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Patients’ Reasons for Refraining from Discussing Internet Health
Information with Their Healthcare Providers
Rebecca S. Imesa
; Carma L. Bylundb
; Christina M. Sabeec
; Tracy R. Routsongd
; Amy Aldridge Sanforde
a
Department of Communication, Carroll University, b
Department of Psychiatry and Behavioral
Sciences, Memorial Sloan-Kettering Cancer Center, c
Department of Communication Studies, San
Francisco State University, d
Department of Communication, Washburn University, e
Department of
Communication and Art, Northeastern State University,
To cite this Article Imes, Rebecca S. , Bylund, Carma L. , Sabee, Christina M. , Routsong, Tracy R. and Sanford, Amy
Aldridge(2008 – Affordable Custom Essay Writing Service | Write My Essay from Pro Writers) ‘Patients’ Reasons for Refraining from Discussing Internet Health Information with Their Healthcare
Providers’, Health Communication, 23: 6, 538 — 547
To link to this Article: DOI: 10.1080/10410230802460580
URL: http://dx.doi.org/10.1080/10410230802460580
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ISSN: 1041-0236 print / 1532-7027 online
DOI: 10.1080/10410230802460580
HHTH Patients’ Reasons for Refraining from Discussing
Internet Health Information with Their
Healthcare Providers
Internet Health Information Rebecca S. Imes
Department of Communication
Carroll University
Carma L. Bylund
Department of Psychiatry and Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
Christina M. Sabee
Department of Communication Studies
San Francisco State University
Tracy R. Routsong
Department of Communication
Washburn University
Amy Aldridge Sanford
Department of Communication and Art
Northeastern State University
This exploratory study examined factors that constrain patients from discussing Internet
health information with their healthcare providers. Participants (N = 714) were asked to
list reasons why they have not talked with their providers about Internet health information they had found. Factors (N = 767) included patient attributions about the information, systems or circumstances, fear of treading on the provider’s turf, face-saving
concerns, and patient perceptions of provider attributions about the information. Comparisons between those who had and those who had not talked to their healthcare providers about their Internet research revealed significant differences in types of constraining
factors indicated. Issues concerning an increasingly Internet-savvy public and provider–patient relationships are considered in the discussion within the framework of the
goals, planning, action theory. Continued efforts in provider and patient education can
help to overcome barriers that restrict communication concerning Internet health
research.
Correspondence should be addressed to Rebecca S. Imes, Department of Communication, Carroll University, 100 N. East Avenue, Waukesha, WI 53186.
E-mail: rimes@carrollu.edu
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INTERNET HEALTH INFORMATION 539
INTERNET
The Internet continues to play an ever-increasing role in
our daily lives, including an intersection with healthcare
provider–patient interactions. An estimated 40% to 66% of
Americans have searched for health or healthcare information online (Baker, Wagner, Singer, & Bundorf, 2003; Diaz
et al., 2002; Fox & Fallows, 2003). As one study indicated,
more people search the Internet for health information on
any given day than have a face-to-face visit with a healthcare provider (Fox & Rainie, 2002). Yet despite the large
number of people searching each day and the likelihood that
an individual person has searched for healthcare information, most people do not search online for health information frequently. In a recent study, 80% of respondents (n =
1,220) reported searching for health information every few
months or less (Fox & Fallows, 2003).
Those who use the Internet for health and healthcare
information also self-report a poorer health status than those
who, although online, do not use the Internet for health and
healthcare information (Baker et al., 2003; Fox & Rainie,
2002). Those more likely to search for health information
include those who are female, more highly educated,
younger than 65, and those who have higher incomes (Diaz
et al., 2002; Fox & Fallows, 2003; Rice, 2006 – Write a paper; Professional research paper writing service – Best essay writers). In addition,
“veteran users,” those with 6 or more years of experience
using the Internet, are 20% more likely to have searched for
information on a major health topic than those online for
2 or 3 years (Fox, 2005). When searching for health information, most often people are doing so for someone else
(Fox & Fallows, 2003) for a wide variety of health-related
issues (Fox, 2005).
The range of sources of online health information varies
in credibility and function. An online health information
seeker can find results of randomly controlled trials published in peer-reviewed medical journals on PubMed, use an
information Web site such as WebMD to investigate a
particular illness, or go to an online discussion board to
obtain health information and support from others who have
experienced similar health issues. However, not all health
information is considered credible (Ademiluyi, Rees, &
Sheard, 2003; Eysenbach, Powell, Kuss, & Sa, 2002). Moreover, sources of online health information function differently.
Whereas health information Web sites provide information to
the reader using a mediated model of sender–receiver, online
social support groups can serve functions of both informational and emotional support (Wright, 2002).
Some health professionals are uneasy about the quality
of health information found on the Internet (Fox, Anderson,
& Rainie, 2006 – Write a paper; Professional research paper writing service – Best essay writers; Ullrich & Vaccaro, 2002). Although 72%
of Internet health information seekers report believing most
or all of the health information that they read online, 73%
report that at some point they have rejected other Internet
health information for reasons such as the material being
too commercial or an inability to determine the date or the
source (Fox & Rainie, 2002). Houston and Allison (2002)
found that approximately one third of respondents report
looking at more than one Web site when searching for
health information.
Other scholars in the area of e-health advocate the role of
the Internet as a way to improve an individual’s
health-related decisions, thus supporting the public’s health
(Eng, 2004; Eng et al., 1998). Despite some level of skepticism, those searching online for health information believe
that the information they find makes a difference in the
health decisions they make and has improved the way they
take care of their health (Fox & Fallows, 2003; Fox &
Rainie, 2002). Madden and Fox (2006 – Write a paper; Professional research paper writing service – Best essay writers) found that of 1,931
adults who search on line for information to assist in the care
of a loved one (e-caregivers), 58% listed an Internet source
as their source for crucial information about the health issue.
Further, Madden (2006 – Write a paper; Professional research paper writing service – Best essay writers) found that 20% of online Americans
perceive that the Internet has “greatly improved the way they
get information about health care” (p. 1).
The reaction to this increased access to information is
mixed. Kreps, commenting on a study on the future impact
of the Internet on health system change stated, “With
increased access to relevant health information, better decisions will be made by health care consumers and providers”
(cited in Fox et al., 2006 – Write a paper; Professional research paper writing service – Best essay writers, p. 36). Conversely, oncologists
report that Internet health information can potentially influence cancer patients to feel confused and anxious and/or
hopeful and knowledgeable (Helft, Hlubocky, & Daugherty,
2003).
This range of reactions indicates that Internet health information may have a significant impact on the provider–patient
relationship. Nearly two fifths (37%-41%) of those who go
online for health information report talking to a doctor
about the information (Diaz et al., 2002: Fox & Rainie,
2002). Of those who do talk, 79% perceive the doctor to
have been at least somewhat interested (Fox & Rainie,
2002). In these discussions, patients are more satisfied when
they perceive that the healthcare provider either took the
information seriously or validated their efforts for discussing the information (Bylund, Gueguen, Sabee, Imes, Li, &
Sanford, 2007). Such discussions have the potential to produce problematic communication scenarios between the
patient and the provider. If a healthcare provider feels that
his or her authority is being challenged, negative outcomes
such as the poorer quality of healthcare, deterioration in the
clinical relationship, and negative patient health outcomes
may result (Murray et al., 2003).
Studies show that 18% of people who search for information online report self-diagnosis or self-treatment based on
the Internet information without consulting a doctor (Fox &
Rainie, 2002). If Kreps’s prediction of better decision making has merit, both provider and patient need to be aware of
the information on which each party is basing his or her decision. Yet little research has explored the reasons why people
do not discuss the information they find on the Internet with
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540 IMES ET AL.
a healthcare provider. From the extant literature, we may
extrapolate some potential reasons why patients may not discuss the information. First, they may not be as sick as those
who do discuss their Internet health research. Those who do
discuss their Internet health information tend to have a lower
health status than those who do not (Houston & Allison,
2002). Second, they may not find the information to be of
high quality, as research shows that those who do talk to
their provider about health information from the Internet rate
the quality of that information higher than those who do not
(Diaz et al., 2002). Third, some patients report feeling disapproved of by their clinicians when they share information
(Broom, 2005), which may lead them to withhold information in future consultations. According to Diaz et al. (2002),
age, gender, and education level were not associated with
whether or not people shared health information. At this
time, conclusions about why patients do not always share
Internet information are tenuous at best, as there has been no
published research examining patients’ stated reasons for not
discussing the information.
THEORETICAL PERSPECTIVE
The theoretical grounding for this project is found in Dillard’s
goals-planning-action (GPA) model (Schrader & Dillard,
1998). This theory of message production proposes that individuals plan their messages to others and that this planning is
influenced by their goal(s) for that message in a particular context. The theory recognizes that individuals have multiple
goals guiding their message production. The GPA model
holds that during each interaction, a primary goal, which
drives the interaction, creates consideration of secondary
goals. Secondary goals constrain the range of possible behaviors for action toward the primary goal. The primary goal
provides a “push” force, directing the conversation, whereas a
secondary goal provides a “pull” force, constraining an individual from certain types of talk (e.g., Sabee & Wilson, 2005).
Although several studies have been conducted concerning
types of primary goals (e.g., Canary, Cody, & Marston, 1986;
Dillard, 1989; Rule, Bisanz, & Kohn, 1985), one primary
goal category included in each of these studies and others is
“gaining assistance.” Given the healthcare provider–patient
relationship, this is a logical primary, and therefore motivating, goal to consider. Other potential primary goals might
include “influencing treatment” and “following procedures.”
However, although the primary goal directs the conversation,
it is the secondary goal, the constraining factor, that is the
focus of interest here.
The GPA model specifies five categories of secondary
goals: (a) identity, (b) interaction, (c) relational resource,
(d) personal resource and (e) arousal management.
Although each of these goals may somewhat constrain the
interaction at any given point, one of the secondary goals
may be more important than another. Identity goals are
secondary goals that concern issues of ethics and personal
standards. Interaction goals are those that apply to impression management and the maintenance of the conversation.
Relational resource goals focus on the management of the
relationship. Personal resource goals reflect communicator
issues that are physical, temporal, and material concerns.
The final secondary goal type, arousal maintenance goals,
covers the management of anxiety when attempting influence (Schrader & Dillard, 1998). In the context of medical
interactions, the research presented here sought to discover
which secondary goals would influence and constrain the
message planning and behavior in a patient seeking to gain
assistance from his or her healthcare provider.
RESEARCH QUESTIONS
Due to the potential for online health information seekers to
obtain false, inaccurate, or misleading information (Levy &
Strombeck, 2002), patients who refrain from sharing the
information that they find on the Internet with healthcare
providers may compromise their health. Given that individuals may be constrained (or “pulled”) from approaching
subject matter due to the secondary goals they value in conversation, Dillard’s (e.g., Schrader & Dillard, 1998) goal
framework may help us better understand why patients do
not mention their Internet health research when talking with
their healthcare providers. Insight into why patients refrain
from discussing such information is important to facilitating
better provider–patient communication and potentially
avoiding negative outcomes.
RQ1: What are the constraining factors that keep patients
from talking with their healthcare providers about
Internet health information?
We recognize that patients may not always talk with their
clinicians about online health information, but the GPA
model indicates that they may make strategic choices about
when and where to have such discussions. This model
would allow for the strategic choice not to talk about what
they found in their online searches. We expect that those
who have talked with a healthcare provider about such
information in the past 12 months and those who have not
may have differing reasons for doing so.
RQ2: Do these constraining factors differ between patients
who have not talked about Internet health information in the past 12 months and patients who have
talked about Internet health information in the past
12 months?
It is clear from the research literature that patients’ Internet
usage varies based on their age (Fox & Fallows, 2003), as
does their preference for involvement in medical decisions
(Chewning, Bylund, Shah, Arora, & Makoul, 2004;
Makoul, 1998). In addition, we considered that a patient’s
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INTERNET HEALTH INFORMATION 541
familiarity with the Internet may also affect choices about
discussing Internet health information.
RQ3: Do these constraining factors vary by patients’ age,
Internet expertise, access, and frequency of use?
METHOD
Participants and Procedure
The study sample (n = 714) was drawn from 1,307 participants recruited from Internet health message boards to participate in an online survey during a 6-month period. IRB
approval was granted contingent on asking permission of
moderators to post on their sites. Moderators of health message boards were approached on 76 unique Web sites with
health message boards located through search engines.
Many of these sites had more than one board, often with
separate moderators. We gained permission to post our
recruitment script on one or more boards on 50 of these
Web sites. The recruitment script provided a link to the
online survey. In total, we posted the recruitment script to
385 individual message boards.
Participant selection criteria were based on a self-report that
the participants had researched their or their loved ones’ health
on the Internet within the last year. The study sample is comprised of two subsamples. The first subsample consisted of participants who reported that they had not talked about health
information they found on the Internet with a healthcare provider within the past 12 months. This group was instructed:
“List the reasons why you did not talk about the information
from the Internet with your or your loved one’s healthcare providers.” In addition, they were asked how likely it was that they
would talk about Internet health information with a healthcare
provider in the future. At that point, their participation in the survey was terminated (survey is available from the first author).
The second subsample reported that they had talked about
the information that they had found within the past
12 months with a healthcare provider. These participants
then went on to complete the entire survey, which was composed of 11 closed-ended items and 4 open-ended items, as
well as demographic information on the patient and the
healthcare provider. One of the open-ended items is pertinent to this study, a very similar item to the one that was
asked of the first subsample. This second group was
instructed: “If you’ve ever had information from the Internet, but did not talk about it with your or your loved one’s
healthcare providers, list the reasons why you did not do so.”
Thus, the study sample is made up of respondents who
listed reasons that they had not talked with a healthcare provider about information from the Internet. Of the overall
data set, 72% of the first subsample (did not talk) listed at
least one reason (n = 283), and 47% of the second subsample (talked) listed at least one reason (n = 431), resulting in
a total N = 714 respondents for this study.
Due to a problem with the overall survey design, we
collected demographic data only in the final section of the
survey. This section followed the additional 11 closed and
open-ended questions, which were accessed only by and
therefore completed by subsample 2 (talked), the larger of the
two subsamples. This subsample (n = 431) was 89.3% female
and 91% White. The median age was 43 (SD = 11.92) and the
median range for household income was $40,000–59,000. In
this group, 58% lived in urban areas, 18% in suburban areas,
16% in small towns, and 8% in rural areas. These participants
also rated themselves as having high levels of Internet expertise, access, and frequency of use.
Coding
We inductively developed a coding manual to classify the
respondents’ answers to the open-ended question previously
described. The second and third authors read the responses
that indicated the patient either “never” talked or “sometimes” refrained from talking to his or her healthcare
provider about the health information found on the Internet.
Six themes were initially identified. The first and third
authors then refined the categories where appropriate, adding subcategories and augmenting the descriptions of the
categories. Although our study sample size of respondents
was 714, participants were not limited to giving a single reason as their response, although most did. The total number
of reasons coded was 776.
The first and third authors acted as coders on this data
set. In assessing reliability, the coders had to agree on how
many reasons were in a given answer and in which specific
category the reason fit to be considered in agreement for the
Kappa calculation. Both coders coded 10% of the data, and
intercoder reliability was calculated using Cohen’s kappa,
which was acceptable at .74, given Baxter and Babbie’s
(2004) claim that coefficients larger than .70 are sufficient
(e.g., Bylund & Makoul, 2002). Each coder then coded half
of each subsample.
RESULTS
Constraining Factors for Talking
Concerning RQ1, six categories emerged as constraining
secondary goals that participants had for refraining from
talking with their healthcare providers about the information they found on the Internet. Although not all of the GPA
model’s secondary goals emerged in our analysis, we were
able to note, in some cases, multiple dimensions of the secondary goals that may reflect the specific context in which
this study was conducted. The first two categories we
derived fall under “personal resource” goals. The third category fits the “relational resource” goal, which is concerned
with relationship management. The final three categories
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542 IMES ET AL.
are concerned with managing impressions and conversations and are examples of the “interaction resource” goal.
For the descriptive purposes of the RQ1, we present the
frequency data here for the two subsamples combined. As
reflected in Table 1, the constraining factors that emerged
from the coding were (1) personal resources: patients’ information attributions; (2) personal resources: systems/circumstance; (3) relational resources: turf concerns; (4) interaction
resources: patient face-saving; (5) interaction resources:
patient perceptions of providers’ information attributions; and
(6) interaction resources: indirect references. The first and
second of these categories also had several subcategories.
Table 2 displays the 10 most frequently given dimensions of
the constraining factors, or reasons, which account for 78.3%
of the total reasons given. Each of these dimensions is
explained in greater detail following. The examples provided
are those that are most representative of each dimension.
Personal resources: Patients’ information attributions. Information attribution by the patient was the most
frequently observed dimension, with 29.2% of the reasons
given falling under this general heading. These reasons
referred to the information that the patient had found and
the attributions the patient made about that information.
These reasons are further divided into the following subcategories: quality, “just looking it up for myself,” relevance,
repetitive information, and quantity. Four of these individual
reasons appear in the list of top 10 reasons (Table 2).
Just over 10% of the total reasons given in the study indicated that the respondent did not talk to a healthcare professional about the information because he or she did not trust the
quality or the source of the health information found online.
Statements such as “It did not seem realistic” and “It did not
come from a credible source” typified these attributions.
Another 9.9% of the reasons fell into the “just looking it
up for myself” subcategory. These responses indicated that
the information had not been shared with the healthcare
professional for the following reasons: the participant found
the information as background material for understanding a
health issue or preparing for an appointment; the information answered his or her questions satisfactorily; or the participant believed that it was not any of the provider’s
business what the patient had looked for online if the patient
did not wish to share the findings. Reasons typifying this
subcategory included:
Y233: The information provided either provided background or
answered questions.
Y46: I am satisfied with what I learn on the internet and feel no
need to discuss it further.
Y96: I now talk in a depression chat room and look up my drugs
on the net as I am given them without telling my health
care providers as I think I have the right to any information
I can find on the subject.
Finally, in the information attribution arena, reasons citing relevance accounted for 3.5% of the total reasons. In
this set of reasons, the participant indicated he or she did not
feel the information was relevant to the specific reason he or
she was seeking healthcare. Similarly, 3.4% of the reasons
given were that the respondent did not talk to the provider
about the Internet information because the information was
repetitive. In other words, the information the patient found
on the Internet was consistent with the information or treatment provided by the healthcare professional.
Personal resources: Systems or circumstance
reasons. The second dimension of the constraining factor “personal resources” was related to healthcare as a system or circumstance. This dimension accounted for 20.2% of
the total responses. Most often, the reasons that fell into this
category (7.6% of total reasons) had one of two explanations.
TABLE 1
Coding Category Frequencies Concerning Why
Patients Refrain from Discussing Internet Health
Information with Their Provider
Category Codea %
1. Information attribution 29.2
2. Systems/circumstances 20.2
3. Turf 13
4. Patient saving face 8.2
5. Healthcare provider closed to information 14.4
6. Indirect strategies 2.7
7. Miscellaneous 7.6
Incomplete answer/otherwise uncodeable 4.7
a
Presented in order of introduction within this article,
not in descending frequency.
TABLE 2
Top 10 Individual Reasons Patients Refrain from Talking to Their
Provider About Information They Find on the Internet (N = 776)
Rank Reason Code Frequency %
1 Health care provider closed to information 112 14.4
2 Turf 101 13
3 Quality of information (information
attribution)
81 10.4%
4 “Just looking it up for myself”
(information attribution)
77 9.9
5 Patient saving face 64 8.2
6 No health care provider/health care
provider not seen since looking up
information
59 7.6
7 Not enough time at appointment
(systems/circumstances)
40 5.2
8 Relevance of information (information
attribution)
27 3.5
9 Information repetitive of what health
care provider supplied (information
attribution)
26 3.4
10 Indirect strategies 21 2.7
Total 78.3
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INTERNET HEALTH INFORMATION 543
One explanation was that the participant was currently without a healthcare provider. A second explanation was that,
due to circumstance, the patient had not seen a healthcare
provider since looking up the Internet information and
therefore had not had the opportunity to discuss it. Examples include:
N145: Do not visit the doctor very often. Only when an illness
doesn’t “run its course” in an average amount of time.
Don’t have health care, so don’t do much preventative
medicine.
N35: Haven’t had the opportunity.
Another reason for not talking about the information was
that the patient perceived there was not enough time during
the appointment to bring up his or her research. This concern accounted for 5.2% of the total reasons. For example,
one participant wrote: “Health care provider was too busy to
answer my questions.” Of the total reasons, 3.2% were that
the participant either forgot to mention the research or felt
that it was not pertinent at this stage of his or her illness.
Other reasons accounting for less than 1% each of the total
reasons in this category included: another problem being
more important, insurance not covering the problem/treatment, and the perceived availability of the treatment.
Relational resources: Turf issues. Reasons related
to turf issues constitute the third category. By turf, we mean
the healthcare providers feeling protective of their claim to
be the sole voice of medical expertise in a consultation. Turf
reasons were those where either the patient did not talk for
fear of invading the provider’s turf or because the patient
perceived the provider would feel as if his or her turf was
being invaded. In addition, answers that indicated the participant perceived the provider felt offended, threatened, or
intimidated by the patient’s attempt to discuss Internet
research during the visit were coded as turf issues.
Responses in this category accounted for 13% of the total
responses. Examples of these reasons are given below:
Y465: I’ve found reactions of doctors being told what a patient
has learned on the Internet to be risky. A lot of times you
get that look of “the Internet”? Or doctors look at you like
they don’t like a patient who learns too much.
N62: I did not want the doctor to feel as if I trusted the information I got on the Internet more than I trusted his medical
education.
Y327: One needs to be selective about discussing such matters.
Many physicians resent the loss of ownership of medical
information that the Internet has allowed to occur.
Interaction resources: Patient face-saving reasons. The fourth dimension of responses is patient face
saving reasons. These reasons include the patient not talking
about the Internet health research because he or she did not
want to be embarrassed, laughed at, seen negatively, or seen
as overly concerned. This dimension constituted 8.2% of
the total responses. Examples of this include:
Y319: I don’t want to sound like I’m paranoid or a hypochondriac.
Y449: Fear of being considered a kook for suggesting herbal
alternatives.
Y380: Embarrassed for searching health information on the Internet.
Interaction resources: Providers’ information attributions. The fifth dimension of constraining factors
concerned the patient’s perceptions about the healthcare
provider’s attribution about the Internet information. These
reasons include the healthcare provider not listening to
the patient, being dismissive, uninterested, or not open to
the information due to its source. Of the total reasons,
14.4% were coded into this category. Examples include:
Y8: Many times when I mention something I found on the
Internet my doctor dismisses it right away.
Y20: I do not think he will help me. He seems very leery of the
Internet.
N9: I don’t really know—I guess I just figure he will poo-poo
anything I say I saw on the web so I just keep quiet about it
and let them tell me what I already know!
Interaction resources: Indirect references. The sixth
and final dimension of constraining factors included indirect references. Indirect references were things that patients
did instead of talking directly about the health information
they had looked up. In other words, the patients talked about
the information without talking about its source. Although
we did not initially think of this as a dimension, it emerged
as a small one, with just 2.7% of total reasons. Participants
using indirect references would talk about their information
by asking a question or by introducing the topic in a way
that does not indicate that the person has been researching
it, yet gets the provider talking about it. When asked to list
the reasons why they did not talk to a healthcare provider
about their Internet health information, participants
responded in ways such as:
N107: Because the endocrinologist tends to reject information
from the Internet as being unreliable and implies that my
own research is an effort to self-diagnosis. If I do feel the
need to ask specific questions as a result of my research
that can’t be explained by simple curiosity, I lie and tell the
doctor, “someone I know with the same problem had this
problem, do you think it could apply to me?”
Y45: Usually, I would mention it in the form of a question. Ex.
“I have heard . . .” Or if the physician was discussing
something I had read about, I would mention it.
Other Categories
Finally, 7.6% of the responses were categorized as miscellaneous. Either the reason did not fit any of the identified
dimensions or it seemed to fit in more than one and the
coder did not feel able to judge which based on the amount
of information provided in the participant’s answer. An
additional 4.7% of the responses were not complete enough
to be coded.
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544 IMES ET AL.
Comparison Between Talkers and Nontalkers
To address RQ2, we used chi-square tests to examine the
differences in frequency of reasons between subsample
1—the group who reported not talking with a healthcare
provider about Internet information within the past 12 months
and subsample 2—the group who reported talking at least
once with a healthcare provider about Internet information
while also, at some point, choosing not to talk to the healthcare provider about some information found on the Internet.
In the following we will refer to these groups as had not
talked and talked.
The talked group was more likely than the had not talked
group to respond that they have not talked about Internet
health information with a healthcare provider in the last 12
months because of the poor quality of information (a subcategory of information attribution; X2 = 34.65, p < .0001,
df = 1), because they forgot to mention it (a subcategory of
systems or circumstances; X2
= 9.43, p < .01, df = 1), or
because the healthcare provider was closed to the information (X2 = 4.84, p < .05, df = 1). The had not talked group
was more likely than the talked group to report they did not
talk because they have not or do not see a healthcare
provider (a subcategory of systems or circumstances; X2 =
52.78, p < .0001, df = 1) or for saving face (X2 = 4.90,
p < .05, df = 1).
Age and Internet Use
Due to the survey error described in the Method section, we
were able to analyze data for RQ3 only for the talked sample, as we had demographic information for these participants. We used independent-sample t tests to examine the
mean age of respondents who used a certain reason versus
those who did not use that reason. We tested this with the
six major dimensions of constraining factors. One significant finding emerged: those who cited turf as a reason for
not talking were older on average than were those who did not
cite turf as a reason (mean difference = 3.5 years, t = –2.02,
p < .05).
In a similar fashion, we used independent-sample t tests
to examine ratings of Internet usage (frequency, expertise,
and access) by presence or absence of reasons. Finding
that the correlation coefficients of the Internet usage variables were low, we treated them as separate dependent
variables. There were two significant differences for frequency of Internet usage. Those who used a reason coded
as information attribution reported using the Internet more
frequently than did those without such a reason (mean difference = .15, t = –2.19, p < .05). In addition, those who
gave a reason of turf reported using the Internet less frequently than did those who did not give that reason (mean
difference = .2, t = 2.01, p < .05). There were no significant differences using expertise or access as dependent
variables.
DISCUSSION
This exploratory study was designed to examine the constraining factors influencing Internet health information
searchers to refrain from talking about Internet health information with a healthcare provider. Through the use of
open-ended questions in an online survey, we were able to
develop a taxonomy of these reasons and examine their
relationship to secondary goals as laid out by the GPA
model. Although we do not contend that this list is exhaustive, it does represent a wide variety of reasons for refraining from talking with a healthcare provider about Internet
health information. This list also indicates that the there are
several constraining goals that people may consider when
choosing whether to discuss this information.
Clearly, it should not always be a concern that a patient
chooses not to talk to a healthcare provider about Internet
health information. Nearly 30% of the reasons that emerged
in this study (coded as patients’ information attribution)
indicate that patients are not blank slates but instead perceive themselves as discriminating consumers of health
information who can make reasonable decisions about what
to do with that information. In many cases, respondents felt
uncomfortable about the quality of the information they
found. Given the earlier study showing that 73% of persons
who do online searches report that at some point they have
rejected Internet health information due to concern about
quality (Fox & Rainie, 2002), it does not seem surprising
that we also found respondents rejecting information based
on quality. Respondents also indicated that they made the
decision that it was not necessary to discuss that information because it was just being used for their own purposes—to get some background information or answer their
own questions. In other words, they were educating themselves about a health issue. Other reasons related to the
information also indicated that people were making decisions about the information’s relevance, repetitiveness, and
quantity. Almost a third of our respondents seemed to feel
they were competent at choosing health information of good
quality and deciding what to do with that information. As
the accuracy of this perception is not known, this may be a
barrier for provider–patient communication. From the perspective of health communication, work in health literacy
may address this barrier. Continuing efforts in health literacy toward educating people to make accurate judgments
about Internet health information is clearly an important
facet of the Internet health seeker’s ability to make sound
decisions about information. The ability to make an
informed decision about what they read (e.g., Institute of
Medicine, 2004; Weiss, 2005) may influence patients’
strategies concerning sharing this information with their
healthcare provider.
Despite responses that indicated patients believe they are
making informed decisions about health information on the
Internet, it seems that there is also reason to be concerned.
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INTERNET HEALTH INFORMATION 545
Most of the remaining reasons (58.5%) for not talking about
Internet information (Table 1, Categories 2–6) are barriers
that can and should be overcome. Although society seems to
be encouraging patients to become informed consumers,
over half of the reasons given by participants in our study
indicated that respondents did not feel that they could discuss their efforts with their healthcare providers. These reasons were all linked with the GPA model’s secondary goals
of “relational” and “interaction” resources. The patient must
strategically consider how the sharing of this information
affects his or her relationship with the healthcare provider.
When patients make decisions to refrain from discussing
information due to these issues, they may miss important
opportunities to both inform and learn from their healthcare
provider about the information that they have found.
Many of the reasons given had to do with a deficiency
with the relationship between the healthcare provider and
the patient. About one fifth of the reasons were those in
which the person did not discuss the information because he
or she was not comfortable with the relationship. In some
cases, the patient was hesitant to step on the provider’s
“turf.” These hesitations stemmed either from the patient’s
own perceptions about the provider’s feelings or from
something the provider or other providers had communicated in the past. Similarly, patients had concerns about
what the provider would think of them if they brought up
that information. Those citing “turf” issues most frequently
were patients who indicated less frequency of Internet use
and older age; yet the results of RQ2 show that relational
issues do not exclusively adhere to one communicative subsample. Clearly, issues of trust are of central importance
here. Without feeling like they are in a trusting, safe relationship, patients are hesitant to begin a discussion about
health information from the Internet. In these cases, the secondary goal of managing face or the relationship trumps
goals that lead to an open discussion of health information.
If the patient feels uncomfortable in the situation, the secondary goal of “arousal management” may supersede all
other goals as the patient struggles to “manage the anxiety
or challenge associated with the relationship” (Schrader &
Dillard, 1998, p. 279).
Respondents in our survey also mentioned that the system or the circumstance was often at fault for them not discussing information. In some cases, the respondent reported
not currently having a healthcare provider, or just that he or
she had not been to a visit with a provider since finding the
information. Without more knowledge of individual circumstances, it is difficult to discern how significant a
problem this reason poses. If a person is unable to visit a
healthcare provider due to a lack of resources (ability to
pay, enough providers in an area), then this could potentially lead to problems if a person were to act inappropriately based on health information found on the Internet.
Another systems issue of concern is that patients believe
they do not have enough time to discuss the information with
their providers. Improving healthcare providers’ ability to set
agendas at the beginning of an interaction is critical to overcoming this barrier. When healthcare providers are able to
elicit the patient’s agenda at the beginning of the interaction
(e.g., asking questions such as “What would you like to discuss today?”) they are able to guide the interaction so it is
appropriate to the time available and perhaps negotiate what
will be discussed during the visit and what may need to be
discussed in a subsequent visit (Marvel, Epstein, Flowers, &
Beckman, 1999). These issues indicate that time and other
systems/circumstance reasons are personal resource goals
that may constrain the conversation. This area is an opportunity for improvement that both provider and patient education efforts could address. Improvements in the skill of
eliciting the patient’s agenda could certainly help patients
feel more comfortable bringing up the information and
knowing that it will be discussed, at some point. In addition,
patient education could stress skills for broaching potentially
uncomfortable topics with healthcare providers.
A final area of concern seems to be the patient’s perception
of the provider’s attributions about the Internet information.
Although it is possible that these are sometimes misperceptions, the patient, as coconstructor of the communicative event,
is acting on those perceptions by not discussing Internet health
information with the provider. Some of the educational efforts
regarding developing more trust and patient-centeredness in
healthcare relationships are pertinent here. In addition, there
may be cases in which the healthcare provider may not be
comfortable with the Internet. Thus a “fear of the unknown”
may come into play, possibly influencing the provider to verbally and nonverbally shut down the patient’s ability and/or
desire to discuss the information. This is an example of how
the secondary goal of interaction resource may constrain the
healthcare provider–patient interaction.
Whether the reason for the lack of discussion is the relationship, the healthcare system, or the provider’s attributions about the information, the lack of discussion of such
information could have profound effects on patient outcomes. First, patient satisfaction may be negatively affected
if a patient feels like his or her expectations for being able to
discuss information were not met. Second, if the Internet
information raised questions for a patient about a prescribed
treatment, but he or she is not comfortable enough with the
relationship to discuss those questions with the healthcare
provider, adherence may decrease. Further, in cases in
which patients learn of complementary treatments on the
Internet but do not discuss their taking part in these with
their provider, there is possible danger to the patient’s
health (e.g., a prescribed medication reacting poorly with an
herbal supplement) or a reduction in the effectiveness of the
prescribed treatment (e.g., the patient receives conflicting
advice from the physical therapist and the chiropractor, so
only does a small portion of any prescribed exercise).
Finally, although many patients state that they prefer to be
involved in medical decision making (Chewning et al.,
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546 IMES ET AL.
2004) and some evidence indicates that shared decision
making leads to better outcomes (Bylund, 2005; Greenfield,
Kaplan, Ware, Yano, & Frank, 1988), it is difficult to
achieve shared decision making if patients feel silenced in
the healthcare environment.
Ultimately, all of these possibilities can lead to poor
patient health outcomes. Given that “eight out of ten Internet
users have looked online for Internet information” (Fox,
2005, p. ii), efforts in educating health professionals at
undergraduate, graduate, and continuing education levels
must continue to teach and reinforce the importance of
patient-centered communication (Stewart et al., 1995) and
professional behavior. This is especially important given
that many of the reasons patients are not talking about information seem to be grounded in a suboptimal provider–patient
relationship. It is our belief that communication skills training at all levels of medical education (Cegala & Broz, 2002)
needs to explicitly address discussing Internet information
with patients.
We do not claim that these are all of the reasons that
patients refrain from talking with healthcare providers about
Internet health information, nor do we claim that they rarely
talk about that information. This study, as well as others
(Diaz et al., 2002; Fox & Rainie, 2002), indicates that
patients often do talk about that information. Research
needs to continue exploring how to make those discussions,
when they do happen, as efficacious as possible so that best
practices concerning this issue can be taught in medical
education settings. Our purpose here was to take a first step
in understanding factors that constrain patients from discussing this information and to consider what steps might
be taken to remove some of those barriers. Although we
make reasonable assumptions in this article about how the
lack of discussion may affect patient outcomes, this is a
topic that deserves further attention. We need better insight
into how the information that patients find is being used,
and in which cases the lack of discussion with a healthcare
provider may lead to poor outcomes.
Limitations of this study include its nongeneralizability.
Although we purposely sampled Internet health information
seekers by recruiting from Internet health message boards,
we did rely on a sample of convenience—those recruited
from the Internet willing to take the time to participate in
our study. Therefore, women and Whites are oversampled
in this study. Further, those who participated in our study
may be different from general Internet health information
seekers, as they may be more motivated to seek interpersonal relationships (Wright, 2002). In addition, the term
Internet health information used here and by other researchers in this area is vague. It may refer to a wide variety of
materials—anywhere from one person’s opinion that is
posted to an Internet health message board to a story on an
online newspaper to a randomized, controlled study found
on PubMed. Future research should examine how the source
of the information affects the conversation that occurs
between provider and patient, as well as the chance of that
conversation occurring at all.
As found in this exploratory research study, patients
do not always feel comfortable discussing Internet health
information with their doctors for a variety of reasons. The
secondary goals explored here are factors that constrain
communication between patients and their healthcare providers. Further research using the GPA model may assist in
the better explication of how these constraints occur and
how they might be avoided. Given the dyadic nature of the
patient–provider exchange, research using the GPA model
could influence the education of both patients and providers
in overcoming the barriers of these constraining factors. As
Kreps noted, it is important to attend to the “careful translation of research findings into healthcare delivery innovations” (Kreps, Arora, & Nelson, 2003, p. 4). The lack of
provider–patient communication about online health information has the potential to lead to poor patient outcomes.
Thus, health communication scholars should consider
appropriate healthcare delivery innovations. This work has
both theoretical and practical implications for understanding
the communicative constraints identified by the GPA model
and will bolster the continued efforts in communication
skills training for both patients and healthcare professionals.
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