E-health services include: (i) seeking information from online resources, (ii) interacting with an application that aims to support patient decision making or change health-related behaviour, (iii) viewing or contributing to their medical records, (iv) seeking emotional or information support from their peers, or (v) communicating with professionals online. Although not consistent across this range, there is increasing evidence that people with long term conditions using e-health services can better manage their care, thus achieving better health outcomes, than those that do not use e-health [1
However, there are continuing concerns over e-health inequalities [2
] and steps taken to try to counter them [4
]. Although e-health inequalities may also result from lack of physical access or for economic reasons, e-health literacy [3
] is one component for which improved support for patients may have positive effects. The types of support that prove effective will vary across the spectrum of e-health literacy. For example, young frequent Internet and social network users may benefit from a better understanding of privacy, confidentiality and security issues for e-health. Older people who have yet to start using the Internet may require convincing of the benefit and face-to-face instruction on getting started. This study focused on those people who already had Internet access but may have lacked confidence to use the full range of possibilities for e-health.
The problems of recruiting patients to studies, particularly in general practice are well known. Campbell et al. reviewed 114 randomised trials noting the problems of recruitment and recommending further research into different recruitment patterns including 'failures' [11
]. Murray et al. have reviewed the special problems encountered in online recruitment [12
], noting that online recruitment even more than traditional methods can potentially result in an unrepresentative sample.
Recruiting participants for studies of Internet based interventions is increasingly common (for example [13
]). Usual practice is to have a registration website and to use various means including online advertisements [14
], emails to relevant groups [17
], as well as 'offline' methods such as press, letters, posters, TV, and radio [15
] to raise awareness and encourage potential participants to visit. Online methods seem more cost-effective in recruiting for online interventions. However, it was difficult to know the best way of raising awareness for our target group given its special characteristics. As the aim is to encourage use of the Internet by more naïve users or people who would not have thought of using it for health, raising awareness 'offline' for online recruitment may be more appropriate.
In a previous study, we piloted email support for people with long term conditions who were less experienced users of the Internet, by raising awareness of the study in outpatient clinics in an acute hospital [17
]. We recruited 39 patients. Most were made aware of the study by a researcher distributing leaflets in outpatient waiting areas. Patients were willing to correspond by email with an e-health facilitator. However, some participants suggested that recruiting patients earlier in 'their journey', in primary care would be more beneficial. Also, recruiting in an acute hospital meant that we were unable to make use of the full range of effective Internet interventions, such as those addressing mild to moderate mental health issues or lifestyle changes, which are more appropriate for general practice. This study explored the feasibility and cost of recruiting patients in general practice for email support for e-health.
Staff in general practice have the opportunity to use practice systems to identify patients who may benefit from Internet use. For example, by searching for people with the diagnosis of depression [19
], or all those who smoke, or with a particular long term condition, patients can be recommended to use an e-health service [21
]. Such methods have been used before with variable success for depression [19
]. However, it was not known if general practitioners (GPs) were willing to engage in the promotion of e-health support in this way, nor what methods were acceptable to them and their patients in raising awareness of e-health.
In order to compare recruitment via general practice with secondary care, or direct to population methods such as mass media campaigns or online advertising [15
], it is essential to determine how much it might cost to recruit patients to a study that offers them supported access to online health information. A literature search failed to identify any previous studies reporting costs of recruiting patients for this type of intervention. Therefore, the aim of this pilot study was to explore the feasibility and cost of recruiting patients to email support for e-health in general practice. Research questions were: (i) which methods of contacting and recruiting practices seem effective, (ii) how much does it cost to recruit practices, (iii) what methods of patient recruitment are practices willing to use, (iv) how many patients are recruited via different methods, (v) what is the cost per patient recruited?