A majority of our European study population now uses the Internet for health purposes. We have seen a significant increase in all countries ().To a great extent this increase in use can be explained by improved Internet access.
In Denmark, Germany, Greece, and Portugal, we see that growth in the number of Internet health users is larger relatively speaking than growth in the number of Internet users. This might indicate that new Internet services for health users have been launched in these countries. In Denmark and Germany, our results also show a significant increase in one of the interactive health services. The relatively large increase in Internet users buying medicines online in Germany is matched by the growing eCommerce market for medicine since new legislation was introduced in 2004 [23
]. In Denmark, we observe an increase in online communication with known health professionals as more and more GPs offer services to meet the expectations of their patients and to implement these services before January 2009, when it will become mandatory for GPs to offer online services [25
There is still a majority of men representing Internet users in the seven countries studied. However, the difference between men and women is diminishing in younger age groups, and the 2007 survey did not show any significant difference between male and female Internet users for respondents aged between 15 and 25. Nearly all in this age group do have access to the Internet. It is therefore logical that it is among the oldest users that we have the largest growth potential.
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 health care receivers. This notion stands in contrast to the characteristics of the average Internet user. Internet health users are a combination of these factors. Looking at the youngest age group, we saw in 2005 that there were more women than men using Internet health services. The difference was 7.6% (4.6 - 10.7). In 2007, this difference increased to 11.1% (8.3 - 13.9). In other words, young women were already overrepresented as Internet health users in 2005, and it seems like this tendency increased in 2007.
In the logistic regression in , some interesting interaction effects can also be observed. While we can see an overall growth in Internet health usage among women, this does not apply to the oldest age group. Here the growth is largest among men, and it is not growth that can be explained by growth in general Internet usage. It is difficult to say why this is happening. One explanation might be that it is due to specific Internet services that target elderly men. Another might be that using the Internet for specific purposes like health is of greater interest to users in older age groups. The first adopters of the Internet in these groups were men, and perhaps they are now among those who use it for health purposes.
The Internet as a Source of Health Information
The importance of the Internet as a source of health information is growing. The absolute numbers for this kind of Internet use in every country seem to rely on how the scale for ranging the importance of health information channels is interpreted. It seems more reliable to focus on the relative importance of the Internet as a health information source (compared to the traditional ones) in a specific country and on the change within that country from 2005 to 2007. From this perspective, it is interesting to notice that the greatest change in the importance of the Internet actually occurs in the countries that already had a high Internet health usage in 2005.
In Denmark for instance, the Internet was the second most important source of health information in 2007—outranked only by information from health professionals. Both in Norway and in Denmark, the Internet is now considered more important as a source of health information than television and radio. The aggregated results for all the countries show that, even if the Internet is at the bottom of the list, there is just a small, non-significant difference between the Internet and more traditional media such as books, newspapers, and magazines. As the latter media decrease in importance and the Internet increases, it is legitimate to predict that the Internet might surpass them over the next few years.
Interactive Use of the Internet for Health Purposes
More in-depth analysis of the actual eHealth activities performed by the Internet health users in our two surveys reveals a tendency toward more “advanced” and more interactive use of the Internet for health purposes. Rather than using the Internet to search for and read health information, people are increasingly taking part in online communication with peers, unknown professionals, and their family doctors. In addition, the Internet is being used by more people for ordering medical health products.
] estimates that 7% of US Internet users communicated online with a health care provider in 2003, and this increased to 10% in 2005. Since our study distinguishes between known health professionals and medical personnel whom patients meet only online, and since the study period is different, it is hard to make a direct comparison. Multimedia Appendix 5
extends to give numbers for the Internet users only. This shows that interaction with Web doctors and other health professionals whom patients have not personally met did increase from 13.2% to 16.8% from 2005 to 2007. Communication with family doctors or other known health professionals increased from 5.0% to 9.7%. Even if the studies are not directly comparable, they give an indication that the average use in our seven European countries is not falling behind the average for the US.
However, both in the US and in Europe, it does seem that the overall trend is moving toward an increase in communication with health personnel over the Internet. The main factor driving this trend is patient demand for such services. In general it appears that patients are considerably more positive in their attitudes toward online communication than physicians are [26
]. Other factors influencing this development are legislation, tariffs, and technical limitations. We see that the legislators are starting to take the consequences of this trend into account in Denmark, where all general practitioners will be obligated to offer eHealth-services to patients in 2009 [25
We can, therefore, see a general growth in the use of the Internet for health purposes which parallels an increase in more interactive use. Even if our study does not follow the same individuals over time, it seems logical to assume that simply browsing for health information is the starting point. It seems that, when Internet users become more experienced and comfortable with opportunities provided by the Web, they also start to use it for two-way communication, either with peers in forums or with health professionals. This could be called the second generation of Internet health users, and the trend which we detect in Web use for health purposes parallels the current movement in general Internet use toward more interactive usage of the so-called Web 2.0.
Nevertheless, the Internet is still a relatively young medium, and its widespread use in some countries at present might still be limited by bandwidth and technical difficulties. We therefore expect that the proportion of more interactive Internet health use will grow significantly in the years to come. Additionally, health services which today still seem to be in a more or less premature phase, or are only recognized by a minority of the population, such as online access to one’s medical record from a health care provider or even managing one’s own personal health record, will gain in importance in the coming years.
With the current movement of mass software providers such as Microsoft and Google into the health care market [27
], we will probably see a tendency among Internet health users to demand a more equitable role in their health care process. As stated by Ball and Lillis in 2001, new eHealth technologies provide opportunities for more empowered patients, and physicians need to be prepared for the likelihood that patients will start acting more as consumers [28
] and challenge the current asymmetry of knowledge [29
] in order to achieve a much fuller participation in health care decision-making processes.
The WHO eHealth consumer trends survey is based on previous surveys carried out in Norway as well as in Europe. Particular attention was devoted to the questionnaire addressing cultural differences with the dual-focus method and pilot surveys. Some variables turned out to be difficult to include in this comparison. One of them was education. There are seven independent educational systems in the countries studied. We used ISCED codes [30
] in order to compare education across countries. The codes are fairly complicated to use, and we detected variations in how they were interpreted over the course of two years. We therefore decided to drop this variable in the analysis.
Another useful variable in the analysis would have been household income. In several of the countries in the study it would, however, have been inappropriate to ask about this in a telephone interview. Even if the question were included in the first Norwegian study, we would have had to drop it in the international questionnaire.
There was an interval of 18 months between the surveys. This is a fairly short time period, and many of the effects studied may not have been significant in such a short time span.
Another limitation of the study is the use of CATI and the sizable percentage of the population which cannot be reached using landline phones. The lack of public mobile-phone directories in several of the countries studied made it hard drawing representative samples. We used strata in compensation for this in 2007. Our main focus in this article is changes between 2005 and 2007. We were therefore especially concerned that such differences could be caused by demographic variation in the samples and chose to use weighting of the 2005 data, as described in Methods. This is not ideal, but we are confident that, in our situation, this did improve the quality of the analysis.
The perceived importance of the Internet as a health information source is increasing. There is relative growth in all age groups and for both men and women in Internet use for health purposes, with especially strong growth among young women. Along with this growth, we also see that the second generation of Internet health users is using the Internet for more than just reading information. They are using the Internet as a channel, for direct communication with health professionals as well as with peers.
Our research has now been able to detect small trends over a two-year period. It will be important to follow up on this research in upcoming years and evaluate whether this trend in second-generation Internet health users continues. Physicians need to be aware of their patients’ use of such new technologies, since this might lead to much better informed patients and requests from patients for more interactive, Internet-based communication pathways.