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Chapter 7

New Technologies and Health Communication

Have you ever looked up information about an illness on-line or used your health insurance company website to find a physician who is in your provider network? If so, you are one of millions of people who search for health information on the Internet each day. New communication technologies have permeated virtually every area of the healthcare delivery system in recent years, including provider–patient email exchanges, electronic records, access to laboratory results via the Internet, text messaging reminders, and the use of iPhone applications that allow you to have quick access to pertinent health information as well as to take a picture of your prescription and text it to your pharmacy for a refill.

The US healthcare system has a long and distinguished history of innovation, and when new technological advances are found to benefit healthcare delivery and the prevention of disease, it is often on the cutting edge of adopting them. For example, even the advent of the telephone was once considered a major technological advancement in terms of increasing a provider’s ability to conveniently reach patients. Later, beginning in the 1980s, providers began using email to communicate with other providers, followed by the use of email to communicate with patients in the 1990s (Avtgis, Polack, Staggers, & Wieczorek, 2011). In recent years we have witnessed the growth of other new communication technologies that have led to major changes in health communication. The convergence of the Internet, wireless computer technology, global satellite positioning, and computer tailoring of messages are just a few examples of the high-tech revolution that has led to communication changes within the health delivery system. The extent to which these newer technologies will transform health communication remains to be seen, but it appears that technology will continue to be used by the healthcare system in the future.

Healthcare organizations hope that the application of these technologies will reduce the costs associated with traditional channels of communication (e.g. telephone, paper-based patient charts, memoranda from healthcare organization administrators) and increase convenience and efficiency. New technologies can also be used in health prevention and education efforts to disseminate and access health information as well as facilitate relationships (provider–provider, provider–patient, and patient–patient). The costs of the current US healthcare system were estimated to be over $1 trillion in 2001 (US Census Bureau, 2010) and are projected to rise over the next decade.

New communication technologies have the ability to impact health communication both positively and negatively (Neuhauser & Kreps, 2003). In some cases the cost of adopting them may not be beneficial to health practitioners, so it is important for health communication scholars to understand the advantages and disadvantages these technologies offer in terms of disseminating health information and facilitating interaction among different stakeholders in the health arena. This chapter examines some of the prominent ways in which new communication technologies are currently being used in the US healthcare system and their potential impact on health outcomes.

Health Information on the Internet

More and more people are using the Internet to search for health information than ever before. Tu and Cohen (2008) found that in 2007 56 percent of US adults sought information about personal health concerns through health-related websites. Fur­thermore, the enmeshment of healthcare systems, globalization of media systems, convergence of media technologies, smartphone applications, text messaging, and the Internet as an information-gathering tool have transformed the decision-making practices of those seeking healthcare. While the growth and popularity of using the Internet for health information may provide consumers with up-to-date information about various aspects of disease prevention, illness, treatment, and control, there are many questions concerning the quality of health-related information that is currently on-line. In addition, there are many concerns about access to the Internet, particularly among traditionally underserved segments of the population (Kreps & Sparks, 2008; Sparks & Nussbaum, 2008).

Health Information Access

At no other point in history has access to health information been so convenient for both providers and consumers (Sundar, Rice, Kim, & Sciamanna, 2011). A recent Pew survey found that 61 percent of US adults had used the Internet for health information (Fox & Jones, 2009). Today, people can gain access to much of the same information as healthcare providers on government and research institution websites or electronic databases on the Internet that are free or charge a fee (e.g. MedLine), yet relatively few people have the education level or technical expertise to understand much of this information in the same way as providers (Shieh, Mays, McDaniel, & Yu, 2009). However, understanding health information, including information gathered from the Internet, influences health in a wide variety of ways. For example, according to Galarce, Ramanadkan, and Viswanath (2011), “accessing and correctly using health information has an enormous influence on health-related lifestyle factors, early detection and diagnosis, coping with disease, managing symptoms, engaging in in active medical decision-making, understanding different treatment options, and ultimately, facing end of life challenges” (p. 167).

Consumers can find a variety of websites sponsored by government organizations, such as the National Institutes of Health (NIH) and the Center for Disease Control (CDC), and on-line medical journals, and they can even pose questions and receive information from healthcare specialists on some websites (e.g. WebMD). On-line health information is continuously available, accessible, and can be acquired anonymously (Viswanath, Ramanadhan, & Kontos, 2007), which is particularly helpful when people are dealing with sensitive health issues (i.e. diet, sexually transmitted diseases, etc.). Access to health information via the web has led to patients bringing information they have found there to discussions with their physicians during office visits (Aspden & Katz, 2001), more talk about information acquired from the Internet during medical interviews (Aspden & Katz, 2001; Ferguson, 1998), and greater patient ability to discuss more specific details of diseases and conditions (Napoli, 2001). According to Sundar et al. (2011), more recent trends in the use of on-line health information include increases in the amount of information people are seeking about diet and exercise, information from other people’s experiences (blogs and on-line support groups), and on-line ratings of physicians and other providers (similar to prominent non-health-related rating websites like Angie’s List).

Many search engines (e.g. Yahoo and Google) often lack an efficient way to access specific health-related websites. A keyword search for a specific disease, such as HIV/AIDS, will result in links to hundreds of sites that may vary in terms of their intended audience, information quality, and specificity of information about the disease (Bass, 2003). People accessing information about HIV/AIDS are often interested in very different aspects of the disease. For example, some people are interested in HIV prevention, while others might be concerned about specific treatment options or finding an on-line support group for people living with the disease. Other individuals interested in HIV/AIDS, such as physicians and researchers, frequently obtain information from HIV/AIDS websites dealing with highly technical aspects of the disease. The major search engines can make it difficult to locate information about health that is tailored specifically to the education level and interests of individuals. This makes it extremely cumbersome to sift through hundreds of links to websites that may not provide the desired information, or information may be presented in language that is too technical or too basic depending upon the background of the searcher (Eng, 2001).

In addition, just because people have access to information does not necessarily mean they will use it, understand it, or change their attitudes and behaviors because of it. For years people have had access to health information from university libraries and many other sources, but they have not necessarily used the information, had the capacity to understand it, or they have lacked the motivation to enact the suggested behaviors for improving health outcomes.

The evolution of the new technologies has also led to the advent of the mobile Internet, where individuals not only access health information via smartphones, but they also can download applications that monitor health behaviors (Hurling et al., 2007; Kim & Kim, 2008), such as accelerometers to monitor physical activity, or disease management, such as mobile web-based applications that monitor blood glucose level and that provide recommendations). One of the authors of this book, who is a vegan, uses an iPhone application to scan bar codes on processed food products that indicates whether it contains animal products enablingdietary decisions at the grocery store. Health campaign designers are increasingly turning to smartphone applications for health campaigns (which often draw on web video platforms like YouTube), such as smoking cessation interventions, abstinence campaigns, and organ donation campaigns (Sundar et al., 2011; Tian, 2010).

Credibility

It is often difficult to assess the credibility of health information found on the Internet. A number of researchers have expressed concerns about credibility in evaluating information on health-related websites (Barnes et al., 2003; Cummins et al., 2003; Wang, Walther, Pingree, & Hawkins, 2008). While government, university, and research organization-sponsored websites typically provide the most credible information, some websites created by interest groups and individuals can also contain credible information. For example, sometimes a cancer survivor or a person who is a caregiver for someone with Alzheimer’s disease may have credible information to offer others because of his or her first-hand experience with the disease. Complicating the issue further, consumers often differ in terms of what they perceive to be credible information. Some people find scientific studies about a disease to be credible whereas others think that accounts of personal experience have more credibility.

Unfortunately, early studies found that much of the health information on the Internet is either inaccurate or incomplete (Bierman, Golladay, & Baker, 1999; Hersch, Gorman, & Sacherek, 1998), and many websites do not conform to standards set by professional medical associations, such as the American Medical Association (Rice, 2001). Typically, standards for credible websites include the provision of informed consent for consumers, editorial control over messages (e.g. controlling spam and other unwanted messages through the use of moderators or website content editors), and disclosure of all website sponsors, such as pharmaceutical companies or other health-related businesses (Rice, 2001). However, Metzger (2007) found that most web users do not undertake recommended information-verification steps, but focus more on design and navigation aspects when assessing website credibility. Researchers are still concerned about health website inaccuracies, particularly since a variety of studies have found a great deal of misinformation (Sundar et al., 2011). Assessing the credibility of websites is often a difficult task for laypersons, and even for researchers and health professionals there are few consistent guidelines. Some researchers have attempted to create guidelines for health information on the Internet (see Cummins et al., 2003; Weiler & Pealer, 2000), but whether or not these will ultimately be adopted on a large scale remains questionable. Yet, more and more people report that their health-related behaviors have been significantly influenced by information they receive on the Internet (Fox & Jones, 2009), leading them to ask doctors more questions, alter their diet, exercise level, or ways of dealing with stress, and affecting how they cope with chronic illness (Sundar et al., 2011).

In recent years, we have witnessed the growth of Web 2.0 technologies that have made the Internet and websites more interactive. Health-related blogs, on-line support groups, and health wikis have proliferated in the past several years, and studies have found that these sources are often perceived as highly credible by people seeking health information (Kovic, Lulic, & Brumini, 2008). When the first author of this textbook inquired about this phenomenon from a blog user recently, he was told “an oncologist can tell you technical things about cancer, but people who live with cancer can tell you all kinds of things that an oncologist does not know.” These included such things as emotions (such as fear and hope) that go along with living with cancer, personal experience with cancer medications, and detail about the many day-to-day challenges of living with the disease. According to Sundar et al. (2011), blogs, wikis, and other interactive web-based applications allow consumers of health information to receive both personal and mass communication. Moreover, it also gives people an opportunity to share their experiences and receive feedback from others. The “first hand” experience they receive from others and the increased ability to clarify information appears to bolster perceptions of credibility (particularly compared to traditional medical expert-based, one-way communication). However, Buis and Carpenter (2009) found that most commentary pertaining to medical issues in health-related blogs cited external media sources to back up statements (such as books, newspapers, and websites), but they contained very little actual medical information.

Literacy Issues/Underserved Populations

Despite the large amount of health information that is currently available on the Internet, there are many underserved populations, including older adults, individuals from lower socioeconomic households, people with low literacy levels or little experience with technology, individuals with disabilities, and people living in rural areas who cannot access the Internet or who have limited access. Although the digital divide has become smaller in recent years due to a decline in the cost of computers and access to the Internet, many members of underserved populations still have difficulty gaining access to health information on-line (Rice, 2001). Unfortunately, these individuals are often also members of high-risk groups for many diseases and conditions, and they would benefit most from the health information that exists on the Internet. Consumers’ unique cultural backgrounds and orientations have powerful influences on their interaction patterns that must be carefully accounted for in health communication efforts (Kreuter & McClure, 2004). It is very important to identify and examine the most important and influential cultural issues that are likely to influence the ways members of vulnerable populations, respond to communication about health and healthcare (Kreps & Kunimoto, 1994; Kreps & Sparks, 2008, Pecchioni et al., 2008; Sparks & Nussbaum, 2008). Several of the key cultural variables that influence health communication outcomes include the unique health beliefs, values, norms, and expectations that different consumers bring to health situations (Kreps & Kunimoto, 1994). It is also important to assess consumers’ culturally based language skills, barriers, their health literacy levels, their motivations to seek health information, and their unique media use patterns (Youmans & Schillinger, 2003; Andrus & Roth, 2003). Examination of these key cultural factors provides crucial information for determining how to best design and deliver key messages for effectively communicating complex health information to diverse populations (Kreps & Sparks, 2008). For instance, Pecchioni, Ota and Sparks (2004) found that in the US older adults are perceived highly negatively and often receive negative remarks or experiences from people in younger age groups. However, the authors found that in Hispanic cultures, the elderly have authority in their families and are treated with respect. Elderly Hispanic men and women emigrating to the US may go through culture shock as they are faced with negative stereotypes that the American culture places on them as older adults relative to the higher status they had in their native countries.

Sometimes, healthcare providers may have trouble communicating in cross-cultural conversations due to language barriers. These instances can lead to what seem like confounding messages regarding causes of illness and appropriate treatment when cancer patients are from different cultures (see e.g. Pecchioni et al., 2008). Additionally, stereotypes can also inhibit openness among patients and providers when they view their patients’ differing cultural beliefs or values about illness and treatments as inferior to their own (Pecchioni, Ota, & Sparks, 2004). Due to this factor, researchers have found that people frequently seek out healthcare providers who share similar cultural backgrounds as their own, with the belief that they share the same values, or they may commonly rely on family members (who may or may not have medical knowledge) to provide care (Pecchioni et al., 2008). This is a type of conversion strategy in which people seek out others who are similar to themselves. Culturally sensitive health communication is a crucial component to providing vulnerable consumers with useful information about health promotion and healthcare.

Efforts have been made to reach members of underserved populations, including organizations such as SeniorNet that attempt to provide access to computers and computer training for older individuals within senior centers, software applications that allow people with disabilities (e.g. people who are visually impaired) to use web browsers, and corporate programs that provide donations of older computers and Internet access to poor communities (Kreps & Sparks, 2008; Mo, Malik, & Coulson, 2009; Sparks & Nussbaum, 2008; Stalberg et al., 2008). However, a great deal of work still needs to be done in order to reduce the digital divide in the US (e.g. Kreps, Neuhauser, Sparks, & Villagran, 2008). Seniors, for example, are half as likely as younger adults to access the Internet for health information, and many ethnic/racial minority groups as well as less educated populations are less likely to rely on the Internet for health decision-making (Tu & Cohen, 2008). Addressing these types of problems will take efforts on many fronts, including making improvements to the Internet infrastructure to allow access in a variety of locations, computer literacy programs, and community efforts to provide locations where individuals can access the Internet for free, such as libraries and community centers. In addition, public health campaigns need to be directed toward helping individuals find information that is tailored to their health needs and helping them make sense of the health information that exists on-line.

New Technologies and Patient–Patient Communication

Health-Related Web Communities and Computer-Mediated Support Groups

The development of the Internet has created possibilities for increased patient–patient communication, mostly through web communities, social networking sites like Facebook, and specialized computer-mediated support groups. Computer-mediated support groups have become more prevalent in recent years as a source of information and support for numerous health concerns as a result of the Internet’s increasing popularity and its ability to connect people who have similar health issues. An estimated 90 million Americans have participated in some type of computer-mediated support group (Sarasohn-Kahn, 2008). A number of scholars, including health communication researchers, have focused their attention on these groups in an attempt to study their benefit to participants and to understand how the nature of supportive communication is affected by both the constraints and advantages of the computer medium (Rains & Young, 2009; Shaw et al., 2006; Tanis, 2008; Wright, Johnson, Bernard, & Averbeck, 2011).

Computer-Mediated Support Groups and Health Outcomes 

There is a growing body of evidence that these groups provide a wide variety of health benefits for users (such as individuals with cancer, diabetes, and substance abuse problems), including reduced stress, increased positive coping, increased quality of life, increased self-efficacy in terms of managing one’s health problems, reduced depression, and increased physical health benefits (Beaudoin & Tao, 2007; Gustafson et al., 2005; Houston, Cooper, & Ford, 2002; Jones et al., 2008; Rains & Young, 2009; Shaw et al., 2006; Wright, 2000a).

Advantages and Disadvantages of Computer-Mediated Support Groups 

Query and Wright (2003) developed a model of on-line support group participation for people facing health concerns to help explain why some people use these groups while others do not. Not everyone who is concerned about a health issue seeks social support: some people choose individually based strategies for coping with stressful events, while others are more socially oriented in coping with stressful situations, such as seeking various types of social support (Kohn, 1996; Pierce, Sarason, & Sarason, 1996). Many people feel that they have sufficient support from family and friends, and they may never feel the need to join an on-line support group. However, as we saw in Chapter 4, there are times when people facing an illness find it difficult to communicate with close ties, such as family members and friends. For example, researchers have found that life-threatening illnesses are difficult topics for most people to discuss, especially when they affect a close relative or loved one, and family members and friends often minimize the concerns of people with a serious illness, avoid interacting with them, steer conversational topics away from emotional talk about the disease, or refrain from any discussion of illness (Dakof & Taylor, 1990; Helgeson, Cohen, Shultz, & Yasko, 2000).

Problems communicating about health with traditional face-to-face support network members may lead some individuals to seek support on-line. Papacharissi and Rubin (2000) concluded that individuals use computer-mediated communication as a “functional alternative” when face-to-face communication is perceived as difficult or not preferred. For individuals facing illness whose support needs are not met by their traditional support network, the Internet allows them to find other people with similar health concerns and provides an opportunity to obtain support from a much larger network than would be possible in the face-to-face world. The Internet is considered an unbounded network because, unlike the face-to-face world, on-line relationships are not hampered by temporal and geographical restrictions. Thus, it is possible for on-line support group participants to meet and obtain support from a large network of other people who come together to discuss very specific health concerns (e.g. prostate cancer groups, HIV/AIDS) as opposed to more general health issues. The Internet can also be seen as a weak tie support network (see Chapter 4), and people may be able to obtain more diverse points of view about health-related problems and talk about difficult issues with less interpersonal risk.

Other features of the Internet may be advantageous to those who use on-line support groups. Wellman (1997) contends that reduced nonverbal and appearance cues in email and other popular text-based forms of computer-mediated communication facilitate relationships that may be inhibited in the face-to-face world. Many of us are reluctant to form relationships with people in the face-to-face world due to cues such as age, gender, race, and appearance. However, in text-based computer-mediated communication, people do not see these cues and relationships tend to form around topics in which people have a mutual interest.

Additionally, social information processing theory (Ramirez, Walther, Burgoon, & Sunnafrank, 2002; Walther, 1996) asserts that in computer-mediated communication, message senders portray themselves in a socially favorable manner to draw the attention of message receivers and foster anticipation of future interaction. Message receivers, in turn, tend to idealize the image of the sender due to overvaluing minimal, text-based cues. In addition, the asynchronous format of most computer-mediated interaction (and to some extent in synchronous formats, such as chat rooms) gives the sender and the receiver more time to edit their communication, making computer-mediated interactions more controllable and less stressful compared to the immediate feedback loop inherent in face-to-face interactions. Idealized perceptions and optimal self-presentation in the computer-mediated communication process tend to intensify in the feedback loop, and this emphasis often leads to what Walther (1996) labels “hyperpersonal interaction,” or a more intimate and socially desirable exchange than face-to-face interactions.

Hyperpersonal interaction is enhanced when no face-to-face relationship exists, so that users construct impressions and present themselves “without the interference of environmental reality” (Walther, 1996, p. 33). Hyperpersonal interaction has been found to skew perceptions of relational partners in positive ways, and in some cases computer-mediated relationships may exceed face-to-face interactions in intensity, including within on-line support groups (King & Moreggi, 1998; Ramirez et al., 2002; Walther, 1996; Wright & Bell, 2003). Interestingly, Houston, Cooper, and Ford (2002) found that 40 percent of the individuals in their study preferred on-line support groups instead of face-to-face counseling, and this was attributed to skewed perceptions due to the computer-mediated environment.

The text-based nature of computer-mediated communication has other advantages. Weinberg, Schmale, Uken, and Wessel (1995) argue that the therapeutic value of writing down problems in text-based computer-mediated support groups may allow for more reflection and distance from others without worrying about other people’s immediate responses. In addition, writing down problems creates distance between people and their dilemmas (Diamond, 2000), and this may help people view their health concerns more objectively. More recent research suggests that the very act of composing affectionate messages in supportive on-line exchanges is related to reduced total cholesterol levels and cortisol levels (Floyd, Mikkelson, Hesse, & Pauley, 2007). Both cholesterol and cortisol are physiological products of stress and have been linked to heart disease and strokes among individuals facing long-term stressful situations.

All of these features of computer-mediated support groups, along with the anonymity and 24-h availability of these groups, may lead people to a support network that fulfills their needs. In addition, some people may augment their support network using on-line support groups rather than replacing their traditional face-to-face network members with virtual ones. Research on health-related computer-mediated support groups indicates that the people who use these groups tend to be satisfied with the support they receive, and they are often able to obtain more (and better-quality) support than would be possible within their face-to-face network (Wright et al., 2011).

Of course, on-line support groups have their disadvantages, and researchers have found that there are other sources of dissatisfaction among people using them (Galinski, Schopler, & Abell, 1997; King & Moreggi, 1998; Preece & Ghozati, 2001; Walther & Boyd, 2002; Wright, 2000b). Participants often find the lack of immediacy when communicating with others frustrating. Other reasons for dissatisfaction include difficulty when expressing and interpreting emotions due to reduced nonverbal cues; dissatisfaction with the inability to touch others; frustration with unwanted messages from unsolicited parties participating in the group (including spam messages); and increased opportunities for some individuals to misrepresent themselves to the group.

New Technologies and Provider–Provider Communication

The Internet and other new communication technologies are transforming provider interaction and access to information in a variety of health settings, such as hospitals, clinics, pharmacies, and research facilities. In the past, long-distance telephone calls, overnight letters, and creation and storage of patient records contributed to the tremendous costs of running a health organization (costs that are eventually passed along to consumers). New communication technologies may present cheaper, more convenient, and more efficient alternatives to traditional ways of communicating within health organizations. This section examines several ways that new communication technologies are facilitating communication among providers.

Email, Wireless/satellite Communication, and Electronic Records

Email and Wireless Communication 

Email is a relatively simple computer application, but it has transformed communication among providers in many important ways. Physicians and other providers can now obtain information and opinions from other key health personnel within and between organizations. The attachment feature of email has allowed providers to send one another detailed information about patient histories, relevant research articles about specific conditions, insurance records, and other important information that can be used to facilitate the healthcare process. In addition, the asynchronous nature of email allows providers to transcend temporal and geographical barriers. Providers at rural health clinics can quickly and cheaply access information from larger urban hospitals and research facilities, consult with specialists, and keep up with current information regarding health conditions from websites sponsored by medical research institutions and government websites (e.g. the NIH and the CDC). Communication researchers have found that most providers have positive attitudes toward email and see its value in improving communication among providers, although there appears to be some resistance among many older physicians to adopt this technology (Aspden, Katz, & Bemis, 2001). However, in the future, more and more physicians and other providers are expected to use email as more Internet training programs are introduced and older physicians retire (Aspden, Katz, & Bemis, 2001).

Satellite Technology 

The convergence of satellite technology and the Internet has led to health information organizations such as HealthNet (www.healthnet.org/

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