] is a frequently used and sometimes abused word entailing an ideal increasing in popularity and application in many domains and particularly in health [5
]. Yet the knowledge available on the dynamics of empowerment of societies [7
] or specific groups [8
] in the health domain is scarce and the link between online access to health information and empowerment needs further empirical investigation [9
Empowerment has been defined as the enhancement of "the possibility for people to control their own lives" [4
]. Empowerment and particularly patient empowerment engages individuals, groups, organizations, communities and governments while it requires the ability to gain control over many aspects of individuals' lives. For citizens it implies individual responsibility in health care, whereas for communities it implies the broader health professional, group, organizational, institutional and societal role in enabling citizens to assume responsibility for their own health, as individuals and as communities.
Empowerment might be seen as both a process and as the outcome of a process [10
]. Empowering processes for individuals might include "participation in community organizations", while empowered outcomes for individuals might include "situation-specific perceived control and resource mobilization skills" [[11
]:570-571]. Recent conceptual model of empowerment for application to a general patient population [12
] represents empowerment as a continuous process based on antecedents, or the elements that allow patients to start the empowerment process (knowledge, health literacy, patient initiative, access to services); processes (information sharing, patient-doctor communication, choice, shared decision making, patient self-care); and outcomes for the patient (health related outcomes, satisfaction, self-efficacy, adherence, control over her/his health, care-seeking behaviour, understanding when medical attention is necessary) [13
]. However, there is no generally accepted definition of empowerment nor agreement on how to conduct its measurement [14
], especially when the Internet and the Web are involved [15
]. Often, assessment instruments are disease specific [16
] and many measure only one or some empowerment related outcomes [18
]. Globally, few instruments measure a patient's degree of individual empowerment in relation to personal health care and services [20
Empowerment can promote the goals of patients but also the goals of other stakeholders [21
]. The emergence of the "empowered patient" concept coincides in time with a steep increase in health care costs in most Western countries and governments' attempt to reduce health care expenditures with the correspondent transfer of responsibility for health care to individuals [22
]. These trends emerged in a context of increasing access to the Internet and its use for health and illness matters. Such pressures, resources and opportunities may be fuelling other significant social trends, as the expansion of self and mutual aid programs focused on the patient, the growth of a certain consumerism associated to the topic of health, the increase of patients' organization and activism and the turn towards complementary and alternative medicine [22
]. All these may have significant impact on the way citizens assume responsibility for their own health and, consequently, on their relationship with health professionals and the health system.
The essence of empowerment is personal control, inextricably linked to available information, acquired knowledge and capacity to learn. Traditionally, the doctor-patient relationship evolves in a context of considerable power imbalance, where the doctor possesses medical knowledge, and patient knowledge is often considered irrelevant [23
]. This competence gap contributes to maintaining patient dependency [25
One of the underlying assumptions of patient empowerment is precisely that providing health information to patients empowers them [22
]. However, such a straightforward approach detracts from a complex reality involving not only the patient, the physician, the particular conditions that brought them together and the relationship they develop at each appointment and over time but also legal, cultural, and educational aspects that are specific to different societies and evolve over time [26
Most citizens will experience the need for healthcare at some time and many interact with the health system on behalf of somebody else [27
]. They participate in society making decisions about health or passively accepting the decisions of others. Objective health information comes from several sources including doctors, patient organizations, National Health Agencies, pharmaceutics [28
], and lately the Internet.
Even accepting that "the principal route to an informed patient is the patient-doctor meeting (the clinical consultation)" [28
] and knowing that the physician is still considered by citizens as the most important [29
] source of generic health information and the most accurate [30
] source of information on mental health issues, the increasing relevance of the Internet is undeniable, and so is its potential to change the patient-doctor relationship [31
]. Medical professionals and researchers no longer control the production and dissemination of health information and citizens now have access to electronic versions of medical journals and other online sources of health related information [23
]. Citizens have become co-producers of health information that is spread through email and virtual communities, a phenomenon often cited as "empowering" [22
] and reading in itself seems sufficient to profit from participation in online patient support groups [33
]. Communicating online seeking advice from doctors they have never met [34
], getting suggestions or recommendations from other patients, and ordering medicine are other opportunities to become informed. Many state that the medical information and guidance they can find online is more complete and useful than the information that is typically provided by their physicians [35
]. General practitioners report that the length of consultation is increased due to patient questions relevant to information found on the Internet and that patients holding Internet healthcare information have higher expectations [36
Evidence on actual use of the Internet for health purposes is mixed. In Europe, it varies from one country to another, but the perceived importance of the technology is rising and recent work suggests that interactive use is increasing [21
]. In the US in 2009, 61% of American adults had looked online for health information and around one third had accessed social media related to health [38
]. In 2005, 10% of Internet users reported communicating online with an healthcare provider [39
] and in 2004, 4% have bought prescription drugs on the Internet [40
]. In a national survey conducted in 2003, 55% of Internet health information seekers reported having consulted a health professional because of the information they received online [41
]. A study comparing data from 2000 and 2002 shows that the gap for the access to online health information between old and young people tends to increase, even as literature continue to promote the Internet as a key source of empowerment for the elderly [42
]. Therefore, investigating if and how the Internet is giving citizens more control over their experiences of health or illness and whether it is changing their relationships with health professionals and health systems becomes crucial.
Better informed and knowledgeable patients as a result of accessing information from health sites and health communities may be better prepared and likely to ask doctors relevant and critical questions [43
]. Information on drugs and treatments may lead to pressure on health professionals to provide access to other options [5
]. Governments and medical professionals fear that patients may use the Internet to avoid doctors altogether, which perceivably could lead to worsened health [23
] while others [[46
]:174] consider the use of some models of online pharmacies "a perfect illustration of the inherent shortcomings of consumer empowerment initiatives that rely on markets without implementing appropriate regulation mechanisms".
In this paper, we explore data originating from the second WHO/European eHealth Consumer Trends Survey (eHealth Trends survey). Previous work [37
] based on the first eHealth Trends survey conducted in 2005 has shown that, in the general population, 29% have turned to the Internet to find health information to decide whether to consult a health professional, 23% to find health information prior to an appointment and 27% to find health information after an appointment; 20% have made suggestions or queries on diagnosis or treatment to a health professional, 2% have changed the use of medicine without consulting a health professional and 6% have made/cancelled/changed a consultation as a result of health information from the Internet.
In the present work, we go deeper in the analysis, investigating the correlation between four Internet activities that might foster the process of empowerment by increasing health knowledge, health literacy, patient initiative and access to services - important antecedents of the process [13
], and two outcomes of this process directly connected to attitudes toward the practice of health professionals and health system.
First, empowerment that enables the individual to be active in looking for information that gives him/her more autonomy and reinforces his/her position when relating with health professionals, namely deciding whether to get an appointment, preparing for the consultation and validating its outcome [[10
]:583]. Second, empowerment that translates into behaviour that directly challenges the authority and autonomy of health professionals, namely making suggestions or queries on diagnosis or treatment, changing the use of medicine without consulting a health professional and (re)scheduling an appointment with a health professional.
The four online activities we explore are: interacting with health professionals never met face to face, participating in forums or self-help groups focusing on health or illness, ordering medicine or other products related to health or illness management and reading about health and illness. Efforts to gain control, access to resources, and a critical understanding of one's socio-political context are fundamental aspects of empowering processes [10
]. Therefore, in the context of this work we expect those performing such Internet activities to be more active in looking for information to help them deal with a consultation and to exhibit behaviour more challenging to the traditional view of authority and autonomy of health professionals [23