This study revealed four principal findings. First, the prevalence of Internet use via personal computer for acquiring health-related information was about one-quarter among those surveyed (23.8%), whereas the prevalence of Internet use via cell phone for this purpose was low (6%). The prevalence of Internet use via personal computer was higher than radio (19.1%), but lower than television (60.1%), newspapers (50.3%), and magazines (34.2%). Second, younger people, people with higher education levels, and people with higher household incomes were more likely to acquire health-related information by accessing the Internet via personal computer. Third, the prevalence of Internet use for health-related communication with health professionals, family, friends, or peers was small. Although cell phones were rarely used for this type of communication in general, 12.3% of respondents used cell phones for contacting family or friends specifically for health-related purposes. Finally, the majority of those using the Internet for health care purposes thought the Internet improved their health-related knowledge and affected their lifestyle attitudes, and felt confident after obtaining health-related information through the Internet. In contrast, less than one-quarter of respondents thought Internet use improved their ability to manage their health or changed their health-related activities. We further discuss these four findings below.
First, we found that the prevalence of Internet use via personal computer for health-related information was lower in Japan (24% in 2007) than in the United States (40% in 2001) [2
] and Europe (42% in 2005 and 52% in 2007) [5
]. On the other hand, the prevalence of using traditional sources of information in Japan, such as television and newspapers, was similar to that in the United States and Europe [3
]. Although the Internet is increasingly being used as a source of health information [10
], consumers still value and use traditional information sources in the United States and Europe [14
]. Therefore, the Japanese general population may also still value traditional sources and not widely use the Internet to obtain health-related information.
Second, our results regarding characteristics of Internet users were consistent with many preceding studies pointing out that older people, people with lower education levels, and people with lower household incomes reported less frequent access to the Internet [23
]. Since these people may be unfamiliar with the Internet, these characteristics could result in a digital divide, a barrier to accessing health-related information through the Internet [29
]. A generation gap in digital knowledge and skills is generally acknowledged [34
]. Approximately 70% of people aged 50–64 use the Internet in the United States [26
], whereas we found that hardly anyone over 50 years of age in Japan accessed the Internet. According to a white paper, the number of Internet users among the older people (over 65 years of age) has increased in recent years (28.1% in 2008, 36.9% in 2009) [35
]. It is also suggested that active seniors who actively use the Internet could encourage other seniors to use the Internet. Some studies have proposed that less healthy people moderately use the Internet for health-related information [2
], although some studies show that people with chronic disease are less likely than healthy people to have access to the Internet [37
]. Although less healthy people are more likely to ask health professionals about information they find online [38
], people who use the Internet for health purposes are more health oriented than people who do not search the Internet [39
]. Therefore, people who use the Internet for health purposes might include both less healthy people, who use the Internet for recovery, and more healthy or health-oriented people, who use it for prevention. The relationship between health status and Internet searching behavior remains controversial.
Third, our results suggest that online communication generally remains uncommon in Japan. For communication with family, friends, or peers, cell phones were more used than personal computers. Cell phones were not used as a tool to acquire information, but as a tool for communication by people of all income levels. This could be because even average people in Japan can have advanced cell phones, which are frequently used for email communication with family or friends. For communication with health professionals, the Internet was less used in Japan than in the Unites States [2
One reason why online communication generally remains uncommon in Japan might be the lack of systems related to eHealth in Japan. In the reimbursement payment system in Japan, the cost of health professional communications with patients is not reimbursed. In the Japanese context of universal health insurance coverage, treatments covered by insurance are not performed together with treatments not covered by insurance. Most health professionals and medical organizations do not promote this communication. Moreover, the legal system pertaining to personal medical information protection in Japan is not fully developed with regard to eHealth. The Japan Internet Medical Association (JIMA) was founded in 1998 to establish a framework for Internet medical usage [40
]. JIMA created the Japanese version of the eHealth code of ethics [41
], and has also developed the JIMA trust program. However, only 14 medical organizations obtained the JIMA trust mark, possibly because these ethics codes are self-imposed. Although the Ministry of Health, Labour and Welfare (MHLW) instituted the Guidelines on Security Management for Health Information Systems (first in 2005, fourth in 2010), there is no Act similar to the Health Insurance Portability and Accountability Act or Health Information Technology for Economic and Clinical Health Act in the United States [42
]. Health professionals and medical organizations autonomously address privacy and security concerns associated with the electronic transmission of health information. Therefore, a nationwide privacy and security framework for eHealth is required in Japan.
The other reason why online communication generally remains uncommon in Japan could be the absence of a well-developed collaborative relationship among industry, government, and academia in Japan. In the United States, the vast majority of active eHealth services, such as WebMD, have been created by ventures put forth by cooperation and innovation among practitioners, researchers, and private industry [43
]. Therefore, more collaborative efforts will be required in Japan. Some websites are being developed in Japan. Medical Information Network Distribution Service, which is operated by the Japan Council for Quality Health Care and funded by MHLW, has provided clinical practice guidelines in Japan on the Internet since 2004 [44
]. Since the Medical Function Information Providing System was instituted by MHLW in 2007, prefectural governments have obligatorily provided information about the structure and outcomes of medical organizations on the Internet [47
]. Websites created by nonprofit organizations and private industries, as well as pharmaceutical companies, have received awards for being the most informative health care websites in 2010 [49
Fourth, our study showed that people tended to use the Internet for obtaining health-related information and felt confident in the information they obtained, which is compatible with many studies [36
]. Obtaining information from the Internet, although it did not apparently change their activities, may encourage users to be confident that their ideas are supported. Nevertheless, our study also showed that few Internet users (6.6% via personal computer and 3.0% via cell phone) used the information for communication with health professionals. The frequency of patient communication with health professionals via the Internet was much lower than the frequency of patient visits to a physician’s office (30.7% in a month) [53
]. According to Hesse et al, people tend to go to the Internet first [11
] and rarely share the information from the Internet with physicians [3
]. They still trust face-to-face contact with physicians as their preferred source of health-related information [11
]. The behavioral discrepancy between searching for information on the Internet and not using this information with health professionals might be due to user trust in health professionals, or to user conflict derived from untrusting health professionals whose attitude and behavior are incompatible with the information from the Internet. This is an important topic regarding communication between health providers and health consumers that should be addressed in the future.
Public Health Implications
Our findings have public health implications. Our results showed that Internet use of health-related information remains less common in Japan than in other developed countries [28
]. Japanese aged 50–64 years, a large segment of the baby boomer generation that is going to require increased access to hospitals, did not access information on the Internet because of the digital divide. As active seniors might lead other seniors to follow their example, it could be important to determine the needs of active seniors regarding Internet use. Our results also suggest a behavioral discrepancy. Inadequate use of information obtained from the Internet might have harmful consequences, such as Internet addiction [55
] or cyberchondria, which is excessive health anxiety generated from online health searches [57
]. To address these issues, we believe it is important to improve users’ so-called eHealth literacy, defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” [48
]. It is appropriate to use the Internet as a supplement to health services rather than as a replacement [13
], and to share the information with health professionals. There are differences between physicians and patients in health literacy [64
], but it is also important that health professionals be mindful of patients’ desire for health information [65
] and the Internet presence [52
]. They should discuss the information offered by patients and guide them to reliable and accurate health websites [52
]. For searching websites, standards for eHealth, such as the e-Health Code of Ethics 2.0 [41
], could be beneficial for both patients and health professionals. Health professionals, public health professionals, and eHealth developers should work together to educate patients about acquiring health information online and critically appraising it [67
], and to provide tools for them to navigate to the highest-quality information [38
In 2007, Japanese moderately used the Internet via personal computers for health purposes, and rarely used the Internet via cell phones. Older people, people with lower education levels, and people with lower household incomes were less likely to access the Internet via cell phone. The Internet moderately improved user health-related knowledge and attitudes, and encouraged user confidence in health-related information. However, it seldom changed their health-related abilities and activities, and was not often used for communicating with physicians. The paucity of Internet use for communication with physicians might be due to the payment system in Japan. Moreover, Internet users did not generally share the information they obtained from the Internet with health professionals. The health-related information from the Internet was inadequately used. Although cell phones were used as a communication tool for health purposes, the reimbursement payment system in Japan might be an obstacle to communication between health providers and health consumers. To encourage this communication, it is important to improve eHealth literacy, especially in middle-aged people. It is also important to make adequate amendments to the reimbursement payment system and nationwide eHealth privacy and security framework, and to develop a collaborative relationship among industry, government, and academia.