of one woman's pursuit of information on infertility. This study recounts the day-by-day meeting between the first researcher and Ms. Doe, both on the telephone and face-to-face. It presents a wonderful account of Ms. Doe's first experience with a computer and the Internet. This first experience is very telling and is championed by writers such as David Bell (2001) in his book Introduction to Cybercultures. Remembering what it was like "not to know" is a very important step in understanding the whole process of using technology. The ethnographic interview and observation provide us with rich data about sense-making.

Part III of the book, "Experiences Developing and Evaluating Health Information Sites," addresses the development and evaluation of health information sites. This section comes the closest to the "how-to's" and "not-how-to's" of communication on the web. Finnegan, et al. (Chapter 7) present the emerging data from the Rapid Early Action for Coronary Treatment (REACT) community program trial. This case study takes the reader through the actual development of a specific health-related website.

Schneider, et al. (Chapter 8) evaluate the medicare.gov website. They enhance their findings with the inclusion of focus group data and an expert's review of the website. They made recommendations for improvement of the site including accessibility for persons with disabilities and structural arrangement and links. Perhaps the most useful part of the chapter is its comprehensive list of evaluation techniques that could certainly be applied to websites in other topic areas.

Elizabeth Witherspoon's (Chapter 9) study focused on "the content of HMO websites in terms of what existing health communication theories suggest for the type and presentation of information and how users will likely process it" (193). Here research questions related to how well top-ranked HMOs used interactive technology and how comprehensive the information on those websites related to: healthy lifestyle choices, preventive health care, and the needs of the chronically ill.

She found that the top-ranked HMOs were not fully exploiting available features in use elsewhere on health information websites. The HMOs did attempt to encourage healthy lifestyles, but mostly through classes, rather than testimonials or hard information. Witherspoon was surprised to find that preventive care was limited to schedules for immunizations and screenings. Finally, little attention was paid to information for the chronically ill. She recommends improvement in these areas and more qualitative research methods (for example, chapter 6), like interviews with HMO members.

Rice, et al. (Chapter 10) tout a dialogic approach to health care that could be achieved through disseminating information on publicly accessible websites. The study of both commercial and governmental database sites resulted in a coding system that could easily be used by those designing and improving health information websites (see 222-229).

Part IV of the book, "Experiences of Online Health Communities and of Organizations Moving to E-Commerce," is divided between online communities and e-commerce. Jennifer Preece and Kambiz Ghozati (Chapter 11) examined empathy online. They studied 100 online communities by extracting 20 messages from each group and coding those messages by communication type (empathic, hostile, or other), gender (male, female, or unknown), and moderation (group was moderated, not moderated, or not classifiable).

They found that empathic communication is common in many online support groups. It appears to be lower in religious, sports, cultural, social, and scientific communities. Women tend to be more empathic in all groups, except support groups, where gender does not seem to be a factor. Finally, the assumption that having a moderator would reduce hostility does not seem to be born out in this study. Some communities appear to be naturally hostile.

Continuing Medical Education (CME) is analyzed in Chapter 12 by Whitten, et al. They examined the websites for CME at two university-run programs: one was successful and one was not. The criteria of credibility, content, design, and navigation served as the modes of comparison. Their comparisons of the programs would provide those designing such programs with ideas to avoid the pitfalls (277-278).

Richard L. Street and Veronica K. Piziak (Chapter 13) used the "model of health promotion" to outline a diabetes care program: increase utilization, increase involvement in message processing, and improve health behavior outcomes. They analyzed the use of the DiabetesNet website over a one-year period. They coded the frequency and type of messages on the site and found giving support and inspiration/humorous postings to tie for the most prevalent type of message. They conclude with recommendations for the improvement in utilization and the value of DiabetesNet.

Lauren B. Eder and Donald E. Wise (Chapter 14) provide a more technical chapter on "web-enabling" hospitals. They analyze the issues of CEO participation, CEO support, information technology infrastructure, information systems alignment, and external pressure. Most informative is the table describing web technology use in hospitals (323). They found that 76% (n=103) reported being web-enabled in the area of hospital marketing, followed by 56% for secure internal communications, and 48% for patient education. The reader wonders what type of education information that was provided for patient education.

Chapter 15 is the only international study included in the book. Elizabeth More and G. Michael McGrath conducted a study on the Australian pharmaceutical industry. The authors explore interorganizational collaboration as a model for success. One wonders: Would the American-based pharmaceutical companies consider moving to this model?

The book closes with Part V: "Public Policy Experience and Expectations." This section explores how public policy can both enhance and deter the acceptance and adoption of technology. Rice and Katz suggest in the opening of that section "when considering policy issues, every program is viewed through at least two lenses . . . efficiency and equity" (351).

Baur et al. (Chapter 16) suggest, in their essay on ehealth, that policy issues fall into six general areas:
  1. The lack of mechanisms to ensure the quality of health information that is being widely disseminated through electronic media to the public.
  2. The lack of evaluation research to determine the impact of ehealth on health care utilization, access, continuity, quality, and health status.
  3. The use of the Internet to engage in potentially fraudulent or deceptive electronic health commerce (ehealth-commerce).
  4. The online collection of personal health information and the potential abuses of privacy and confidentiality.
  5. The inefficiencies, errors, and missed opportunities to improve health and well-being that occur because of the lack of a fully integrated national health information infrastructure.
  6. Inequities in access to the Internet and appropriate health information (362).
The authors close with a discussion of ethics and reference to the Health Ethics Initiative and the American Medical Association ethical guidelines. They also suggest that Healthy People 2010, a part of the US Health Department, shows promise for addressing the six areas above.

Barry D. Bayer (Chapter 17) explores the usability of an online pharmacy drugstore.com and discusses its benefits and disadvantages.

Katz and Aspden (Chapter 18) examine security and privacy issues of electronic health records and find that the military and financial model of security is not a good fit in the health care arena. They also found that there is a general lack of awareness on the part of many health care professionals and nearly all patients of how information is gathered and the ramifications of that information on their privacy and security. Finally, the authors find that no set of a priori rules can be established in this life and death type of business.

In the closing essay (Chapter 19), Katz and Rice present an insightful summary of this widely diverse subject of health communication and the Internet. They address cost benefit comparisons. Here they suggest that the costs will come quickly, but the efficiencies will come more slowly. They find that a prominent early development will be the use of a personal digital assistant (PDA) because of its ease of use and portability. The authors outline a list of foci which will assist in the development of Internet use (422). They express the unlikelihood that doctors will adopt Internet use for direct contact with their patients any more than they did direct telephone contacts. The "managed boundaries" are likely to continue to exist.

The inescapable ethics issues will continue to be a concern as doctors such as C. Everett Koop attach their names to websites and receive financial gain from the products sold at those sites.

With the Internet comes quackery and folk medicine, but also personal empowerment. The authors close with recommendations for further research. They suggest a "process focus" to research: the who (community of interest), the what (content), where and when (connectivity), the how (computers and software), the real vs. the virtual (care), who pays? (cash), and rules and regulations (quality) (See 427).

This book fills a void in the literature on health communication and the Internet. It explores both quantitatively and qualitatively the subject, although the qualitative studies are few.

Practical information for web designers can be found in Part III of the book and in each chapter the authors provide a theoretical grounding for their research. The practical and the theoretical are woven together.

The tables are effectively placed to provide a shorthand summary. The case studies, especially Anigbogu and Rice's study of infertility information seeking, share valuable information on the process of using the Internet. It is recommended that more of this type of study would be insightful.

Finally, the issue of public policy cannot be stressed enough. It is echoed in many of the studies in this book and elsewhere that issues of the "digital divide" must be addressed in the early stages of technology adoption and development or the disenfranchised may be left behind.

Bell, David. (2001). Introduction to Cybercultures. London: Routledge.

Kathleen M. Golden:
Kathleen M. Golden (Ph.D., Kent State University) is associate professor of Speech and Communication Studies at Edinboro University of Pennsylvania. She teaches organizational communication, communication theory, communication research, technology of communication, small group, interviewing, public speaking, and oral interpretation. Her current research interests are online support groups, women in vaudeville, and group decision support systems (GDSS).  <kgolden@edinboro.edu>

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