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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

Background

Internet has become a significant resource for dissemination of medical information. We sought to investigate prevalence and usage patterns of Internet access among consecutive patients with cardiovascular diseases.

Methods

A cross-sectional study was performed using a questionnaire as study tool. Among patients with Internet access, the type of health information sought and the impact of these on daily life were assessed.

Results

Of 1063 patients invited to the study, 1000 patients [68% male gender, mean age 66 ± 11 years (range 27–83 years)] agreed to complete the questionnaire. 216/1000 (21.6%) used Internet to obtain information related to their disease. The patient education was graded as: low (15%), medium (66%) and high (19%). Reasons for Internet use were as follows: 24-h availability 142/216 (65.7%); free of charge 58/216 (26.9%); and anonymity 50/216 (23.2%). Younger (≤ 66 years) age (35.2% vs. 15.3%; p = 0.0001), male gender (24.6% vs. 15.4%; p = 0.001) and higher education level (49.4% vs. 16.1%; p = 0.001) were significantly associated with Internet use. 30.6% (66/216) of Internet users changed their individual health behaviour attributable to information found on the Internet. However, this was not related to age, gender or level of education (p = 0.5, p = 0.6 and p = 0.4, respectively). Patients without Internet use obtain health information mainly from the pharmacist (62%) or from their treating physician (58%).

Conclusions

A relevant number of patients with cardiovascular disease access the Internet for health information. The impact of such information on health-related behaviour in daily life was low.

What's known

  • The Internet is increasingly being used as a source of health information. However, Internet use for health-related information differs considerably with regard to age, gender and type of underlying medical condition.

What's new

  • The results from our study demonstrate that a relevant number of patients with known or suspected cardiovascular diseases access Internet for health purposes. However, Internet use in this group of patients is less frequent than previously reported for other medical conditions. Moreover, the influence of the obtained information on health-related behaviour in daily life was low.

Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

The Internet has become a significant resource for dissemination of information. The Pew Internet and American Life Project [1] estimated that on a typical day, 70 million Americans are online and 7 million look for health-related information. Also in Europe, a significant growth in the number of Internet users was noted over the last years [2]. Institutions and medical personnel have invested significant financial resources to improve their Internet capabilities [3, 4]. Jadad et al. found that over 90% of a sample of cancer-care providers reported that patients had brought information from the Internet to them for discussion [5].

Recent studies showed that there are considerable regional and disease-related differences in the use of Internet information [2, 6, 7]. To date, there are only few published studies on Internet access and usage patterns among patients with cardiovascular diseases [8-10]. We sought to document the prevalence of Internet access and usage patterns among this group of patients.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

Patient survey

Patients age 18 years or older were recruited for this cross-sectional study from the waiting rooms of our Cardiology Clinic. Exclusion criteria were insufficient knowledge of German language to complete a written survey or severe and unstable disease. Data collection lasted from January 2011 through March 2011. Following informed consent, individuals were asked to complete an anonymous questionnaire that included a demographic section and five questions inquiring about Internet access as: (i) the resource used (i.e. magazine, medical insurance, hospital website …); (ii) the type (if any) of health-related information searched (i.e. disease, medication …); (iii) the reason for the research; (iv) the impact of Internet information on their daily life; and (v) their personal assessment of information quality. Patients were left free to provide additional information (Box 1). The questionnaire was given to the patients prior to their consultation and they were asked to return them to the clinic receptionist. The study was approved by our institutional review board.

Data analysis

The data were entered independently by two fellows, and differences (i.e. typing errors or misclassification of patient data) were resolved by consensus. Categorical variables are presented as percentages or numbers. Continuous variables are summarised as mean ± standard deviation. Comparisons for categorical variables were made with chi-squared or Fisher's exact, as appropriate. The t-test was used to compare continuous variables. A p-value < .05 was considered statistically significant.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

Patient survey

Of 1000 of the 1063 cardiology patients invited to participate to the study did so (94% response rate). 68.4% of the patients were male gender; the mean age of the total population was 66.4 ± 10.7 years (range 27–83 years). 21.6% (216/1000) patients reported Internet use to obtain health-related information. Patients using Internet as a source of health information were significantly younger than patients who did not (61 ± 11 years vs. 68 ± 10; p = 0.0001). However, the oldest participant of our study (an 83-year-old man) is daily surfing the Internet. Patients were fairly well educated: 85% successfully completed high school (Table 1). The most frequent reasons for Internet access were as follows: 24-h availability in 65.7% (142/216); ‘free of charge’ in 26.9% (58/216); and anonymity in 23.2% (50/216) of the patients.

Box 1. Survey questions

A. Have you ever used the Internet to access information about your heart condition?
If yes:
1. Which Internet resource did you access?
Magazines, Medical insurance, Physician, Hospital, Internet portal, Communities, Pharmacy, Pharmaceutical industry, other
2. Do you think the Internet information is trustworthy? (1 = very much; 6 = not at all)
Information provided from: Physician, Medical insurance, Hospital, Pharmacy, Communities, Internet portal, Magazines, Pharmaceutical industry, other
3. Which type of health-related topics did you access?
Specific disease or condition, Medications, Alternative therapies, Share experience with other patients, other
4. Why do you use the Internet to access health-related information?
anonymity, 24-h availability, free of charge, other
5. What is the impact of Internet information on your daily life?
Feeling better informed, more critical towards physicians, better nutrition, more exercise, illness prevention, smoking cessation, reduction in body weight, reduction in physician visits, other
B. In case you never accessed the Internet for health-related information
6. Which alternative sources of information do you use?
Pharmacist, Physician, Magazines, Medical insurance, Friends/relatives, Television, Hospital, Pharmaceutical industry, other
Table 1. Demographic characteristics
CharacteristicInternet user n (%)Non-Internet user n (%)p-value
Sex
Male168 (78)518 (52)0.001
Female48 (22)266 (48)
Age
Mean age (years)61 ± 11 (95% CI 59.52–62.48)68 ± 10 (95% CI 67.3–68.7)< 0.001
Range (years)27–8329–81 
< 40 years10 (4.6)10 (1.3)0.004
40–64 years122 (56.5)268 (34.2)< 0.001
≥ 65 years84 (38.9)506 (64.5)< 0.001
Education
Less than high school20 (9.3)128 (16.3)0.009
High school graduate110 (50.9)556 (70.9)< 0.001
≥ Bachelor's degree 86 (39.8)100 (12.8)< 0.001

Internet access and types of health information sought

Of the 1000 patients who participated in the study, 216 (21.6%) reported access and use of the Internet to find information regarding health issues or medical conditions. Age, sex and education were each significantly associated with Internet access (Table 1).

The questionnaire enquired about types of Internet and health information for which the Internet users searched. Because the participants were instructed to check all options that would apply, and users often used the Internet for more than one category of information, the sum of the frequencies of responses is greater than the number of Internet health information seekers. Magazines and homepages of medical insurances were most frequently accessed. Disease-specific information was most frequently sought, followed by medication information (Table 2).

Table 2. Internet access and types of health information sought
  N %
Type of Internet source accessed
Magazines11050.9
Medical insurance10247.2
Physician homepage9041.7
Hospital homepage6429.6
Internet portal5023.2
Internet communities3817.6
Pharmacy homepage3616.7
Pharmaceutical industry websites188.3
Other (e.g. Wikipedia)52.3
Health topics searched on-line
Specific disease or condition16676.8
Medications11653.7
Alternative therapies11050.9
Share experience with other patients2210.2

Trust in Internet information and impact on daily life

Internet access was rated useful to gain additional information by 69.4% (150/216) of the patients. 18.6% (40/216) of the patients said that they were more critical towards physicians and their advices. Only in a minority of patients (16.7%, 36/216), the information found surfing the Internet significantly changed health-related behaviour in daily life. These patients started a healthier diet and regular workout as a consequence of Internet-related information (Table 3).

Table 3. Impact of information on daily life and Internet reliability
  n %
Impact of Internet-based information
Feeling better informed15069.4
More critical towards physicians4018.6
Healthier nutrition and starting workout3616.7
Illness prevention3013.9
Smoking cessation146.5
Reduction in body weight62.8
Visiting the physician less frequently41.9
Perceived accuracy and reliability of web-based information provided from: 1 = very high; 6 = very low 
Physician2.0 
Medical insurance2.1 
Hospital2.1 
Pharmacy2.7 
Internet portal2.8 
Internet communities2.8 
Magazines2.9 
Pharmaceutical industry3.6 

In our study, we found profound differences regarding the accuracy and perceived reliability of web-based information depending on the organisation providing them. Websites of physicians, medical insurances and hospitals were perceived as the most reliable source of health information. Information of pharmaceutical industry websites was rated as less trustworthy (Table 3). Again, responses were not mutually exclusive, and more than one answer could be selected.

Alternative sources of health information in non-Internet users

We also explored alternative sources of health information of those patients without Internet access. Pharmacists and physicians were the most frequent sources of health information for them, whereas information provided by the pharmaceutical industry was a very infrequent source of health information (Figure 1).

image

Figure 1. Alternative sources of health information in non-Internet users

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Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

21.6% of a large sample of patients with known or suspected cardiovascular diseases reported to access Internet as a source of health information. Internet use was significantly associated with every measured demographic variable. Education and male gender were positively associated; increasing age was negatively associated with Internet use.

Demographics

Population-based studies have shown that 61% of American and 52% of European citizens have consulted Internet for health-related information at least once [1, 2]. The prevalence of Internet users among patients in our series is very similar to the one of a study on Internet access of patients with coronary heart disease in urban Australia [8]. However, other studies reported higher Internet access rate, ranging from 50% to 66% [1, 2, 4, 11].

The different relevance credited to Internet-related health information in European countries and among different diseases might, at least in part, explain these results [2-5]. Internet has been rated as a useful information resource and its use has been steadily growing in all investigated countries, except Germany [2]. There is little evidence that describes how individuals lacking latest technologies, as high-speed Internet Service Providers, cannot access resource-intensive Web sites, including those requiring audio or video streaming [12]. Another reason might be found on difference in regional income. For this reason, better educated, higher income classes might have easier access to technology allowing Internet consultation [12]. Only 18% of surveyed minority patients belonging to lower income and education social class from Los Angeles, California, had Internet access, considerably less than the corresponding national estimate of 36–45% [12, 13].

In developing countries such as China, India and Pakistan, rates of personal computer possession and use are much lower than the one of the developed world [14]. Technology costs, impossibility to have a stable electricity supply, illiteracy and no support to use complex technology account for the reasons why personal computer use rates are so low [14]. Cell phones are easy to use, affordable and suitable for non-literate populations; cell phone use across the developing world is increasingly remarkable [15].

Based on these observations, design and development of telephone-based interfaces for health information (human–human and/or human–computer interaction) seems to be promising for these populations [14]. Many individuals are using smartphones to access Internet and look for health-related information. Fast data connections, several applications and relative large screens counterbalance lack of a traditional PC-based Internet connection. This might considerably change how technology and Internet access are [16].

The gender differences in Internet health use should be seen in the context of overall Internet use. Elderly people and women are traditionally overrepresented as healthcare receivers [2]. This notion stands in contrast to the characteristics of the average Internet user and more men than women are using Internet. It is worth noting that men and women do report different needs for support after a cardiac event, with men valuing information exchange and women preferring emotional support [17]. Nevertheless, gender-related differences in Internet access are shrinking when younger generations are taken in consideration, as a recent large survey among more than 14,000 participants in Europe demonstrated. In this study, young women (< 25 years) more often than men use Internet to search for health-related information [2].

Age was associated with Internet use in our as well as in a previous study in patients with chronic cardiovascular disease [8]. A striking difference was observed between older (≥ 65 years) and younger (< 65 years) patients both in Internet access and its use. As already showed by previous studies, a relevant rate (up to 80%) of patients able to navigate sites, open links, complete forms and watch videos is found only among patients younger than 65 years [8, 18].

The Internet as a source of health information

Our study sample appears similar to those in the Pew project and other surveys [1, 4] in the health topics searched on-line, providing some confidence in the generalisability of our study results. The most commonly searched topics reported by our group of Internet users were, in descending order, specific disease or condition, medications, alternative therapies and interactive activities by sharing personal experiences with other patients.

Several articles about Internet-related information in medical journals have raised concern on their quality [19]. In addition, the lack of a peer review process and the often anonymous nature of Internet increase the risk of propagating misinformation [3]. Health information might be written by individuals without appropriate qualification and the information may not be evidence based [11]. Websites differs widely in their quality [19], and about 3% of a sample population affirm that health-related information found in the Internet cause harm either to them or to somebody they knew [1]. In addition, websites promoting commercial products or companies may introduce additional biases [11]. However, this might not represent a major issue as our study showed that most patients rate information provided by physicians and pharmacists as most accurate and reliable, whereas information provided by pharmaceutical industries were considered less reliable.

Internet as a tool to deliver health information to cardiovascular patients

To establish Internet as a valuable source of health information for patients with cardiovascular disease, three topics are particularly: (i) the simplicity of the web page; (ii) the importance of practical advices; and (iii) a tailored Internet-based program for different patient groups.

Simplicity of web design

Patients have been reporting underuse of Internet to increase their personal disease knowledge because of concerns about safety and complexity of websites [8, 20]. It seems that considerable amount of information available on the Internet and the related feeling of being overwhelmed by such an amount of notion is, for patients, as relevant as lack of knowledge or specific disease-related fears [8]. Patients with cardiovascular heart disease value simplicity of web design, simple layout, a search box on the homepage, and features such as on-line monitoring and a discussion forum with both expert and patients [8]. When planning an Internet-based program, there is a need to take fears, expectations and misconceptions into account.

Importance of relevant and practical advice

In the study of Neubeck et al., patients with cardiovascular disease underlined the importance of relevant and practical advice not only for themselves but also for their family member or carers [8]. Particularly valued were information on specific disease, treatment alternatives, lifestyle modifications, and benefit and side effect of medications [8]. Many Internet users requested some form of personalised monitoring as well as additional training in Internet use, so that health-related web programs could be handled without difficulties [8, 21].

Tailored Internet-based programs

Internet has been shown to be beneficial to almost all social classes including also lower income ones or ethnic minority and to people under constraints of distance [8, 10]. It has already been showed that the use of a specific Internet-based program is related to personal computer skills more than the social class of a specific individual [8, 10]. In addition, the possibility of generating tailored interventions has evolved with the capabilities of computer technology [20]. Current ‘third generation’ computer-based applications are constantly adjusting to the characteristics of the user. In this way, a third generation application will add, delete or rearrange specific issues in response to the user and his level of computer skill [20]. The advantages, if such an approach over a generic website, have been already confirmed [8, 21].

Conclusion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

The Internet is becoming an important resource of health information. In the population of individuals attending our Cardiology Clinic, a relevant number of patients with cardiovascular diseases access the Internet for health information. Internet use was significantly associated with younger age, male sex and higher educational level. Nevertheless, the influence of the obtained information on health-related behaviour in daily life was low.

Author contributions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

Ohlow MA: Concept/design, data analysis/interpretation, drafting the article, approval of the article, statistics. Brunelli M: Concept/design, critical revision of the article, approval of the article. Lauer B: Concept/design, critical revision of the article, approval of the article.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References

The authors would like to acknowledge the following individuals for assisting with study recruitment: Margret Schulz, Claudia Ewald, Thea Romaniec, Nicole Heerlein and Rosita Heyne. Funding for the research and its publication: None.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Author contributions
  9. Acknowledgements
  10. References