General use of the Internet compared with health-related purposes and demographics
The vast majority of the Polish population nowadays uses the Internet for health purposes. We can observe a significant increase of 25% usage from 2005 to 2012. The growth is consistent with the trends observed in both Europe and globally [9,11,13,33]. According to the Manhattan Research, a 30% increase in health-related usage of the Internet was seen for the four years ranging from 2004 to 2008 [34]. In turn, the Cybercitizen Health Survey showed that since 2002 the use of the Internet for activities seeking health information has steadily increased, reaching 72% of e-health consumers in 2011 [35]. It is also worth noting that in Polish surveys the growth in the number of IUHP is relatively larger than the growth due to the number of IU and cannot solely be explained by improved Internet access (IUHP accounted for 79.9% of IU in 2007 and 89.7% of IU in 2012). A similar situation for Denmark, Germany, Greece, and Portugal was reported by Kummervold et al. [11]. This may indicate that new Internet e-health services appeared on the consumer market and have become available via the Internet.
The main IU as well as IUHP are still younger people [10,11,23,26,36,37]. However, the elderly have the largest growth potential: this figure tripled during the study period. Strong growth in e-health adoption among older consumers is also confirmed by other authors [9,27,35]. Men’s predominance, observed in 2005, as IU and IUHP gradually disappeared, and in 2012 women reported more health-related usage, which is in line with many other studies [10,11,33,36-39]. While an overall growth in Internet health-related usage among women was seen, this did not apply to the oldest age category, where the increase was largest among men. This might be explained by the fact that elderly people are still first generation of IU, where male dominance is typical.
Sources of information about health and illness
The significance of the Internet as a source of health information is growing. As the study showed, the Internet has become an important source of health information for almost half of Polish citizens ahead of TV/radio, newspapers/magazines, and courses/lectures in the ranking. A population-based survey on e-health trends in Europe from 2007 [11] revealed that the Internet was important source of health information for 46.8% of the population. Clearly leading in this respect were the Nordic countries, especially Denmark, for whom the Internet was the second most important source outranked only by information from health professionals. Other findings are even more encouraging. The international survey conducted in 2011 by Health On the Net Foundation showed the Internet as the second-ranked source of health information after physicians, due to its accessibility and “easiness of use” [40]. In turn, a recent cross-sectional survey conducted among Dutch population, has already found the Internet as the number one source for health-related information (82.7% of respondents) [41]. Furthermore, the Cybercitizen Health Survey reports that Internet currently has the greatest reach as a health information source. However, doctors, nurses, pharmacists, and other health care professionals have still the strongest influence on citizens’ health decisions [35].
Patterns of the Internet use for health purposes
Searching for information about health and illness was definitely the most frequent activity performed online by respondents in the study and reflects their main interests in this area. Similar patterns of medically related Internet activities, with searching for health information as a dominant activity, were reported in many other studies concerning both general Internet use [9,10,13,15,21,22,26,42] and its use in various selected groups of population [19,27,28,43,44]. However, a tendency towards a more “advanced” usage of the Internet for health purposes is also found. In the study, the use of all interactive, health-related online services increased significantly, ending in a total of 44.2% of respondents in 2012. This trend had already been observed earlier by other authors [11,29,30]. Kummervold et al. [11] reported a growth of European consumers using interactive Internet health services at least once a year from 15.3% in 2005 to 22.7% in 2007. Additionally, online communication with doctors or other health professionals whom they have not previously met proved to be the leading choice among interactive Internet services, which is also confirmed by our survey.
The interactive use of the Internet for health purposes has been of particular interest in Poland in recent years. This can be partially explained by the growing dissatisfaction of the Polish society with a functioning health care system based on public hospital services and outpatient care provided by the private sector working mainly on a contract with the National Health Fund [18,45,46]. Deteriorating access to health care services, a queue system frequently forcing patients to wait months for certain specialist services, and a large, omnipresent bureaucracy force Polish citizens to seek medical help in online forums and make them eager to use various e-health services offered by private medical centers [10,19,20,47-49]. On the other hand, as IU become more experienced and comfortable with opportunities provided by the Web, they begin to use the Internet increasingly often as a useful communication channel with health professionals. New e-health technologies provide opportunities for more empowered patients, so-called e-patients who see themselves as equal partners with their doctors in the health care process [34,35,50,51]. The Cybercitizen Survey showed that 99 million adults in the United States are e-empowered patients and actions most often undertaken by them have been aimed at using the Internet instead of a doctor (61.1%), discussing information found online at appointments with health professionals (54.7%), and changing their health decisions based on information obtained online (45.8%) [35]. It seems that the trend can develop in the future, and physicians should be prepared for it.
Factors affecting Internet usage and Internet health usage
A number of factors proved to be related to the general use of the Internet and its use for health purposes in 2005–2012. Regarding age and gender, as it has been mentioned, younger people and women were the most active Internet health users. In terms of education, higher levels of education strongly affected the use of the Internet; however, for health purposes the relationship was not so clear and significant only for the survey conducted in 2012. In the study, significantly more IU had paid work or were in education; similarly, in other surveys, studying [36], employment status [18,23,36,38], higher socio-cultural position [10,37], higher income, and stable income [18,26,39] were factors that significantly influenced both general Internet usage and its use for health-related activities. With respect to place of residence, citizens in urban locations (above 100.000 residents) more often used the Internet than inhabitants in rural areas. However, the relationship seemed to be weak, and when we took into consideration only the subgroup of IUHP, a digital division between urban and rural residents was not present, which was also confirmed by Duplaga [19]. As far as health status and medical issues are concerned, the findings differ depending on whether the group of IU or IUHP was taken into account. Better self-rated state of health proved to affect only general Internet use, and IU significantly less frequently visited a doctor and suffered from long-term illnesses or disability. On the contrary, no significant relationship was found between IUHP and health status, and IUHP significantly more often visited a doctor. Moreover, IUHP or person close to them more frequently suffered themselves from long-term illnesses/disabilities. Such a discrepancy is difficult to explain; however, it seems that the situation is associated with a predominance of females among IUHP that actively search Internet for health-related information, more frequently share their health problems with a doctor, and experience various chronic diseases themselves or in their family. Other authors have confirmed some of these issues [10,36,39,52-54], but the studies in this area should certainly be continued. Finally, in what has been confirmed by several other studies [9,26,49], IU used mobile phones significantly more often; this association can be observed also among IUHP but dependency is weaker and without the statistical significance.
In most cases, all relationships were stable and did not change during the study period (2005–2012), which indicates their strong and well-established connection with the use of the Internet. The exception, as mentioned earlier, is the gender feature: in this case, male domination was replaced by female in health-related information seeking during the study period.
Profiles of IU and citizens for whom the Internet is an important source of health information
Based on correspondence analysis, profiles of the most likely Internet user and the citizen for whom the Internet is an important source of health information were constructed. The most significant variables determining both profiles in 2012 were: younger age, higher level of education, living in a big city, paid work and/or continuing education, good health status, infrequent visits to the doctor, chronic diseases in relatives, and a positive attitude regarding teleconsultations, telediagnosis, and getting access to their own medical records. The findings are to some extent consistent with the results presented by Santana et al. [31]. In seven European countries participating in the study, the citizen using the Internet to get health information to help deal with the consultation was most likely to appear as someone young, with higher education, living in a big city, consulting at least once with a doctor the previous year, and using the Internet frequently to read health websites, order medicine, participate in forums, and on an infrequent basis, to interact with a health professional they had never before met face-to-face. In turn, the study comparing e-health consumer attitudes in Poland and Greece [55] showed that, regarding teleconsultation, the acceptance of medical televisits was still low in citizens in both countries; much more positive attitudes were related to telediagnosis and online access to their own medical records. In particular, which corresponds with our profiles, acceptance appeared to be wider among IU in general and for health purposes.
Limitations
The study has several limitations. The method of collecting data used in the study was CATI, so some variables seemed to be difficult to include in the survey. One of them was income. It would have been inappropriate to ask about income during a telephone interview. Furthermore, there were few variables such as telemonitoring, telediagnosis, online access to medical records, and mobile phone use that were not included in the first survey in 2005 and even in the second survey in 2007 (mobile phone use). So in these cases, it was not possible to fully observe how and if these characteristics are subject to change over time and the corresponding designation of the trend line.
The average response rate of 33.5%, as is usual for this type of study, was low, so it could cause “non-response” and “non-coverage” bias and affect the estimates that were made. In Poland in 2005–2012, average telephone penetration was 74% (taking into consideration both landlines and mobile phones) but one should be aware that the utilization of telecommunication instruments is usually much lower among people living in rural areas, having low education, and being of advanced age.
The method of sample collection, reporting the data, and analyzing the data were exactly the same during all three waves of the study; however, the study did not follow the same individuals over the research period. So changes observed in the use, perception, and preferences regarding the Internet and, in particular, its use for health purposes, can be analyzed only from the perspective of the general population or distinguished subgroups and cannot represent the attitudes and opinions of individual participants in the study.
Although some of these results have already been reported in the published literature, the study complements preceding surveys significantly. It investigates trends and changing patterns of Polish health-related Internet use over the past seven years. To the best of our knowledge, it is the first Polish long-term study in this field.