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Internet health-information seekers in Croatia—who, what,and why?
DEAN DELIC1, OZREN POLASEK2 & JOSIPA KERN2
1Cybermed Ltd, Gospodska 28, 10000 Zagreb, Croatia and 2Department of Medical Statistics,
Epidemiology and Medical Informatics, Andrija Stampar School of Public Health, Medical School,
University of Zagreb, Rockefellerova 4, 10000 Zagreb, Croatia
(Received February 2006; accepted August 2006)
AbstractThe aim of this study is to investigate the characteristics of the Internet users in Croatia related toseeking health information, which information they seek, the reasons, and the outcomes of thatinformation on them. We surveyed the users of the Internet health portal ‘Cybermed’, in spring 2003and autumn 2004. Responses were collected from a pop-up questionnaire, which appeared at everywebsite visit. There were 369 respondents in 2003 and 580 respondents in 2004. Most respondents werewomen (82% in 2003 and 80% in 2004). While more than half of the respondents (55%) in 2003 had acollege or university degree, this changed in 2004, when only 40% of respondents had a college oruniversity degree (P5 0.001). Also, we recorded a significant age-related change, suggesting that theaverage age of the respondents increased in 2004 (P5 0.001). The leading motivation for seekingmedical information was ‘unanswered questions after visiting a physician’. Most respondents (90% in2003, 87% in 2004) went online to seek information on a specific illness or condition. Women soughtinformation for friends and colleagues more often than men (42% vs. 28%, P¼ 0.031) in 2003, whilethese differences were diluted in 2004. Approximately half of all respondents discussed the informationthey found online with their physicians. Patients who feel they were given insufficient information, orsimply seek more information than the physician provided, turn to using online health information,which no longer seems to be reserved to those with the highest education degrees. Health-care providersshould consider creating health-related Internet portals, supplementing the information they provide.
Keywords: Internet, health information, Croatia, information, patient, physician
1. Introduction
The Internet has been recognized as the fastest-growing technology ever. The number of Web
users across the globe reached one billion by the end of 2003 [1]. Research suggests that
health issues are among the most common reasons for searching Internet [2], and that 79%
of all Internet users have looked online for health information at some time [3]. Therefore,
e-health presents an interesting and communication channel, with a strong potential for
further developing patient-centred medicine [4,5].
The Internet is rapidly changing the patient – physician relationship. It is prompting
patients to ask new questions about the quality of medical care, by providing access to medical
Correspondence: Dean Delic, Cybermed Ltd, Gospodska 28, 10000 Zagreb, Croatia. E-mail: [email protected]
Medical Informatics and the Internet in Medicine
December 2006; 31(4): 267 – 273
ISSN 1463-9238 print/ISSN 1464-5238 online � 2006 Informa UK Ltd.
DOI: 10.1080/14639230600991726
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information, online medical advice, and online support groups [6]. With medical information
becoming increasingly available online, patients are becoming more active and deeply
involved in their own health, at the same time becoming more sophisticated in the questions
they ask health-care providers [7,8]. The majority of patients seeking online health
information report that the Internet improved the way they take care of their health [9].
Increased interest in the Internet was confirmed by the finding that 90% of Internet users
would like to communicate with their physicians by e-mail [8,10].
In the United States, women are more likely than men to seek health-care information
online, and the highest proportion of health information seekers are aged 30 – 64 years
[3,9,11 – 13]. A survey conducted in the European Union suggested that men were more
frequent users [14]. Although some studies suggest that the use of Internet as a supplemental
health information source declines with age [15 – 17], a recent study reported inverse results,
a greater extent of access to the Internet among younger users, but greater access to health-
related sites among older users [18].
By the end of 2004, the estimated number of Web users in Croatia was just under 1.2
million, or 27.5% of the population [19]. A country marked by a transition from a socialist to
a market economy, Croatia is struggling with new health-care standards. One of the health-
care problems is extreme workload placed upon many working physicians. In such cases,
patients may feel under-informed, and often seek additional information especially on the
Internet [19]. However, profiles and information on the health-information-seeking habits of
Internet users in Croatia remain scarce. The aim of this study was to investigate the behaviour
of Internet users in Croatia in relation to seeking health information, which information they
seek, the reasons, and the effect of that information on their behaviour.
2. Subjects and methods
2.1. Sample
The study was based on data collected by a pop-up questionnaire filled out by users of the
health portal Cybermed (http://www.cybermed.hr). The Cybermed website started in 2001 as
the first interactive and independent health portal in Croatia aiming to be a reliable source for
health information. Soon after starting, the portal received a HON Code (The Health on the
Internet Foundation Code of Conduct). The portal has two segments: a public portal for
patients, which includes a forum named Hrabri (‘brave’) for abused and neglected children;
and a second portal for health professionals. The health portal Cybermed is in compliance
with the HON Code.
The pop-up questionnaire was connected to the first page of the patients’ portal
and contained a cookie that prevented users from completing the questionnaire twice.
We collected the data over two periods, in spring 2003 and autumn 2004.
2.2. Questionnaire
The questionnaire contained questions on the gender, age, and education of visitors. In
addition, there were questions about the type of information the visitors search for, their
motivations for online searching, and for whom they seek information. Visitors also answered
questions about the effect of Internet health information they found on their own health-care
routine or the way they cared for someone else. Finally, participants responded to questions
regarding whether they believe such information, and whether they talk to their physicians
about health information found on the Internet (see Appendix 1).
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2.3. Statistical analysis
The chi-square test was used in statistical analyses, using SAS software (SAS Institute, Cary,
NC). Statistical significance was set at P5 0.05.
3. Results
The respondents in this study were mostly women (80.9%) (Table I). A total of 203
respondents (55.0%) in 2003 had a higher level of education, college or university diploma.
This percentage decreased in 2004, with only 231 respondents (39.8%) (w2¼ 37.3,
P5 0.001).
Table I. Education, type of information, reasons, and effects of Internet health-information seeking in Cybermed
portal users, surveyed during 2003 and 2004.
2003 2004 Statistics
No. (%) of respondents 369 580
Gender
Women 304 (82.4) 464 (80.0) 0.362
Men 65 (17.6) 116 (20.0)
Education and gender of the health-information seekers
High school diploma or less 122 (33.1) 308 (53.1)a 50.001
Students 44 (11.9) 41 (7.1)a
College or university degree 203 (55.0) 231 (39.8)
Type of information
Information about a specific illness or condition 332 (90.0) 502 (86.6) 0.115
Information about a specific drug 151 (40.9) 216 (37.2) 0.256
Information about a specific surgical or diagnostic procedure 115 (31.2) 138 (23.8) 0.012
Information about fitness, nutrition, or general wellness 131 (35.5) 209 (36.0) 0.867
Basic healthcare news 85 (23.0) 107 (18.5) 0.086
Other 31 (8.4) 57 (10.0)a 0.460
Reasons why health seekers have gone online for medical information
Being diagnosed with a new health problem of their own 171 (46.3) 248 (42.8) 0.279
Dealing with an ongoing medical condition 63 (17.1) 124 (21.4)a 0.104
Someone they know has been diagnosed with a medical condition 182 (49.3) 324 (55.9) 0.049
Being a care giver to someone else 100 (27.1) 161 (27.8) 0.825
Deciding to change their diet or exercise habits 139 (37.7) 222 (38.3) 0.851
Being prescribed a new medication or course of treatment 152 (41.2) 257 (44.3) 0.344
Having unanswered questions after a visit to a physician 314 (85.1) 431 (74.3) 50.001
Not having time to visit their physician 110 (29.8) 193 (33.3) 0.264
Being unable to get a referral or an appointment with a specialist 102 (27.6) 170 (29.3) 0.580
For whom health seekers go online
Themselves 348 (94.3) 540 (93.1) 0.460
Family member 291 (78.9) 468 (80.7) 0.493
Others 146 (39.6)a 147 (25.3) 50.001
Effect of online health information
Major 220 (59.6) 351 (60.5)a 0.136
Minor 139 (37.7) 199 (34.3)a 0.292
No effect at all 10 (2.7) 30 (5.2) 0.066
Online health information—subject of discussion with physician
Talked to the physician 192 (52.0) 286 (49.3)a 0.414
aSignificant gender differences in a single investigated year.
Internet health-information seekers 269
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There was no gender difference in the education profiles of health-information seekers in
2003 (w2¼ 1.69, d.f.¼ 2, P¼ 0.194), while in 2004 we detected a significant increase in the
number of men with high school or lesser education (w2¼ 7.05, d.f.¼ 2, P¼ 0.029). Most
respondents in 2003 were 31 – 55 years of age (195, 52.9%), with another large group coming
from the 19 – 30 age group (162, 43.9%). Other age groups (younger than 19 and older than 55)
exhibited less interest in Internet health information, with only 12 recorded cases in our
study (3.3%). The age profile in 2004 changed significantly (w2¼ 21.1, d.f.¼ 3, P5 0.001),
with a marked increase in the proportion of elderly users; the 19 – 30 age group was represented
by 219 cases (37.8%), while the 31 – 55 age group was represented by 333 cases (57.4%).
During their last online session, most respondents (a total of 87.9%) looked for information
about a specific illness or condition, which was followed by information about a specific drug.
Unanswered questions after visiting a physician were the leading motivation for seeking online
medical information, as indicated by 314 respondents (85.1%) in 2003, and 431 (74.3%) in
2004. Both men and women looked for health information for themselves and for family
members with nearly the same frequency (Table I). However, women in 2003 were more
likely to search for health information for patients other than themselves and family members
(18 males, 128 females, w2¼ 4.65, d.f.¼ 1, P¼ 0.031). We did not detect such gender
differences in 2004 (Table I).
Most respondents (220, 59.6% in 2003, 351, 60.5% in 2004) indicated that health
information found on the Internet had a major effect on their health-care routine or the way
they care for someone else. We detected significant gender differences in 2004, suggesting
that men reported more effects of health-related information than did women (w2¼ 7.39,
d.f.¼ 1, P¼ 0.007) (Table I). About half the respondents (192, 52.0% in 2003, and 286,
49.3% in 2004) talked to their physicians about the information they found online. Women
talked to their physicians more than did males in 2003, but the difference was not statistically
significant. However, during 2004, a strong gender-related difference was recorded,
suggesting that women discussed Internet health information more often with their physicians
(w2¼ 19.38, d.f.¼ 1, P5 0.001).
4. Discussion
This study provided a valuable insight into the behaviour of health-information seekers in
Croatia. The leading motivation for the health information search was ‘unanswered
questions after visiting physician’. This percentage is higher than that reported in other
studies. A common reason for health-information seeking in the US was ‘that someone they
know had been diagnosed with a medical condition’ [11]. Our finding could indirectly
indicate insufficient communication between physicians and patients in primary health-care
units and hospitals. Patients may feel under-informed and seek alternative ways to find out
more about their or someone else’s health problems. The effect of the health information
was substantial, as almost all respondents reported that they had learned something new
from the information they found online. Other studies reported that 81% respondents
learned something new [11].
Many studies have suggested that women are more frequent health-information seekers than
men [3,9,11 – 13]. The gender profiles of the respondents in this study suggest similar results,
but this may be due to a greater willingness among females to fill out pop-up questionnaires.
However, the interpretation of these results is potentially difficult, especially taking into an
account a fine interplay between gender and age among health-information seekers [18].
The age profile of the respondents suggests that the highest proportion of health-
information seekers in 2003 were in the younger group, 19 – 30 years, whereas in 2004 the
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average respondent’s age seems to have increased, and respondents from the 31 – 55 age
group were most common. The previous study performed in Croatia reported a younger
average age of health-information seekers [19,20]. This finding is in line with other
studies, suggesting that the Internet is no longer restricted to young users [18].
Health-information seekers holding a college or university diploma were most frequent in
2003, corresponding to several previous study results [3,9,11 – 13]. However, during 2004 we
recorded a highly interesting change, an increased proportion of users that did not have a
university degree, suggesting that Internet health information is no longer restricted to those
with the highest education degrees.
The last time respondents went online for health information, almost all searched for
information about a specific illness or condition. Interestingly, females seem to be more
interested in the health problems of others, since they searched the Internet for this
reason more often than did males. Greater female involvement has been reported elsewhere
[3,9,11 – 13]. The health information they found online had a major effect on health-care
routine for the majority of users. Most users (60%) believed the information they found
online, whereas a smaller proportion exhibited various levels of disbelief.
Approximately half of the health seekers talked to a physician about the information
they found online. Females discussed the information with their physicians more than
did males. These findings may reflect the confidence health seekers have in their ability
to discuss their health problems and health-care routines with health professionals. This may
be in line with a recent study among physicians in the USA, where 85% of physicians stated
that patients brought health-related Internet information with them [21].
One shortcoming of this study lies in the potential selection bias, since it was based only on
the responses of people that were willing to fill out the survey. However, this study supports a
role of the Internet as a supplementary health-information source. The true benefits of the
Internet can be seen in cases when patients feel under-informed, and seek additional
information online. Health-care providers should consider providing easy, free-access
information on Internet, in those health systems that are encumbered by reforms and high
physician workloads.
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Appendix 1. Questionnaire
1. Gender
a) Male
b) Female
2. Education level
a) High school diploma or less
b) Student
c) College or university diploma
3. Age group
a) less than 18
b) 19 – 30
c) 31 – 55
d) 56 – 65
e) More than 65
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4. Type of information searched
a) Information about a specific illness or condition
b) Information about a specific drug
c) Information about a specific surgical and diagnostic procedure
d) Information about fitness, nutrition, or general wellness
e) Basic health-care news
f) Others
5. Reasons why health seekers have gone online for medical information
a) Being diagnosed with a new health problem of their own
b) Dealing with an ongoing medical condition, like diabetes or high blood pressure
c) Someone they know has been diagnosed with a medical condition
d) Being a care giver to someone else
e) Deciding to change their diet or exercise habits
f) Being prescribed a new medication or course of treatment
g) Having unanswered questions after a visit to a physician
h) Not having time to visit their physician
i) Being unable to get a referral or an appointment with a specialist
6. For whom do you seek health information?
a) Myself
b) Family member
c) Others
7. Did the information you got online affect any of your decisions about health
treatments or the way you take care of yourself, or didn’t this information have any
effect on your decisions?
a) Major
b) Minor
c) No effect at all
8. Have you learned something new from the Internet health information?
a) Yes
b) No
9. Have you talked to your physician about health information you found on Internet?
a) Yes
b) No
Internet health-information seekers 273
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