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eHealth as a field of research

Source: Chapter 6 on eHealth, from New Intersections of Internet Research


"The Internet is one of the most widely adopted communication technologies in the world today (2009). The communicative practices within the healthcare systems are no exception. According to the Pew Internet & American Life Project, more than 75 percent of American adults have used the Internet to find medical information (Pew Internet & American Life Report, 2008). Similar data can be seen amongst European countries (Internet World Stats, 2009). The Internet is not only used to locate health information, but also to locate treatment plans, buy drugs, and keep track of health data. The widespread use of the Internet for such a variety of purposes demonstrates the need for a systematic approach to the study of its impact on the healthcare system and the individuals who navigate it. For this reason, a new field of research, eHealth, has been created. Currently, one of the most widely recognized definitions of eHealth states that it is the use of emerging information and communication technology, especially the Internet, to improve or enable health and healthcare (Eng, 2001). According to Eysenbach (2005), this field has grown in the intersection of medical informatics, public health, and business and is defined as referring to health services and information delivered or enhanced through the Internet and related technologies. The scope of eHealth, according to these definitions, is very large and includes technologies that might not necessarily be web-based.

A literature review conducted by Oh, Rizo, Enkin, and Jaded (2005) found more than 51 definitions for the term. They also found that despite the terminological disagreement a number of these definitions have common characteristics including the use of technology as the main communication channel and a focus on health-related issues. The combination of these two components results in eHealth interventions, which Bennett and Glasgow (2009) defined as “systematic treatment/prevention programs, usually addressing one or more determinants of health (frequent health behaviors), delivered largely via the Internet (although not necessarily web-based), and interfacing with an end user.”

Benefits of eHealth Approaches

“There are two ways to evaluate the effectiveness of eHealth interventions: the first is the potential reach of the interventions, and the second, the impact of the intervention on the patient’s health status. Whether this impact is direct, mediated, or moderated will be discussed later. However, it is important to note that several randomized studies have shown the effectiveness of Internet interventions within a variety of clinical studies, including asthma management, smoking cessation, chronic pain, diabetes, alcohol abuse, anxiety and depression, headache, insomnia, HIV prevention, mental health disorders, physical activity, organ donation, sexually transmitted diseases, stress management, and weight loss (see Bennett & Glasgow [2009] for a review). Furthermore, within these clinical outcomes, medical decisionmaking and risk assessments have proven to be well-supported by interactive web applications.

Evidence of the effectiveness of eHealth interventions is well-documented in recent literature. For example, Griffith, Lindenmeyer, Powell, Lowe, and Thorogood (2006) conducted a qualitative systematic review in order to understand the reasons why healthcare interventions are delivered over the Internet. The main result of this study was the creation of a categorization of reasons for using the Internet, as well as drawbacks, and suggestions for future research. The six main reasons for using the Internet identified were: reducing costs for users, reducing costs for health services, reducing isolation of the user, the need for timely information, reducing the social stigma, and increased user and supplier control of the intervention. As for drawbacks, the authors found that the Internet might reinforce the problems interventions are intended to help and, therefore, the Internet should not become a substitute for face-to-face interactions (e.g., patients may overestimate the potential of a peer support group and become more reluctant to meet their physician).

Additionally, the authors suggested incorporating the costs for the users and their social networks into the study, not limiting the scope of the healthcare system and comparing the Internet with traditional care in order to mark its added benefits. It is important also to note that a revised version of the Cochrane review by Murray, Burns, See, Lai, and Nazareth (2005) revealed that interactive health communication applications (IHCA) have had a positive effect on knowledge, social support, behavioral outcomes, and clinical outcomes. IHCA are also likely to have a positive effect on self-efficacy. The impact of IHCA on emotional and economic outcomes was not able to be determined.

Internet interventions are not beneficial simply as a supplementary treatment option, but they have also been proven to be more effective than traditional interventions in various domains. In particular, Wantland, Portillo, Holzemer, Slaughter, McGhee (2004) reviewed clinical trials investigating the difference between webbased versus non-web-based interventions. Sixteen out of the seventeen studies included in the analysis favored the web-based intervention. However, only six of these studies showed a significant improvement when compared to their offline counterparts. This is a general problem of Internet-based randomized controlled trials, which often suffer from a high attrition rate as stated by Eysenbach (2005). However, eHealth intervention literature shows that regardless of these attrition rates, the benefits of eHealth interventions are consistent (Strecher, 2007; Van Meter, 1999; Ybarra & Eaton, 2005).”


“Research on the impact of eHealth interventions is no longer in its infancy. Throughout this chapter, we have shown how this field has been able to build upon theories and applications borrowed from different disciplines. The problem of exploiting networking technology in order to reduce the divide between consumers’ expectations and healthcare systems’ performances may remain unsolved. However, the constant effort to integrate eHealth applications into healthcare delivery is proving beneficial in terms of social support, empowerment, health literacy, and health outcomes. This scientific enquiry is far from complete. Our overview suggests future research opportunities or nexuses, as summarized later in the chapter, with distinctions kept between those linked to the theoretical dimension of the discipline and empirical research.

The two main theoretical dimensions that emerge from this research are the integration of the social networking approach in the field of eHealth and Health communication, and the need for eHealth-specific theories and models. Individual and networking approaches to the study of eHealth interventions focus on different aspects of their impact, and should be considered as complementary rather than oppositional. Indeed, Internet interventions in healthcare impact characteristics, such as knowledge, empowerment, motivation, and intention to behave. These characteristics are strongly affected by the social network in which the individual is embedded and, thus, the concepts of social support, social capital, diffusion and adoption become extremely relevant in regard to gaining a comprehensive understanding of what does and does not work in terms of technological support for healthcare delivery. Individual approaches are grounded in the tradition of psychology and, more recently, social marketing. The networking approaches have been developed from a sociological and media studies perspective. These contributions are merging in the eHealth and health communication domains with results that are promising and likely to be refined in the near future. This integrative perspective requires the definition and empirical verification of theories and models that are specifically aimed at exploring eHealth interventions. As we underlined previously, these kinds of theoretical contributions are still scarce in the eHealth domain. After almost ten years of qualitative and quantitative studies on the impact of Internet technology in healthcare, the need for further efforts to enrich the theoretical dimension of the discipline persists.

From an empirical perspective, we mentioned a series of interventions that responded to the current uses and needs for gratification of the individual accessing eHealth tools. However, at least three challenges still need addressing: namely, the evaluation of single components that constitute an eHealth intervention, the need for an integration of new web technologies into a single intervention, and some level of agreement in respect to the metrics for eHealth evaluation. The attempt to “unpack” the black box that was introduced in this chapter underlies the fact that we must not limit experimental research in regard to the evaluation of eHealth interventions as a whole. Instead, an urgent need exists for more refined factorial designs in order to evaluate the effectiveness of the single tools that are offered to patients. This methodological challenge is likely to become increasingly relevant, considering the variety of tools that can be exploited, from podcasting to real-time monitoring. Eventually, the ways in which individuals use these tools will make a difference in terms of their effectiveness. However, in order to include actual usage in empirical models, it is necessary to reach an agreement on the metrics that are used to assess it (e.g., a consensus on the measurement units of weblogs metrics).

These theoretical and empirical challenges represent a nexus for the eHealth domain, grounded in the work done so far. The pursuit is ongoing, and future research on the impact of the Internet in the healthcare domain should aim to generate a solid point of reference for researchers, health professionals, and public health policymakers alike.”

Source: Chapter 6 on eHealth, from New Intersections of Internet Research