Information, Communication & Society

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Information, Communication & Society

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Tackling the digital divide: Exploring the impact of ICT on managing heart conditions in a deprived area To link to this article: DOI: 10.1080/13691180701193127 URL: http://dx.doi.org/10.1080/13691180701193127

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Sally Lindsay, Simon Smith, Frances Bell & Paul Bellaby TACKLING THE DIGITAL DIVIDE Exploring the impact of ICT on managing heart conditions in a deprived area

The Internet is increasingly used to communicate health knowledge and there is growing belief that it can help transform both personal and public health. There is no lack of information on healthy lifestyles, but the manner of communication of risk and the level of support for lifestyle change need improvement, especially among deprived populations. Assisting vulnerable persons to increase their health knowledge could help them to be more responsible for maintaining their health. The Internet offers potential for interactivity by providing a dynamic medium for influencing learning and behaviour change, especially in so far as it enables inter-subjective communication among peers. This paper examines how the Internet might help tackle health inequalities by improving communication of risk and providing support for those who are most susceptible to changing their behaviour. The authors provide a descriptive account of whether facilitated access to the Internet may improve the capacity of older men to manage their heart conditions. Nine men aged 50 to 74 living in multiply deprived areas of Salford were given computers, Internet access and training for six months. Interviews and qualitative data were collected to assess the influence the Internet had on the management of their heart conditions before they were given the computers, after six months and three years after they were introduced to the Internet. The study was exploratory but its results suggest that interactive learning is worthwhile because it can help strengthen social support and influence behaviour change. Home access to the Internet via their own personal computer had a beneficial influence in building confidence and facilitating healthy behaviour change. Although less than half of the participants had ever used the Internet before the study, the majority of them reported using the Internet and email regularly after their involvement in the project. Keywords disease

Digital divide; interactive learning; e-health; heart

Information, Communication & Society Vol. 10, No. 1, February 2007, pp. 95 – 114 ISSN 1369-118X print/ISSN 1468-4462 online # 2007 Taylor & Francis http://www.tandf.co.uk/journals DOI: 10.1080/13691180701193127


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Introduction Health informatics already plays a central role in health education and disease prevention. The Internet has revolutionized the process of health promotion and is a valuable resource for effectively communicating health knowledge (Wong et al. 2005). It has quickly established itself as a leading source for health information and health is the single largest type of news sought by online users (Milio 2001; Bensley et al. 2004). Some 52 million adults, or approximately half of those online, have used the Internet to obtain health information and this number is expected to rise (Pew Internet & American Life Project 2001). E-health services are used for such things as online consultations, social support groups and self-management advice (Bessell et al. 2002; Hsu et al. 2005). E-health promotion may be particularly valuable to certain groups who are deprived because it can increase social support and build community, thus developing and maintaining social capital (Drentea & Moren-Cross 2005). The pitfall, however, is that the deprived are also the least likely to have Internet access in their own homes, a key factor in accessing health information (Mead et al. 2003; Dutton et al. 2005). Capacity building is a key means of tackling digital exclusion in UK policy. Such an approach is based on the assumption that participation in the information society is a community endeavour where positive social outcomes require complementary interventions in different spheres of community life. More recently, there has been a policy shift from strategies to combat the digital divide that focus exclusively on public access provision, towards a belief that public access is not ‘full’ access (Liff et al. 2002). Research suggests that public Internet access points (PIAPs) mainly augment the facilities available to people who already have experience with and access to ICT either at home or at work (Selwyn 2002). Estimates suggest that, at best, around a quarter of current non-users of information and communication technologies (ICT) in the UK can be included by a policy of public provision alone (Hall Aitken 2003). On the other hand, survey evidence shows that not only one’s own home but even relatives’ and friends’ houses are likely to be perceived as potential points of access to the Internet by more people, especially those from lower socioeconomic groups and the elderly, than are public access sites of any type (European Opinion Research Group 2001; Selwyn 2002). Evidence from focus groups conducted among Internet non-users from deprived areas in Glasgow confirms the importance of the home environment. Many participants felt more comfortable learning in their own space (Boyes & McCormick 2003). Consequently, there have been increasing attempts to take ICT directly into people’s homes, backed by outreach support and centre-based training (Loader & Keeble 2004). Given the investment in online services by


ICT AND HEART CONDITIONS IN A DEPRIVED AREA

the NHS, the same potential exists to transform networked homes into settings for access to healthcare. By implication those deprived of this option may experience an additional form of social exclusion.

E-health promotion and behaviour change E-health promotion may be a useful tool for empowering patients to become more active in their care by improving their health behaviours and using health services more efficiently (Anthony et al. 2004; Winnett et al. 2005; Wong et al. 2005). This may be especially true for online support for heart disease (Gordon 2003). In general, leading a healthy lifestyle can help reduce symptoms and extend survival time (Wise et al. 2000). However, lifestyle changes are complex and only a small proportion of heart patients attend clinics or groups for cardiac rehabilitation. The Internet may fill a gap by assisting those who are at exceptional risk for poor health, yet might not attend to cardiac rehabilitation, to increase their knowledge and ability to self-manage their disease. For example, Scherrer-Bannerman et al. (2000) examined the impact of a Web-based education and support programme for patients on the cardiac surgery waiting list. Using two forms of patient education, both a printed form and a website, they found that the Web-based format increased social support and decreased anxiety as compared with the print-based format. Similarly, Ikemba et al. (2002) found that people are increasingly using the Internet to educate themselves about heart disease. In the US, where Internet adoption is more widespread than in the UK, surveys of patients’ use of the Internet indicate that there is a real demand for online health information. Seventy-eight per cent of a 2002 US survey have used the Internet for seeking health information, and 50 per cent indicate an abiding interest in its use for clinical purposes (Anderson 2004). Middle-aged males were the most highly represented group in another US survey which also suggested that 30 per cent of people using the Internet were likely to seek support (Ybarra & Suman 2006). McMullan (2006) identifies the Internet as one of the factors in the shift from patients as passive recipients to patients as active consumers of health information who can collaborate with willing health professionals in a more patient-centred relationship. A major disadvantage in using the Internet for health promotion is that access to such resources is often under-represented among disadvantaged groups (Cotton & Gupta 2004). Those who are deprived spend the least time in institutional settings, and are therefore not as receptive to health messages delivered by the standard channels (Dooris 2004; Wong et al. 2005). Similarly, the UK’s NHS Direct Online, a dedicated site set up by the state to promote public health, has shown that users tend to be middle

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class with self-limiting conditions (National Audit Office 2002). Thus, the realistic potential of Internet access for this purpose is yet to be assessed. Little is known about Internet use for health purposes amongst those who are older and deprived, except that many in this category do not have Internet access (Dutton et al. 2005) or do not see the need for it (Mead et al. 2003). Although in popular discourse ICT is depicted as determining the shape of society, it is more accurate to say that the diffusion of ICT has been socially shaped (Hine 2000; Holloway & Valentine 2003). The Internet is mutually constituted along with the real physical and social environments in which people use it (Graham 1998). Much social shaping occurs on a community scale. For example, in low-income areas patterns of technology adoption cannot flow across from the spheres of work and higher education to the same extent as in wealthier neighbourhoods, because the deprived tend to be excluded from work and higher education. Instead, the deprived rely more on kinship and neighbourhood networks and, owing to limited exposure to ICT, there is a greater requirement that they mesh with existing ‘cultures of practice’, including informal learning practices.

Interactive learning strategies for health information seekers Interactive learning has been defined in two ways: (1) ‘allowing or relating to the continuous two-way transfer of information between a user and the central point of a communication system, such as a computer or television’; and (2) (of two or more persons, forces, etc.) ‘acting upon or in close relation with each other; interacting’ (Hanks 1989, p. 650). Much health promotion has been guided by the idea that providing highquality information should be sufficient to change beliefs and that changing of beliefs should be sufficient to change behaviour (Department of Health 2004). However, whether learning, let alone changing behaviour, takes place depends on more nuanced processes such as how well the message is heard, understood and trusted and how much support individuals get in translating new knowledge into changing practices (Vingilis & Lindsay 2001). On the one hand, the Internet offers potential for interaction with the source of information, that is, a dynamic medium for influencing learning and maybe changing behaviour (Nguyen et al. 2004). This is consistent with John Dewey’s (1991) educational philosophy, which has been highly influential in education, particularly in informal education (Kolb 1984; Boud & Solomon 2001). Dewey sought to displace attention from facts to be learned and knowledge to be stored, to the process of interactive learning in the course of activity and experience, and to focus on growth in capacity as opposed to reaching a definable end-point. Early notions of interactivity in computer-aided learning (CAL) concentrated on the interaction between the learner and the computer, usually



through a piece of instructional software. However, Moore (1989), recognizing the imprecision in use of the term ‘interactivity’ in distance education, identified three types of interactive learning: learner –content, learner – instructor and learner – learner. Since then, with the increasingly widespread use of ICT and the spread of the Internet, CAL has taken a turn toward the social aspects of learning. There has been growing interest in social constructivist approaches in education in general. Brown et al. (1989) characterize the meaning of activities within a domain as being socially constructed between members – past and present. They say that authentic activities ‘are most simply defined as the ordinary practices of the culture’ (Brown et al. 1989, p. 34). The new emphasis on learning in the course of interaction with peers links to the observation that patients’ trust in experts tends to decline following a heart attack. In this circumstance, learning in interaction with peers may be effective in encouraging patients to self-manage their disease (Stout et al. 2001). Evidence suggests that peer-led social support has positive health benefits (Turner 2001). The Internet offers a diluted form of social interaction, lacking in face-to-face cues such as mannerisms and accent. Given that these cues indicate social class, the Internet offers the potential for social support and influence across class boundaries. The Internet also offers an opportunity for virtual social support among individuals who might otherwise be isolated. Assuming that the culture of patients seeking health information is responsive to increasing Internet use and malleable for changes in communication and support-seeking behaviours, it is appropriate to consider the possible impact of the relatively new phenomenon, online communities. There are many online health communities that offer various configurations of support and information resources to their growing number of users (Blank & Adams-Blodnieks 2007). Many are examples of what are called ‘empathic communities’ (Preece 1998), where participants can learn and engage in authentic activities. They are experiencing what Brown et al. (1989) call ‘situated cognition’ in which it is easier to learn from natural activities, contexts and cultures. A bigger question is whether they can translate this learning into behavioural changes (e.g. smoking, diet and exercise) that can realize health gains that go beyond feeling supported and less anxious. As Dewey (1991) might have recommended, we should try to understand health information seekers’ behaviours both on- and offline.

Methodology Here we provide a descriptive account of the impact that providing home Internet access may have had on the health and social behaviour of a small

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number of older deprived men with heart disease. The description is largely theirs and much of it is in retrospect. It is not the hard evidence that we are now seeking by means of a randomized control trial, in which both cases (who have Internet access) and controls (who have normal treatment only) are monitored systematically. The study reported here nevertheless informs our current work at many levels. This medical sociology project focuses on heart disease because it is the most common cause of death in the UK (Peterson et al. 2004). Our sample was drawn from Salford in Greater Manchester, England, because nearly half of the electoral wards here are in the top 10 per cent of the most multiply deprived wards in England, including for increased risk for heart disease (Salford PCT 2005). A purposive sample of nine men aged 50 to 74 from deprived areas of Salford was recruited from a cardiology follow-up clinic (n ¼ 1), a cardiac rehabilitation group (n ¼ 2), a heart care support group (n ¼ 2) and a community health action programme run as part of New Deal for Communities (n ¼ 4). All of the men were given computers to keep, training at the outset and home dial-up Internet access for six months. A technician installed the computers in the respondents’ homes and also assisted with any technical difficulties that arose for six months. Access to the Internet was through a purpose-built, password-protected project portal. Through the designated website for the project, participants could share information and provide support to one another, but they were free to use the Internet as they wished. Data were collected between November 2002 and December 2005, but intermittently. The study received ethics approval from Salford University and the Greater Manchester local research ethics committees and governance clearance from Salford Primary Care Trust. No conflicts of interest existed between the researchers and the participants. A baseline questionnaire was conducted while most of these patients (n ¼ 7) attended a two-day, face-to-face training workshop in a local community centre on how to use a computer, specifically the Internet and email. Two of the participants were unable to attend as they were recovering from recent bypasses. Although the participants were not trained directly in e-health literacy (i.e. what is good and useful information) they were encouraged to use links on the portal to health websites that were recommended by an expert panel of heart care professionals and also to evaluate how informative and user-friendly they were. The baseline questionnaire examined the following variables: age, marital status, employment status, whether or not they had heart surgery, how much alcohol they consumed, number of cigarettes smoked per day, types of exercise engaged in, amount of fruit and vegetables per day. Computer-related questions included: whether they had used a computer, Internet and email. We also asked how often they used the Internet and email three years



later, about the usefulness of the Internet for health information and how the Internet helped to change their health behaviour. Interviews were conducted at the beginning and after six months to assess the influence the Internet had on the management of their heart conditions. A focus group was conducted with the smaller group of men (n ¼ 6) three years after they entered the study, in order to explore the sustainability of any initial impacts their exposure may have had. One of the original nine could not participate because his health was too poor; another had just undergone heart surgery and was unable to attend, while a third could not be contacted. The interviews were guided by a brief questionnaire and detailed field notes were made by the researcher. The focus group discussion was tape-recorded and transcribed verbatim. Data collected in the focus group were sorted, coded and categorized with the aid of NVIVO, a qualitative data analysis program (Richards 1999). This program assisted in condensing the data and identifying relationships among central themes around the issues of Internet use and self-management of heart conditions. The project drew on interpretive traditions within qualitative research, where the researcher seeks an in-depth understanding of the experiences of the participants (Miller & Dingwall 1997; Green & Thorogood 2004). The analysis began by reading through each transcript several times and noting emerging themes and patterns. Analysis gradually evolved into the stage of axial coding, which was concerned with the properties of the themes and their interrelationships. A validation process was built in whereby the first and second authors compared established codes and developed additional categories when necessary. The trustworthiness of findings was established by ‘peer debriefing’ and ‘member checking’. Peer debriefing took place by discussing the interpretation of the data with each of the authors. Member checking took place by discussing the key themes with two of the men who participated in the focus group to ascertain whether the results reflected their experience.

Results The age of the initial sample ranged from 51 to 66 years. The majority of the sample were married and either retired or unemployed. Although some of the participants (n ¼ 4) had some prior (yet limited) computer experience the majority of them did not own one (n ¼ 7) and most of these had never used the Internet or email. Although four of the nine patients had ever used a computer before the study started, three years later all but one of the eight who took part originally and were traced for the focus group reported using the Internet and email regularly.

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Overcoming barriers in going online This deprived older male sample encountered a number of obstacles, including a fear of technology, lack of confidence and literacy problems. For example, two participants claimed: I think a lot of people won’t do it [go on the Internet] because they haven’t been encouraged. They seemed frightened. It’s there and you just need someone to guide you through. I think we were frightened of it [computers], because we think ‘modern technology’, you know. I think we’ve sort of come down from this generation where you can’t teach old dogs new tricks but we are completely the opposite. You’ve taught these dogs new tricks. Some of these participants had poor literacy and were apprehensive at first about posting messages and emailing. For example, one man claimed that he was worried about posting messages because he ‘was never any good at writing at school’. Although many of the participants reported lack of confidence in using the Internet at first, they said that their confidence increased over time. This enabled them to find out more about their heart condition. Many of the participants did not feel confident enough to be fully open with each other by email during the pilot unless they had a prior relationship. For instance, one participant said, ‘You’re going to be a bit defensive and do not want to reveal anything to strangers’. It quickly emerged that participants wanted a page where they could share personal information and, in negotiation with them, an About Us section was added. This consisted of a page of photographs and biographical details of the participants. The use of photos is also important to develop empathy because it portrays identity and increases trust. This was important in developing an interactive element, which is critical for influencing learning and behaviour change. The participants reported that one is going to make mistakes along the way but it is all a part of the learning process. For example, they reported: ‘You get your confidence and it just doesn’t matter if you make a fool of yourself because that’s how you learn’. Another said, ‘I was terrified at first but I feel proud of myself now’. Although there were several barriers to overcome, having an interactive learning approach seemed to help them to overcome their fear of computers.

Information seeking and confidence building Before participants sought support from others in a similar situation, they first wanted to become better informed about their heart condition. Many of



the participants found that their confidence in managing their health increased once they found out more about how the heart works. One participant captured it best: ‘You just learn what your heart is and what it does and basically it’s just like a pump isn’t it?’ Similarly, others claimed that having access to health information online helped to take the fear out of having their heart condition: There’s a lot of information there. It makes you feel a lot better. It takes a lot of the fear away. It’s a horrible feeling once you’ve had a heart attack. It’s very frightening but once you go into the Internet and find out everything about the condition, you feel a lot better. Seeking information and support online helped many participants to realize that they have something to contribute to the world. For example: I know now that I’ve got something to offer the world rather than ‘what’s the world got to offer me?’ That’s what the Net does. You’d be surprised how many people think they were worthless and they know a hell of a lot but they don’t realize it themselves what they’ve got up here. So they think ‘well I’ve had a heart attack so I’m ready for my box’. It’s just encouraging them to see through that. The participants described how they wanted to learn more about their heart condition in order to increase their confidence in managing it. They all tended to agree that ‘once you’ve had a heart attack you have to educate yourself’. Indeed, having a heart attack does change you because when we first had a heart attack we thought ‘I’m finished’. That’s the way you feel but as you get into it and you learn a little bit more about some of the conditions it does ease your mind and you’re more relaxed about it. I thought well, I’m not letting it beat me and I want to find out as much as I can about heart disease. The Internet was seen as a useful resource for informing patients and helping to take some of the fear out of what had happened to them: People seem to be a little bit more informed by what they’re learning on the net. I think that’s the frightening thing about it when you’ve first had one is, ‘well, what’s happening to me now?’

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Becoming more informed about their heart condition also helped to build their confidence: I feel confident in the things that I look on the Internet for and getting in touch with other people and people being in touch with me. It gives you more life after a heart attack. It doesn’t stop and that’s what the Net tells you. Many of the patients felt empowered by learning more about their heart condition, especially how the heart works and what causes a heart attack. This encouraged them to seek more support from others in similar situations.

Seeking support Many participants in this sample found the Internet useful for interacting with others who had heart and other health problems. They especially wanted to know if it was normal to feel the way they did after they had their heart attack and particularly whether other people had similar feelings and experiences. One man said, ‘that’s where the Internet helped me because I wasn’t getting the information I wanted’. He particularly wanted to know: why am I feeling like this? I wanted somebody else to say, ya, I felt the same way to make me feel a little bit better and that it just wasn’t me that was causing problems. I was looking for people in my predicament and telling me what they felt. Several participants also discussed how their use of the Internet helped to increase their social contacts. For example, one man reported, ‘My social contacts are up ten-fold’. Other participants reported meeting people through chatrooms: I go on AOL, well the AOL people that I met when I go into the chatrooms they have bashes around the UK, you know, get-togethers. They all get together and sometimes I meet these people and we’ll talk on the Net too at these bashes. So we do meet on a face-to-face. So that’s nice when you can do that as well. One important result of meeting such people online was that it helped these participants to appreciate their lives more. I found out that I’ve had quite a damn good life. Until I got to know those people and started talking to them now and that’s what’s made me really appreciate the area that I’ve been in.



When you’ve had a heart attack you don’t feel like talking to people, whereas when you’re in a group like we are, you realize that you’re going through the same experiences. We were a bit quiet when it happened to us because we couldn’t really accept it. The Internet provides an opportunity to interact with others, which can stimulate learning and behaviour change.

Improving health behaviours Having home access to the Internet appeared to influence the self-reported health behaviours of these patients in several ways. Most of the participants found the Internet helpful for increasing their knowledge of healthy eating, particularly the fat content of food and the importance of eating five portions of fruit/vegetables per day. For example, one man claimed: ‘Regarding the Internet I eat a lot better. I eat more fruit’. Similarly, others claimed that searching for information online helped them to realize that ‘diet is one of the main things’. Several participants also used the Internet to find new healthy recipes to try. Others claimed that health information online was valuable because it helped them to be more informed about their condition and the medication they were taking. A couple of participants were not sure if they actually had had a heart attack so they checked the medical terminology online: ‘Well . . . my doctor said I had myocardial infarction and I never knew for sure before now that I had had a heart attack’. Some were particularly interested in finding someone who had been in a similar situation, as was a man who had nausea and was concerned that it might indicate a worsening of his heart condition: On the net there was somebody that was having the same type of problem. That led me down a different road because this guy was having it. Many described that the Internet was practical for finding new healthy and low-fat recipes. One participant said that the health information he found on the Internet regarding fat consumption led him to eat more healthily and reduce his fat intake. Similarly, another patient found useful dieting information through the Internet, which helped him to reduce his cholesterol. Many participants used the Internet to find out more about their condition, the causes of heart attacks and the medication they were taking. For example, one man claimed that he searched the net to find out about ‘what my medication does. So I have a good idea of what each tablet does and know why I’m taking them.’

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Another patient used the Internet to find out about the side effects of his cholesterol medication because it was making him feel ill. He took this information to his GP who then reduced the dosage to minimize his symptoms. Thus, this helped to empower him and helped him to take a more active approach in the management of his heart condition. I think that’s the information that you want on the Internet. I have low blood pressure and if I get up quick then everything starts to go. You can’t regulate yourself when you get up. If you remember then you just stay for that few seconds. Nobody ever taught me about this and of course, I’m in the hospital because of low blood pressure and from bending down – and that is information. The patient who had nausea emerged in the course of the study as an ‘expert patient’, checking his cholesterol medication online and realizing that one side effect was nausea. He consequently visited his GP and got the dosage reduced. I was having lots of sickly problems and [the GP had] put me on these magnesia tablets. . . . I went back to the doctor and said look, would you mind changing the statin to something else, I’m on a very high dose. Then he reduced it. The improvement was unbelievable. For some, the Internet also helped to increase awareness of local exercise programmes. Some patients mentioned how ‘We do a lot more health walks now’. Meanwhile, others described: I go to exercise groups which are phase four from the hospital. Exercise is very important whether you’ve had a heart attack or not. You know, just an hour a day is important. In the participants’ eyes, using the Internet not only helped to increase confidence but also helped some of them to overcome their depression as well. For instance: The Internet makes me value my own life because I didn’t really know until I went on there [the Internet], what a decent life I’ve had. I thought I was just a needy old goliath but when I go out and I speak to people on the Net it makes me appreciate my life a lot more. Hearing other people’s stories has made me appreciate what I’ve had in life so far.



You don’t take it [your health] for granted as much as what you used to. You look after it a bit more. You’re realizing what it does. When you’re younger you don’t. You just take it for granted. Accessing more health information through the Internet helped to empower many of these patients to challenge their healthcare providers. If you see something new on the Internet you can go and have a word with your GP. So it’s helping you to prevent having another one. If your doctor takes them off [statins] you want to know why because there’s a lot of false information. There’s a few people under the conception that the beta-blockers are a steroid. The idea of those is that they keep your heart rate down. Last year I was in the hospital and they took me off the tablets, off everything but my pulse rate was up to 120– 130 and the doctors were coming around and they couldn’t understand why my pulse rate was so high. I said, it’s because of the medication and I’m trying to explain to them what it did because I’m just a lay person compared to the doctors but they didn’t seem to know. I’m trying to explain to them that I need to go back on that and this is as I was getting a lot better. Most of the participants in this study found the Internet very useful for providing health information. By their own accounts, the Internet also brought about changes in their health behaviours, particularly their eating habits, medication use and relations with healthcare providers.

Discussion and conclusions The Internet is increasingly used as a forum to communicate health knowledge. The results suggest that home access to the Internet may provide an effective resource for influencing learning and behaviour change. Although many of the participants lacked the knowledge and confidence to manage their disease at the beginning of the study, three years after their original introduction to the Internet the majority were more informed and confident about managing their health and had developed strategies for meeting their specific informational needs and making better informed decisions. Facilitating a face-to-face training session and encouraging participants to have a ‘frequently-asked questions’ section on how to deal with common computer problems may have been an effective way to overcome initial fears of using the Internet among an older, deprived group. Once some of the fear of having the disease was allayed, they began to seek support from others in similar situations. Learning how to self-manage

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their heart condition was important, because patients who are more informed about their disease tend to make better use of health professionals’ time, the severity of their symptoms tends to reduce and their confidence, resourcefulness and self-efficacy tend to improve (Wheeler 2003). The results suggest that seeking information helped to reduce fear and build confidence in managing their disease. After having their heart attack many of the participants felt as if they wanted to search the Internet because they wanted information on what had happened to them and what they should do now. Information and knowledge may help people to feel reassured about their condition (Nettleton et al. 2004). This is consistent with the research by Mehra et al. (2004), who found that developing IT literacy among minority and marginalized users was in itself rewarding and empowering. The findings in this study are consistent with Wise et al. (2000), who found that online communication is linked with improving self-confidence and diet. Improving self-confidence is important because it is a powerful mediator of self-care, especially in cardiac patients (Carroll 1995). Similarly, an improved knowledge of what constitutes a healthy diet is crucial for those with heart disease because it can provide a protective effect on health. Evidence suggests that an increase of fruit and vegetables can help lower blood pressure (Ziebland et al. 2002). It may be that, at first, the patients in this study had what Nettleton et al. (2004) refer to as ‘affective reflexivity’, a passive form of Internet use, with no consequences for observable social action but many at an emotional level. As participants became more comfortable with the Internet and more informed about their heart conditions, they became ‘instrumentally reflexive’ (seeking information and then acting on it) (Nettleton et al. 2004). The Internet helped to influence a better understanding of their condition, contributed to better decision-making and helped to frame their disease and the management of it in a different way. Later still, seeking support from others seemed to reassure these patients that they were doing the ‘right’ thing and that others had had similar experiences. This is consistent with the findings of Nettleton et al. (2004) after examining how lay people engage with e-health. In the participants’ own eyes, the Internet had led to changes in behaviour. Some participants felt empowered to ask their doctors questions or even to challenge them about why a certain medication had been prescribed. This is consistent with Hardey’s (1999) observation that the Internet informs a new struggle over expertise in health that will transform doctor –patient relations. The men’s increased awareness of their condition may have led them to be less deferential towards their health providers and more reflexive in their approach to their advice and treatment. Given that they were men, their sense of empowerment may have arisen from ‘disembodied participation’, the fact that virtual reality permitted them to interact with each other unseen. ‘Hegemonic masculinity’ tends to lead



men to deny weakness or vulnerability, to assert emotional and physical control, to try to appear strong, and to dismiss any need for help (Courtenay 2000). The tiny online community may have provided an opportunity for these men to seek support from other men without threatening their masculinity. To reach marginalized groups, both ICT and health policy initiatives need to target everyday settings such as the workplace, school and home, or wellfrequented clubs and community centres, which are deemed ‘safe, familiar environments’ that people use for other reasons, including social ones (Robson 2001). If ICT can help bridge the gap between formal and informal settings, by ‘networking’ the domestic environment and the traditional ‘third places’ of neighbourhoods and by designing online social architecture responsive to the needs of deprived communities, it may also play a role in reducing health inequalities. There was evidence of increased social contact online that developed into face-to-face meetings at AOL ‘bashes’ for one participant; and also a fresh appreciation of their local area through online social contact with new people from their own neighbourhood. Effective health interventions that make use of the Internet therefore need to take into account the social context of Internet use and work with the opportunity structures defined by the resources and social networks accessible to particular individuals and groups. Those that do so have the potential to facilitate the types of healthpromotion strategy increasingly called for by the World Health Organization (2005), going beyond the modification of individual risk behaviour by acting on the social determinants of health, empowering people and communities to make choices previously unavailable to them because of social or environmental constraints. This would be particularly pertinent to places like Salford, where poor health outcomes can be explained in part by the prevalence of ‘pathways to ill health’ leading through loss of social support and social cohesion and an ‘ontological insecurity’ driven by the pace of change in the urban environment (Popay et al. 2003). The larger project of which this study is a pilot phase addresses an important gap in the literature on e-health and the digital divide. First, this project is one of the few of its kind to distribute home computers and free Internet access among a deprived, older population. Some evidence suggests that public interventions that have given out computers help to increase social capital (e.g. Smith et al. 2004) but they tend to have had a communitywide focus and have often targeted young families. This study has helped to bridge the digital divide by encouraging older and somewhat less experienced persons to use the Internet to help manage their health. Most previous research has tended to focus on the use of the Internet for health information amongst those who already own a computer while little is known about Internet use and impact on behaviour among specific populations, particularly

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those who are older and deprived (Diaz et al. 2002). Finally, most studies examine immediate changes in behaviour while this study has thrown some light on changes in health behaviour and Internet use over the longer term (three years). The importance of this research lies in the generalizability of the key concept of ‘empowerment’. It refers to a mobilizing force that enhances the health-seeking strategies of the participants. The concept is constituted by ideas of normalcy, control and the reinforcement of self-identity through increased interactivity online, which leads on to a more active form of citizenship (Barry 2001; Green & Thorogood 2004). A limitation of the small pilot study is that it cannot address the efficacy of the intervention and any underlying causal processes since there was no control group. The results themselves are not generalizable since this research was qualitative in nature. Thus, future research should examine the impact of online interventions while testing them on larger numbers against the experience of controls that receive normal treatment only.

Acknowledgements The authors acknowledge gratefully the contribution of Pauline Marshall, who undertook the pilot study, and also the broader influence exercised by Paul Bellaby’s co-investigators, Rose Baker, Dick Heller and Steve Kay. The current phase of the project is funded by the Economic and Social Research Council within its ‘e-Society’ programme and the HEFCE Science Research Infrastructure Fund.

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Wong, B., Yung, B., Wong, A., Chow, C. & Abramson, B. (2005) ‘Increasing internet use among cardiovascular patients: new opportunities for health promotion’, Canadian Journal of Cardiology, vol. 21, no. 4, pp. 349 – 354. World Health Organization (2005) Investing in Poor People and Empowering Them to Participate in Development, Annual Report 2005, World Bank, New York. Ybarra, M. & Suman, M. (2006) ‘Help seeking behavior and the Internet: a national survey’, International Journal of Medical Informatics, vol. 75, no. 1, pp. 29– 41. Ziebland, J., Yudkin, P., Roe, L. & Neil, H. (2002) ‘Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomized controlled trial’, Lancet, vol. 359, no. 9322, pp. 1969– 1974. Sally Lindsay is a Medical Sociologist and a Research Fellow in the Institute for Social, Cultural & Policy Research at the University of Salford. Her research interests include health and social inequalities and gender issues. Address: 4th Floor Humphrey Booth House, University of Salford, Salford M5 4QA, UK. [email: [email protected]] Simon Smith is a Sociologist and Research Fellow in the Institute for Social, Cultural & Policy Research at the University of Salford. Address: 4th Floor Humphrey Booth House, University of Salford, Salford M5 4QA, UK. [email: [email protected]] Frances Bell is a Lecturer and Post Graduate Tutor in the Informatics Research Institute at the University of Salford, 500d Maxwell Building, University of Salford, The Crescent, Salford M5 4AQ, UK. [email: [email protected]] Paul Bellaby is a medical sociologist, Professor of the Sociology of Health and Director of the Institute for Social, Cultural & Policy Research, University of Salford. Address: 4th Floor Humphrey Booth House, University of Salford, The Crescent, Salford M5 4QA, UK. [email: [email protected]]