Patient satisfaction, e-health and the evolution of the patient-general practitioner relationship: Evidence from an Italian survey

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Please cite this article in press as: De Rosis S, Barsanti S. Patient satisfaction, e-health and the evolu-tion of the patient–general practitioner relationship: Evidence from an Italian survey. Health Policy (2016),

http://dx.doi.org/10.1016/j.healthpol.2016.09.012

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Contents lists available atScienceDirect

Health

Policy

j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Patient

satisfaction,

e-health

and

the

evolution

of

the

patient–general

practitioner

relationship:

Evidence

from

an

Italian

survey

Sabina

De

Rosis

∗

,

Sara

Barsanti

ScuolaSuperioreSant’Anna,IstitutodiManagement,LaboratorioManagementeSanità,Pisa,Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14November2014

Receivedinrevisedform7September2016 Accepted18September2016 Keywords: E-health E-patient Empowerment Healthliteracy Behaviour Doctor–patientrelationship Satisfaction Healthcaresystem Generalpractitioners

a

b

s

t

r

a

c

t

Background:Scientiﬁcand publicinterestintheuseoftheInternetforhealth-related

purposeshasgrownconsiderably.Concernsregardingitsimpactonpatient–doctor

rela-tionshipandrisksforpatientshaveinﬂamedthedebate.Literatureprovidesscarceevidence

inthisﬁeld.Thispaperinvestigateswhetherapatient’sdecisiontousethewebalsodepends

onpreviousexperienceandsatisfactionwithhealthcare.

Method:Statisticalanalyseswereconductedusingdatafromasurveyofmorethan1700

citizensinTuscany(Italy).TheAndersenbehaviouralmodelwasadoptedasframeworkfor

investigatingtwopatientbehaviours:Internetuseforhealth-relatedpurposes;discussion

ofonlineﬁndingswiththephysician.Twoseparatemultivariatelogisticmodelswere

per-formedtoverifywhethersatisfactionandexperiencewithhealthcaresystemandgeneral

practitionerswereassociatedwiththee-healthbehaviours.

Results:Age,educationanddissatisfactionwiththehealthcaresystemarethemain

determi-nantfactorsofe-healthuse.Thebehaviourofsharingthee-healthexperiencewithgeneral

practitionersismorediffusedamongthosepatientswhoaremoresatisﬁedwithphysicians

fortheinvolvementinthedecision-makingprocessandsuggestionsonlife-style.

Implications:Whetherpatientschoicetoshareinformationfoundonlinewiththedoctor

dependsontheabilityofthedoctortoengagepatientsindecision-making,e-healthcan

producea‘double-empowerment’process:experiencedbythepatientontheInternet,and

legitimatedbythedoctorduringencounters.

theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Theexpression“e-health”referstohealthservicesand easily updated health-related information enhanced or

Abbreviations:CATI,computer-assistedtelephoneinterviews;CI, con-ﬁdenceinterval;GP,generalpractitioner;LHA,localhealthauthority;HD, healthcaredistricts;OR,oddsratio.

∗ Correspondingauthorat:ScuolaSuperioreSant’Anna,Istitutodi Man-agement,LaboratorioManagementeSanità,MartiridellaLibertà,33, 56127Pisa,Italy.

E-mailaddress:s.derosis@sssup.it(S.DeRosis).

providedbytheInternetand relatedtechnologies[1–3]. Traditionally, healthcare professionals are the patients’ mostreliablesourceofhealth-relatedinformation.Greater accessibilitytotheInternetandthebroadavailabilityof online health-related information have provided a new sourceofhealthknowledgeforpeople.Currently,59%of Europeansgoonlinewhenlookingforhealth-related infor-mation [4]. The growing use of e-health [5–7] and its potentialcontributiontothegoalsofprevention, promo-tionandprotectioninhealth-enhancingstrategies[8–10]

havemadee-healthakeyissueforhealthcaremanagers

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2 S.DeRosis,S.Barsanti/HealthPolicyxxx(2016)xxx–xxx andpolicymakers,aswellasbeinganareaofinterestfor

thescientiﬁccommunity.

Doctors also need to face tackle the challenges related to e-health, particularly in light of the increas-ingnumberofinformedpatients.E-healthcanaffectthe physician–patientrelationship,aspatientsbecomemore (wellorbadly)informed.Furthermore,thedoctor–patient relationship is changing, also in terms of the medical decision-makingprocess.Thepatient’sroleisprogressively shiftingfromthecompliantorsilentpatient,tothepatient whowantstotakehis/herowndecisions.Aconsensual,or collaborative,decision-makingprocessrequiresmorethan atop–downprocess[11].Thus, thepatientbehaviourof reportinginformationfoundonlinetothephysiciancould becrucialinthedevelopmentofabetterpatient empow-erment,becausebasedonthelegitimationandvalidation ofinformationfoundonline.

Currently,theevidence ontheseissues issomewhat conﬂicting. In the literature, we foundagreement only onthegeneralproﬁleofpatientswhoadoptthese tech-nologiesofinformationandcommunication(e-patients). Thereisalsoagreatfragmentationofempiricalresearch atthreelevels:(i)thetypologyofpopulationstudiedand thesamplingmethods;(ii)thefocusofthestudy(i.e. dif-ferenthealth-relatedpurposesofInternetuseore-patient behavioursaftertheInternetsearch);(iii)thedeterminant factorsusedtoanalysethefocusofthestudy.

Our study thus focuses on two speciﬁc patient behaviours:(i)usingtheInternetforhealth-related infor-mation; (ii) sharing the information foundonline with thegeneralpractitioner(GP).Theaimofthisresearchis toinvestigatewhetherthesetwo patientbehavioursare affectedbythepreviousrelationshipandexperiencewith theGP and the healthcare system. Multivariatelogistic modelswereusedtoestimatetheassociations between patientcharacteristics, experienceand satisfaction with the physician and the healthcare system, and the two patientbehavioursdescribedabove.Lastly,thiswork pro-videsinsightsintothepotentialroletheGPcouldstillplay in strengthening therelationship withthe patient, also whene-healthisused.TheAndersen’sbehaviouralmodel, developed and widely used for investigating patients’ health-relatedbehaviours[12],wasadoptedasframework fortestingifandhowpotentialinﬂuencingfactorsimpact e-healthbehavioursofinterest.

2. Background

Table1reportstheresultsofourliteratureanalysisof

e-healthrelatedsurveysandarticlesontheuseofthe Inter-netforhealth-relatedpurposes.Despitethewideinterest in this topic,the scientiﬁc basis of e-health behaviours determinants still needsto be establishedand the evi-denceseemslimited [2,13,14].In general,most surveys one-healthusehavetendedtouseskewedsamples[15], suchas:patientswithspeciﬁcconditions[16–19],patients interviewed in the place where the healthcare service isprovided [20–23],Internet users surveyedduring the onlineexperience[24–31],orhealthcareproviders[23,32]. Moreover,publishedstudiesone-healthhavebeen con-ductedbothatnational[5,16,20,23,24,26],andlocallevels

[21,33–35],and mostofthemintheUSA[25,28,35–41].

In the Italian context, we found some studies on e-health [20,33,42]that were not always ableto provide population-basedestimatesofInternetuse,itsrelationship tosocio-economicstatus,and behaviouralconsequences associated withtherelationshipwithGPs.Furthermore, althoughassociationswithprevioussatisfactionand expe-riencewithGPsandhealthcareservicesmayseemobvious, theyhavenotbeenwidelyexplored.

2.1. Thee-healthuserproﬁle

Results from empirical studies on e-health are con-ﬂicting, with the sole exception of the e-patient pro-ﬁle in terms of age (young adult or adult, usu-ally between 18–45 years old) and educational level (medium–high)[5,20,21,24,33,36–39,42–46].Thereisno gender-difference in most researchworks. Only certain studieshavefoundthatwomenaremorelikelytosurfthe Internetforhealthinformation[5,41,47].Patients’health conditions (one or more chronic diseases or bad self-perceptionofhealthstatus)havebothbeenfoundtobe associated[5,20,24,45],aswellasnotassociatedwith e-health use[22,38,39,48].In a few studies,patients’ bad experienceanddissatisfactionwiththeirrelationshipwith primarycare(PC)servicesorthehealthcaresystemwere foundtobedeterminantindecidingtousetheInternetfor health-relatedinformation[20,25–28,38].

2.2. Thee-patientbehaviourandtherelationwiththeGP Despite the physician remaining as the most pre-ferred and trusted source of information for patients

[5,34,36,40,42,49–51],byusingtheInternet,thepatients

could occupy a new position in the relationship with thefamilydoctorand havea differentkindofpowerin thedecision-makingprocess[52].TheInternetis consid-ered as a potential powerful tool for health education andempowerment[15,30,51,53–56],aswellasfora pos-itive reconsideration of the patient–doctor relationship

[57].Somestudieshaveinvestigatedtheconsequencesof Internet useby patients in terms of change in general health-behaviour[5,16,20,29,58]and/orintherelationship withphysicians[5,20,26,27,30,36,37,40,59].

Amongthee-healthrelatedbehavioursdescribedin lit-erature,thee-patientchoiceofsharinginformationfound onlinewiththeGPisconsideredanimportantstepinthe patientempowermentprocess.Infact,someauthorshave describedthislatternotonlyasanindividualpattern,but also as product of a complex process involvingseveral actors,basedoninteractions andrelationshipsandona productivepartnershipwiththefamilydoctors[55,60–62]. Inthissense,theempowermentprocessisthusalsobased onthelegitimationbyanexpertprofessionalofthenew knowledgeacquiredontheInternet[29].

However, we found a great variability in the litera-tureoftheratesofe-patientswhodiscusstheinformation found online with their GP: more than a third [59], almost two ﬁfths [35,63], almost a half [26]. In a few works,thee-patientsdidnotreportanyoftheir health-behaviouralchangestothefamilydoctor[27,50].Wewere

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Please cite this article in press as: De Rosis S, Barsanti S. Patient satisfaction, e-health and the evolu-tion of the patient–general practitioner relationship: Evidence from an Italian survey. Health Policy (2016), http://dx.doi.org/10.1016/j.healthpol.2016.09.012

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Mainﬁndingsfromananalysisoftheliteratureone-healthuseande-health—relatedbehavioursandtheirinﬂuencingfactors.ThesearchwasrestrictedtopaperswritteninEnglishandpublishedbeforeMay 2015.

Primaryauthor Year Country Sample Results

E-healthdeterminantfactors E-healthoutcomes Determinantfactorsof e-healthoutcomes AndreassenHK 2007 Norway,Denmark,

Germany,Greece, Poland,Portugaland Latvia

Citizens VisitstotheGPduringthepast year,long-termillnessor disabilities,andasubjective assessmentofone’sownhealthas good

Feelingreassuredafterusingthe Internetforhealthreasons,butalso willingtochangedietorlifestyle habitsanddiscusssuggestionsor queriesaboutdiagnoseswithGPs BeckF 2014 France Frenchaged15–30

years

Havingachild;experiencing psychologicaldistress;having alreadyseenadoctor

Changesinhealthbehaviours(e.g. frequencyofmedicalconsultations, wayoftakingcareofone’sownhealth)

Differentfactorswere associatedwithdifferent outcomesofchange,but psychologicaldistress,poor qualityoflife,andlowincome werethemostcommon BiancoA 2013 Italy,Calabria Parentsofstateschool

students

Nosatisfactionwiththeirgeneral practitioner’shealth-related information,butsatisfactionwith informationfromscientiﬁc journals

BiermannJS 2006 USA Patientswith musculoskeletal problems

Perceptionofe-healthasauseful adjuncttotraditional

physician–patientinteraction:patients becomemoreexpertonagiventopic; clinicalencountersbecomemore efﬁcient

BrietJP 2014 USA Patientswhouseda freeconsultation website

Dissatisfactionwiththedoctor alreadyseenorthesurgeryhador withtheircurrenttreatment BroomA 2005 Australia Menwithprostate

cancer

Somemedicalspecialistsview Internet-informedpatientsasa challengetotheirpowerinmedical encountersand,asaresult,employ disciplinarystrategiesthatreinforce traditionalpatientrolesandalienate patientswhousetheInternet Caiata-ZuffereyM* ₂₀₁₀ _Switzerland _Patients_in_medical

practices

Needing:acknowledgment, reductioninuncertainty,and perspective.Thethreeneeds dependonthecharacteristicsof theillness(length,seriousness),of theindividual(toleranceto uncertainty,andsoforth),ofthe doctor(communicativestrategies, andsoforth)andofthecurrent socialcontext

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E-healthdeterminantfactors E-healthoutcomes Determinantfactorsof e-healthoutcomes Deli ´cD 2006 Croatia UsersoftheInternet

healthportal

Theleadingreasonforseeking medicalinformationwas ‘unansweredquestionsafter visitingaphysician’.Most respondentswentonlinetoseek informationonaspeciﬁcillnessor condition

Approximatelyhalfofallrespondents discussedtheinformationtheyfound onlinewiththeirphysicians

Patientswhofeeltheyare giveninsufﬁcientinformation, orsimplyseekmore informationthanphysicians provide,turntousingonline healthinformationwhichno longerseemstobereservedfor thosewiththehighestlevelsof education

DiazJA 2002 USA,ProvidenceRI Patientsenrolledina primarycarepractice

Thee-healthusersareyounger (meanage=45.8years),more educatedandwithgreaterincomes (p≤.001)

59%ofe-healthusersdidnotdiscuss informationwiththeirdoctor.11%of e-healthusersusedtheInternet insteadofseeingorspeakingwiththeir doctors

Neithergender,education level,noragewereassociated withpatientssharingornot sharinginformationwiththeir doctors.Therateof

health-informationqualitywas higheramongthosewho discussedtheinformationthan thosewhodidnot.Ofthose usingInternetinsteadofan encounterwiththedoctor, severalrespondentsreported additionalreasonslinkedto therelationshipwiththe doctortojustifythisbehaviour HesseBW 2005 USA Adultcitizens Theneedforinformationona

speciﬁcdisease(cancer)

Physiciansremainedthemosthighly trustedinformationsourceforpatients HouJ 2010 USA Adultcitizens Lesspatient-centred

communication,moreonline healthactivities(forhealthy lifestyles,searchingforhealthcare providers,andhealthinformation). Trustinonlinehealthinformation

Patient–physiciancollaborationcan produceanewbidirectionaloreven networkedmodelthatcanaccelerate clinicalresearchandimprovedelivery ofcancercare

HoustonTK 2002 USA Generalpopulation Internetusersweremostlyfemale, hadamedianageof42years,were whiteandhealthy

Mostindividualsindicatedthatthey “learnedsomethingnew”thelasttime theywentonline

Theincreaseinknowledgedid notvarybyhealthstatus.A fair/poorhealthwasfoundto beassociatedwiththe communicationwiththe healthcareprovider KatzJE 2014 Canada,Quebec Oncologypatients Havingtheneedtolearnmore

abouttheircondition,associated withthewishthatthephysicians providedlinks

KlinarI 2011 Croatia UsersofafreeInternet medicalconsultation service

Beingpregnant;beingtoo embarrassedtotalktoaphysician inperson;wishtoprotectprivacy

Considerablesatisfactionwiththe onlineservice

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E-healthdeterminantfactors E-healthoutcomes Determinantfactorsof e-healthoutcomes LemireM 2008 Canada Usersofa

well-established CanadianWebsite

E-healthusedevelopsfeelingsofcompetence andcontrol.Thisimplies:doingwhatis prescribed,makingchoicesbasedonpersonal judgment,andmutualassistance

MartinezCH 2014 USA COPDpatients Perceptionofneedsinsufﬁciently metbythehealthcaresystem, includingdiagnosticdelay,feeling poorlytreated,insufﬁcient physiciantime,andfeelingtheir physiciandidnotlistentothem MehrotraA 2013 USA Patientswhoused

“eVisit”website

Havingsinusitisoranurinarytract infection,oralongertravel distancetoclinic

Pe ˜na-PurcellN 2008 USA HispanicsintheUS Perceptionofimprovementinunderstanding medicalconditionsandtreatments,andmore conﬁdencetalkingtodoctorsabouthealth concerns.Perceptionofworseningof physician–patientrelationship

RiceRE 2006 USA Generalpopulation Thee-healthoutcomefoundinthisresearch worksareimprovementofwayofobtaining informationonhealthcare,andofhealthand medicalinformationservicesreceived.In addition,theInternetplayedaroleinhow patientstreatthemselveswithamajorillness orotherhealthcondition.IftheInternetwas usedforhealthinformationbothforthe personaluseandforothers,itaffectsdecisions abouthealthtreatmentsorthewaypeople takecareofothersorofthemselves.Infact, e-healthaffectshowtodealwithhealth conditionorhealthandleadstoaskdoctor newquestions,oropinionfrom2nddoctor

Thee-healthoutcomesare determinedbythetypologyof Internetactivity,thehealth seekingbehaviour,education, race,andsex.Alsotheown(or other’s)healthconditions,such ashavingmultiplespeciﬁc healthreasonsofInternetuse (includingself-diagnosis),a majorillnessora

disability/handicap,affectthe e-healthoutcomes.Thisstudy alsofoundtobedeterminant thepresenceofonlinesupport groupsandthecredibilityofa website

SiliquiniR 2011 Italy Patientsinhospital Medicalmalpracticeassociated withgender

Achangeinthehealthbehavioursand relationshipswiththeirmedicalproviders:in particular“self-medication”and“negative behaviours”(‘tostartatherapynotprescribed’ and/or‘tochangeorsuspendthetherapy recommendedbythedoctor’)

Asigniﬁcantlyhigherriskof negativebehaviourswasfound withincreasingageupto53 years,whiletheabsenceof chronicdiseasesdecreasedthe riskofnegativebehaviours Valero-AguileraB 2014 Spain,Granada Patientswith

urologicalcanceror breastcancerduring theoncology appointment

Thepatient’sactiveroleinthe decision-makingprocess,and undergoingmoreaggressive treatment

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6 S.DeRosis,S.Barsanti/HealthPolicyxxx(2016)xxx–xxx unabletoidentifyintheliteraturethemostlikelyproﬁle

ofthee-patients whoengagewiththeirgeneral practi-tionerregardingtheire-healthexperience[64].Inaddition, havingapoorer healthstatus isa characteristic bothof those whodiscusses e-health ﬁndings withfamily

doc-tors[41,47],andofthosewhotakehealth-relateddecisions

autonomouslyaftertheonlineexperience[20].

Thecurrentliteraturefocusesondifferentaspectsofthe e-healthphenomenon,butfailstocoversomeelements thatmayaffectonlinepatientempowerment.Thereisstill insufﬁcientempiricalevidenceonthee-healthconsequent behaviourof discussingInternethealth-related informa-tionwiththefamilydoctor,onthetypeofpatientswho usuallydecidetosharetheinformationfoundonlinewith thephysician,andonwhatfactorsinﬂuencethisbehaviour

[13,64].

3. Aimsandhypotheses

Theaimofthisresearchistoinvestigatewhetheran individual’suseofe-healthisaffectedbyhis/herprevious relationshipandexperiencewiththeGPandthe health-caresystem,both inrelation tothedecision tousethe Internettomeettheirinformation needs,andtodiscuss whattheyfoundontheInternet withtheirfamily doc-tor.Theinﬂuencingfactorsrelatedtothee-healthusers andtothee-patientbehaviourareselectedconsideringthe previousempiricalstudiesandthepossiblerelationsare investigatedadoptingtheAndersenmodelasthereference framework[12].

In particular, according to the empirical evidence, we formulated three basic hypotheses that we veri-fiedperformingstatisticalmodels.Accordingtothefirst hypothesis,thoseindividualswhofeellesssatisfiedorhave abadexperienceof(a)theirGPor(b)thehealthcare sys-tem,use theInternet for health-related purposes more frequently.Infact,becauseagoodrelationshipwiththe GPisassumedasthebasisofadoctor–patientpartnership, weexpectedtofindanegativeassociationbetween sat-isfactionandgoodexperiencewiththephysicianandthe decisiontousetheInternetforhealth.Ontheotherhand, wehypothesizedthatsharinghealth-relatedinformation foundontheInternetwiththeGPispositivelyassociated withahighersatisfactionandbetterexperiencewiththe samefamilydoctor.

4. Methods

4.1. Contextoftheresearch

The context of the research is Tuscany Region, in Italy.Italyhasapublichealthcaresystem,whichprovides universalcoverageforhealthservices,throughgeneral tax-ation.Thehealthcaresystemismanagedataregionallevel; localhealthauthorities (LHAs) andorganize healthcare servicesand arecomposedofhealthcaredistricts (HDs). TheHDsareresponsibleforprimarycareservicesfortheir area,andintegratehealthcareactivitiesintowelfare ser-vices[65,66].GPshaveagatekeepingroleinthehealthcare system,usuallybeingtheﬁrstcontactbetweenpatients andspecialistcare.

AlthoughtheInternet penetrationisbelowthe Euro-pean average(58.5%in Italy;70.5% in Europe;76.5% in theEuropeanUnion—2014)[4,67],Italy presentsa simi-larpatternofInternetuseforhealth-relatedinformation searching[4].

Tuscanyisa3,7mlinhabitantsregionincentralItaly thatshows characteristicsofe-healthdiffusionand per-formanceofthehealthcaresystemintermsofqualityand usersatisfactionwhichareinlinewithboththenational andtheEuropeancontexts[68].InTuscany,thenumberof familieswithbroadbandInternetaccessisalmost67%[69], whichisanalogoustotheEuropeanpenetrationrate[67]. Inaddition,therateofInternetsearchesforhealth-related purposes in our sample is consistent withthe national samplesinItaly[20,33,42],aswellasinotherEuropean countries[3,5,20,45,70,71],thussuggestingthate-health useissimilarthroughoutEurope[20].

4.2. Designofthestudy

Wecarriedoutananalysisontheresultsofa population-basedcross-sectionalsurveyonsatisfactionandexperience withthehealthcaresystemandservicesinTuscanyRegion (Italy).Thesamplewasrandomlyextracted,andwas repre-sentativeofthewholepopulationofTuscany.Thesampling methodwaschosentomaximisetherepresentativenessof thepopulationandthedifferentexperienceswithseveral differentsettingsofthehealthcaresystem.Thesampling hadastatisticalsigniﬁcancelevelof95%andaprecision levelof7%.

The survey wascomposedof four mainsections: (i) satisfaction and experience with GPs; (ii) satisfaction and experiencewiththehealthcaresystem;(iii) health-informationand communication-relatedbehaviours;(iv) socio-economicconditions.Thestructuredquestionnaire wasvalidated by apilot testand administered through computer-assistedtelephoneinterviews(CATI),whichare usedextensivelyinquantitativeresearch[50–52,72]. 4.3. Statisticalanalysis

Weexploredtwodifferentmultivariatelogisticmodels forevaluatingtherelationshipbetweenpatients’ charac-teristics, experiences and satisfaction withbothGP and healthcaresystems,andtheirtwobehavioursobjectsofour study(e-healthuseandthebehaviourafterthee-health use),thusverifyingthehypothesesdescribedabove. 4.3.1. Dependentvariables

Considering the aims of the research, people were asked: ‘When you need health-related information, do youusethe Internet?’,categorisedintotwodichotomous behaviours:‘Iuse/IdonotusetheInternetforhealth-related purposes’.Respondentswereidentiﬁedase-healthusersif theyansweredthequestionafﬁrmatively.

The behaviour after the e-health experience was explored by asking e-health users: ‘After you used the Internetforhealth-relatedpurposes,didyoureturntoyour physiciantotalkaboutyouronlineﬁndings?’.Alsoin this case, the behaviours were dichotomous and mutually exclusive:‘Ishare/Idon’tsharee-healthﬁndingswithmyGP’.

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S.DeRosis,S.Barsanti/HealthPolicyxxx(2016)xxx–xxx 7 Consequently,thetwobehavioursarerepresentedby

binaryvariables,whichindicatetheabsenceorpresenceof acertainbehaviourbytakingthevalue0(no)or1(yes).

4.3.2. Independentvariables

Theindependentvariables wereselectedconsidering thepreviousempiricalstudies.

As described in Table 3, gender and chronic illness weredichotomousfactors:respectively,male(0)vsfemale (1), and chronic patients(1) vs not chronicpatient (0). Alltheotherindependentvariableswerecategoricaland interval-based.Inparticular,questionsonsatisfactionand experiencewerebasedonaLikerttypescalewith3or5 intervals.Table3describesintheﬁrsttwocolumnseach independentvariableandtherelativescales.Moreover,in ordertoavoidcollinearityinthemodels,wealso exam-inedthecorrelationmatrixbetweenallthevariables.With theaimofeliminatingmutualcorrelatedindependent vari-ablesfromthemodel,weconsideredstrongacorrelation withr≥.7.

4.3.3. Modelsofanalysis

Relations betweendependentand independent vari-ableswereinvestigated,accordingtothebehavioural mod-els for investigating patients health-related behaviours. Indeed,basedontheAndersen’smodelofpatient health-relatedbehaviour[12],weconsider‘predisponent’factors, ‘enabling’ factors, and ‘health needs’ at the individual level.Weintegratedseveral‘relational’determinantfactors among‘predisponent’factors,asdescribedinTable2.We deﬁned‘relational’thefactorsrelatedtotheinteractions withthehealthcaresystemandthegeneralpractitioners, intermsofbothpatients’experienceandsatisfaction.In fact,the‘relational’factorslinkedtothehealthcaresystem canaffectboththedeliveryofprimarycareservices,andthe patients’behaviour[48].The‘relational’factorsrelatedto theGPwereincorporatedinthemodel,duetotheir poten-tialpositiveinﬂuenceonpatients’behavioursofe-health use,aswellasbehavioursthatareconsequenttotheonline experience[73].

For investigating the correlations between the two behaviours and the selectedvariables, two multivariate logisticmodelsweregeneratedseparatelyusingastepwise selectionprocedure,wherebygroupsofvariableswere pro-gressively dropped from the model, if not signiﬁcantly correlated with the dependentvariables. Consequently, thisprocedureleaveonlytheindependentvariableswith statisticalsigniﬁcantcorrelationswiththedependent vari-able.

For each independent variables, we calculated and reportedoddsratios(OR)with95% conﬁdenceintervals (95%CI)and p values.Statisticalsigniﬁcance wassetat p<.05.ByreportingtheOR,wequantitativelydescribedthe associationbetweenanexposure(representedbythe inde-pendentvariables,forexamplebeingachronicpatient)and anoutcome(representedbythee-healthbehaviour)[74].

Wereportedthepseudo-R2andtheresultsofthe Like-lihoodratiotest,asindicationofthegoodnessofﬁtofeach multivariatelogisticmodel[75].

AllanalyseswereperformedwithSASsoftware(version 9.2).

5. Results

5.1. Sampleanalysis

Atotalof1793citizensansweredallfoursectionsand werestudied;ofwhich,629(35%ofthetotalsample)said theyhad used theInternet for health-related purposes.

Table3reassumestheresultsoftheanalysisforeach

vari-ableinassociationwiththetwodichotomousbehaviours ofinterest(chisquaretest).

Themostlikelyprofileofthee-patientwassomeone between18 and 45 years old(n=283; 45% of the sub-sample of e-patients), or someone between 46 and 65 yearsold (n=289;46%)(p<.0001),withatleasta mid-dle school diploma (n=485; 77%; p<.0001). Obviously, havinganADSLconnectionisanimportantfacilitator fac-toralsoforthespecificbehaviourofhealth-relatedonline information-seeking:infact,the96.5%ofe-patientshad suchtypeofInternetconnectionathome(n=607;96.5%; p<.0001).TheInternetusersforhealth-relatedpurposes weremorelikelytobehealthypeople,withahealthstatus reportedasgoodorexcellent(n=599;95%;p<.001),and notaffectedbychronicdiseases(n=415;66%;p<.001). E-healthusersappearedtobehighusersofGPservices:most ofthemvisitedthephysicianmorethanthreetimes dur-ingthelastyear(n=319;50.8%;p<.001).Incontrast,they werelesssatisfiedwiththequalityofthehealthcare sys-temingeneralterms:lessthananhalfofthemhadagood orvery goodopinion ofthehealthcare system(n=288; 47.8%);17.7%(n=111)thoughtthatthehealthcareservices werepoororverypoor(p<.001).

Ofthee-patients,onlyasmallnumbersaidtheyhad never discussed their Internet findings with their GP (n=106;17%):themajority reportedthee-health expe-rience to their GP. Their significant socio-demographic characteristicsshowedthatthesharinge-patientismainly anadultbetween18and65yearsold(18–45years:n=212; 46%;45–65years:n=261;45%;p<.0001),withahigher educationlevel(n=401;76,8%;p<.001)andanADSL con-nection at home(n=503; 96.3%;p<.001); and without health-relatedproblems(goodorexcellentdeclaredhealth status:n=493;54.4%;p<.001;notaffectedbychronic dis-eases: n=337; 64.5%; p<.001). In contrast with results aboutpeoplewho surfedtheInternetfor health-related purposes, who decidedalso toshare the e-health find-ingswiththeGPappearedsignificantlymoresatisfiedwith his/herGP.Infact,the81.7%ofthemwasfullysatisfiedin termsofoverallsatisfactionwiththeGP(n=427;p<.01); 77%fullysatisfiedwiththeinvolvementbytheGPinthe decision making processes (n=403; p<.001); 81% fully satisfiedwithtimespentintheencounterswiththeGP (n=423;p<.01).Intermsofsignificantexperienceswith GPreported bythe interviewede-patients, who shared withtheGPwhatwasfoundonlinehadahigherfrequency ofvisitsin thelastyear(2–3 times:n=192;34%;more than3times:n=280;53.6%;p<.01).Inaddition,these e-patientsalsoreportedasignificantlyworstexperiencein

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Table2

Percentagedistributionofthesamples’characteristicsandresultsofthechisquaretestforeachindependentvariable(ﬁrstcolumn)inrelationtoeachof thetwopatientbehavioursofinterest.Asterisksindicatesigniﬁcantassociations.

Variables Categories(scale) Totalsample(n=1793) Chisquaretest UseoftheInternetfor health-relatedpurposes

Sharingofe-health ﬁndingswiththeGP No(n=1165) Yes(n=629) No(n=106) Yes(n=522)

Agegroup***

18–45(1) 29.11 20.52 45.06 40.57 45.99

46–65(2) 46.12 46.09 46.18 50 45.23

Over65(3) 24.76 33.39 8.76 9.43 8.78

Sex Male_Female(0)₍₁₎ 30.73_69.27 30.47_69.53 31.21_68.79 38.68_61.32 29.58_70.42

Education*** Low(1) 43.95 55.28 22.93 27.36 22.14 Medium(2) 41.27 33.99 54.78 53.77 54.77 High(3) 14.78 10.73 22.29 18.87 23.09 ADSL*** No(0) 27.00 39.74 3.5 2.83 3.63 Yes(1) 73.00 60.17 96.5 97.17 96.37 Healthstatus* Low(1) 5.91 6.52 4.78 .94 5.53 Medium(2) 49.69 51.59 46.18 50.94 45.04 High(3) 44.39 41.89 49.04 48.11 49.43 Chronicillness* No(0) 61.52 58.97 66.24 73.58 64.5 Yes(1) 38.48 41.03 33.76 26.42 35.5 ExplanationsofGP recommendation Notsatisfied(1) 2.51 2.15 3.19 4.72 2.87 Quitesatisfied(2) 13.18 12.9 13.72 16.98 13 Fullysatisfied(3) 84.3 84.95 83.09 78.3 84.13 Participationin decisionwithGPˆˆ Notsatisfied(1) 6.03 5.42 7.18 16.04 5.35 Quitesatisfied(2) 16.2 15.91 16.75 12.26 17.59 Fullysatisfied(3) 77.77 78.68 76.08 71.7 77.06

Timespentduringthe visitwiththeGPˆ

Notsatisfied(1) 4.13 4.3 3.83 10.38 2.49 Quitesatisfied(2) 15.53 14.27 17.86 24.53 16.44 Fullysatisfied(3) 80.34 81.43 78.31 65.09 81.07 Overallsatisfaction withGPˆ Notsatisfied(1) 3.69 3.69 4.94 8.49 4.2 Quitesatisfied(2) 13.91 13.91 15.92 24.53 14.12 Fullysatisfied(3) 82.4 82.4 79.14 66.98 81.68

NumberofGPvisitsper year***ˆ

Neveroronce(1) 10.09 8.58 12.9 15.09 12.4

2–3times(2) 31.96 29.61 36.31 48.11 33.97

Morethan3times(3) 57.95 61.8 50.8 36.79 53.63

Suggestionsaboutlife styleˆ Never(1) 40.4 40.83 39.62 50.48 37.28 Sometimes(2) 25.8 25.06 27.16 30.48 26.77 Always(3) 33.8 34.11 33.23 19.05 35.95 Overallsatisfaction abouttheRHS**

Notsatisﬁedatall(1) 2.23 1.63 3.34 8.49 9.16

Notverysatisﬁed(2) 13.5 13.05 14.33 36.79 35.31

Quitesatisﬁed(3) 31.62 30.04 34.55 45.28 49.24

Verysatisﬁed(4) 48.35 49.96 45.38 9.43 5.15

Fullysatisﬁed(5) 4.29 5.32 2.39 0 1.15

KnowledgeaboutRHS services

Notsatisﬁedatall(1) 10.21 10.82 9.08 4.72 3.05

Notverysatisﬁed(2) 37.42 38.37 35.67 12.26 14.69

Quitesatisfied(3) 46.4 45.24 48.57 39.62 33.4 Verysatisfied(4) 4.91 4.46 5.73 41.51 46.18 Fullysatisfied(5) 1.06 1.12 .96 1.89 2.67 ReturntoRHSoffices duetomalpractice Always(1) 2.01 1.63 2.71 1.89 2.86 Sometimes(2) 14.5 13.48 16.4 13.21 17.18 Never(3) 83.49 84.89 80.89 84.91 79.96

***_p_value_<_.0001_for_e-health_use. ** _p_value_<_.001_for_e-health_use.

* _p_value_<_.01_for_e-health_use.

ˆˆ _p_value_<_.001_for_e-health_information_sharing. ˆ_p_value_<_.01_for_e-health_information_sharing.

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n=195;37.3%;sometimes:n=140;26.7%;p<.01).

5.2. Multivariateanalysis

Afteracollinearityanalysistoidentifymutually corre-latedfactors,thefollowingvariableswereeliminated:(ii.1) ADSLconnectionathome,co-linearwiththesocio-cultural features(i.1)ageand(i.3)education;(iv.5)general satis-factionwithGP,co-linearwithitscomponents(iv.1;iv.2); (v.2)durationofGPvisit,co-linearwithothercomponents ofsatisfactionandexperiencewithGP(iv.1;iv.2;iv.3;v.1; v.3).

Resultsofthemultivariatelogisticanalysiswith step-wise selection are reported in Table 4 for the general e-health behaviour, and in Table 5 for the e-patient behaviouraftere-healthuse.

5.2.1. E-healthuserproﬁle

Ashighlightedbythestatisticsabove,thosewho gener-allyusetheInternetforhealth-relatedpurposesinTuscany weremainlyyoung(p<.0001)withamedium–high edu-cationallevel(p<.0001)(Table2).

Thevariablerelatedtotheoverallsatisfactionwiththe healthcaresystemappearedtobesignificantlyassociated withe-healthuse(Table4).Thehigherthegeneral satisfac-tionwiththehealthcaresystem,thelowerthetendencyto usetheInternetforhealthpurposes.Inparticular,those whowerequitesatisfied(OR=.48;p=.03),verysatisfied (OR=.4;p=.008)andfullysatisfied(OR=.28;p=.005)used theInternetlessthanthosewhowerenotatallsatisfied.In contrast,ourresultssuggestthatvariablesrelatedto satis-factionandexperiencewithGPswerenotassociatedwith e-healthuse,andthereforethesevariableswereexcluded fromthelogisticmodelbythestepwiseselectionprocess.

5.2.2. Behaviouraftere-healthuse

Whenperformingthelogisticanalysisforthee-health behaviour,‘Idiscuss/Idon’tdiscusswhatIfindonthe Inter-netwithmy GP’,a significantchangewasfoundinthe typologyofvariablesinfluencinghealth-relatedbehaviour

(Table5).

Thesocio-demographicvariableswerenotfoundtobe signiﬁcantlyassociatedwiththedecisiontoshareonline ﬁndingswiththeGP,andwereexcludedfromthemodel bythestepwiseselectionprocedure.

Theanalysisshowedasignificantandpositive associ-ationbetweenthepositivebehaviour‘Idiscuss’andtwo variablesrelated tosatisfactionandexperiencewiththe GP.PatientstalkedtotheirGPaftertheire-health experi-encemorefrequentlyiftheyfeltmoresatisfiedwiththeir involvementintheirGP’sdecisionsconcerningtheirhealth (‘quitesatisfied’:OR=2.6,p=.005;‘fullysatisfied’:OR=4, p=.0001).TheperceptionoftheirGP’sinterestintheir gen-eralhealthstatusalsopositivelyaffectsthebehaviourof e-healthusers:thosewhoreceivedalwaystheGP’s sug-gestions regarding their life-style shared their e-health findingswiththeirGPmore(OR=2.3,p=.005). Table

3 List of independent variables selected on the base of the literature, for each of the two multivariate logistic models: use of the Internet for health related purposes (model 1); sharing with the GP the information found online (model 2). Main category Typology of factors Level Independent variables Use of Internet for health information (model 1) Sharing with GP the information found online (model 2) Individual factors (i) Predisponent factors /// (i.1) Age x x (i.2) Gender x x (i.3) Education x x (ii) Enabling factors /// (ii.1) ADLS connection at home (iii) Health needs /// (iii.1) Health status x x (iii.2) Presence of chronic illness x x Relational factors (iv) Predisponent factors: level of satisfaction GP (iv.1) Explanations offered by the GPs x x (iv.2) Level of participation in the decision-making process regarding treatment and care x x (iv.3) Overall satisfaction with the GP Healthcare system (iv.4) Overall satisfaction with the healthcare system x (iv.5) Level of knowledge of healthcare system x (v) Predisponent factors: experience GP (v.1) Number of GP visits per year x x (v.2) Time spent with the GPs x x (v.3) Suggestions by the GPs regarding life style x x Healthcare system (v.4) Return to administrative healthcare ofﬁces again for the original purpose due to inefﬁciency or malpractice x

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Table4

Internetuseforhealth-relatedpurposes,accordingtosocio-demographicfeaturesandvariablesofsatisfactionandexperiencewithGPandhealthcare system:resultsofthemultivariatelogisticregressionwithstepwiseselection(n=629).

Socio-demographicsandhealthneeds OR 95%CI p-Value

Individual predisponentfactors

Agegroup Over65 Reference

46–65 3.002 3.756 7.514 <.0001

18–45 5.312 2.165 4.162 <.0001

Education Low Reference

Medium 2.955 2.312 3.776 <.0001

High 3.838 2.791 5.279 <.0001

Satisfactionwiththehealthcaresystem OR 95%CI p-Value

Relational predisponentfactors

Overallsatisfaction Notsatisﬁedatall Reference

Notverysatisﬁed .524 .258 1.068 .0491

Quitesatisﬁed .481 .244 .948 .0345

Verysatisﬁced .406 .207 .796 .0087

Fullysatisﬁed .284 .116 .695 .0058

PseudoR2.171.Likelihoodratiotest307.31.p-Value<.001. Theboldvaluesarestatisticallysigniﬁcantvalues.

Table5

Behaviour(aftertheInternetuse)ofsharingtheinformationfoundonlinewiththeGP,accordingtosocio-demographicfeaturesandvariablesofsatisfaction andexperiencewithGP:resultsofthemultivariatelogisticregressionwithstepwiseselection(n=522).

SatisfactionwiththeGP OR 95%CI p-Value

Relational predisponentfactors

Participation Notsatisﬁed Reference

Quitesatisﬁed 2.621 1.321 5.254 .0057

Fullysatisﬁed 4.002 1.366 5.209 .0014

ExperiencewiththeGP OR 95%CI p-Value

Relationalpredisponentfactors Suggestionsaboutlifestyle Never Reference

Sometimes 1.070 .711 1.571 .7842

Always 2.352 1.197 2.766 .0051

PseudoR2.1003.Likelihoodratiotest58.78.p-Value<.001. Theboldvaluesarestatisticallysigniﬁcantvalues.

6. Discussion

Thisstudyprovidesabetterunderstandingoftwo

spe-ciﬁcpatientbehavioursrelatedtoe-health: (i)usingthe

Internet for health-related purposes;(ii) sharingonline

ﬁndingswiththeirGP.

The proﬁle of the e-health user described by this

article (young person with a medium-to-high level

of education) is in accordance with the literature

[5,20,21,24,33,36–39,42–46]. Our results conﬁrm that

thereisstilla“digitaldivide”betweenonlineandoffline healthinformationseekers:elderlypeopleandpeoplewith alowerlevelofeducationarelesslikelytousetheInternet forhealth-relatedpurposes.Thisreflectsageneralmodel ofpeople’sInternetuse,aswellasthelowerincidenceof Internetaccessinolderpeople’shomes,whichshouldbe an“enablinge-healthresource”[76].Withregardto disad-vantagedpatientsintermsofhealthconditions,wedidnot findanysignificantassociation.

Accordingtotheresultsofourstudy,only ‘predispo-nentfactors’,bothatindividualandrelationallevels,were foundtobestatisticalsignificantassociatedwiththetwo patientbehavioursofinterest. Oneofthemainfindings ofourresearchwasthate-healthuseis,ingeneral, sig-nificantly determined only by the satisfaction with the healthcaresystem,inadditiontosocio-demographic fea-tures.Ourhypothesisthatpatientswhowerelesssatisfied

withthehealthcaresystemusede-healthmorewas con-firmedbyourresults,incontrasttothefindingsofanother recentstudy[21].Thesefindingssuggestthatpatient sat-isfactionwithlocalhealthcaresystemhaveaninfluenceon thecomplexprocessofpatienthealthliteracyonline,by representingalevertorefertotheInternetforobtaining health-relatedinformation.

This study indicates that neither satisfactory nor unsatisfactory relationshipswiththe GPare necessarily associatedwiththedecisionofwhetherornottousethe Internet.Theseresultscontradictourhypothesisthatthe satisfactionandexperiencewithaGPinﬂuencese-health useandarenotinaccordancewiththeliterature[28,33].

Althoughthereisnoassociationbetweene-healthuse andsatisfactionwithGPs,theroleoftheGPremains sig-niﬁcantlyimportantinthepatientbehaviouraftere-health experience. According to the relational perspective of patientempowerment[29,55,60],aproductivepartnership with the family doctor, encompassing his/her legitima-tionofinformationfoundonline,couldsupporta‘better’ health literacy (preventing the e-health risk related to inaccurateinformation),andamore‘appropriate’ empow-erment(ﬁllingthegapbetweenpatienthealtheducation achieved online and positive health-related decisions)

[29,55,60–62,77,78].Ourresultsrelatedtothebehaviour

ofsharingonlineinformationwiththeGPshowedthat e-patientsinvolvetheirGPinthee-healthexperiencemore,if

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processes.Thisseemstoconﬁrmtheideathatthe empow-erede-patientneedsastrongerrelationshipwiththeirGP

[79].

Inrelationtothosestudiesthatemphasiseareduction inthephysicians’inﬂuenceonpatients’decisionsasa con-sequenceofInternetuse[15,80],ourﬁndingsalsoindicate that GPs couldhavea role in theimpactof e-health,if theytreatnotonlythepatient’s illnesses,butalsomeet thepatient’sinformationneeds(forexample,offering sug-gestionsonthelife-styleofthepatient)andbuildonthe relationshipduringtheencounters(forexample,involving patientsinthedecisionmakingprocess).

7. Policyimplications

The results of our study emphasise that e-health is widelydiffusedandmayhaveanimportantrolein health-carechange.WefoundthatInternetuseforhealth-related purposes is not universal and does not influence the useofhealthcareservicesandhealthinformation-seeking behavioursofthewholepopulation[59].Equalaccessto onlinehealthinformationandliteracycannotbetakenfor granted.Indeed,successfulempoweringinterventions can-not be“standard” [81],but shouldbe tailoredtotarget groups.Specificformsofcommunicationandinformation may bedeveloped by takinginto consideration specific information-seekingbehaviours,healthskills,educational levelande-skillsofpotentialpatients.Ouranalysis high-lightedtwomaingroups:olderpeopleand/orpeoplewith alowerlevelofeducation;youngerpeopleand/ormore literatepeople.

Ourresultsindicatethatdissatisfactionwiththe health-caresystemaffectthepatient’sdecisiontochoosee-health to improve their health knowledge. This may result in increasingthedistancebetweenthepatientandthe health-caresystem,oradecreaseinthetrustinthehealthcare systemassourceofhealth-relatedinformation.Public poli-ciescouldfollow a double strategy,in ordertoprevent antagonism and to improve convergence among these two potentialinstrumentsofhealth-literacy:(i) consen-susregardinghealthknowledgeanditsorganisationand collection online, or its legitimation, by selecting reli-able health-related websites; (ii) analysis of the levels of patient satisfaction with the health-caresystem and services,aimedatidentifyingweaknessesandat improv-ing health-careservices, theirpatient-centeredness and responsiveness.

Theroleofthegeneralpractitionersappearstobevery important.A‘double-empowerment’processisneeded:by thepatientontheInternetandbytheGPduring encoun-ters. The patient–Web–physician [55] triangulation can impactonthedynamicsofthedoctor–patientrelationship and ontheempowermentprocess.In thistriangulation, theroleoftheGP(andtheprecedingrelationshipbuiltup withthepatient)coulddeterminewhetherthebehaviour after the e-health experience will be positive or nega-tive,orwhetherornotthee-healthexperiencewilllead to an ‘appropriate’ empowerment. If patientsare satis-ﬁedwiththeGP’swillingnessandabilitytoinvolvethem, thentheywillreturntotheirfamilydoctortodiscussthe

informationfoundontheInternetand,possibly,applyit properly.Thus,thevirtuouscircleofappropriate empow-ermentthroughtheInternetrequiresGPstoplayanactive role. Currently,the useoftheInternet is quitediffused amongphysicians,butforrespondingtoinformationneeds ofthecliniciansmorethantoexplorethepotentialsources ofhealth-relatedinformationforpatients[82].Incontrast, physiciansshouldknowwhatonlineresourcesare avail-able,beamentorformoreinformedorcuriouspatients, guidingthemtoreliableandaccuratewebsites,anddiscuss the information they ﬁnd online [36,83,84]. This ‘net-friendly’behaviourofthephysician“canbeeffectivefor agenuinepartnershipwithpatients”[55].

Effectiveempowermentstrategiesshouldbuildonand reinforceparticipation[81],andthusestablishabalance betweenincreasedpatientautonomyindecision-making andtrustin thephysician.Thispracticecouldavoidthe e-healthrisksrelatedtomisinformationduetothe inaccu-rateand/ornon-scientiﬁcknowledgeavailableonline,and relatedtothepotentialinabilityofe-healthusersto under-standorappropriatelyusehealthinformationfoundonline

[55,85,86]. Furthermore, GPs could empower patients

in their daily practice, by responding to their health informationneedsaccordingtotheire-skillsandhealth competences,andbybuildingarelationshipaccordingto patientpreferencesregardingparticipationordelegation indecision-making.

8. Conclusions

Our study explored the correlations between two patients’behaviours(togoonlineforhealth-related pur-posesandtoshareonlineﬁndingswiththeGP)andseveral variablesrelatedtosocio-demographiccharacteristicsand health needs of the patientsand their satisfaction and experiencewith thehealthcare systemand thegeneral practitioner.

Ourfindingsdemonstratethattherecoursetothe Inter-net for health-related purposes by patients is positive associatedwithbeingyoung,literateanddissatisfiedwith theoverallhealthcaresystem.Incontrast,thebehaviourof sharinghealth-relatedinformationfoundonlinewiththe physicianispositivelystatisticalsignificantassociatedwith thesatisfactionforthelevelofparticipationinthedecision makingprocessandwiththefrequencyofGP’ssuggestions onlife-style.

In general, thetrust and satisfaction for the health-caresystemappearedgoodleversfororientatingpatients towardsahealth-relatedinformationsource.Ontheother hand, our ﬁndings demonstrate that e-patients need a strong partnership with the physician for involving him/her in their e-health experience. It emerged the importanceofshareddecision-makingprocessandmutual engagementinthedigitalera.

9. Limitationsandfutureresearch

Oursurveyquestionsdidnotfocusonthequalityofthe informationfoundonline.However,concernsremainabout thequalityofinformation availableontheInternetand thequalitymeasuringmethods.Futureresearchshouldbe

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differ-entsourcesofonlineinformationone-patientbehaviour. Thestudywasa “snapshot”surveyand cannot iden-tifytrendsintheuseofe-health.Wewerethereforeable toexamineassociationsbetweendependentand indepen-dentvariables.

Another limitation in this study is that the survey wasconducted only in Tuscany.Although our research describesalocalexperience,resultscouldalsobe gener-alizedwithcautionattheinternationallevel.Itcouldbe comparedtoothersimilarcontextswithanalogous charac-teristics.Furthermore,ourstudyispopulation-based:the samplewascomposedofmorethan1700adults(over18 years)ofanyage.Theanalysisandthemethodologyhave aninternalviabilityandcanbereplicatedbothintermsof thesurveyandstatisticalmodels.

However,thedatasourceforthisstudywasinformation self-reportedby respondents.The information provided wasnotvalidatedbyanobjectivesource.Recallbiasisa possibilitybecausetheevaluationofself-reported infor-mationand behaviourpatternswasretrospective. Thus, therespondentsmighthaveforgottensomeoftheir experi-encesandpreviousvisitstohealthcarefacilities.However, thereislittleevidenceintheliteratureofmoredataloss ordistortion intelephoneinterviewscomparedto face-to-faceinterviews,orthattheinterpretationorqualityof ﬁndingscanbecompromisedwheninterviewdatais col-lectedbytelephone.

Despitetheseconstraints,webelievethatthestudyhas advancedtheknowledgeone-health,integratedwiththe issuesofpatient–doctorrelationshipandpatient empow-ermentparadigms. Futureresearchshouldbroaden this analysis,according toother cultural and organisational backgrounds.Otherpatientbehavioursshouldbe inves-tigated,whichcouldresultfrome-healthexperiences,in ordertodeepentheunderstandingofhowe-healthaffects thedynamicsofhealthcareorganisations.

Conﬂictofinterest

Theauthorsdeclarethattheyhavenocompeting inter-estsorconﬂictofinterest.

Authors’information

SDR,PhDinManagement,Competitivenessand Devel-opment with a Telecom Italia grant, has actually a post-doctoralfellowshipattheScuolaSuperioreSant’Anna (SSSA)ofPisa,Italy.Herresearchinterestistechnological andbusinessinnovationinhealthsystems.

SBisan AssistantProfessorat SSSA.Shecoordinates applied research projects and contributes to executive education programs. Her current interests are perfor-manceevaluationsystemsandbenchmarkinginprimary healthcare,andinequalitiesinhealthcareandinternational healthcaresystems.

Authors’contributions

SDRandSBparticipatedinthestudydesignand inter-pretedtheresults.SBparticipatedinacquiringthedataand

performedtheanalyses.SdRandSBwrotehypothesesand analysisframework,methods,resultsandlimitationsofthe manuscript.SDRwroteliteraturereviewanddiscussions. Allauthorsread,revisedandapprovedtheﬁnalmanuscript. Acknowledgements

ThisworkwasﬁnancedbytheRegionofTuscany.We thank thestaffof Laboratorio ManagementeSanità for theirworkin surveyadministrationanddatacollection. WeareespeciallygratefultoProfessorsSabinaNuti,Chiara SeghieriandAnnaMariaMurantefortheirinspiration, sup-portandsuggestions.SdRisgratefultoTelecomItaliafor hergrantandforthesupportofTelecomJointWhiteLabof Pisa,Italy.

References

[1]EysenbachG.Whatise-health?JournalofMedicalInternetResearch 2001;3(April–June(2)):E20[inEnglish].

[2]BlackAD,CarJ,PagliariC,AnandanC,CresswellK,BokunT,etal.The impactofeHealthonthequalityandsafetyofhealthcare:a system-aticoverview.PLoSMedicine2011;8(1):e1000387[inEnglish]. [3]e-Health. Making healthcare better for European citizens: an

action plan for a European e-health area; 2004. Available: http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX: 52004DC0356&from=EN.

[4]EuropeanCommission.FlashEurobarometer 404.European citi-zens’digitalhealthliteracy;2014.Available:http://ec.europa.eu/ publicopinion/ﬂash/ﬂ404factiten.pdf.

[5]AndreassenHK,Bujnowska-FedakMM,ChronakiCE,DumitruRC, PuduleI,SantanaS,etal.Europeancitizens’useofE-healthservices: astudyofsevencountries.BMCPublicHealth2007;7:53[inEnglish]. [6]KummervoldPE,ChronakiCE,LausenB,ProkoschHU,RasmussenJ, SantanaS,etal.eHealthtrendsinEurope2005–2007:a population-basedsurvey.JournalofMedicalInternetResearch2008;10(4):e42 [inEnglish].

[7]McMullanM.PatientsusingtheInternettoobtainhealth informa-tion:howthisaffectsthepatient-healthprofessionalrelationship. PatientEducationandCounseling2006;63(October(1–2)):24–8[in English].

[8]WallersteinN.Powerlessness,empowerment,andhealth: implica-tionsforhealthpromotionprograms.AmericanJournalofHealth Promotion1992;6(January–February(3)):197–205[inEnglish]. [9]AndersonJM.Empoweringpatients:issuesandstrategies.Social

Sci-ence&Medicine1996;43(September(5)):697–705[inEnglish]. [10]MinklerM.Personalresponsibilityforhealth?Areviewofthe

argu-mentsandtheevidenceatcentury’send.HealthEducationand Behavior1999;26(February(1)):121–40[inEnglish].

[11]RoettlJ,BidmonS,TerlutterR.Whatpredictspatients’willingnessto undergoonlinetreatmentandpayforonlinetreatment?Resultsfrom aweb-basedsurveytoinvestigatethechangingpatient-physician relationship.JournalofMedicalInternetResearch2016;18(2):e32 [inEnglish].

[12]AndersenRM.Revisitingthebehavioralmodelandaccessto med-icalcare:doesitmatter? JournalofHealthandSocialBehavior 1995;36(March(1)):1–10[inEnglish].

[13]DeddingC,vanDoornR,WinklerL,ReisR.Howwille-healthaffect patientparticipationintheclinic?Areview ofe-healthstudies andthecurrentevidenceforchangesintherelationshipbetween medical professionals and patients. Social Science & Medicine 2011;72(January(1)):49–53[inEnglish].

[14]AnkerAE,ReinhartAM,FeeleyTH.Healthinformationseeking:a reviewofmeasuresandmethods.PatientEducationandCounseling 2011;82(March(3)):346–54[inEnglish].

[15]Murray E, Lo B, Pollack L, Donelan K, Catania J, Lee K, et al. The impact of health information on the Internet on health careandthephysician-patientrelationship:nationalU.S.survey among1.050U.S.physicians.JournalofMedicalInternetResearch 2003;5(July–September(3)):e17[inEnglish].

[16]BeckF,RichardJB,Nguyen-ThanhV,MontagniI,ParizotI,RenahyE. UseoftheinternetasahealthinformationresourceamongFrench youngadults:resultsfromanationallyrepresentativesurvey.Journal ofMedicalInternetResearch2014;16(5):e128[inEnglish].

(13)

ARTICLE IN PRESS

G Model

S.DeRosis,S.Barsanti/HealthPolicyxxx(2016)xxx–xxx 13 [17]ChaudhuriS,LeT,WhiteC,ThompsonH,DemirisG.Examininghealth

information-seekingbehaviorsofolderadults.Computers, Informat-ics,Nursing2013;31(November(11)):547–53[inEnglish]. [18]BertF,RichardJB,Nguyen-ThanhV,MontagniI,ParizotI,Renahy

E,etal.Pregnancye-health:amulticenterItaliancross-sectional studyonInternetuseanddecision-makingamongpregnantwomen. JournalofEpidemiologyandCommunityHealth2013;67(December (12)):1013–8[inEnglish].

[19]Sparud-Lundin C, RanerupA, Berg M.Internet use, needs and expectationsofweb-basedinformationandcommunicationin child-bearingwomenwithtype1diabetes.BMCMedicalInformaticsand DecisionMaking2011;11:49[inEnglish].

[20]SiliquiniR,CerutiM,LovatoE,BertF,BrunoS,DeVitoE,etal. Surf-ingtheinternetforhealthinformation:anItaliansurveyonuseand populationchoices.BMCMedicalInformaticsandDecisionMaking 2011;11:21[inEnglish].

[21]Valero-Aguilera B, Bermúdez-Tamayo C, García-Gutiérrez JF, Jiménez-PernettJ,Cózar-OlmoJM,Guerrero-TejadaR,etal. Infor-mationneeds andInternet useinurological andbreast cancer patients.SupportiveCareinCancer2014;22(February(2)):545–52 [inEnglish].

[22]Caiata-ZuffereyM,AbrahamA,SommerhalderK,SchulzPJ.Online healthinformationseekinginthecontextofthemedical consul-tationinSwitzerland.QualitativeHealthResearch2010;20(August (8)):1050–61[inEnglish].

[23]Purcarea VL, PetrescuDG, Gheorghe IR,Petrescu CM. Optimiz-ingthetechnologicalandinformationalrelationshipofthehealth care processand ofthecommunicationbetweenphysicianand patient—factorsthathaveanimpactontheprocessofdiagnosisfrom thephysician’sandthepatient’sperspectives.JournalofMedicine andLife2011;4(May(2)):198–206[inEnglish].

[24]Klinar I, Balazin A, Barsi ´c B, Tiljak H. Identiﬁcation of general characteristics,motivation,andsatisfactionofinternet-based med-icalconsultationserviceusersinCroatia.CroatianMedicalJournal 2011;52(August(4)):557–65[inEnglish].

[25]WilsonEV,LanktonNK.Modelingpatients’acceptanceof provider-deliverede-health.JournaloftheAmericanMedical Informatics Association2004;11(July–August(4)):241–8[inEnglish]. [26]Deli ´cD,PolasekO,KernJ.Internethealth-informationseekersin

Croatia—who,what,andwhy?MedicalInformaticsandtheInternet inMedicine2006;31(December(4)):267–73[inEnglish]. [27]Bylund CL, Gueguen JA, SabeeCM,Imes RS,Li Y, Sanford AA.

Provider-patientdialogue aboutInternet healthinformation: an explorationofstrategiestoimprovetheprovider-patient relation-ship.PatientEducationandCounseling2007;66(June(3)):346–52 [inEnglish].

[28]BrietJP,HagemanMG,BlokR,RingD.Whendopatientswithhand illnessseekonlinehealthconsultationsandwhatdotheyask? Clini-calOrthopaedicsandRelatedResearch2014;472(April(4)):1246–50 [inEnglish].

[29]LemireM,SicotteC,ParéG.Internetuseandthelogicsofpersonal empowermentinhealth.HealthPolicy2008;88(October(1)):130–40 [inEnglish].

[30]BroomA.Virtuallyhe@lthy:theimpactofinternetuseondisease experienceandthedoctor-patientrelationship.QualitativeHealth Research2005;15(March(3)):325–45[inEnglish].

[31]MehrotraA,PaoneS,MartichGD,AlbertSM,ShevchikGJ. Char-acteristicsofpatientswhoseekcareviaeVisitsinsteadofofﬁce visits.TelemedicineJournalandE-Health2013;19(July(7)):515–9 [inEnglish].

[32]WestHJ,DebronkartD,DemetriGD.Anewmodel:physician-patient collaborationinonlinecommunitiesandtheclinicalpracticeof oncology.AmericanSocietyofClinicalOncologyEducationalBook 2012:443–8[inEnglish].

[33]BiancoA,ZuccoR,NobileCG,PileggiC,Pavia M.Parents seek-ing health-related information on the Internet: cross-sectional study. Journal of Medical Internet Research 2013;15(9):e204 [inEnglish].

[34]BowesP,StevensonF,AhluwaliaS,MurrayE.‘Ineedhertobea doctor’:patients’experiencesofpresentinghealthinformationfrom theinternetinGPconsultations.BritishJournalofGeneralPractice 2012;62(November(604)):e732–8[inEnglish].

[35]DiazJA,GrifﬁthRA,NgJJ,ReinertSE,FriedmannPD,MoultonAW. Patients’useoftheInternetformedicalinformation.Journalof Gen-eralInternalMedicine2002;17(March(3)):180–5[inEnglish]. [36]DiazJA,GrifﬁthRA,NgJJ,ReinertSE,FriedmannPD,MoultonAW,

etal.Trustandsourcesofhealthinformation:theimpactofthe Inter-netanditsimplicationsforhealthcareproviders:ﬁndingsfromthe

ﬁrstHealthInformationNationalTrendsSurvey.ArchivesofInternal Medicine2005;165(December(22)):2618–24[inEnglish]. [37]Pe ˜na-Purcell N. Hispanics’ use of Internet health information:

anexploratorystudy.JournaloftheMedicalLibraryAssociation 2008;96(April(2)):101–7[inEnglish].

[38]MartinezCH,StJeanBL,PlauschinatCA,RogersB,BeresfordJ, Mar-tinezFJ,etal.InternetaccessandusebyCOPDpatientsintheNational Emphysema/COPDAssociationSurvey.BMCPulmonaryMedicine 2014;14:66[inEnglish].

[39]MarrieRA,SalterAR,TyryT,FoxRJ,CutterGR.Preferredsources ofhealthinformationinpersonswithmultiplesclerosis:degreeof trustandinformationsought.JournalofMedicalInternetResearch 2013;15(4):e67[inEnglish].

[40]BiermannJS,GolladayGJ,PetersonRN.Usingtheinternettoenhance physician-patientcommunication.JournaloftheAmericanAcademy ofOrthopaedicSurgeons2006;14(March(3)):136–44[inEnglish]. [41]Rice RE. Inﬂuences, usage, and outcomes of Internet health

information searching: multivariate results from the Pew sur-veys.InternationalJournalofMedicalInformatics2006;75(January (1)):8–28[inEnglish].

[42]CensisFplrB.Qualefuturoperilrapportomedico-pazientenella nuovasanità?Ilfuturodellasanità.Trarisorsevincolateedeﬁcit dicompliance.Milan,Italy;2013.

[43]AyantundeAA,WelchNT,ParsonsSL.Asurveyofpatientsatisfaction anduseoftheInternetforhealthinformation.InternationalJournal ofClinicalPractice2007;61(March(3)):458–62[inEnglish]. [44]AtkinsonNL,SapersteinSL,PleisJ.Usingtheinternetfor

health-related activities: ﬁndings from a national probability sample. JournalofMedicalInternetResearch2009;11(1):e4[inEnglish]. [45]RenahyE,ParizotI,ChauvinP.Determinantsofthefrequencyof

onlinehealthinformationseeking:resultsofaweb-basedsurvey conductedinFrancein2007.InformaticsforHealthandSocialCare 2010;35(January(1)):25–39[inEnglish].

[46]KatzJE,RobergeD,CoulombeG.Thecancerpatient’suseand appre-ciationoftheinternetandothermodernmeansofcommunication. TechnologyinCancer ResearchandTreatment 2014;13(October (5)):477–84[inEnglish].

[47]HoustonTK,AllisonJJ.UsersofInternethealthinformation: dif-ferences byhealth status.Journal ofMedical InternetResearch 2002;4(April–November(2)):E7[inEnglish].

[48]SantanaS,LausenB,Bujnowska-FedakM,ChronakiCE,Prokosch HU,WynnR.Informedcitizenandempoweredcitizeninhealth: resultsfromanEuropeansurvey.BMCFamilyPractice2011;12:20 [inEnglish].

[49]RokadeA,KapoorPK,RaoS,RokadeV,ReddyKT,KumarBN.Hasthe internetovertakenothertraditionalsourcesofhealthinformation? Questionnairesurveyofpatients attendingENT outpatient clin-ics.ClinicalOtolaryngologyandAlliedSciences2002;27(December (6)):526–8[inEnglish].

[50]CooleyDL,MancusoAM,WeissLB,CorenJS.Health-related Inter-netuseamongpatientsofosteopathicphysicians.Journalofthe AmericanOsteopathicAssociation2011;111(August(8)):473–82[in English].

[51]TozziAE,MingarelliR,AgricolaE,GonfiantiniM,PandolfiE,CarloniE, etal.TheinternetuserprofileofItalianfamiliesofpatientswithrare diseases:awebsurvey.OrphanetJournalofRareDiseases2013;8:76 [inEnglish].

[52]GerberBS,EiserAR.ThepatientphysicianrelationshipintheInternet age:futureprospectsandtheresearchagenda.JournalofMedical InternetResearch2001;3(April–June(2)):E15[inEnglish]. [53]KassirerJP.Patients,physicians,andtheInternet.HealthAffairs

2000;19(November–December(6)):115–23[inEnglish].

[54]HenwoodF,WyattS,HartA,SmithJ.‘Ignoranceisblisssometimes’: constraintsontheemergenceofthe‘informedpatient’inthe chang-inglandscapesofhealthinformation.SociologyofHealthandIllness 2003;25(September(6)):589–607[inEnglish].

[55]WaldHS,DubeCE,AnthonyDC.UntanglingtheWeb—theimpactof Internetuseonhealthcareandthephysician-patientrelationship. PatientEducationandCounseling2007;68(November(3)):218–24 [inEnglish].

[56]KrepsGL, Neuhauser L.Newdirectionsin eHealth communica-tion:opportunitiesandchallenges.PatientEducationandCounseling 2010;78(March(3)):329–36[inEnglish].

[57]Ulrike F, Lisa G, Astrid M. Shaping the future e-patient. The citizen-patientin public discourse on e-health.Science Studies 2009;22(1):24–43.

[58]SchookRM,LinssenC,SchramelFM,FestenJ,LammersE,SmitEF, etal.WhydopatientsandcaregiversseekanswersfromtheInternet

(14)

ARTICLE IN PRESS

G Model

14 S.DeRosis,S.Barsanti/HealthPolicyxxx(2016)xxx–xxx andonlinelungspecialists?Aqualitativestudy.JournalofMedical

InternetResearch2014;16(2):e37[inEnglish].

[59]HayMC,StrathmannC,LieberE,WickK,GiesserB.Whypatients goonline: multiplesclerosis,theinternet,andphysician-patient communication. Neurologist 2008;14(November (6)):374–81 [in English].

[60]FergusonT,FrydmanG. Theﬁrst generation ofe-patients.BMJ 2004;328(May(7449)):1148–9[inEnglish].

[61]SchulzPJ,NakamotoK.Patientbehaviorandthebeneﬁtsof artiﬁ-cialintelligence:theperilsofdangerousliteracyandillusorypatient empowerment.PatientEducationandCounseling2013;92(August (2)):223–8[inEnglish].

[62]Lu Y, Yong T. Feeling blue? Go online: an empirical study of onlinesupports among patients.Information SystemsResearch 2014;25(4):690–709.

[63]FoxS,RainieL.E-patientsandtheonlinehealthcarerevolution. Physician Executive 2002;28(November–December (6)):14–7 [in English].

[64]BylundCL,SabeeCM,ImesRS,SanfordAA.Explorationofthe con-structofrelianceamongpatients whotalkwiththeirproviders about internet information. Journal of Health Communication 2007;12(January–February(1)):17–28[inEnglish].

[65]NutiS,SeghieriC.Isvariationmanagementincludedinregional healthcaregovernancesystems?SomeproposalsfromItaly.Health Policy2014;114(January(1)):71–8[inEnglish].

[66]BarsantiS,NutiS.Theequitylensinthehealthcareperformance evaluationsystem.InternationalJournalofHealthPlanningand Man-agement2014;29(July–September(3)):e233–46[inEnglish]. [67]Internet world stats, internet in Europe stats; 2014.

Avail-able: http://www.internetworldstats.com/stats4.htm [accessed 25.05.15].

[68]NS,BA.Ilsistema divalutazionedella performancedeisistemi sanitariregionali: Basilicata,Liguria,Marche,P.A.,Bolzano,P.A., Trento,Toscana,Umbria,Veneto.Report2012.ScuolaSuperiore Sant’Anna—LaboratorioManagementeSanità,Pisa;2013. [69]Istat.Cittadinienuovetecnologie,inreport2014;2014.Available:

http://www.istat.it/it/archivio/143073.

[70]vanUden-KraanCF,DrossaertCH,TaalE,ShawBR,SeydelER,van deLaarMA.Empoweringprocessesandoutcomesofparticipation inonlinesupportgroupsforpatientswithbreastcancer, arthri-tis, orﬁbromyalgia.Qualitative HealthResearch2008;18(March (3)):405–17[inEnglish].

[71]RenahyE,ChauvinP.Internetusesforhealthinformation seek-ing:aliteraturereview.Revued’epidemiologieetdesantepublique 2006;54(June(3)):263–75[inEnglish].

[72]MuranteAM,VainieriM,RojasD,NutiS.Doesfeedbackinﬂuence patient–professionalcommunication?EmpiricalevidencefromItaly. HealthPolicy2014;116(June(2–3)):273–80[inEnglish].

[73]RubinelliS,SchulzPJ,NakamotoK.Healthliteracybeyondknowledge andbehaviour:lettingthepatientbeapatient.InternationalJournal ofPublicHealth2009;54(5):307–11[inEnglish].

[74]SzumilasM.Explainingoddsratios.JournaloftheCanadianAcademy ofChildandAdolescentPsychiatry2010;19(August(3)):227–9[in English].

[75]ShtatlandES,KleinmanK,CainEM.OnemoretimeaboutR2measures ofﬁtinlogisticregression.NESUG15Proceedings2002;(15):222–6. [76]MonteagudoPe ˜naJL,MorenoGilO,editors.e-Healthforpatient empowermentinEurope.Madrid:InstitutodeSaludCarlosIII;2007. [77]BlockM,SternDB,RamanK,LeeS,CareyJ,HumphreysAA,etal. Therelationshipbetweenself-reportofdepressionandmediausage. FrontiersinHumanNeuroscience2014;8:712[inEnglish]. [78]SchulzPJ,NakamotoK.“Bad”literacy,theinternet,andthe

lim-its of patient empowerment. Presented at the AI and Health Communication—AAAI2011SpringSymposium;2011.

[79]Chatzimarkakis J. Whypatientsshould bemore empowered:a Europeanperspectiveonlessonslearnedinthemanagementof dia-betes.JournalofDiabetesScienceandTechnology2010;4(November (6)):1570–3[inEnglish].

[80]Iverson SA,Howard KB,PenneyBK. Impactof internetuseon health-relatedbehaviorsandthepatient-physicianrelationship:a survey-basedstudyandreview.JournaloftheAmericanOsteopathic Association2008;108(December(12)):699–711[inEnglish]. [81]Wallerstein N. What is the evidence on

effective-ness of empowerment to improve health? Copenhagen: WHO Regional Ofﬁce for Europe; 2006. Available: http://www.euro.who.int/Document/E88086.pdf.

[82]De Rosis S,Seghieri C. Basic ICTadoption and useby general practitioners: an analysisof primarycare systems in31 Euro-pean countries. BMC Medical Informatics and Decision Making 2015;15(1):70[inEnglish].

[83]ZablockiE.Anewresource:empoweredpatients.QualityLetterfor HealthcareLeaders1998;10(August(8)):2–10[inEnglish]. [84]HannanTJ,CeliaC.Aredoctorsthestructuralweaknessinthe

e-healthbuilding?InternalMedicineJournal2013;43(10):1155–64[in English].

[85]GilliamAD,SpeakeWJ,ScholeﬁeldJH,BeckinghamIJ.Findingthe bestfromtherest:evaluationofthequalityofpatientinformation ontheInternet.AnnalsoftheRoyalCollegeofSurgeonsofEngland 2003;85(January(1)):44–6[inEnglish].

[86]AyonrindeO. Patientsincyberspace: informationorconfusion? Postgraduate MedicalJournal 1998;74(August(874)):449–50[in English].