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An evaluation of the health applications (and implications) of digital interactive television: case study of the LivingHealth Channel

David Nicholas, Paul Huntington, Peter Williams and Barrie Gunter Ciber, Department of Information Science, City University, London Received 23 April 2002 Revised 19 September 2002

Abstract. A large-scale and pioneering evaluation of the use of digital interactive television for the provision of health information and advice has been carried out. As part of a Department of Health (DoH) funded pilot, researchers at City University are evaluating the attempts of four media consortia to deliver health information and advice to the general public. Reported here are the initial results of one of the first pilots to complete, Flextech’s LivingHealth Channel, distributed by the cable company Telewest to 38,000 of its Birmingham subscribers. Data on subscribers’ use or non-use, ease of use, service satisfaction and health outcomes were analysed using a combination of log analysis and questionnaire survey methods. Over 1100 people were questioned and logs were monitored for a period of four months.

Correspondence to: D. Nicholas, Department of Information Science, City University, Northampton Square, London EC1V 0HB, UK. E-mail: [email protected]

1. Introduction During the 1980s there was a variety of information technology ‘platforms’ in existence, most notably Commercial online, CD-ROM, and OPACs, and therefore considerable debate in the information profession as to which was the ‘best’ or most ‘appropriate’ platform. This debate was largely conducted with regard to the use of information services for information professionals or other professional or academic end-users. The debate largely came to an end with the arrival of the PC/world wide web platform combination. It has since been re-ignited as a result of the emergence of a whole range of new digital platforms – the touch screen information kiosk, the mobile device and, most recently, digital interactive television (DiTV) – most of which, unlike the platforms of the 1980s, are targeted at the general public. If anything, the information fog we now find ourselves descending into is even thicker. Little research has been undertaken on how the newly information-enfranchised general public relates to these seemingly very different delivery platforms, nor has much thought been given to their relative appropriateness or adequacy. This paper carries the debate into the under-researched, but hugely strategic and political, consumer information field, by examining the use of the most recent and heralded recruit to the consumer information cause – DiTV. DiTV, the vehicle for WebTV, is not only a brand new platform about which very little is known, it is also a platform in which much hope is invested.

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Evaluation of health applications of digital interactive television

There is a sense, amongst politicians certainly, that this is the platform. It has wide consumer reach, uses a medium with long-standing public credentials and is thus envisaged as a principal conduit for a whole range of e-government and e-local government services for the public. Confidence in this platform stems from the fact that virtually everybody has a television set (and within a few years most viewers will possess a digital television). Most people, and most importantly even those not yet signed up to the Internet on a PC platform, are familiar with TV sets. Hence it throws an ICT lifeline to all those who have been excluded from the digital revolution to date – the poor, socially excluded, elderly etc. The hopes that politicians have for DiTV were plainly manifest in a proclamation in 2000 by the then Minister for Health, Gisela Stuart: Digital TV promises faster, easier access to health information for all and is likely to allow us to take a further significant step towards the NHS becoming the authoritative provider of advice on health at home and a proactive partner in helping people to change to healthier lifestyles.

The Government is pinning many hopes on the digital delivery of information. In addition to its fledgling NHS Direct online web site, it is introducing NHS Direct Digital, set to become the digital TV arm of this initiative. Kingston Interactive Services in Hull and Video Networks in London have been engaged in pilot NHS Direct digital video-on-demand services. However, it is not just politicians advocating the case for DiTV. Television directors, content producers, participating GPs and other health professionals, and the communities involved in these pilots, also saw themselves as pioneers of a new communications age, where passive television viewing – although still a major part of people’s everyday recreational habits – would not be the sole television option. In future, the television set would become a multimedia information database and two-way communications conduit. In short, viewers (perhaps more aptly named ‘viewerusers’) would be able both to utilize their television to obtain video-based entertainment and to send/receive information in a range of formats. The television set would thus become an information retrieval and twoway communications platform as well as a tool for both leisure and work In order to determine the success or otherwise of DiTV as an information platform for the general public, City University researchers have been evaluating a number of pilot DiTV initiatives in the health field, 182

funded by the Department of Health.* Areas of study include impact (in terms of usage figures), reasons for turning to the services, impact on the health services, and accessibility/usability issues. The study does not concern itself with the evaluation of the actual information contained in health information services – that requires medical and other subject experts. Needless to say this is also an important area of study, and some of our work [1] discusses the literature on issues such as the lack of quality control of information that can be found on the Internet.

1.1. Aims and objectives The broad aim of the study was to determine how health information and advisory services carried on DiTV were being used by the general public and whether they were satisfied with them. This paper concentrates on one of the four pilot services being evaluated: the LivingHealth channel, the first pilot project to run its course.{ Specifically, the following information was sought: . what kinds of people viewed it – personal characteristics of users, e.g. age, gender, occupation; . use data – number of users and pages viewed, time spent viewing and health topics viewed; . ease of use; . what the service was used for and perceptions of usefulness and value; . reasons for non-use and characteristics of nonusers; . future use expectations; . relationship with use of other health information and advisory sources/services.

2. Literature review We believe this is the first piece of research that has been conducted into the health applications of digital interactive television. Indeed, the research presented here constitutes the first academic analysis of the use of DiTV information services by the general public. Proprietary research has been conducted by the main interactive television players (ITV Digital, Sky Digital, * An evaluation of pilot projects exploring the health applications of digital interactive television. Department of Health, 2001–2002. {The others featuring in the pilots are: DKTV, Communicopia and Channel Health. Journal of Information Science, 29 (3) 2003, pp. 181–192 # CILIP

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NTL and Telewest) on audience penetration and reach, while advertisers using the medium have tracked where the most significant impacts have occurred. For advertisers, of course, digital interactive television provides a vehicle not just for product or service promotion, but a conduit through which consumers can actually place orders. The Yankee marketing group [2] identifies ‘key customer groups’ likely to take ITV services, including: . ‘Aggressive early adopters’ – this group is eager to acquire a second interactive device in the home, but not at the cost or space requirements of a new PC; and . ‘Third wave adopters’ – the mass-market group of ‘Internet users to come’. This refers to the potential users who may not be able to afford a PC, but have an interest in tapping the new basic interactive services available over ITV, such as e-mail, banking, shopping and travel services. Similarly, Interactive TV was said by marketing company GartnerG2 [4] to reach consumers that ‘the traditional PC Internet can’t reach. Half of interactive TV users don’t use the PC Internet – typically less educated, blue collar workers on average incomes’. Commercially confidential information acquired by the present authors (hence, it is not possible to cite) suggests that interactive television users most closely followed the profiles of early adopters of other technologies, that is, they were male and in their twenties. However, there seems to be some dispute regarding the relationship between PC owners and interactive television, with the commercially sensitive source claiming that there was no relationship between non-ownership of PCs and interest in interactive television. Research by the National Opinion Poll (NOP) organization supports the view that interactive television consumers are young. An NOP survey [5] found that among the nearly 5 million 7–16-year-olds now using the Internet almost one in 10 (9%) does so through digital TV, and that over a fifth (22%) of 14–16year-old boys accessing the Internet do so using digital TV. Research agencies such as Forrester have indicated that some high street names, such as Domino’s Pizza, Argos and Woolworth’s, together with some travel companies, have reported a degree of success with this new medium [7]. However, these cases have so far been the exception rather than the rule, and it is clear that there is still much to be learned about how to use DiTV effectively, whatever the application. This last point underlines the importance at this early stage in its evolution of conducting considered research into its

usability and effectiveness in different communications contexts.

3. Background: Flextech LivingHealth channel The service comprises both interactive and transactional services made available on a cable TV platform (see Fig. 1 for the channel’s opening screen). The pilot was carried by Telewest in Birmingham to its ca. 38,000 subscribing households – more than 45,000 people. In addition, the service is being made available on the intranets of Birmingham City Council and Birmingham Area Health Authority. The interactive service component is a content database (mostly text) on a wide range of health topics largely adapted from NHS Direct Online, although supplemented by content from other suppliers (e.g. updated daily news bulletins, medicines and services directories, and public health alerts). There is also NHS careers information provided by the Department of Health Communications Directorate. There are two transactional services: (1) NHS Direct In-Vision and (2) an On-Line Surgery Appointment Booking Service. In-Vision provides a one-way video link between a nurse in a NHS Direct Call Centre and the user at home; the video link is supplemented by a telephone link to provide oral communication between the two parties. The On-Line Appointments Booking Service allows users to book an appointment with their general practitioner (GP). Three GP surgeries in Birmingham are partners in this venture. The general service and GP booking element was launched on 28 June 2001. The In-Vision element was rolled out across Birmingham cable hubs starting 30 July 2001, and was available in all cable homes.

4. Methods A two-pronged research approach was taken to ensure that the topic could be examined in the round and in detail: . the transactional logs of the service were evaluated for the period July to November 2001 to provide detailed, real-time records of user activity; . two questionnaire surveys were conducted to provide personal, satisfaction and causal data – one shortly before the channel’s launch and the other towards the end of the pilot in October 2001.


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Fig. 1. LivingHealth opening screen.

4.1. Log analysis Log files are machine-generated records of user activity. DiTV logs are similar to those of other digital platforms and a detailed explanation of how the data is analysed can be found in a number of articles published by the authors [8, 9] Generally speaking LivingHealth logs are relatively refined and accurate by comparison with, say, the logs of a health web site. There are no problems with robot use, for instance. There are a few differences though, and these are considered briefly here: . User identification on Digital Television depends on the routing and access procedures used by the provider. In the case of LivingHealth, users can be identified only by using techniques that defeat caching by router hubs (see below). Each individual subscriber can be identified by number, but subscriber here refers to a household and the user may in fact be a family of users. . DiTV viewed pages are cached. Requested cable DiTV pages are routed through hubs that are then 184

sent on to the user’s set. Once a page has been requested, the hub will cache the page and make that page available to other users on the hub without re-requesting the page from the original server. This can result in some under-reporting of pages viewed. Caching of pages by a DiTV hub may be defeated by the inclusion of a non-cacheable ‘gif’. The idea here is that each page includes an image that cannot be cached by the hub and so requests are made to the server every time and a page count recorded. LivingHealth employed this method to defeat caching so the statistics reported below are not compromised by page caching.

4.2. Questionnaire surveys The logs disclose nothing about the personal characteristics of users and non-users, nor tell us why people use the service and what they thought of it. To obtain this information it was necessary to turn to questionnaires, given the size and geographical spread Journal of Information Science, 29 (3) 2003, pp. 181–192 # CILIP


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of the population. Two questionnaires were sent out – one near channel launch time and the second close to the end of the pilot (nearly three months after launch). The first questionnaire was designed and delivered by LivingHealth and analysed by City researchers. The second was constructed by the authors. Together, more than 1100 people responded to one or other of the surveys. . Questionnaire 1 – a questionnaire was sent by Flextech to all Telewest subscribers in the Birmingham area on the 2 and 3 July 2001. The questionnaire was sent out as part of a promotional pack. Subscribers were invited to use the channel and were asked to complete and return the questionnaire. In all, 38,000 promotional packs were sent out and by 28 July 2001 450 questionnaires had been returned. This represents a return rate of 1.5%. The low response rate is probably due to the fact that many people would not have had time to view the service as it had only been launched days earlier. Clearly, any users represent the early adopters and are people interested in health information. The questionnaire asked subscribers which parts of the broadcast they used, how often they would use it, their current healthy living practices and how easy they found it to use as well as their age and gender. The results were processed using the SPSS software package. . Questionnaire 2 – the team also constructed its own questionnaire to ascertain users’ attitudes and responses towards the service. This was distributed by LivingHealth to the 38,000 Telewest Birmingham subscriber households, and 723 (2% of the population) were returned and analysed. The sample is plainly a small one and the data should be regarded as illustrative rather than representative. Wherever possible these data have been triangulated with other data sets. The questionnaire was designed to obtain responses on the use and non-use of digital television for health information, specifically, with regard to LivingHealth. Furthermore, it asked for personal information details as well as asking people to rank the importance of a variety of other sources for health information. Apart from the sample size the study was also limited by the non-random make-up of the respondents. Those who chose to complete the survey were, of course, selfselecting. They may well have had a greater interest in the topic than non-respondents, or more time or have other attributes that biased their responses. This is, however, a common problem, and an attempt has been made to overcome this with use of other available data

where possible – in particular, the transaction logs of service use.

5. Results 5.1. Personal characteristics of subscribers and users The population surveyed was Telewest subscribers who lived in the Birmingham area. Of course not all subscribers were users of the LivingHealth channel. For clarity, the terms users (meaning Living-Health viewers) and respondents (Telewest subscribers: LivingHealth users and non-users) are used.

5.2. Gender and age More men than women responded to the survey but the difference was not great: 51% and 49% respectively. However, Fig. 2 shows that the majority of users were in fact women (57%). Typically, users were not very young, with only a little over a quarter (27%) being under 36 years of age. Encouragingly, perhaps, for the information providers targeting the older people, a higher proportion (28%) were 56 years old or more (Fig. 3). By marked contrast, children under 15 were the majority users in the case of touch-screen kiosks [10], and women in the case of a health web site surveyed [11]. Men tended to feature strongly amongst the younger users and women among the older users.

Fig. 2. Percentage frequency distribution of ‘users’ over gender. Source: Questionnaire 2.


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the number of layers that have to be penetrated to find anything. The DiTV retired/unemployed user group was not as constrained by time as those in employment and clearly that made them more willing users of the service. This is backed up by the fact that the unemployed and housewives/mothers said that they would consult the channel most frequently – 29% said they would consult the service weekly (Fig. 4b). Research with users of other DiTV initiatives [3] has also shown that unemployed or retired people are the biggest users of the health services offered.

5.4. Health responsibility for others Fig. 3. Percentage frequency distribution of users over age.

5.3. Occupation Figure 4a provides the occupation for all respondents. Just over 40% were not in employment and stated that they were either a housewife/mother, retired or unemployed. The largest group was those who said they were retired: 30% of respondents fell into this group. It may be that users are unwilling to interrogate a medical information system if they have to invest too much of their time. This was the case with kiosks, where the social situation/location of the technology also has a bearing on time spent using it. It appears that there are two factors at work here: first, context of use and pressure to move on quickly; second, complexity/ difficulty of reaching information content because of

Just under half of all respondents reported having health responsibilities for others – as we have found elsewhere [10]; this is something of a feature of health information seeking.

6. Use of the LivingHealth channel Little is known about how digital interactive television subscribers use the information and advisory services that are available to them. We believe this study represents, if not the first, certainly the most substantial analysis of use of DiTV for these purposes. Use is shown in a number of ways – users, repeat users, reach, time spent viewing, pages viewed per visit.

Fig. 4. (a) Respondents by occupation. (b) Occupation of respondent by perceived frequency of viewing. Source: Questionnaire 1.

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6.1. Number of individuals using the service daily and pages viewed The number of LivingHealth users varied quite considerably over the survey period – 18 July to 28 November 2002. Just after the launch of the channel it stood at just under 400 users a day. The number of users remained high for September (after a technical problem forced a 2 week service break) at approximately 320 users a day. The number of users recorded fell after 24 September, and from the beginning of October the number of daily users remained in the band 220–270.

6.2. Return viewers Coming back to a site constitutes conscious and directed use – as good an approximation of this as you are likely to get from web logs. Just over 59% of users visited the channel only once during the survey period – meaning that a relatively high proportion (41%) revisited the service. Figure 5 provides the number of times users returned by the first date that they used the system. It confirms expectations in that those users who visited the site early were more likely to be regular users – plainly they showed an early interest and were more willing to revisit. It can be seen that users who first visited the channel in July/August, on average, visited the channel three times in total or visited at the rate of about once a month. In looking at just those users who visited twice, the average number of days between the first and second visit was calculated at 26 days, also suggesting a return visit

frequency of approximately once a month. However, it might be expected that the period between repeat visits will lengthen over time as initial and long-standing needs are met. There might also emerge over the longer term another pattern – frequent visits followed by a period of abstinence, caused by the researching of a particular health problem. Generally, as the number of visits increased, so did the time spent on a session, although session time did decline for those users who visited the site over 15 times in the period of study. 6.3. Reach The above-mentioned figures do not tell the whole story because, self-evidently, checking on one’s health, unlike consuming the news, for instance, is unlikely to be a daily or even periodic event for most people. Reach – the percentage use made of a service by those who had access to it – provides another way at looking at use. During the period of analysis, LivingHealth was available to approximately 38,000 households. Over the period 13,718 subscriber households used the system and, based upon this figure, it is estimated that 36% of potential users accessed the service during the survey period. Note that reach is a function of the service period over which the figure is calculated. The longer the period over which reach is calculated, the higher one would expect the reach figure would be. By comparison, reach for DiTV services offering primarily video-on-demand marterial was far lower 20%. 6.4. Time spent viewing Using Huber’s robust M-estimator, the average page view time, as elicited from the transaction logs is nearly 13 seconds and session time is just over 4 minutes. On average, page view time tends to vary from about 11 to 13 seconds. However, there are (as yet) unexplained surges and falls. Not surprisingly, comparative data for services including videos showed a 50–100% longer view time [3]. 6.5. Pages viewed during a visit (service/site penetration)

Fig. 5. Number of times users have visited by date of first visit.

Service penetration, as shown by the number of screens viewed in a visit, is an important factor in measuring use because, in many menu-based information systems, the user has to navigate through a number of menu screens to arrive at what can be termed an information page. On average, 15 pages were


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Table 1 Number of pages viewed in a visit Number of pages viewed in a visit

Percentage frequency of users (%)

1–3 pages viewed 4–10 pages viewed 11–20 pages viewed Over 20 pages viewed

21.9 23.1 18.1 36.9

viewed in a visit to the channel. However this tells only part of the story. Clearly positive use implies that the information seeker navigates beyond the collection of initial menu screens to the actual information pages. Service penetration denotes how many pages the user has viewed. Table 1 groups users by the number of pages viewed. Approximately 22% of users viewed one to three pages and these users were unlikely to have penetrated past the menu screens and would not have viewed an information page. These users were unlikely to have found anything of interest and, in consequence, would then probably have bailed out quickly – a case of information-seeking without success one may assume. Note this figure compares very favourably with both users of the Internet and touch screen kiosks [8]. A large proportion (78%) of users of LivingHealth, however, navigated to an information page, and 37% showed their interest by viewing more than 20 pages on a visit. These figures have not changed since the beginning of the study and one can assume that the figures will be typical for this service.

Fig. 6. Use of sections.

the appointments booking service and the video nurse, which are the feature of a separate investigation.

7. Ease of use Ease of use information was obtained from both questionnaires. Figure 7 shows that a small majority of people did not have difficulties with using the service. Fifty-two per cent thought it very easy or easy to use the information. Of course that left a lot of

6.6. Topics viewed Figure 6 shows the sections that were available for use and the amount of use they attracted. Illness and treatment was plainly the most popular section by some margin – 39% viewed these pages. This pattern was also found in other DiTV services evaluated by the researchers. A section on ‘A to Z of medical conditions’, including diabetes, lower back pain and asthma appearing in the top 10 pages, was the most popular viewed on The NHS Direct Digital service offered by KIT in Hull [3]. This may point to the direct and practical needs to which health DiTV is being put or, perhaps, to the particular audience it attracts – the unemployed and elderly feature strongly. This bodes well one would have thought for the interactive and transactional health services hosted on the channel – 188

Fig. 7. Did you find it easy to get information (percentage frequency distribution)? Source: Questionnaire 1. Journal of Information Science, 29 (3) 2003, pp. 181–192 # CILIP


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Fig. 8. Ease of use by trust of source – percentage component. Source: Questionnaire 2. Fig. 9. General usefulness and ease of navigation of the LivingHealth service.

people saying that it was OK, hard or very hard to find information on the channel. It was found that users who only trusted the information most of the time or who did not trust the information were, respectively, twice and five times as likely to say that the service was either OK, hard or very hard to use, compared with users who said that they trusted the information on the channel. Figure 8 portrays the relationship between ease of use and the user’s trust in the service. While 51% of those finding the service either very easy or easy to use said that they trusted the service, this figure fell to 27% for those people finding the site OK, hard or very hard. Clearly there is a relationship between trust of the source and ease of use. However, the relationship here may well be that users will be less likely to trust the site if they find the system difficult to use. Future qualitative research needs to identify why this relationship might hold.

8. Usefulness, value and trust In the second survey, users were asked about the general usefulness of the service and how easy the site was to navigate, how they found the menus if the site was easy to read and understand and if the site was full of medical jargon (Fig. 9). Eighty-one per cent of respondents reported that the site was useful all or most of the time. In comparing the questions, respondents were more likely to say that the

site was easy to read all of the time – 55% of respondents said this. Furthermore, 45 and 39% of respondents reported that the site had easy menus and easy navigation all of the time. More men than women reported that the service was useful all of the time or some of the time, and those with an interest in health topics were also more likely to say the service was useful. Users were asked how much help the information they found was in dealing with the doctor, improving their condition, in changing their feelings to their condition and in understanding their condition. Nearly half were very positive about the outcome, with 49% saying that the information found had either helped or helped a lot in dealing with their doctor (Fig. 10). In this regard the videos offered by NHS Direct Digital also appear to have been very effective – a similar survey of users found that 62% of NHS Direct users said that the information found either helped a little or helped a lot in improving their condition [3].

9. Non-use Clearly, we are still going through a very early period in the development of DiTV and it is therefore important to get the views not just of early users of interactive television services, but also of those individuals within the catchment area of these services


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Fig. 10. How much help has the information found on the service been. Source: Questionnaire 2.

doctor told them everything they needed to know, compared with 20% of females (w2 ¼ 6:2, 1 d.f., p ¼ 0.13). With regard to the preference for printed information, the differences were even greater – 48% of men compared with 33% of women (w2 ¼ 11:64, d.f. ¼ 1, p ¼ 0.001). An analysis of the reasons for non-use by age shows that the older the respondents were the more likely they were to say that they got all the information they needed from their doctor. Also the older the respondents were, the more likely they were to prefer written information. As expected, and as found in other studies undertaken in the research programme [12], fears about technology increased significantly with age. People with responsibility for children were noticeably less inclined to just rely on information from their doctor and printed information than those without this responsibility.

9.1. Non-users vs users who chose not to try these services. Seventy-seven per cent of respondents had not used the service by the end of October 2002. The main reason given for not using the service 3 months after the service was launched was that printed information was preferred to DiTV information for health information – 40% said so (Fig. 11). Just under a quarter (24%) said that the doctor told them all they wanted. Examining the data by gender produces interesting results. Of those who did not use the service 29% of males reported that their

Fig. 11. Why respondents did not use the system. Source: Questionnaire 2.

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Multiple logistic regression was used to determine what factors could be important in explaining why some people had used the service and others had not. The best model fitted to the outcome variable identified four explanatory variables – whether the respondent had phoned NHS direct in the last 12 months, whether leaflets were important to the respondent, if users had an interest in general health and if the respondent had an interest in a particular condition. People who had phoned NHS Direct in the last 12 months were more than twice as likely to use the LivingHealth channel, as were users who had not phoned. Figure 11 charts this relationship; 63% of those people who had phoned NHS Direct in the last 12 months had also used LivingHealth – this was true only of 37% of people who had not used NHS Direct telephone line. Whether the user considered ‘leaflets in the surgery’ as important was also significant. Users who considered leaflets as important information sources were five times more likely to use the LivingHealth channel compared with users who did not consider the leaflets important at all. Only 17% of those users who said that leaflets in the surgery were not at all important as a health information source had also used LivingHealth. However, this use percentage increased to 56% for those users who said that leaflets were a very important information source. This suggests that people see the service in a broad context and alliance with ‘leaflets in the surgery’ and the NHS Direct phone service. Journal of Information Science, 29 (3) 2003, pp. 181–192 # CILIP


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10. Use of other health information sources People use an array of sources to obtain information and advice on health matters. Plainly DiTV is a new and novel source and it was important to know where DiTV would fit into the information array and whether it would displace other sources in the array or simply enrich the array. It has not been possible to answer this question completely at this early juncture, but a start has been made. It was found that respondents who had phoned NHS Direct in the last 12 months were more than twice as likely to use the LivingHealth service as were users who had not phoned – 65% of those people who had phoned NHS Direct in the last 12 months had also used LivingHealth – this was only true of 37% of people who had not used the NHS Direct phone line. In comparing those who had not used LivingHealth with those who had not used it but had heard of it, it was found that respondents who considered the Web important as a source for health information were more likely to have heard of the service but not used it compared with those who did not consider the Web as an important source. This suggests that those using the Web for their health information needs are not switching to digital television, even though they know about the service. For these individuals, DiTV is not a substitute for Web-based information. Further research needs to clarify why these people believe this. Those people who report visiting the doctor more frequently were more likely to report using LivingHealth. Twenty-seven per cent of users who said they had visited a doctor two or more times in the past year had used the service compared with 17% of those who said they had not visited a doctor in the last year claimed to have tuned into LivingHealth. Those people who reportedly visited the doctor more frequently were more likely to say that the LivingHealth system was useful all the time. Twenty-seven per cent of users who had reportedly visited a doctor two or more times in the past year said that the LivingHealth system was very useful compared with 14% of those who said they had not visited a doctor in the last year. This is not too surprising since we might expect unwell users to make use of the system more than well users.

11. Conclusions It is believed that what is presented here is one of the most comprehensive and detailed analyses provided for a digital consumer information platform, and most

certainly for DiTV. The methodological combination of the logs and questionnaires provides a particularly powerful data-rich evaluation of use, non-use, satisfaction and outcomes. To summarize, the key findings are: . the majority of users were women (57%) and a high proportion (28%) were 56 years old or more; users aged over 56 were more likely to be men; . just over 40% of users were not in employment and stated that they were a housewife/mother, retired or unemployed; . just under half of all respondents reported having health responsibilities for others; . use, no matter how measured, declined over the survey period; however, it is estimated that 34–39% of potential users had accessed the service during the survey period and of these a high 41% were repeat users and had visited the service at least twice; . a large proportion (78%) of users had managed to navigate themselves to an information page and 37% showed their strong interest in the service by viewing more than 20 pages on a visit; . ‘illness and treatment’ was the most popular section, however there was a marked interest in sexually related health topics; . 52% of respondents thought the service very easy or easy to use; . it was found that respondents who had phoned NHS Direct in the last 12 months were more than twice as likely to use the LivingHealth channel as were users who had not phoned; . there is an indication that those who use the Web as a source of health information are not using the DiTV in a similar way. DiTV appears to be reaching a new audience who previously did not have access to digital health information. Overall, then, the pilot must be regarded to have been a limited success. It is still early days so how successful is not quite clear yet, and it remains to be seen whether the channel will develop sufficiently. Ways in which access and use might be increased include the (planned) introduction of more interactive and targeted services, and integration of the service more with the actual health services used by the subscribers. An example of this might be where medical professionals have a good knowledge of the LivingHealth information service and are able to refer their patients to particular pages, either for consultation in concert with any leaflets or other material provided by the surgery/hospital or as alternatives to these.


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