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«HEALTH PSYCHOLOGY Series Editors: Sheila Payne and Sandra Horn Di an ne Be rr y ion at ce nic cti mu Pra om and h C ory alt The He Health ...»

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People in the developed world are increasingly using computers to communicate information. This increased usage is recognized to have advantages and disadvantages. Computers allow interactions to take place over large distances and across time zones, and with a large number of people. However, computer-mediated communication can suppress the amount of information that is exchanged, which in turn can lead to poorer communication outcomes (e.g. Hollingshead, 1996). Similarly, by restricting paralanguage and non-verbal communication, it can detrimentally affect interactions, particularly between participants who have a closer relationship (Hollingshead, 1998). In general, however, people do adapt to the mode of communication with time, and often respond as it if were not computer mediated (e.g.

Walther, 1996).

Computers are being increasingly used in health communication. Health professionals now frequently communicate with each other via e-mail.

Computers can also be used to aid decision making by both health professionals and patients (see, for example, O’Connor and Edwards, 2001;

O’Connor et al., 2003), and for patient-education purposes, complementing more traditional spoken and leaflet-based approaches. Many public places, such as supermarkets, community centres and medical practices, house computers running health-related programmes. Although few would argue that computers are an effective replacement for personal contact between healthcare providers and patients, there is evidence that they can play a 106 Health communication useful complementary role. As Bental et al. (1999), noted, many patients find information access using a computer acceptable and, sometimes, less embarrassing than having to interact directly with healthcare providers.

One advantage of computers, compared with written communications, is that they can be used interactively. Thus, consumers using a computer health information system can input personal data and receive timely and appropriate responses and advice. Many studies in the field of education have shown that people are generally more motivated and learn better in interactive settings. A second advantage of computers is that they can be used to provide information that is tailored, or personalized, to a particular individual. Whereas the majority of written health information (e.g. Patient Information Leaflets, campaign posters) is generic, computers can be used to provide information that has taken account of the particular patient’s background, knowledge, needs and preferences.

Tailored systems have now been developed in several medical domains, including asthma, diabetes, migraine, cancer and dental treatments. A number of studies have shown that use of tailored systems is beneficial as tailored communications are generally better remembered than generic ones and are more effective for influencing behaviour change (e.g. Kreuter and Holt, 2001; Skinner et al., 1999; Straus, 2002). Kreuter et al. (1999) argued that there is a strong public health rationale for tailoring materials, and that computer-tailored health communications should be viewed as a tool of public health communicators to be incorporated into comprehensive programmes of health promotion, disease prevention and disease management.

Although computers offer these potential benefits in the field of health communication, it has to be recognized that not everyone can gain easy access to computerized health information (e.g. Fogel, 2003). Even in the twenty-first century, there still exists a ‘digital divide’ between those who have access and those who do not. Moreover, many of the latter (such as the elderly and those from lower socio-economic classes) often have the most need of healthcare and health-related information. This is referred to as the ‘inverse information law’ (Eysenbach, 2000), in that access to appropriate information is particularly difficult for those who need it most.

The Internet The most common use of computers today in relation to health communication is to gain access to the Internet. Over the past 20 years, the Internet has become a global communication network that is now accessed by tens of millions of users. The Office of National Statistics in the UK, for example, reported that, in spring 2004, 11.7 million households in Britain (that is, 47 per cent of all households) had access to the Internet (ONS, 2004), and this number is likely to have increased since then. Through the Internet, increasing numbers of the general population and healthcare professionals can gain free and easy access to vast amounts of health-related information that was Health promotion and the wider public 107 previously unavailable. It has been noted by Levy and Strombeck (2002), for example, that ‘health and medicine’ is the fourth most popular ‘on-line subject’ and that there are well over 20 000 different Internet sites that provide health-related information. A survey of over 500 patients enrolled in a primary care practice in the USA (Diaz et al., 2002) showed that over 50 per cent of respondents regularly used the Internet to obtain medical information. Similarly, Fox and Fallows (2003) reported that over 80 per cent of adult Internet users have accessed the Internet for general health information, with 36 per cent seeking information about medicines. If anything, this level of usage is likely to have increased since then.

Research has shown that sufferers of a serious illness, such as cancer, are particularly inclined to access information about their disease via the Internet (e.g. Whitte et al., 2005). A recent qualitative study of 175 adult cancer patients found that the patients used the Internet for a wide range of informational and support needs through all stages of cancer care, from diagnosis to follow-up treatment (Ziebland et al., 2004). The patients liked the privacy of the Internet, as well as the ability to obtain reassurance that their doctor was doing the right thing for them. Many also felt that it helped them to display competence and social fitness in the face of their illness.

Not surprisingly, this massive increase in access to health-related information can have advantages and disadvantages for health communication.

On the positive side, it can enable health professionals to gain easy access to up-to-date research findings about illnesses and potential treatments. It can also lead to increased patient knowledge, which may result in early detection of particular conditions and improved self-care and treatment management, as well as access to relevant support groups and organizations. As noted by Jadad (1999), the Internet should have a significant effect on the way doctors and patients interact, in that it ‘will foster a new level of knowledge among patients, enable them to have input into making decisions about their healthcare, and allow them to participate in active partnerships with various groups of decision makers’ (p. 761). Thus, the Internet can function as a great leveller by placing lay persons on virtually equal footing with scientific and technical experts (Horsch and Harding, 1997).

On the negative side, however, this increased access to information can lead to increased confusion and anxiety in users, particularly when conflicting information and advice is available (or when information that they have found themselves conflicts with advice from their healthcare provider).

Petrie and Wessely (2002) argued that the Internet has led to the spread of information about health scares and has brought a new dimension to patients’ worries in relation to these. Furthermore, not all healthcare professionals (particularly doctors) are happy with their patients accessing additional sources of information and being more proactive in their healthcare. As Hardey (1999) observed, the Internet can represent a challenge to the previously hierarchical model of information giving, with a shift in control and a decline in awe of doctors by patients. Many doctors do not like 108 Health communication (and can feel upstaged or threatened by) being faced with patients who bring information downloaded from the Internet to their consultations (Jadad, 1999).

One of the biggest problems with using the Internet to access healthrelated information is that there is no guarantee that the information is accurate or reliable. Indeed, Berland et al. (2001) reviewed a large number of US health information sites and found that many offered incomplete, misleading or difficult-to-understand information, or blurred the distinction between providing information and advice and companies advertising their own products. Clearly, widespread access to inaccurate and misleading information can pose a public health threat. In this context, Eng (2001) suggested that some of the consequences of poor quality Internet information include ‘inappropriate treatment or delays in seeking appropriate healthcare and damage to the patient provider relationship’ (p. 12). One reason for the wide variation in quality of information available is that currently anyone can post health-related information on the Internet, regardless of their personal expertise or intentions (Levy and Strombeck, 2002). Although some commercial organizations have produced codes of practice for helping to ensure information quality and reliability, there is currently no obligation for information providers to use these.

Clearly, an issue for healthcare providers is that they frequently have no idea about what other information sources their patients have accessed and the level of (both accurate and inaccurate) knowledge they possess.

Furthermore, the time-limited nature of most consultations often means that healthcare providers interact with the patient without being able to take account of this and adapt their communications accordingly. On occasion, this can lead to patients feeling frustrated and confused.

Designing effective health messages

Whether information is distributed in written form or via the media and/or the Internet, the message needs to be effectively designed. Some simple guidelines in relation to the graphical presentation of written forms of dissemination were presented earlier. More generally, as noted by Maibach and Parrott (1995), an essential first step is to get people to attend to the message. Louis and Sutton (1991) found that people are more likely to engage actively in message processing if the content is unusual or unfamiliar, if it represents a discrepancy between expectations and reality, and when an external or internal request causes an individual to initiate an increased level of conscious attention. Thus Maibach and Parrott (1995) recommended that communicators should use novel messages, settings and media to present health messages, and that they should consider the use of discrepant and unexpected messages, media and settings. In addition, they should instruct the audience to pay attention to the message.

Health promotion and the wider public 109 Hale and Dillard (1995) suggested that the use of fear appeals is often a successful method of disseminating health information to the wider public.

Fear appeals are persuasive messages that emphasize the harmful physical or social consequences of failing to comply with the message’s recommendations. Hale and Dillard argued that fear appeals have enormous persuasive potential and can promote better health. They suggested that, to be effective, a fear appeal needs to include a severe threat, evidence suggesting that the target is especially vulnerable to the threat, and solutions that are easy to perform and effective. It should be noted, however, that fear appeals do not work in all circumstances. It is necessary to take account of the age of the target audience and the likelihood of voluntary message processing.

More generally, Witte (1995) has advocated a Persuasive Health Message Framework (PHM) based on elements from the Theory of Reasoned Action (Azjen, 1988), the Elaboration Likelihood Model (Petty and Cacioppo, 1986) and Protection Motivation Theory (Rogers, 1975). Witte argued that a persuasive health message should contain a threat message, an efficacy message, various cues, and that it should be targeted towards a specific award, regardless of the topic, type of message or environment. Thus, to motivate audiences into action, the message needs to convince individuals that they are susceptible to a severe threat and that adopting an easy and feasible recommended response would effectively avert the threat. In terms of types of specific arguments that can be used, Witte pointed out that these can either try to change beliefs, reinforce existing beliefs or introduce new beliefs. He noted that it is far easier to introduce, reinforce or build on existing beliefs in a health campaign than it is to try to change existing and entrenched beliefs. Thus the best campaigns are those that are framed to fit within acceptable beliefs and behaviours.

In terms of age, health campaigns are increasingly targeting children younger than has been the norm in the past. As far as child health campaigns are concerned, Austin (1995) has suggested that, to be effective, strategies need to micro-target the needs and interests of children of different ages and in different environments. They must also provide consistent messages from a variety of sources and over an extended period of time. Finally, they must emphasize giving children control and ownership of their own health decisions. Campaigns based on moralizing, scare tactics and knowledge-only approaches tend to be less effective with children. Rather, it is necessary to understand and respect the child’s perspective, and how the problem relates to the child’s resources, needs, goals and conflicting interests. Austin (1995) noted that children of different ages are motivated by different things and are particularly influenced by different information sources. Thus, children under the age of 5, tend to be motivated by tangible rewards from others and the avoidance of punishment, and find all information sources credible.

Those between the age of 5 and 7 are motivated by rewards, moral labels and conventional rules, and find most sources of information credible. Children aged between 7 and 10 are motivated by social norms and the need for 110 Health communication acceptance, and are particularly influenced by school, family and peers.

Finally, older children are motivated by physical attractiveness and social power, and are most influenced by everyday role models and peers.

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