IHC may help reduce health disparities through their potential for promoting health, preventing disease, and supporting clinical care for all. Recent data indicates that the profile of Internet users may be becoming more representative of the general population (PRCP&P, 1999), but the poor and others who have preventable health problems and lack health insurance cover- age are unlikely to have access to such technologies (Eng et al., 1998; US Department of Commerce, 1998). Data shows that lower income families, rural households, African Americans, and Hispanics are less likely to own a computer or have Internet access than other groups (US Department of Commerce, 1998). For example, in 1997, only 2 percent of rural US house- holds with incomes between $5,000 and $10,000 had access to online services compared to 50 percent of families with incomes greater than $75,000 in 1997. Enhancing access to health information and support may promote more efficient use of services (Pane et al., 1991; Stern et al., 1991), reduce the total costs of illness (Gustafson, Peterson-Helstad et al., 1995), and help avert preventable health conditions that disproportionately impact lower income populations (Shimakawa et al., 1994; Liu et al., 1996). Although data on the impact of IHC on underserved populations are limited, some studies suggest that it can improve health knowledge, attitudes, and cognitive functioning (Gustafson, Hawkins, Boberg, Bricker, Pingree et al., 1994; Carroll et al., 1996); enhance emotional well-being (Gustafson et al., 1993); and reduce utilization of health services without impacting health (Alemi, Mosavel et al., 1996; Gustafson, Hawkins, et al., 1999). If these effects can be consistently replicated, substantial improvements in public health and health care cost savings can be realized among the underserved. In addition, as reliance on online health information and support resources become more common for routine functions such as making appointments and communicating with health professionals (Zallen, 1995), access to IHC becomes an increasingly essential component of health services access and health maintenance.
Barriers to IHC access include those related to technology infrastructure access and those associated with the characteristics of nonusers and the infor- mation and applications themselves. Certain populations also have difficulty accessing online health resources because most IHC applications are designed primarily for educated, literate, and nondisabled audiences. Many people have inadequate skills in science, technology, or reading literacy; cannot understand or use health information; have a physical disability; or cannot communicate in English (Williams et al., 1995; Baker et al., 1996; Yom, 1996; Williams et al., 1998; WWW Consortium, 1998).
Underserved populations are keenly interested in using technology includ- ing the Internet (US Department of Commerce, 1995; Hoffman and Novak, 1998). Studies show that, with appropriate training, many underserved groups including low-income families (Kinzie et al., 1993; Watkins et al., 1994; Gropper et al., 1995; Bier et al., 1996; Kraut et al., 1996); residents of inner cities, housing projects, and rural areas (McTavish et al., 1994; Alemi, Stephens, Muise et al., 1996); disabled persons (Hassett et al., 1992); the elderly (Ellis et al., 1991); racial/ethnic groups (Gustafson et al., 1994; Pingree et al., 1996); and drug users (Alemi, Mosavel et al., 1996; Alemi, Stephens, Javalghi et al., 1996); can successfully use technology to address health concerns. Studies suggest that low-income consumers are savvy about persuasive marketing communications (Alwitt and Donley, 1996), want independent information when purchasing a range of products (Mogelonsky, 1994), and, thus, can critically evaluate information.
Providing universal access will require a collaborative effort among a wide variety of stakeholders on all levels (Milio, 1996; McCray and Maloney, 1997). Without external intervention, market forces are unlikely to address the needs of those without access. While universal access at home is ultimately desired, for the near term, until home access is universally available and affordable, universal access may necessitate a combination of private (i.e., home) and public (e.g., schools, libraries, public buildings, post offices, shopping malls, com- munity centers, health care facilities, places of worship) access points (Eng et al., 1998). The Telecommunications Act of 1996 provided support for univer- sal access to advanced telecommunications by authorizing universal service discounts to K-12 schools, libraries, and rural health care and public health facilities, but full implementation of the program is uncertain (FCC, 1998). Additional models for supporting access that have multisector backing may be necessary.
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VII
Recommendations
The following recommendations of the Panel stem from reviews of published data and studies, discussions among Panel members, interactions with other participants at Panel meetings and presentations, and comments and suggestions from the liaisons to the Panel during the course of more than 2 ½ years. Although the ideas presented here resulted from careful and systematic evaluation of available information and data about IHC by many experts, the science base on IHC is limited, and these recommendations should be viewed as informed guidance rather than as definitive directives. The Panel’s recom- mendations are intended to promote and focus debate and discussion among IHC stakeholders—those who develop applications, those who use them, those who purchase them for others to use, and those who establish policies that affect their use. Additional consensus-building processes could build on and further refine the Panel’s suggested guidance in this evolving field. Disagree- ments about some of the Panel’s recommendations may emerge because some of the issues around IHC are controversial and challenge traditional roles and systems. In these cases, colleagues are encouraged to offer differing perspec- tives on these issues and engage in a constructive public dialog to advance the field of IHC.
Vision
“Interactive health communication will play an essential role in enhancing health, minimizing total burden of ill- ness, and optimizing relationships between individuals and health professionals.”
The Panel believes that IHC has the potential to contribute substantially to the health of the public. Individual health status can be enhanced through the use of IHC for health promotion and disease prevention. By reaching, informing, and motivating people in innovative ways, these technologies can augment public health efforts and minimize the total burden of illness and its economic and social costs. By providing peer and emotional support, IHC has the potential to alleviate the adverse social and emotional consequences of illness, and, perhaps, improve functional status. The Panel believes that IHC will not replace health care professionals, but complement what they do. Indeed, IHC could strengthen the relationship between patients and health professionals in several ways. For example, by providing appropriate health information to patients outside the context of an office visit, patient-provider encounters may be better focused and more efficient. By enabling and facili- tating shared decisionmaking processes, patients are more likely to achieve their desired outcomes and express satisfaction with their care.