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1.  Internet Use among Ugandan Adolescents: Implications for HIV Intervention 
PLoS Medicine  2006;3(11):e433.
Background
The Internet is fast gaining recognition as a powerful, low-cost method to deliver health intervention and prevention programs to large numbers of young people across diverse geographic regions. The feasibility and accessibility of Internet-based health interventions in resource-limited settings, where cost-effective interventions are most needed, is unknown. To determine the utility of developing technology-based interventions in resource-limited settings, availability and patterns of usage of the Internet first need to be assessed.
Methods and Findings
The Uganda Media and You Survey was a cross-sectional survey of Internet use among adolescents (ages 12–18 years) in Mbarara, Uganda, a municipality mainly serving a rural population in sub-Saharan Africa. Participants were randomly selected among eligible students attending one of five participating secondary day and boarding schools in Mbarara, Uganda. Of a total of 538 students selected, 93% (500) participated.
Of the total respondents, 45% (223) reported ever having used the Internet, 78% (175) of whom reported going online in the previous week. As maternal education increased, so too did the odds of adolescent Internet use. Almost two in five respondents (38% [189]) reported already having used a computer or the Internet to search for health information. Over one-third (35% [173]) had used the computer or Internet to find information about HIV/AIDS, and 20% (102) had looked for sexual health information. Among Internet users, searching for HIV/AIDS information on a computer or online was significantly related to using the Internet weekly, emailing, visiting chat rooms, and playing online games. In contrast, going online at school was inversely related to looking for HIV/AIDS information via technology. If Internet access were free, 66% (330) reported that they would search for information about HIV/AIDS prevention online.
Conclusions
Both the desire to use, and the actual use of, the Internet to seek sexual health and HIV/AIDS information is high among secondary school students in Mbarara. The Internet may be a promising strategy to deliver low-cost HIV/AIDS risk reduction interventions in resource-limited settings with expanding Internet access.
A survey among 500 adolescent pupils in rural Uganda suggests widespread interest in online information about sexual health and HIV/AIDS. Over one-third of Internet users had already searched for relevant information online, and many of the others said they would like to educate themselves about HIV/AIDS online.
Editors' Summary
Background.
HIV/AIDS is a major health burden in sub-Saharan Africa, including Uganda. Despite a recent reduction of the number of HIV-infected individuals, HIV transmission remains a problem among Ugandan adolescents. Recent surveys suggest that about half of sexually active adolescents do not consistently use condoms, and that young people are less knowledgeable about HIV than they were 15 years ago.
Why Was This Study Done?
The Internet has a number of characteristics that make it an attractive tool in health education and HIV prevention, especially for adolescents—including interactivity, privacy, the overlap between education and play, and the ability to individualize information based on an initial assessment of background conditions, interest, and knowledge. It is also thought that despite these advantages, the Internet's potential in resource-poor settings with higher HIV infection rates and limited access to other health care resources has not been explored much. This study was done to gain some initial insights on the desired and actual use of the Internet to seek sexual health and HIV/AIDS information among adolescents in Uganda.
What Did the Researchers Do and Find?
They did a survey of 500 adolescent pupils randomly selected from five participating boarding schools in Mbarara, a small town in a rural part of Uganda. They asked three questions: To what extent are the adolescents exposed to computers and the Internet? Are they interested in accessing health information online? Who uses the Internet and how? Almost half of the participants said they had used the Internet at least once, and the majority said they had been online during the previous week. Most Internet users (82%) reported going online at school; 57% said they use Internet cafes, 17% access the Internet at home; and 11% at someone else's house. More than a third of all participants reported having used the Internet or computer to look up health information, and many had been looking for information on sexual health and HIV/AIDS. About two-thirds of the participants said that if Internet use were free, they would search for information on sexual health and HIV/AIDS prevention. The researchers analyzed the responses further to identify the most influential factors in whether one of the Internet users would go online to educate themselves about HIV/AIDS. They found that those participants who used the Internet more often and those who engaged in online activities like chat rooms, games, and e-mail, were more likely to search for HIV/AIDS information. On the other hand, those who went online only at school were less likely to do so.
What Do These Findings Mean?
Approximately the same proportion—roughly one-third—of adolescents in a rural setting in Uganda reported having used the Internet to look up health-related information as of young people in the United States. Together with the result that an additional third said that they would go online to educate themselves about HIV/AIDS if Internet use was free, this study suggests that initiatives in Africa to improve online access for adolescents as well as to develop content tailored for young people in specific settings would make a difference.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030433
Links page for adolescents and youth from HIV InSite at UCSF
Africa Initiative
HIV/AIDS education module from the US Public Broadcasting System
Lesson plan for “Using the Internet to Access Sexual Health Information” from the Information Institute of Syracuse
doi:10.1371/journal.pmed.0030433
PMCID: PMC1630714  PMID: 17090211
2.  A framework for evaluating e-health: Systematic review of studies assessing the quality of health information and services for patients on the Internet 
Context
A recent concern and topic of many publications in the last three years has been the quality of health information and services for the public on the Internet.
Objectives
To identify and summarize studies published in the peer-reviewed literature evaluating the quality of information and services for consumers on the Internet, including information published on web sites, information on newsgroups and mailing lists and other venues such as email contacts with doctors, as well as studies evaluating the quality of ehealth services such as cyberdoctors and cyberpharmacies.
Data Sources
MEDLINE and PREMEDLINE (1966 - May 2000), Science Citation Index (1992-May 2000), Social Sciences Citation Index (1992- May 2000), Arts and Humanities Citation Index (1992-May 2000) and a personal bibliographic database.
Study Selection
We included empirical studies where investigators searched the Internet systematically for specific health information or clearly define a set of specific services to be included, evaluated the quality of information or services found, and reported quantitative data.
Data Extraction
Study characteristics, medical domain, search strategies used, quality criteria and methodology of quality assessment, results (number of sites rated as sufficient pertaining to a quality), quality and rigor of study methodology and reporting.
Data Synthesis
A total of 41 studies met the inclusion criteria, dealing either with content of websites, information on e-commerce sites, quality of online-care or community venues. A) Content: 29 evaluated information on websites, of those 5 evaluated information on websites from the field of pediatrics, 3 from oncology, 3 pharmacology information, 2 nutrition information, 4 general clinical information and 12 specific information from other clinical disciplines. Studies varied widely in methodology, quality and results. Among the 29 studies dealing with quality of health information on websites, one study evaluated the authority of source, 19 studies checked sites for presence or absences of technical criteria (such as disclosure of sponsorship, authorship, presence of references or last update), three evaluated readability, 20 evaluated the accuracy of information, and 12 content completeness. B) E-Commerce: Three studies dealt with drug information on e-commerce sites. To evaluate the quality authors extracted prices, checked for completeness of online-history taking and/or information provided on the site e.g. pertaining to contraindications or the presence/absence of disclaimers and/or liability waivers. Only one of these three studies actually used the service by ordering drugs, allowing to evaluate quality of online-advice, qualification of cyberdocs, delivery time, reasons for non-delivery. C) Care: Five studies dealt with the quality of online consultations, of them one dealt with advice given by ordinary physicians in response to a unsolicited fictionous patient request, two evaluated the responses of cyberdocs soliciting patient requests, and two evaluated advice given in response to a request for an online prescription directed to drug e-commerce sites. D) Community: Seven studies evaluated messages on mailing lists or usenet newsgroups. Two studies collected messages from a venue and evaluated them for accuracy, two studies posted a "test" message on a newsgroup and evaluated the accuracy of responses. In three studies authors used the cumulative impact factor of the published research of the mailing list contributors as an indicator for the qualification of the authors and thus as quality indicator of the mailing list.
Of the 23 studies evaluating accuracy and/or completeness of information provided on websites, 10 used guidelines as gold standard (all of the to extract a-priori criteria), five used peer-reviewed literature (all to compare information a posteriori), two used textbooks, one used consensus among the raters and three used the personal experience or opinion of the author. All three studies which compared information against personal opinion came to a positive conclusion regarding the accuracy of information, while all of the more rigorous studies comparing information against guidelines concluded that much of the information found on the web were of low quality. In two cases it was not reported where the gold standard comes from. 9 studies used more than one rater to assess a website, 6 of them provided some sort of information on inter-observer variability.
Conclusions
Methodology, results and conclusions of investigators vary widely. There is a wide variability even regarding the evaluation of formal criteria such as authorship and references. Differences in study conclusions regarding the quality of Internet information are likely a result of difference in study rigor, evaluation criteria and topic chosen. All but five studies concluded that quality is a problem on the Internet. The rigor of these five studies coming to a more positive conclusion as expressed in a "assessment quality score" was significantly inferior to the remaining studies.
Although there were two comparative studies of the quality of information on the Internet compared with information found outside of the Internet, there is little evidence that health information found on the Internet is worse than health information in traditional media.
A conceptual and methodological framework is presented for describing, comparing, and analyzing the structure and quality of e-health, based on Donabedians quality measures of structure, process and outcome.
doi:10.2196/jmir.2.suppl2.e13
PMCID: PMC1761875
3.  A framework for evaluating e-health: Systematic review of studies assessing the quality of health information and services for patients on the Internet 
Context
A recent concern and topic of many publications in the last three years has been the quality of health information and services for the public on the Internet.
Objectives
To identify and summarize studies published in the peer-reviewed literature evaluating the quality of information and services for consumers on the Internet, including information published on web sites, information on newsgroups and mailing lists and other venues such as email contacts with doctors, as well as studies evaluating the quality of ehealth services such as cyberdoctors and cyberpharmacies.
Data Sources
MEDLINE and PREMEDLINE (1966 - May 2000), Science Citation Index (1992-May 2000), Social Sciences Citation Index (1992- May 2000), Arts and Humanities Citation Index (1992-May 2000) and a personal bibliographic database.
Study Selection
We included empirical studies where investigators searched the Internet systematically for specific health information or clearly define a set of specific services to be included, evaluated the quality of information or services found, and reported quantitative data.
Data Extraction
Study characteristics, medical domain, search strategies used, quality criteria and methodology of quality assessment, results (number of sites rated as sufficient pertaining to a quality), quality and rigor of study methodology and reporting.
Data Synthesis
A total of 41 studies met the inclusion criteria, dealing either with content of websites, information on e-commerce sites, quality of online-care or community venues. A) Content: 29 evaluated information on websites, of those 5 evaluated information on websites from the field of pediatrics, 3 from oncology, 3 pharmacology information, 2 nutrition information, 4 general clinical information and 12 specific information from other clinical disciplines. Studies varied widely in methodology, quality and results. Among the 29 studies dealing with quality of health information on websites, one study evaluated the authority of source, 19 studies checked sites for presence or absences of technical criteria (such as disclosure of sponsorship, authorship, presence of references or last update), three evaluated readability, 20 evaluated the accuracy of information, and 12 content completeness. B) E-Commerce: Three studies dealt with drug information on e-commerce sites. To evaluate the quality authors extracted prices, checked for completeness of online-history taking and/or information provided on the site e.g. pertaining to contraindications or the presence/absence of disclaimers and/or liability waivers. Only one of these three studies actually used the service by ordering drugs, allowing to evaluate quality of online-advice, qualification of cyberdocs, delivery time, reasons for non-delivery. C) Care: Five studies dealt with the quality of online consultations, of them one dealt with advice given by ordinary physicians in response to a unsolicited fictionous patient request, two evaluated the responses of cyberdocs soliciting patient requests, and two evaluated advice given in response to a request for an online prescription directed to drug e-commerce sites. D) Community: Seven studies evaluated messages on mailing lists or usenet newsgroups. Two studies collected messages from a venue and evaluated them for accuracy, two studies posted a "test" message on a newsgroup and evaluated the accuracy of responses. In three studies authors used the cumulative impact factor of the published research of the mailing list contributors as an indicator for the qualification of the authors and thus as quality indicator of the mailing list.
Of the 23 studies evaluating accuracy and/or completeness of information provided on websites, 10 used guidelines as gold standard (all of the to extract a-priori criteria), five used peer-reviewed literature (all to compare information a posteriori), two used textbooks, one used consensus among the raters and three used the personal experience or opinion of the author. All three studies which compared information against personal opinion came to a positive conclusion regarding the accuracy of information, while all of the more rigorous studies comparing information against guidelines concluded that much of the information found on the web were of low quality. In two cases it was not reported where the gold standard comes from. 9 studies used more than one rater to assess a website, 6 of them provided some sort of information on inter-observer variability.
Conclusions
Methodology, results and conclusions of investigators vary widely. There is a wide variability even regarding the evaluation of formal criteria such as authorship and references. Differences in study conclusions regarding the quality of Internet information are likely a result of difference in study rigor, evaluation criteria and topic chosen. All but five studies concluded that quality is a problem on the Internet. The rigor of these five studies coming to a more positive conclusion as expressed in a "assessment quality score" was significantly inferior to the remaining studies.
Although there were two comparative studies of the quality of information on the Internet compared with information found outside of the Internet, there is little evidence that health information found on the Internet is worse than health information in traditional media.
A conceptual and methodological framework is presented for describing, comparing, and analyzing the structure and quality of e-health, based on Donabedians quality measures of structure, process and outcome.
doi:10.2196/jmir.2.suppl2.e9
PMCID: PMC1761871
4.  Internet-Based Device-Assisted Remote Monitoring of Cardiovascular Implantable Electronic Devices 
Executive Summary
Objective
The objective of this Medical Advisory Secretariat (MAS) report was to conduct a systematic review of the available published evidence on the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted remote monitoring systems (RMSs) for therapeutic cardiac implantable electronic devices (CIEDs) such as pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. The MAS evidence-based review was performed to support public financing decisions.
Clinical Need: Condition and Target Population
Sudden cardiac death (SCD) is a major cause of fatalities in developed countries. In the United States almost half a million people die of SCD annually, resulting in more deaths than stroke, lung cancer, breast cancer, and AIDS combined. In Canada each year more than 40,000 people die from a cardiovascular related cause; approximately half of these deaths are attributable to SCD.
Most cases of SCD occur in the general population typically in those without a known history of heart disease. Most SCDs are caused by cardiac arrhythmia, an abnormal heart rhythm caused by malfunctions of the heart’s electrical system. Up to half of patients with significant heart failure (HF) also have advanced conduction abnormalities.
Cardiac arrhythmias are managed by a variety of drugs, ablative procedures, and therapeutic CIEDs. The range of CIEDs includes pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. Bradycardia is the main indication for PMs and individuals at high risk for SCD are often treated by ICDs.
Heart failure (HF) is also a significant health problem and is the most frequent cause of hospitalization in those over 65 years of age. Patients with moderate to severe HF may also have cardiac arrhythmias, although the cause may be related more to heart pump or haemodynamic failure. The presence of HF, however, increases the risk of SCD five-fold, regardless of aetiology. Patients with HF who remain highly symptomatic despite optimal drug therapy are sometimes also treated with CRT devices.
With an increasing prevalence of age-related conditions such as chronic HF and the expanding indications for ICD therapy, the rate of ICD placement has been dramatically increasing. The appropriate indications for ICD placement, as well as the rate of ICD placement, are increasingly an issue. In the United States, after the introduction of expanded coverage of ICDs, a national ICD registry was created in 2005 to track these devices. A recent survey based on this national ICD registry reported that 22.5% (25,145) of patients had received a non-evidence based ICD and that these patients experienced significantly higher in-hospital mortality and post-procedural complications.
In addition to the increased ICD device placement and the upfront device costs, there is the need for lifelong follow-up or surveillance, placing a significant burden on patients and device clinics. In 2007, over 1.6 million CIEDs were implanted in Europe and the United States, which translates to over 5.5 million patient encounters per year if the recommended follow-up practices are considered. A safe and effective RMS could potentially improve the efficiency of long-term follow-up of patients and their CIEDs.
Technology
In addition to being therapeutic devices, CIEDs have extensive diagnostic abilities. All CIEDs can be interrogated and reprogrammed during an in-clinic visit using an inductive programming wand. Remote monitoring would allow patients to transmit information recorded in their devices from the comfort of their own homes. Currently most ICD devices also have the potential to be remotely monitored. Remote monitoring (RM) can be used to check system integrity, to alert on arrhythmic episodes, and to potentially replace in-clinic follow-ups and manage disease remotely. They do not currently have the capability of being reprogrammed remotely, although this feature is being tested in pilot settings.
Every RMS is specifically designed by a manufacturer for their cardiac implant devices. For Internet-based device-assisted RMSs, this customization includes details such as web application, multiplatform sensors, custom algorithms, programming information, and types and methods of alerting patients and/or physicians. The addition of peripherals for monitoring weight and pressure or communicating with patients through the onsite communicators also varies by manufacturer. Internet-based device-assisted RMSs for CIEDs are intended to function as a surveillance system rather than an emergency system.
Health care providers therefore need to learn each application, and as more than one application may be used at one site, multiple applications may need to be reviewed for alarms. All RMSs deliver system integrity alerting; however, some systems seem to be better geared to fast arrhythmic alerting, whereas other systems appear to be more intended for remote follow-up or supplemental remote disease management. The different RMSs may therefore have different impacts on workflow organization because of their varying frequency of interrogation and methods of alerts. The integration of these proprietary RM web-based registry systems with hospital-based electronic health record systems has so far not been commonly implemented.
Currently there are 2 general types of RMSs: those that transmit device diagnostic information automatically and without patient assistance to secure Internet-based registry systems, and those that require patient assistance to transmit information. Both systems employ the use of preprogrammed alerts that are either transmitted automatically or at regular scheduled intervals to patients and/or physicians.
The current web applications, programming, and registry systems differ greatly between the manufacturers of transmitting cardiac devices. In Canada there are currently 4 manufacturers—Medtronic Inc., Biotronik, Boston Scientific Corp., and St Jude Medical Inc.—which have regulatory approval for remote transmitting CIEDs. Remote monitoring systems are proprietary to the manufacturer of the implant device. An RMS for one device will not work with another device, and the RMS may not work with all versions of the manufacturer’s devices.
All Internet-based device-assisted RMSs have common components. The implanted device is equipped with a micro-antenna that communicates with a small external device (at bedside or wearable) commonly known as the transmitter. Transmitters are able to interrogate programmed parameters and diagnostic data stored in the patients’ implant device. The information transfer to the communicator can occur at preset time intervals with the participation of the patient (waving a wand over the device) or it can be sent automatically (wirelessly) without their participation. The encrypted data are then uploaded to an Internet-based database on a secure central server. The data processing facilities at the central database, depending on the clinical urgency, can trigger an alert for the physician(s) that can be sent via email, fax, text message, or phone. The details are also posted on the secure website for viewing by the physician (or their delegate) at their convenience.
Research Questions
The research directions and specific research questions for this evidence review were as follows:
To identify the Internet-based device-assisted RMSs available for follow-up of patients with therapeutic CIEDs such as PMs, ICDs, and CRT devices.
To identify the potential risks, operational issues, or organizational issues related to Internet-based device-assisted RM for CIEDs.
To evaluate the safety, acceptability, and effectiveness of Internet-based device-assisted RMSs for CIEDs such as PMs, ICDs, and CRT devices.
To evaluate the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted RMSs for CIEDs compared to usual outpatient in-office monitoring strategies.
To evaluate the resource implications or budget impact of RMSs for CIEDs in Ontario, Canada.
Research Methods
Literature Search
The review included a systematic review of published scientific literature and consultations with experts and manufacturers of all 4 approved RMSs for CIEDs in Canada. Information on CIED cardiac implant clinics was also obtained from Provincial Programs, a division within the Ministry of Health and Long-Term Care with a mandate for cardiac implant specialty care. Various administrative databases and registries were used to outline the current clinical follow-up burden of CIEDs in Ontario. The provincial population-based ICD database developed and maintained by the Institute for Clinical Evaluative Sciences (ICES) was used to review the current follow-up practices with Ontario patients implanted with ICD devices.
Search Strategy
A literature search was performed on September 21, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from 1950 to September 2010. Search alerts were generated and reviewed for additional relevant literature until December 31, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search.
Inclusion Criteria
published between 1950 and September 2010;
English language full-reports and human studies;
original reports including clinical evaluations of Internet-based device-assisted RMSs for CIEDs in clinical settings;
reports including standardized measurements on outcome events such as technical success, safety, effectiveness, cost, measures of health care utilization, morbidity, mortality, quality of life or patient satisfaction;
randomized controlled trials (RCTs), systematic reviews and meta-analyses, cohort and controlled clinical studies.
Exclusion Criteria
non-systematic reviews, letters, comments and editorials;
reports not involving standardized outcome events;
clinical reports not involving Internet-based device assisted RM systems for CIEDs in clinical settings;
reports involving studies testing or validating algorithms without RM;
studies with small samples (<10 subjects).
Outcomes of Interest
The outcomes of interest included: technical outcomes, emergency department visits, complications, major adverse events, symptoms, hospital admissions, clinic visits (scheduled and/or unscheduled), survival, morbidity (disease progression, stroke, etc.), patient satisfaction, and quality of life.
Summary of Findings
The MAS evidence review was performed to review available evidence on Internet-based device-assisted RMSs for CIEDs published until September 2010. The search identified 6 systematic reviews, 7 randomized controlled trials, and 19 reports for 16 cohort studies—3 of these being registry-based and 4 being multi-centered. The evidence is summarized in the 3 sections that follow.
1. Effectiveness of Remote Monitoring Systems of CIEDs for Cardiac Arrhythmia and Device Functioning
In total, 15 reports on 13 cohort studies involving investigations with 4 different RMSs for CIEDs in cardiology implant clinic groups were identified in the review. The 4 RMSs were: Care Link Network® (Medtronic Inc,, Minneapolis, MN, USA); Home Monitoring® (Biotronic, Berlin, Germany); House Call 11® (St Jude Medical Inc., St Pauls, MN, USA); and a manufacturer-independent RMS. Eight of these reports were with the Home Monitoring® RMS (12,949 patients), 3 were with the Care Link® RMS (167 patients), 1 was with the House Call 11® RMS (124 patients), and 1 was with a manufacturer-independent RMS (44 patients). All of the studies, except for 2 in the United States, (1 with Home Monitoring® and 1 with House Call 11®), were performed in European countries.
The RMSs in the studies were evaluated with different cardiac implant device populations: ICDs only (6 studies), ICD and CRT devices (3 studies), PM and ICD and CRT devices (4 studies), and PMs only (2 studies). The patient populations were predominately male (range, 52%–87%) in all studies, with mean ages ranging from 58 to 76 years. One study population was unique in that RMSs were evaluated for ICDs implanted solely for primary prevention in young patients (mean age, 44 years) with Brugada syndrome, which carries an inherited increased genetic risk for sudden heart attack in young adults.
Most of the cohort studies reported on the feasibility of RMSs in clinical settings with limited follow-up. In the short follow-up periods of the studies, the majority of the events were related to detection of medical events rather than system configuration or device abnormalities. The results of the studies are summarized below:
The interrogation of devices on the web platform, both for continuous and scheduled transmissions, was significantly quicker with remote follow-up, both for nurses and physicians.
In a case-control study focusing on a Brugada population–based registry with patients followed-up remotely, there were significantly fewer outpatient visits and greater detection of inappropriate shocks. One death occurred in the control group not followed remotely and post-mortem analysis indicated early signs of lead failure prior to the event.
Two studies examined the role of RMSs in following ICD leads under regulatory advisory in a European clinical setting and noted:
– Fewer inappropriate shocks were administered in the RM group.
– Urgent in-office interrogations and surgical revisions were performed within 12 days of remote alerts.
– No signs of lead fracture were detected at in-office follow-up; all were detected at remote follow-up.
Only 1 study reported evaluating quality of life in patients followed up remotely at 3 and 6 months; no values were reported.
Patient satisfaction was evaluated in 5 cohort studies, all in short term follow-up: 1 for the Home Monitoring® RMS, 3 for the Care Link® RMS, and 1 for the House Call 11® RMS.
– Patients reported receiving a sense of security from the transmitter, a good relationship with nurses and physicians, positive implications for their health, and satisfaction with RM and organization of services.
– Although patients reported that the system was easy to implement and required less than 10 minutes to transmit information, a variable proportion of patients (range, 9% 39%) reported that they needed the assistance of a caregiver for their transmission.
– The majority of patients would recommend RM to other ICD patients.
– Patients with hearing or other physical or mental conditions hindering the use of the system were excluded from studies, but the frequency of this was not reported.
Physician satisfaction was evaluated in 3 studies, all with the Care Link® RMS:
– Physicians reported an ease of use and high satisfaction with a generally short-term use of the RMS.
– Physicians reported being able to address the problems in unscheduled patient transmissions or physician initiated transmissions remotely, and were able to handle the majority of the troubleshooting calls remotely.
– Both nurses and physicians reported a high level of satisfaction with the web registry system.
2. Effectiveness of Remote Monitoring Systems in Heart Failure Patients for Cardiac Arrhythmia and Heart Failure Episodes
Remote follow-up of HF patients implanted with ICD or CRT devices, generally managed in specialized HF clinics, was evaluated in 3 cohort studies: 1 involved the Home Monitoring® RMS and 2 involved the Care Link® RMS. In these RMSs, in addition to the standard diagnostic features, the cardiac devices continuously assess other variables such as patient activity, mean heart rate, and heart rate variability. Intra-thoracic impedance, a proxy measure for lung fluid overload, was also measured in the Care Link® studies. The overall diagnostic performance of these measures cannot be evaluated, as the information was not reported for patients who did not experience intra-thoracic impedance threshold crossings or did not undergo interventions. The trial results involved descriptive information on transmissions and alerts in patients experiencing high morbidity and hospitalization in the short study periods.
3. Comparative Effectiveness of Remote Monitoring Systems for CIEDs
Seven RCTs were identified evaluating RMSs for CIEDs: 2 were for PMs (1276 patients) and 5 were for ICD/CRT devices (3733 patients). Studies performed in the clinical setting in the United States involved both the Care Link® RMS and the Home Monitoring® RMS, whereas all studies performed in European countries involved only the Home Monitoring® RMS.
3A. Randomized Controlled Trials of Remote Monitoring Systems for Pacemakers
Two trials, both multicenter RCTs, were conducted in different countries with different RMSs and study objectives. The PREFER trial was a large trial (897 patients) performed in the United States examining the ability of Care Link®, an Internet-based remote PM interrogation system, to detect clinically actionable events (CAEs) sooner than the current in-office follow-up supplemented with transtelephonic monitoring transmissions, a limited form of remote device interrogation. The trial results are summarized below:
In the 375-day mean follow-up, 382 patients were identified with at least 1 CAE—111 patients in the control arm and 271 in the remote arm.
The event rate detected per patient for every type of CAE, except for loss of atrial capture, was higher in the remote arm than the control arm.
The median time to first detection of CAEs (4.9 vs. 6.3 months) was significantly shorter in the RMS group compared to the control group (P < 0.0001).
Additionally, only 2% (3/190) of the CAEs in the control arm were detected during a transtelephonic monitoring transmission (the rest were detected at in-office follow-ups), whereas 66% (446/676) of the CAEs were detected during remote interrogation.
The second study, the OEDIPE trial, was a smaller trial (379 patients) performed in France evaluating the ability of the Home Monitoring® RMS to shorten PM post-operative hospitalization while preserving the safety of conventional management of longer hospital stays.
Implementation and operationalization of the RMS was reported to be successful in 91% (346/379) of the patients and represented 8144 transmissions.
In the RM group 6.5% of patients failed to send messages (10 due to improper use of the transmitter, 2 with unmanageable stress). Of the 172 patients transmitting, 108 patients sent a total of 167 warnings during the trial, with a greater proportion of warnings being attributed to medical rather than technical causes.
Forty percent had no warning message transmission and among these, 6 patients experienced a major adverse event and 1 patient experienced a non-major adverse event. Of the 6 patients having a major adverse event, 5 contacted their physician.
The mean medical reaction time was faster in the RM group (6.5 ± 7.6 days vs. 11.4 ± 11.6 days).
The mean duration of hospitalization was significantly shorter (P < 0.001) for the RM group than the control group (3.2 ± 3.2 days vs. 4.8 ± 3.7 days).
Quality of life estimates by the SF-36 questionnaire were similar for the 2 groups at 1-month follow-up.
3B. Randomized Controlled Trials Evaluating Remote Monitoring Systems for ICD or CRT Devices
The 5 studies evaluating the impact of RMSs with ICD/CRT devices were conducted in the United States and in European countries and involved 2 RMSs—Care Link® and Home Monitoring ®. The objectives of the trials varied and 3 of the trials were smaller pilot investigations.
The first of the smaller studies (151 patients) evaluated patient satisfaction, achievement of patient outcomes, and the cost-effectiveness of the Care Link® RMS compared to quarterly in-office device interrogations with 1-year follow-up.
Individual outcomes such as hospitalizations, emergency department visits, and unscheduled clinic visits were not significantly different between the study groups.
Except for a significantly higher detection of atrial fibrillation in the RM group, data on ICD detection and therapy were similar in the study groups.
Health-related quality of life evaluated by the EuroQoL at 6-month or 12-month follow-up was not different between study groups.
Patients were more satisfied with their ICD care in the clinic follow-up group than in the remote follow-up group at 6-month follow-up, but were equally satisfied at 12- month follow-up.
The second small pilot trial (20 patients) examined the impact of RM follow-up with the House Call 11® system on work schedules and cost savings in patients randomized to 2 study arms varying in the degree of remote follow-up.
The total time including device interrogation, transmission time, data analysis, and physician time required was significantly shorter for the RM follow-up group.
The in-clinic waiting time was eliminated for patients in the RM follow-up group.
The physician talk time was significantly reduced in the RM follow-up group (P < 0.05).
The time for the actual device interrogation did not differ in the study groups.
The third small trial (115 patients) examined the impact of RM with the Home Monitoring® system compared to scheduled trimonthly in-clinic visits on the number of unplanned visits, total costs, health-related quality of life (SF-36), and overall mortality.
There was a 63.2% reduction in in-office visits in the RM group.
Hospitalizations or overall mortality (values not stated) were not significantly different between the study groups.
Patient-induced visits were higher in the RM group than the in-clinic follow-up group.
The TRUST Trial
The TRUST trial was a large multicenter RCT conducted at 102 centers in the United States involving the Home Monitoring® RMS for ICD devices for 1450 patients. The primary objectives of the trial were to determine if remote follow-up could be safely substituted for in-office clinic follow-up (3 in-office visits replaced) and still enable earlier physician detection of clinically actionable events.
Adherence to the protocol follow-up schedule was significantly higher in the RM group than the in-office follow-up group (93.5% vs. 88.7%, P < 0.001).
Actionability of trimonthly scheduled checks was low (6.6%) in both study groups. Overall, actionable causes were reprogramming (76.2%), medication changes (24.8%), and lead/system revisions (4%), and these were not different between the 2 study groups.
The overall mean number of in-clinic and hospital visits was significantly lower in the RM group than the in-office follow-up group (2.1 per patient-year vs. 3.8 per patient-year, P < 0.001), representing a 45% visit reduction at 12 months.
The median time from onset of first arrhythmia to physician evaluation was significantly shorter (P < 0.001) in the RM group than in the in-office follow-up group for all arrhythmias (1 day vs. 35.5 days).
The median time to detect clinically asymptomatic arrhythmia events—atrial fibrillation (AF), ventricular fibrillation (VF), ventricular tachycardia (VT), and supra-ventricular tachycardia (SVT)—was also significantly shorter (P < 0.001) in the RM group compared to the in-office follow-up group (1 day vs. 41.5 days) and was significantly quicker for each of the clinical arrhythmia events—AF (5.5 days vs. 40 days), VT (1 day vs. 28 days), VF (1 day vs. 36 days), and SVT (2 days vs. 39 days).
System-related problems occurred infrequently in both groups—in 1.5% of patients (14/908) in the RM group and in 0.7% of patients (3/432) in the in-office follow-up group.
The overall adverse event rate over 12 months was not significantly different between the 2 groups and individual adverse events were also not significantly different between the RM group and the in-office follow-up group: death (3.4% vs. 4.9%), stroke (0.3% vs. 1.2%), and surgical intervention (6.6% vs. 4.9%), respectively.
The 12-month cumulative survival was 96.4% (95% confidence interval [CI], 95.5%–97.6%) in the RM group and 94.2% (95% confidence interval [CI], 91.8%–96.6%) in the in-office follow-up group, and was not significantly different between the 2 groups (P = 0.174).
The CONNECT Trial
The CONNECT trial, another major multicenter RCT, involved the Care Link® RMS for ICD/CRT devices in a15-month follow-up study of 1,997 patients at 133 sites in the United States. The primary objective of the trial was to determine whether automatically transmitted physician alerts decreased the time from the occurrence of clinically relevant events to medical decisions. The trial results are summarized below:
Of the 575 clinical alerts sent in the study, 246 did not trigger an automatic physician alert. Transmission failures were related to technical issues such as the alert not being programmed or not being reset, and/or a variety of patient factors such as not being at home and the monitor not being plugged in or set up.
The overall mean time from the clinically relevant event to the clinical decision was significantly shorter (P < 0.001) by 17.4 days in the remote follow-up group (4.6 days for 172 patients) than the in-office follow-up group (22 days for 145 patients).
– The median time to a clinical decision was shorter in the remote follow-up group than in the in-office follow-up group for an AT/AF burden greater than or equal to 12 hours (3 days vs. 24 days) and a fast VF rate greater than or equal to 120 beats per minute (4 days vs. 23 days).
Although infrequent, similar low numbers of events involving low battery and VF detection/therapy turned off were noted in both groups. More alerts, however, were noted for out-of-range lead impedance in the RM group (18 vs. 6 patients), and the time to detect these critical events was significantly shorter in the RM group (same day vs. 17 days).
Total in-office clinic visits were reduced by 38% from 6.27 visits per patient-year in the in-office follow-up group to 3.29 visits per patient-year in the remote follow-up group.
Health care utilization visits (N = 6,227) that included cardiovascular-related hospitalization, emergency department visits, and unscheduled clinic visits were not significantly higher in the remote follow-up group.
The overall mean length of hospitalization was significantly shorter (P = 0.002) for those in the remote follow-up group (3.3 days vs. 4.0 days) and was shorter both for patients with ICD (3.0 days vs. 3.6 days) and CRT (3.8 days vs. 4.7 days) implants.
The mortality rate between the study arms was not significantly different between the follow-up groups for the ICDs (P = 0.31) or the CRT devices with defribillator (P = 0.46).
Conclusions
There is limited clinical trial information on the effectiveness of RMSs for PMs. However, for RMSs for ICD devices, multiple cohort studies and 2 large multicenter RCTs demonstrated feasibility and significant reductions in in-office clinic follow-ups with RMSs in the first year post implantation. The detection rates of clinically significant events (and asymptomatic events) were higher, and the time to a clinical decision for these events was significantly shorter, in the remote follow-up groups than in the in-office follow-up groups. The earlier detection of clinical events in the remote follow-up groups, however, was not associated with lower morbidity or mortality rates in the 1-year follow-up. The substitution of almost all the first year in-office clinic follow-ups with RM was also not associated with an increased health care utilization such as emergency department visits or hospitalizations.
The follow-up in the trials was generally short-term, up to 1 year, and was a more limited assessment of potential longer term device/lead integrity complications or issues. None of the studies compared the different RMSs, particularly the different RMSs involving patient-scheduled transmissions or automatic transmissions. Patients’ acceptance of and satisfaction with RM were reported to be high, but the impact of RM on patients’ health-related quality of life, particularly the psychological aspects, was not evaluated thoroughly. Patients who are not technologically competent, having hearing or other physical/mental impairments, were identified as potentially disadvantaged with remote surveillance. Cohort studies consistently identified subgroups of patients who preferred in-office follow-up. The evaluation of costs and workflow impact to the health care system were evaluated in European or American clinical settings, and only in a limited way.
Internet-based device-assisted RMSs involve a new approach to monitoring patients, their disease progression, and their CIEDs. Remote monitoring also has the potential to improve the current postmarket surveillance systems of evolving CIEDs and their ongoing hardware and software modifications. At this point, however, there is insufficient information to evaluate the overall impact to the health care system, although the time saving and convenience to patients and physicians associated with a substitution of in-office follow-up by RM is more certain. The broader issues surrounding infrastructure, impacts on existing clinical care systems, and regulatory concerns need to be considered for the implementation of Internet-based RMSs in jurisdictions involving different clinical practices.
PMCID: PMC3377571  PMID: 23074419
5.  Determinants of the frequency of online health information seeking: results of a web-based survey conducted in France in 2007 
Objective
The Internet is a widespread source of health information for health-care professionals and patients. Social inequalities in Internet access have been well studied but not practices. This study was conducted to determine whether differences exist in the frequency of Internet use for health information among online health seekers.
Methods
We conducted an Internet-based survey from November 2006 to March 2007. The 3720 residents of France who had searched for health information during the previous year were considered.
Results
This study reveals different practice of online health information seeking between men, women, the general population and people who work in the health sector. Health status and active Internet use were associated with higher frequencies to varying degrees. Greater health concerns and some issues in the physician-patient relationship were associated with higher frequencies of Internet use in the general population.
Conclusions
The Internet seems to be used as a substitute information tool when issues of communication or confidence with physicians arise as well as to lead people to question physicians and medicine.
Practical implications
Physician and public health actors should remain cautious about these disparities in online health information seeking access and practices, quality issues concerning online information and about possible self-exclusion from the health-care system.
doi:10.3109/17538150903358784
PMCID: PMC3034225  PMID: 20302437
Adolescent; Adult; Age Factors; Attitude to Health; Caregivers; Consumer Health Information; methods; Female; France; Health Status; Humans; Internet; Male; Middle Aged; Questionnaires; Sex Factors; Socioeconomic Factors; Young Adult
6.  Welcome Message from the Scientific Programme Committee 
It gives us great pleasure to welcome you to MEDNET99 - The 4th World Congress on the Internet in Medicine.
MEDNET99 is an international meeting which aims to bring together researchers, developers and users involved in the application of the Internet in Medicine. The Congress - this year under the theme "Towards the Millennium of Cybermedicine - will provide a forum for exploration of the rapidly developing relationship between medical sciences and the Internet, and is relevant to all medical and health care professionals, as well as those involved in the development and application of the new technological opportunities offered to the medical field by the Internet and the World Wide Web.
This year's Congress will take place over three full days, 19th - 21st September 1999, in the small and beautiful town of Heidelberg, one of the most famous tourist destinations in Germany and the town with the oldest German University.
MEDNET99 follows on from three successful MEDNET meetings, all held in the United Kingdom, which were attended by large international and multi-disciplinary groups of delegates. MEDNET98 was attended by more than 250 participants. After these three successful conferences in the United Kingdom, this year's MEDNET will for the first time be hosted outside of the UK. It will therefore hopefully be the first in a long series of World Congresses of Internet in Medicine hosted in different countries around the globe.
MEDNET99 will be preceded by several events on Saturday, 18th September: In a series of tutorials, experts in the field share their knowledge. To take account of local developments in the Internet scene we also organised a satellite symposium on "Internet and Medicine in Germany". A further novum is the "patient afternoon", where we bring together health care professionals with consumers to talk about medical information — in particular cancer information — on the Internet.
MEDNET99 will be focusing on the following themes:
applications of the Internet in medical information exchange and medical education
role of Internet and information exchange in evidence-based healthcare
use of the Internet for consumer health promotion and impact of the Internet on public health
global and regional health information networks
commercial information systems and portal sites for physicians
eJournals and scientific publishing on the Internet, online peer-review, impact of Internet on traditional medical publishing
telemedicine
search engines, search agents and other search tools
electronic mail
using the Internet for medical research and clinical trials
quality of Internet information
Internet usage statistics and demographics
clinical information systems and Intranets
system design issues
legal and ethical issues
As well as providing a forum for delegates to exchange valuable information, MEDNET99 will provide a varied program of social events and interesting workshops.
On behalf of the organisers and the Scientific Programme Committee of MEDNET99, we would like to extend a warm welcome to Heidelberg and we hope that you will all have a stimulating and rewarding Congress.
doi:10.2196/jmir.1.suppl1.e1
PMCID: PMC1761831
7.  Health Information on the Web and Consumers’ Perspectives on Health Professionals’ Responses to Information Exchange 
Medicine 2.0  2014;3(2):e4.
Background
Health information technology, which is sometimes referred to as informaticization of medicine, is changing the extent to which patients become competent producers of their own health by enabling them access to health information anytime and anywhere.
Objective
This research provides preliminary information on users' perceptions of the extent to which use of the Internet for health information impacts medical encounters. We specifically explored the following questions: (1) To what extent perceptions of positive or negative changes in medical encounters are associated with sociodemographic background of online health information seekers, and how often the Internet information is discussed with providers? (2) To what extent is there an association between perceived changes in medical encounters and frequency of referring to the Internet during medical encounters? (3) To what extent is there an association between sociodemographic background of online health information users and frequency of discussing of the Internet information with providers?
Methods
The data for this study was derived from a national sampling of online health and medical information users who participated in the Study of Health and Medical Information in Cyberspace—Survey of User Perceptions (N=710). This study used a nationally representative online research panel of the US adults maintained by the Knowledge Networks. Analysis of variance (ANOVA), chi-square, and t tests were performed to examine the data.
Results
Although Internet sources allow people the opportunity to gather health or medical information, discussion of this information was not a very common activity. It is noteworthy that half of the sample never or rarely discussed health/medical information obtained from Internet sources with health professionals. Chi-square analyses revealed that discussion of online health information with providers were associated with education, income, and marital status. We also found that discussion of the Internet information mostly promotes better physician-patient interactions. Analyses with post-hoc tests identified that perceived changes in medical encounters were associated with age, education, and income. However, 9.1% (64/703) of our respondents strongly agreed that the interactions with their providers have been strained. T test analyses showed that marital status, race, and gender were not significant.
Conclusions
Embracing new technologies, and adapting to changing roles and relationships in delivery of medical care are critical to effective delivery of patient-centered care. Health professionals could also guide patients on how to evaluate information and where to access to reliable and accurate information.
doi:10.2196/med20.3213
PMCID: PMC4087097  PMID: 25075248
health communication; Internet; information; patient-physician relationship
8.  Who Searches the Internet for Health Information? 
Health Services Research  2006;41(3 Pt 1):819-836.
Objective
To determine what types of consumers use the Internet as a source of health information
Data Sources
A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002
Study Design
We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior
Data Collection
Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year
Principal Findings
Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times
Conclusions
Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.
doi:10.1111/j.1475-6773.2006.00510.x
PMCID: PMC1713205  PMID: 16704514
Internet; health information; uninsured; travel time; chronic conditions
9.  Patients' request for and emergency physicians' prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak 
BMC Public Health  2005;5:2.
Background
Inappropriate use of antibiotics by individuals worried about biological agent exposures during bioterrorism events is an important public health concern. However, little is documented about the extent to which individuals with self-identified risk of anthrax exposure approached physicians for antimicrobial prophylaxis during the 2001 bioterrorism attacks in the United States.
Methods
We conducted a telephone survey of randomly selected members of the Pennsylvania Chapter of the American College of Emergency Physicians to assess patients' request for and emergency physicians' prescription of antimicrobial agents during the 2001 anthrax attacks.
Results
Ninety-seven physicians completed the survey. Sixty-four (66%) respondents had received requests from patients for anthrax prophylaxis; 16 (25%) of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin while 8 physicians prescribed doxycycline.
Conclusion
During the 2001 bioterrorist attacks, the majority of the emergency physicians we surveyed encountered patients who requested anthrax prophylaxis. Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events. Elucidation of the relationship between public health response to outbreaks and outcomes would yield insights to ease burden on frontline clinicians and guide strategies to control inappropriate antibiotic allocation during bioterrorist events.
doi:10.1186/1471-2458-5-2
PMCID: PMC546188  PMID: 15634353
10.  eHealth Literacy: Extending the Digital Divide to the Realm of Health Information 
Background
eHealth literacy is defined as the ability of people to use emerging information and communications technologies to improve or enable health and health care.
Objective
The goal of this study was to explore whether literacy disparities are diminished or enhanced in the search for health information on the Internet. The study focused on (1) traditional digital divide variables, such as sociodemographic characteristics, digital access, and digital literacy, (2) information search processes, and (3) the outcomes of Internet use for health information purposes.
Methods
We used a countrywide representative random-digital-dial telephone household survey of the Israeli adult population (18 years and older, N = 4286). We measured eHealth literacy; Internet access; digital literacy; sociodemographic factors; perceived health; presence of chronic diseases; as well as health information sources, content, search strategies, and evaluation criteria used by consumers.
Results
Respondents who were highly eHealth literate tended to be younger and more educated than their less eHealth-literate counterparts. They were also more active consumers of all types of information on the Internet, used more search strategies, and scrutinized information more carefully than did the less eHealth-literate respondents. Finally, respondents who were highly eHealth literate gained more positive outcomes from the information search in terms of cognitive, instrumental (self-management of health care needs, health behaviors, and better use of health insurance), and interpersonal (interacting with their physician) gains.
Conclusions
The present study documented differences between respondents high and low in eHealth literacy in terms of background attributes, information consumption, and outcomes of the information search. The association of eHealth literacy with background attributes indicates that the Internet reinforces existing social differences. The more comprehensive and sophisticated use of the Internet and the subsequent increased gains among the high eHealth literate create new inequalities in the domain of digital health information. There is a need to educate at-risk and needy groups (eg, chronically ill) and to design technology in a mode befitting more consumers.
doi:10.2196/jmir.1619
PMCID: PMC3374546  PMID: 22357448
eHealth literacy; digital literacy; health literacy; digital divide; health information search
11.  Parents Seeking Health-Related Information on the Internet: Cross-Sectional Study 
Background
The Internet represents an increasingly common source of health-related information, and it has facilitated a wide range of interactions between people and the health care delivery system.
Objective
To establish the extent of Internet access and use to gather information about health topics and the potential implications to health care among the adult population in Calabria region, Italy.
Methods
This cross-sectional study was conducted from April to June 2012. The sample consisted of 1544 adults aged ≥18 years selected among parents of public school students in the geographic area of Catanzaro in southern Italy. A 2-stage sample design was planned. A letter summarizing the purpose of the study, an informed consent form, and a questionnaire were given to selected student to deliver to their parents. The final survey was formulated in 5 sections: (1) sociodemographic characteristics, (2) information about chronic diseases and main sources of health care information, (3) information about Internet use, (4) data about the effects of using the Internet to search for health information, and (5) knowledge and use of social networks.
Results
A total of 1039 parents completed the questionnaire, with a response rate equivalent to 67.29%. Regarding health-related information types, 84.7% of respondents used the Internet to search for their own medical conditions or those of family members or relatives, 40.7% of parents reported looking for diet, body weight, or physical activity information, 29.6% searched for vaccines, 28.5% for screening programs, and 16.5% for smoking cessation tools and products. The results of the multiple logistic regression analysis showed that parents who looked for health-related information on the Internet were more likely to be female (OR 1.53, 95% CI 1.05-2.25), with a high school diploma (OR 1.69, 95% CI 1.02-2.81) or college degree (OR 2.14, 95% CI 1.21-3.78), younger aged (OR 0.96, 95% CI 0.94-0.99), with chronic conditions (OR 1.94, 95% CI 1.17-3.19), not satisfied with their general practitioner’s health-related information (OR 0.6, 95% CI 0.38-0.97), but satisfied with information from scientific journals (OR 1.99, 95% CI 1.33-2.98).
Conclusions
Our analyses provide important insights into Internet use and health information–seeking behaviors of the Italian population and contribute to the evidence base for health communication planning. Health and public health professionals should educate the public about acquiring health information online and how to critically appraise it, and provide tools to navigate to the highest-quality information. The challenge to public health practice is to facilitate the health-promoting use of the Web among consumers in conjunction with their health care providers.
doi:10.2196/jmir.2752
PMCID: PMC3785974  PMID: 24047937
adult; consumer health information; cross-sectional studies; health survey; Internet; Italy; questionnaires
12.  Use of the Internet as a Resource for Consumer Health Information: Results of the Second Osteopathic Survey of Health Care in America (OSTEOSURV-II) 
Background
The Internet offers consumers unparalleled opportunities to acquire health information. The emergence of the Internet, rather than more-traditional sources, for obtaining health information is worthy of ongoing surveillance, including identification of the factors associated with using the Internet for this purpose.
Objectives
To measure the prevalence of Internet use as a mechanism for obtaining health information in the United States; to compare such Internet use with newspapers or magazines, radio, and television; and to identify sociodemographic factors associated with using the Internet for acquiring health information.
Methods
Data were acquired from the Second Osteopathic Survey of Health Care in America (OSTEOSURV-II), a national telephone survey using random-digit dialing within the United States during 2000. The target population consisted of adult, noninstitutionalized, household members. As part of the survey, data were collected on: facility with the Internet, sources of health information, and sociodemographic characteristics. Multivariate analysis was used to identify factors associated with acquiring health information on the Internet.
Results
A total of 499 (64% response rate) respondents participated in the survey. With the exception of an overrepresentation of women (66%), respondents were generally similar to national referents. Fifty percent of respondents either strongly agreed or agreed that they felt comfortable using the Internet as a health information resource. The prevalence rates of using the health information sources were: newspapers or magazines, 69%; radio, 30%; television, 56%; and the Internet, 32%. After adjusting for potential confounders, older respondents were more likely than younger respondents to use newspapers or magazines and television to acquire health information, but less likely to use the Internet. Higher education was associated with greater use of newspapers or magazines and the Internet as health information sources. Internet use was lower in rural than urban or suburban areas.
Conclusions
The Internet has already surpassed radio as a source of health information but still lags substantially behind print media and television. Significant barriers to acquiring health information on the Internet remain among persons 60 years of age or older, those with 12 or fewer years of education, and those residing in rural areas. Stronger efforts are needed to ensure access to and facility with the Internet among all segments of the population. This includes user-friendly access for older persons with visual or other functional impairments, providing low-literacy Web sites, and expanding Internet infrastructure to reach all areas of the United States.
doi:10.2196/jmir.3.4.e31
PMCID: PMC1761915  PMID: 11772546
Internet, health care surveys, socioeconomic factors, age factors, family practice
13.  Parents of Urban Adolescents in Harlem, New York, and the Internet: A Cross-sectional Survey on Preferred Resources for Health Information 
Background
Vulnerable populations suffer disproportionately from a variety of health conditions. Access to health information is an important component of health promotion. Reports suggest that while health providers and print media are traditional sources of information, the Internet may be becoming an increasingly important resource for consumers. Particularly, for parents of urban adolescents of color, the Internet could prove to be a valuable asset in helping them understand adolescent health and behavioral issues.
Objective
To determine the types of adolescent health and behavioral issues of concern to parents of color and to assess their preference for sources of health information, including the Internet.
Methods
A confidential, self-administered survey was administered to parents (largely of African American and Hispanic descent) of 9th-grade students over a 2-year period during 2001-2002 in Harlem, NY. The instrument assessed health and behavioral topics of concern, preferred resources for information, ownership and utilization patterns of computers and the Internet, and interest in obtaining additional computer/Internet training.
Results
A total of 419 surveys were completed; 165 in 2001 (67% response rate) and 254 in 2002 (no response rate available). Analysis of responses indicated a substantial degree of interest in obtaining information about a variety of adolescent health issues, including: HIV, sexually transmitted infections, , mental health concerns and relationships with family and peers. While home ownership of computers (84%) and access to the Internet were reasonably high (74%), use of the Internet for health information was low (14%). However, 62% of parents indicated a strong desire to have more instruction on computers and the Internet.
Conclusions
Compared to other sources of health information, the Internet is underutilized by urban parents of color. Additional research is needed to identify strategies to improve utilization and assess subsequent impact on parenting activities.
doi:10.2196/jmir.6.4.e43
PMCID: PMC1550623  PMID: 15631967
Internet; urban; minority; parents; adolescents; health; school
14.  Health information seeking on the Internet: a double divide? Results from a representative survey in the Paris metropolitan area, France, 2005–2006 
BMC Public Health  2008;8:69.
Background
The Internet is a major source of information for professionals and the general public, especially in the field of health. However, despite ever-increasing connection rates, a digital divide persists in the industrialised countries. The objective of this study was to assess the determinants involved in: 1) having or not having Internet access; and 2) using or not using the Internet to obtain health information.
Methods
A cross-sectional survey of a representative random sample was conducted in the Paris metropolitan area, France, in the fall of 2005 (n = 3023).
Results
Close to 70% of the adult population had Internet access, and 49% of Internet users had previously searched for medical information. Economic and social disparities observed in online health information seeking are reinforced by the economic and social disparities in Internet access, hence a double divide. While individuals who reported having a recent health problem were less likely to have Internet access (odds ratio (OR): 0.72, 95% confidence interval (CI): 0.53–0.98), it is they who, when they have Internet access, are the most likely to search for health information (OR = 1.44, 95% CI = 1.11–1.87).
Conclusion
In the French context of universal health insurance, access to the Internet varies according to social and socioeconomic status and health status, and its use for health information seeking varies also with health beliefs, but not to health insurance coverage or health-care utilisation. Certain economic and social inequalities seem to impact cumulatively on Internet access and on the use of the Internet for health information seeking. It is not obvious that the Internet is a special information tool for primary prevention in people who are the furthest removed from health concerns. However, the Internet appears to be a useful complement for secondary prevention, especially for better understanding health problems or enhancing therapeutic compliance.
doi:10.1186/1471-2458-8-69
PMCID: PMC2275260  PMID: 18291024
15.  Acceptance of Internet-Based Health Care Services Among Households in Poland: Secondary Analysis of a Population-Based Survey 
Background
Polish society is benefiting from growing access to the Internet, but the use of advanced e-services is still limited. The provision of Internet-based health services depends not only on the penetration of the Internet into society, but also on the acceptance of this technology by potential users.
Objective
The main objective of this study was focused on the assessment of predictors of acceptance of Internet use for provision of health services (eg, sociodemographic status, the use of information technologies, and consumption of health care services) among households in Poland.
Methods
The study was based on a secondary analysis of the dataset from the 2011 Social Diagnosis survey (a biannual survey conducted since 2001 about economic and non-economic aspects of household and individual living conditions in Poland). Analysis of the questionnaire results focused on the situations of the households included in the study. The predictors for 2 outcome variables describing the acceptance of households for Internet use for provision of a full health care service, or at least access to information and download of required forms, were assessed using multivariate logistic regression.
Results
After excluding those households that would not consider the use of health care services or for which predictor variables assumed missing values, the final analyses were conducted on data from 8915 households. Acceptance of the use of the Internet for provision of full health care services in Polish households was significantly higher among households in urban locations with ≥ 200,000 inhabitants than among households in rural areas; it was also higher with salaried employment as the source of income than with self-employment in agriculture (odds ratio [OR] = 0.53, 95% CI 0.40 - 0.70), retirement pension (OR = 0.46, 95% CI 0.39 - 0.54), disability pension (OR = 0.48, 95% CI 0.34 - 0.68), or with several simultaneous income sources (OR = 0.66; 95% CI 0.57 - 0.79). Furthermore, acceptance of Internet-based health care was higher in households with a higher monthly net income per capita (OR = 2.11, 95% CI 1.75 - 2.53 for households from the lowest and the highest income interval), among households with > 1 child aged < 15 years (OR = 1.38, 95% CI 1.20 - 1.59), among households with at least some books (with OR = 3.33, 95% CI 2.39 - 4.64 for household with no books and those with over 500 books). Acceptance was also higher in households with a computer (OR = 1.86, 95% CI 1.35 - 2.56), Internet access (OR = 1.95, 95% CI 1.37 - 2.76), and Internet access for a longer duration (OR = 1.36, 95% CI 1.06 - 1.75 and OR = 1.81, 95% CI 1.40 - 2.33 for households with access < 1 year versus those with access for 1-5 years and > 5 years, respectively). Greater self-declared confidence in using technology was also associated with higher acceptance of the Internet for health care services (OR = 2.94, 95% CI 2.21 - 3.91 for the least confident households versus those with the highest confidence). Furthermore, recent use of health care services increased acceptance of using the Internet for at least some health-related services (OR = 1.49, 95% CI 1.16 - 1.91), but not for full provision of online health care services (OR = 1.20, 95% CI 0.92 - 1.55). Neither the hospitalization of a member of a household nor the opinion about satisfying health care needs of a household affected the degree of acceptance.
Conclusions
The acceptance of health care services through the Internet is higher in households from larger cities, with stable income from an employee salary, as well as with higher income levels per capita. Furthermore, general computer and Internet use in the household influenced the perception of eHealth. Paradoxically, the use of health care services or the level of satisfaction with the coverage of the household’s health needs has a limited influence on acceptance of Internet-based health care services.
doi:10.2196/jmir.2358
PMCID: PMC3510773  PMID: 23187116
eHealth; health care service; Internet use; computer use
16.  An Epidemiological Network Model for Disease Outbreak Detection 
PLoS Medicine  2007;4(6):e210.
Background
Advanced disease-surveillance systems have been deployed worldwide to provide early detection of infectious disease outbreaks and bioterrorist attacks. New methods that improve the overall detection capabilities of these systems can have a broad practical impact. Furthermore, most current generation surveillance systems are vulnerable to dramatic and unpredictable shifts in the health-care data that they monitor. These shifts can occur during major public events, such as the Olympics, as a result of population surges and public closures. Shifts can also occur during epidemics and pandemics as a result of quarantines, the worried-well flooding emergency departments or, conversely, the public staying away from hospitals for fear of nosocomial infection. Most surveillance systems are not robust to such shifts in health-care utilization, either because they do not adjust baselines and alert-thresholds to new utilization levels, or because the utilization shifts themselves may trigger an alarm. As a result, public-health crises and major public events threaten to undermine health-surveillance systems at the very times they are needed most.
Methods and Findings
To address this challenge, we introduce a class of epidemiological network models that monitor the relationships among different health-care data streams instead of monitoring the data streams themselves. By extracting the extra information present in the relationships between the data streams, these models have the potential to improve the detection capabilities of a system. Furthermore, the models' relational nature has the potential to increase a system's robustness to unpredictable baseline shifts. We implemented these models and evaluated their effectiveness using historical emergency department data from five hospitals in a single metropolitan area, recorded over a period of 4.5 y by the Automated Epidemiological Geotemporal Integrated Surveillance real-time public health–surveillance system, developed by the Children's Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology on behalf of the Massachusetts Department of Public Health. We performed experiments with semi-synthetic outbreaks of different magnitudes and simulated baseline shifts of different types and magnitudes. The results show that the network models provide better detection of localized outbreaks, and greater robustness to unpredictable shifts than a reference time-series modeling approach.
Conclusions
The integrated network models of epidemiological data streams and their interrelationships have the potential to improve current surveillance efforts, providing better localized outbreak detection under normal circumstances, as well as more robust performance in the face of shifts in health-care utilization during epidemics and major public events.
Most surveillance systems are not robust to shifts in health care utilization. Ben Reis and colleagues developed network models that detected localized outbreaks better and were more robust to unpredictable shifts.
Editors' Summary
Background.
The main task of public-health officials is to promote health in communities around the world. To do this, they need to monitor human health continually, so that any outbreaks (epidemics) of infectious diseases (particularly global epidemics or pandemics) or any bioterrorist attacks can be detected and dealt with quickly. In recent years, advanced disease-surveillance systems have been introduced that analyze data on hospital visits, purchases of drugs, and the use of laboratory tests to look for tell-tale signs of disease outbreaks. These surveillance systems work by comparing current data on the use of health-care resources with historical data or by identifying sudden increases in the use of these resources. So, for example, more doctors asking for tests for salmonella than in the past might presage an outbreak of food poisoning, and a sudden rise in people buying over-the-counter flu remedies might indicate the start of an influenza pandemic.
Why Was This Study Done?
Existing disease-surveillance systems don't always detect disease outbreaks, particularly in situations where there are shifts in the baseline patterns of health-care use. For example, during an epidemic, people might stay away from hospitals because of the fear of becoming infected, whereas after a suspected bioterrorist attack with an infectious agent, hospitals might be flooded with “worried well” (healthy people who think they have been exposed to the agent). Baseline shifts like these might prevent the detection of increased illness caused by the epidemic or the bioterrorist attack. Localized population surges associated with major public events (for example, the Olympics) are also likely to reduce the ability of existing surveillance systems to detect infectious disease outbreaks. In this study, the researchers developed a new class of surveillance systems called “epidemiological network models.” These systems aim to improve the detection of disease outbreaks by monitoring fluctuations in the relationships between information detailing the use of various health-care resources over time (data streams).
What Did the Researchers Do and Find?
The researchers used data collected over a 3-y period from five Boston hospitals on visits for respiratory (breathing) problems and for gastrointestinal (stomach and gut) problems, and on total visits (15 data streams in total), to construct a network model that included all the possible pair-wise comparisons between the data streams. They tested this model by comparing its ability to detect simulated disease outbreaks implanted into data collected over an additional year with that of a reference model based on individual data streams. The network approach, they report, was better at detecting localized outbreaks of respiratory and gastrointestinal disease than the reference approach. To investigate how well the network model dealt with baseline shifts in the use of health-care resources, the researchers then added in a large population surge. The detection performance of the reference model decreased in this test, but the performance of the complete network model and of models that included relationships between only some of the data streams remained stable. Finally, the researchers tested what would happen in a situation where there were large numbers of “worried well.” Again, the network models detected disease outbreaks consistently better than the reference model.
What Do These Findings Mean?
These findings suggest that epidemiological network systems that monitor the relationships between health-care resource-utilization data streams might detect disease outbreaks better than current systems under normal conditions and might be less affected by unpredictable shifts in the baseline data. However, because the tests of the new class of surveillance system reported here used simulated infectious disease outbreaks and baseline shifts, the network models may behave differently in real-life situations or if built using data from other hospitals. Nevertheless, these findings strongly suggest that public-health officials, provided they have sufficient computer power at their disposal, might improve their ability to detect disease outbreaks by using epidemiological network systems alongside their current disease-surveillance systems.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040210.
Wikipedia pages on public health (note that Wikipedia is a free online encyclopedia that anyone can edit, and is available in several languages)
A brief description from the World Health Organization of public-health surveillance (in English, French, Spanish, Russian, Arabic, and Chinese)
A detailed report from the US Centers for Disease Control and Prevention called “Framework for Evaluating Public Health Surveillance Systems for the Early Detection of Outbreaks”
The International Society for Disease Surveillance Web site
doi:10.1371/journal.pmed.0040210
PMCID: PMC1896205  PMID: 17593895
17.  Mental health related Internet use among psychiatric patients: a cross-sectional analysis 
BMC Psychiatry  2014;14(1):368.
Background
The Internet is of great importance in today’s health sector, as most Internet users utilize online functions for health related purposes. Concerning the mental health care sector, little data exist about the Internet use of psychiatric patients. It is the scope of this current study to analyze the quantity and pattern of Internet usage among mental health patients.
Methods
Patients from all services of the Department of Psychiatry at a university hospital were surveyed by completing a 29-item questionnaire. The data analysis included evaluation of frequencies, as well as group comparisons.
Results
337 patients participated in the survey, of whom 79.5% were Internet users. Social media was utilized by less than half of the users: social networks (47.8%), forums (19.4%), chats (18.7%), blogs (12.3%). 70.9% used the Internet for mental health related reasons. The contents accessed by the patients included: information on mental disorders (57.8%), information on medication (43.7%), search for mental health services (38.8%), platforms with other patients (19.8%) and platforms with mental health professionals (17.2%).
Differences in the pattern of use between users with low, medium and high frequency of Internet use were statistically significant for all entities of social media (p < 0.01), search for mental health services (p = 0.017) and usage of platforms with mental health professionals (p = 0. 048).
The analysis of differences in Internet use depending on the participants’ type of mental disorder revealed no statistically significant differences, with one exception. Regarding the Internet’s role in mental health care, the participants showed differing opinions: 36.2% believe that the Internet has or may have helped them in coping with their mental disorder, while 38.4% stated the contrary.
Conclusions
Most psychiatric patients are Internet users. Mental health related Internet use is common among patients, mainly for information seeking. The use of social media is generally less frequent. It varies significantly between different user types and was shown to be associated with high frequency of Internet use. The results illustrate the importance of the Internet in mental health related contexts and may contribute to the further development of mental health related online offers.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0368-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-014-0368-7
PMCID: PMC4299476  PMID: 25599722
Internet; Psychiatry; Availability; Information seeking; Social media; Internet-based interventions
18.  Traditional and Mobile Public Health Alert Communications with Health Care Providers 
Objective
To systematically compare mobile (SMS) and traditional (email, FAX) communication strategies to identify which modality is most effective for communication of health alerts and advisories between public health agencies and health care providers in order to improve emergency preparedness and response.
Introduction
The effectiveness of emergency preparedness and response systems depends, in part, on the effectiveness of communication between agencies and individuals involved in emergency response, including health care providers who play a significant role in planning, event detection, response and communication with the public. Although much attention has been paid to the importance of communicating clinical data from health care providers to public health agencies for purposes of early event detection and situational awareness (e.g., BioSense) and to the need for alerting health care providers of public health events (e.g., Health Alert Networks), no studies to date have systematically identified the most effective methods of communication between public health agencies and community health care providers for purposes of public health emergency preparedness and response.
The REACH (Rapid Emergency Alert Communication in Health) study is a 4-year randomized controlled trial to evaluate and compare the effectiveness of mobile (SMS) and traditional (email, FAX) communication strategies for sending public health messages to health care providers—physicians, pharmacists, nurse practitioners, physician’s assistants and veterinarians.
Methods
Providers were recruited from three sites (King County, WA; Spokane County, WA; and across the state of Montana; N=845) and randomized to receive time-sensitive public health messages via email, Fax, short message service (SMS) or to a control group that did not receive messages. For one year, alerts based on real events of public health interest were sent quarterly with follow-up telephone interviews conducted 5–10 days after the delivery date. Interviews consisted of approximately six questions that elicited information about message receipt, recall of its content and perceived credibility and trustworthiness of the message and source. In addition, provider access to online alert information and delivery success or failure was collected.
Results
Frequency of receipt, timeliness, content awareness, perceived credibility and perceived trustworthiness were measured and compared across communication delivery systems. On average 84.0% of participants were contacted in each follow-up survey following all alerts and across all three sites. Primary data analysis was designed to measure differences between the three communication groups using intent-to-treat methods. A set of secondary analyses examined the outcomes excluding providers who could not have received messages (due to incorrect contact information, known technical failures, or because providers could not receive messages by the assigned delivery message—for example, a provider without a Fax number randomized to the Fax group).
We will discuss preliminary results of intent-to-treat analyses regarding rate of recall of study alert message content between traditional and mobile communications and perceived trustworthiness and credibility of message and message source by providers. In addition, we will report on frequency of accessing online alert information between traditional and mobile delivery groups.
Conclusions
There is currently no evidence-based research to guide or improve the practice of public health communication between public health agencies and health care providers before, during and after a public health emergency. Improving this communication via the use of effective media can enhance disease surveillance, which will aid in early detection and enhance case finding and situational awareness for public health emergencies. By systematically evaluating the relative effectiveness of mobile and traditional message delivery systems for emergency preparedness and response communications, the REACH study contributes to building the evidence base for novel and effective approaches to emergency communications.
PMCID: PMC3692770
Emergency Preparedness and Response; Public Health Communication; Surveillance and Alerting
19.  Physicians' Motives for Professional Internet Use and Differences in Attitudes Toward the Internet-Informed Patient, Physician–Patient Communication, and Prescribing Behavior 
Medicine 2.0  2012;1(2):e2.
Background
Physicians have differing motives for using the Internet and Internet-related services in their professional work. These motives may affect their evaluation of patients who bring with them health-related information from the Internet. Differing motives may also affect physician–patient communication and subsequent prescribing behavior.
Objectives
To segment physicians into types based on their motives for using the Internet in connection with professional activities and to analyze how those segments differ in their attitudes in three areas: toward patients who bring along Internet-sourced information; in their own subsequent prescribing behavior; and in their attitudes toward using the Internet to communicate with patients in future.
Methods
We surveyed 287 German physicians online from three medical fields. To assess physicians’ motives for using the Internet for their professional activities, we asked them to rate their level of agreement with statements on a 7-point scale. Motive statements were reduced to motive dimensions using principal component analysis, and 2-step cluster analysis based on motive dimensions identified different segments of physicians. Several statements assessed agreement or disagreement on a 7-point scale physicians’ attitudes toward patients’ bringing Internet information to the consultation and their own subsequent prescribing behavior. Further, we asked physicians to indicate on a 7-point scale their valuation of the Internet for physician–patient communication in the future. Data were then subjected to variance and contingency analyses.
Results
We identified three motive dimensions for Internet use: (1) being on the cutting edge and for self-expression (Cronbach alpha = .88), (2) efficiency and effectiveness (alpha = .79), and (3) diversity and convenience (alpha = .71). These three factors accounted for 71.4% of the variance. Based on physicians’ motives for using the Internet, four types of physician Internet user were identified: (1) the Internet Advocate (2), Efficiency-Oriented, (3) Internet Critic, and (4) Driven Self-expressionist. Groups differed significantly concerning (1) their attitude toward informed patients in general (F 1234 = 9.215, P < .001), (2) perceived improvement in the physician–patient relationship Internet information brings (F 1234 = 5.386, P < .001), (3) perceived accuracy of information the patient brings (F 1234 = 3.658, P = .01), and (4) perceived amount of time needed to devote to an Internet-informed patient (F 1234 = 3.356, P = .02). Physician segments did not differ significantly in reported prescribing behavior (F 1234 = 1.910, P = .13). However, attitudes toward using the Internet to communicate with patients in future differed significantly (F 1234 = 23.242, P < .001).
Conclusions
Based on self-reporting by German physicians of their motives for professional Internet use, we identified four types of Internet users who differ significantly in their attitude toward patients who bring along Internet information and their attitudes toward using the Internet to communicate with patients in future.
doi:10.2196/med20.1996
PMCID: PMC4084769  PMID: 25075230
Physician; Internet use; attitude; Internet-informed patient; communication; prescribing behavior; physician-patient relationship; motivation research
20.  Utilization and Perceived Problems of Online Medical Resources and Search Tools Among Different Groups of European Physicians 
Background
There is a large body of research suggesting that medical professionals have unmet information needs during their daily routines.
Objective
To investigate which online resources and tools different groups of European physicians use to gather medical information and to identify barriers that prevent the successful retrieval of medical information from the Internet.
Methods
A detailed Web-based questionnaire was sent out to approximately 15,000 physicians across Europe and disseminated through partner websites. 500 European physicians of different levels of academic qualification and medical specialization were included in the analysis. Self-reported frequency of use of different types of online resources, perceived importance of search tools, and perceived search barriers were measured. Comparisons were made across different levels of qualification (qualified physicians vs physicians in training, medical specialists without professorships vs medical professors) and specialization (general practitioners vs specialists).
Results
Most participants were Internet-savvy, came from Austria (43%, 190/440) and Switzerland (31%, 137/440), were above 50 years old (56%, 239/430), stated high levels of medical work experience, had regular patient contact and were employed in nonacademic health care settings (41%, 177/432). All groups reported frequent use of general search engines and cited “restricted accessibility to good quality information” as a dominant barrier to finding medical information on the Internet. Physicians in training reported the most frequent use of Wikipedia (56%, 31/55). Specialists were more likely than general practitioners to use medical research databases (68%, 185/274 vs 27%, 24/88; χ2 2=44.905, P<.001). General practitioners were more likely than specialists to report “lack of time” as a barrier towards finding information on the Internet (59%, 50/85 vs 43%, 111/260; χ2 1=7.231, P=.007) and to restrict their search by language (48%, 43/89 vs 35%, 97/278; χ2 1=5.148, P=.023). They frequently consult general health websites (36%, 31/87 vs 19%, 51/269; χ2 2=12.813, P=.002) and online physician network communities (17%, 15/86, χ2 2=9.841 vs 6%, 17/270, P<.001).
Conclusions
The reported inaccessibility of relevant, trustworthy resources on the Internet and frequent reliance on general search engines and social media among physicians require further attention. Possible solutions may be increased governmental support for the development and popularization of user-tailored medical search tools and open access to high-quality content for physicians. The potential role of collaborative tools in providing the psychological support and affirmation normally given by medical colleagues needs further consideration. Tools that speed up quality evaluation and aid selection of relevant search results need to be identified. In order to develop an adequate search tool, a differentiated approach considering the differing needs of physician subgroups may be beneficial.
doi:10.2196/jmir.2436
PMCID: PMC3713956  PMID: 23803299
information seeking behavior; physicians; Internet; search engine; information quality; language barriers
21.  The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review 
PLoS Medicine  2013;10(1):e1001362.
Caroline Free and colleagues systematically review a fast-moving field, that of the effectiveness of mobile technology interventions delivered to healthcare consumers, and conclude that high-quality, adequately powered trials of optimized interventions are required to evaluate effects on objective outcomes.
Background
Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.
Methods and Findings
We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72–0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47–1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77–2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Every year, millions of people die from cardiovascular diseases (diseases of the heart and circulation), chronic obstructive pulmonary disease (a long-term lung disease), lung cancer, HIV infection, and diabetes. These diseases are increasingly important causes of mortality (death) in low- and middle-income countries and are responsible for nearly 40% of deaths in high-income countries. For all these diseases, individuals can adopt healthy behaviors that help prevent disease onset. For example, people can lower their risk of diabetes and cardiovascular disease by maintaining a healthy body weight, and, if they are smokers, they can reduce their risk of lung cancer and cardiovascular disease by giving up cigarettes. In addition, optimal treatment of existing diseases can reduce mortality and morbidity (illness). Thus, in people who are infected with HIV, antiretroviral therapy delays the progression of HIV infection and the onset of AIDS, and in people who have diabetes, good blood sugar control can prevent retinopathy (a type of blindness) and other serious complications of diabetes.
Why Was This Study Done?
Health-care providers need effective ways to encourage "health-care consumers" to make healthy lifestyle choices and to self-manage chronic diseases. The amount of information, encouragement and support that can be conveyed to individuals during face-to-face consultations or through traditional media such as leaflets is limited, but mobile technologies such as mobile phones and portable computers have the potential to transform the delivery of health messages. These increasingly popular technologies—more than two-thirds of the world's population now owns a mobile phone—can be used to deliver health messages to people anywhere and at the most relevant times. For example, smokers trying to quit smoking can be sent regular text messages to sustain their motivation, but can also use text messaging to request extra support when it is needed. But is "mHealth," the provision of health-related services using mobile communication technology, an effective way to deliver health messages to health-care consumers? In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of mobile technology-based health behavior change interventions and disease management interventions delivered to health-care consumers.
What Did the Researchers Do and Find?
The researchers identified 75 controlled trials (studies that compare the outcomes of people who do and do not receive an intervention) of mobile technology-based health interventions delivered to health-care consumers that met their predefined criteria. Twenty-six trials investigated the use of mobile technologies to change health behaviors, 59 investigated their use in disease management, most were of low quality, and nearly all were undertaken in high-income countries. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lower-quality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases.
What Do These Findings Mean?
These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using mobile technologies. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a high-income setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other mobile technology–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further trials are undertaken to establish their clinical benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001362.
A related PLOS Medicine Research Article by Free et al. investigates the ability of mHealth technologies to improve health-care service delivery processes
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
More information about Txt2stop is available, the UK National Health Service Choices website provides an analysis of the Txt2stop trial and what its results mean, and the UK National Health Service Smokefree website provides a link to a Quit App for the iPhone
The US Centers for Disease Control and Prevention has launched a text messaging service that delivers regular health tips and alerts to mobile phones
doi:10.1371/journal.pmed.1001362
PMCID: PMC3548655  PMID: 23349621
22.  Health-related Information on the Web: Results From the HealthStyles Survey, 2002–2003 
Preventing Chronic Disease  2006;3(2):A36.
Introduction
The World Wide Web is being used increasingly as a resource for accessing health-related information. In our study, we identified types of health-related Web sites visited most often, determined how often patients shared Web-accessed health information with their doctors, and examined factors that encouraged Internet use for locating health-related information. We also compared health-related Internet use among people who did not have any type of chronic disease with people who reported having one or more chronic diseases.
Methods
We merged data from the 2002 and 2003 HealthStyles surveys to generate frequency and descriptive statistics and used multivariate logistic regression to estimate odds ratios.
Results
Approximately 35% of survey participants reported using the Internet to search for health-related information. Among them, the Web sites visited most often included health information portals, government agencies, and nonprofit organizations. About 53% reported that they "sometimes" shared Internet information with their doctors. The most important features of the Internet that would encourage its use for health information were ease of finding and using the information and clarity of the information provided. Internet use differed by sex and age and was strongly associated with income and education. Respondents who reported having a chronic disease (odds ratio [OR] = 1.30; 95% confidence interval [CI], 1.16–1.45) were more likely to use the Internet to access health-related information, especially among those with depression (OR = 1.47; 95% CI, 1.27–1.71) and high cholesterol (OR = 1.18; 95% CI, 1.02–1.37). In addition, respondents who reported having two or more chronic diseases (OR = 1.35; 95% CI, 1.16–1.56) were more likely to search for online health information than respondents who reported having no chronic disease.
Conclusion
Public health professionals have a unique opportunity to use the Internet as a tool to complement and supplement the health information that the public receives from health care professionals.
PMCID: PMC1563974  PMID: 16539777
23.  Social Media Use in the United States: Implications for Health Communication 
Background
Given the rapid changes in the communication landscape brought about by participative Internet use and social media, it is important to develop a better understanding of these technologies and their impact on health communication. The first step in this effort is to identify the characteristics of current social media users. Up-to-date reporting of current social media use will help monitor the growth of social media and inform health promotion/communication efforts aiming to effectively utilize social media.
Objective
The purpose of the study is to identify the sociodemographic and health-related factors associated with current adult social media users in the United States.
Methods
Data came from the 2007 iteration of the Health Information National Trends Study (HINTS, N = 7674). HINTS is a nationally representative cross-sectional survey on health-related communication trends and practices. Survey respondents who reported having accessed the Internet (N = 5078) were asked whether, over the past year, they had (1) participated in an online support group, (2) written in a blog, (3) visited a social networking site. Bivariate and multivariate logistic regression analyses were conducted to identify predictors of each type of social media use.
Results
Approximately 69% of US adults reported having access to the Internet in 2007. Among Internet users, 5% participated in an online support group, 7% reported blogging, and 23% used a social networking site. Multivariate analysis found that younger age was the only significant predictor of blogging and social networking site participation; a statistically significant linear relationship was observed, with younger categories reporting more frequent use. Younger age, poorer subjective health, and a personal cancer experience predicted support group participation. In general, social media are penetrating the US population independent of education, race/ethnicity, or health care access.
Conclusions
Recent growth of social media is not uniformly distributed across age groups; therefore, health communication programs utilizing social media must first consider the age of the targeted population to help ensure that messages reach the intended audience. While racial/ethnic and health status–related disparities exist in Internet access, among those with Internet access, these characteristics do not affect social media use. This finding suggests that the new technologies, represented by social media, may be changing the communication pattern throughout the United States.
doi:10.2196/jmir.1249
PMCID: PMC2802563  PMID: 19945947
Internet; social media; social networking; demography; population surveillance; eHealth, new technologies; health communication
24.  Incidence of Online Health Information Search: A Useful Proxy for Public Health Risk Perception 
Background
Internet users use search engines to look for information online, including health information. Researchers in medical informatics have found a high correlation of the occurrence of certain search queries and the incidence of certain diseases. Consumers’ search for information about diseases is related to current health status with regard to a disease and to the social environments that shape the public’s attitudes and behaviors.
Objective
This study aimed to investigate the extent to which public health risk perception as demonstrated by online information searches related to a health risk can be explained by the incidence of the health risk and social components of a specific population’s environment. Using an ecological perspective, we suggest that a population’s general concern for a health risk is formed by the incidence of the risk and social (eg, media attention) factors related with the risk.
Methods
We constructed a dataset that included state-level data from 32 states on the incidence of the flu; a number of social factors, such as media attention to the flu; private resources, such as education and health insurance coverage; public resources, such as hospital beds and primary physicians; and utilization of these resources, including inpatient days and outpatient visits. We then explored whether online information searches about the flu (seasonal and pandemic flu) can be predicted using these variables. We used factor analysis to construct indexes for sets of social factors (private resources, public resources). We then applied panel data multiple regression analysis to exploit both time-series and cross-sectional variation in the data over a 7-year period.
Results
Overall, the results provide evidence that the main effects of independent variables—the incidence of the flu (P<.001); social factors, including media attention (P<.001); private resources, including life quality (P<.001) and health lifestyles (P=.009); and public resources, such as hospital care utilization (P=.008) and public health funds (P=.02)—have significant effects on Web searches for queries related to the flu. After controlling for the number of reported disease cases and Internet access rate by state, we estimate the contribution of social factors to the public health risk perception levels by state (R2=23.37%). The interaction effects between flu incidence and social factors for our search terms did not add to the explanatory power of our regression models (R2<1%).
Conclusions
Our study suggests a practical way to measure the public’s health risk perception for certain diseases using online information search volume by state. The social environment influences public risk perception regardless of disease incidence. Thus, monitoring the social variables can be very helpful in being ready to respond to the public’s behavior in dealing with public health threats.
doi:10.2196/jmir.2401
PMCID: PMC3713924  PMID: 23773974
health risk perception; social influence; ecological system
25.  Internet Use for Health-Related Information via Personal Computers and Cell Phones in Japan: A Cross-Sectional Population-Based Survey 
Background
The Internet is known to be used for health purposes by the general public all over the world. However, little is known about the use of, attitudes toward, and activities regarding eHealth among the Japanese population.
Objectives
This study aimed to measure the prevalence of Internet use for health-related information compared with other sources, and to examine the effects on user knowledge, attitudes, and activities with regard to Internet use for health-related information in Japan. We examined the extent of use via personal computers and cell phones.
Methods
We conducted a cross-sectional survey of a quasi-representative sample (N = 1200) of the Japanese general population aged 15–79 years in September 2007. The main outcome measures were (1) self-reported rates of Internet use in the past year to acquire health-related information and to contact health professionals, family, friends, and peers specifically for health-related purposes, and (2) perceived effects of Internet use on health care.
Results
The prevalence of Internet use via personal computer for acquiring health-related information was 23.8% (286/1200) among those surveyed, whereas the prevalence via cell phone was 6% (77). Internet use via both personal computer and cell phone for communicating with health professionals, family, friends, or peers was not common. The Internet was used via personal computer for acquiring health-related information primarily by younger people, people with higher education levels, and people with higher household incomes. The majority of those who used the Internet for health care purposes responded that the Internet improved their knowledge or affected their lifestyle attitude, and that they felt confident in the health-related information they obtained from the Internet. However, less than one-quarter thought it improved their ability to manage their health or affected their health-related activities.
Conclusions
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 users’ health-related knowledge and attitudes but seldom changed their health-related abilities and activities. To encourage communication between health providers and consumers, 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.
doi:10.2196/jmir.1796
PMCID: PMC3278096  PMID: 22169526
eHealth; email; cell phones; health literacy; information-seeking behavior; patient-provider communication

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