Articles/1995/1
RHP&EO is the electronic journal of the International Union for Health Promotion and Education

Health promotion on the Internet

Doron S. Gradstein, Michael S. Hofman and Yigal Reuben

Internet publication: October, 1995
Work by Monash University Medical students, produced as part of the health promotion subject offered at year three.

Gradstein D, Hofman S, Reuben Y. Health Promotion on the Internet. Internet Journal of Health Promotion, 1996. URL: ijhp-articles/1995/1/index.htm.

Abstract

The Internet was successfully utilised as a novel and interactive medium for health promotion. The project involved setting up a Home Page for Health Promotion available to the global community (http://www.monash.edu.au/health). This served as a platform from which numerous health issues and resources could be accessed. A broad community approach encompassing all major health issues was adopted due to the potential world-wide penetrability of the Internet. As our project was based in Melbourne, an extensive listing of Victorian self help groups and resources was also constructed. In addition, an electronic journal and database of community health promotion projects were created.

Community awareness of the Internet and interest in its use for health promotion was assessed by conducting a preliminary questionnaire. We found that the vast majority of persons had heard of the Internet and believed it to be a good means of obtaining health related information.

In a short period of three weeks, 385 people visited our page from all corners of the world. In addition, we created an online questionnaire to allow visitors the ability to provide feedback. The vast majority of respondents portrayed a positive attitude to our project. Of 66 respondents, 95% believed the Internet to be a good source of health information and 85% said they would recommend the Home Page to others.

Keywords:

Health Promotion, Internet, Information Superhighway, Support Groups, Victorian Health Resources, World Wide Web

Background

Once an important community health issue is discerned, a means of disseminating relevant information becomes necessary. Traditionally, it was the role of the general practitioner to educate his patients with general health information. However, this was a very individualised approach to health promotion and certain issues required action at a community level. To educate a community, information has to be transmitted en mass in the hope that a significant number of community members will encounter it. Methods used to achieve this have included poster displays on community boards, advertisements or articles in newspapers, radio ads or reports, televisions commercials or programs as well as lectures, health seminars and information pamphlets. Basically, the aim has been to utilise or exploit the existing infrastructure in the general media to propagate the information. Nevertheless, one medium, which arguably contains the most potentiality, has yet to be fully realised in the domain of health promotion. This medium has been popularly coined the 'Information Superhighway', or more accurately the Internet. An industry which relies on the transmission of information, such as health promotion, must embrace, and not shun in fear, this new medium for its possibilities are infinite.

The Internet is made up of thousands of interconnected computers in over 70 countries, comprised of academic, commercial, government and military networks. At present a vast pool of information and resources exist on the Internet. Information can be accessed from any computer in the world connected to the Internet and may also contain interactive elements, such as 'on-line' doctors to answer specific questions. The growth of new users and information access points on the Internet has being growing exponentially for the last few years. The World Wide Web (WWW) is the newest information service available on the Internet and has become the centerpiece of Internet activity. Using the WWW anybody can construct a 'Home Page' from which an information service is tendered. The page directs users to points of further information which may be located on the same or another computer. These pointers are known as 'links' and can be thought of as the threads which bind the web together. Choosing a particular link may have you accessing a computer on a different continent!

Our project involved setting up a Home Page for Health Promotion. As we aimed for a broad community approach to health issues, numerous topics were addressed on this page. Important areas of health promotion in both men's and woman's health were included. We also established a database of community health promotion projects undertaken in this Unit of the Monash medical course. A fledgling electronic journal was included as was a detailed listing of health resources including self help groups in Victoria. The purpose of this report is to detail the objectives, strategies and methods, evaluation plan and results of this health promotion project.

Priority Population

The priority population group being targeted are users of the Internet. In order to promote relevant health issues it is necessary to know the demographics of Internet users and this is summarised below (1):

An estimated 36 million world-wide users with an Australian audience of 600,000.
The average age of users of the Internet is 35, with 30% between the ages of 21 and 30.
15.5% of Internet users are female, but this number is increasing, and it is predicted that an even ratio will be achieved some time in the year 1997.
About half the users are married, with about 30% in computer-related fields and 24% in education-related fields (including students).
The most common use of the World Wide Web is simply for browsing (82.6%) followed by entertainment (56.6%) and work (50.9%). It is estimated that those using the Internet for research is between 32% and 45%.

We chose to target this group as the Internet represents a new medium in which to promote health issues. More specifically, Victorian Internet users are targeted as we have provided information specific to this audience.

Aims

The project consists of many aims, as outlined below:

To exploit the Internet as a new medium in which to promote health. This includes the use of the Internet as new means of health information promulgation.
To evaluate community awareness of the Internet by conducting a questionnaire and performing a literature survey on the topic.
To create a structured "Home Page" for the Monash Health Promotion Unit on the Internet. This service provides a base for accessing the Health Promotion information provided as well as pointing to other information services.
To make more accessible the huge archive of health information and services currently available on the Internet by creating an index of these.
To compile and make accessible a database of health resources available in Victoria, encompassing a list of self help groups.
To establish a database of community health promotion projects as undertaken by the Monash Health Promotion Unit.
To set up a health promotion electronic journal for the Monash Health Promotion Unit that will initially contain this report. Feedback and correspondence facilities in the form of a 'letter to the editor' will be implemented.
To evaluate the community impact of our page by creating an 'on-line' questionnaire that also allows for user feedback and suggestions.
To have created an infrastructure which allows for future people to use the Internet as a medium to promote their health issue.

Goals and Targets

Ultimately we hope to have achieved the following goals and targets:

To have developed an innovative, interactive and novel approach to health promotion.
To enable people to have easy access to a wealth of health information thereby empowering them to make better informed decisions.
To increase the accessibility of information concerning health resources and more specifically, self help and social action groups, available to the community in Victoria.

Strategies and Methods

Research: Community Questionnaire and Literature Survey

Rather than assuming that the Internet is a good medium for health promotion, a questionnaire was conducted to evaluate the feasibility of the project (see Appendix A: Preliminary Questionnaire). This survey was conducted on 107 people at Westfield Shoppingtown in Doncaster to gauge the general community awareness of the Internet. In addition, we surveyed 90 people at Monash University, Clayton Campus, who we believe have a greater awareness of the Internet. This was performed in order to assess whether the Internet is a good medium for health promotion. The participants of the survey were randomly selected.

Our surveyed revealed marked differences between the two groups with respect to awareness of the Internet and their accessibility to it. Both groups, however, agreed that the Internet is a good medium for obtaining health related information with much interest expressed in using the Internet to obtain information about support groups. Key results are summarised in Figure 1 and Figure 2 below (see Appendix D: Tabulated Results for Preliminary Questionnaire for full results).

Figure 1

Figure 2

A literature survey was then undertaken to determine who uses the Internet. This was done so that health information appropriate to the priority population could be chosen.

Construct a 'Home Page'

To promote health on the Internet, a Home Page titled "Health Promotion on the Internet" was constructed. An endeavour was made to structure the page in such a way so that information retrieval would be simple and efficient while ensuring that it could be easily updated in the future. This involved liaison with Dr Bridget Hsu-Hage, the Health Promotion Unit Convenor. The Home Page was structured as illustrated below (Figure 3):

Figure 3

The objective of the Health Issues page was to make more accessible the huge archive of health information and services currently available on the Internet. While the demographics of Internet users was kept in mind, we aimed to deal with a broad range of health issues so that it would be of interest to most people.

There is currently limited information on the Internet concerning Victorian health resources and therefore we aimed to create a database of such resources. It was not viable to list all health resources so a focus on self-help groups was incorporated, while a list of other health-related organisations was also included. Information on self-help groups was obtained with permission from the Collective of Self Help Groups (2).

This proposed design then had to be converted into "computer language". This involved researching and learning the HyperText Mark Up Language (HTML), the standard language used on the World Wide Web (WWW) for production of pages (3,4,5,6). Details of this are beyond the scope of this report (see Appendix F with the diskette containing the HTML files). The WWW is a multimedia medium incorporating both text and graphics and therefore effort had to be put into the visual impact of the Home Page; the objectives in designing the page were:

It should be attractive and pleasing to the eyes
It should communicate its message effectively
It should have its information ordered in a way meaningful to the reader

Once this had been accomplished, the Home Page had to be linked to the Internet. Initially, this was done with the help of Dr Adrian Vanzyl from Monash Medical Informatics. He provided us with the resources so that the Home Page could be accessed via the existing Monash Medical Informatics World Wide Web server. This was extremely valuable as it allowed us to extensively test our page and make appropriate changes. However, since the Monash Health Promotion Unit is run independently of Monash Medical Informatics it was decided to move the Home Page to the Monash University server. This was accomplished with the help of Ms Sue Steele from the Main Library.

Publicise the 'Home Page'

The Internet provides many mechanisms by which new Home Page's can be publicised. Foremost, are "search engines" whereby users enter a keyword (eg. "Health promotion") and Internet resources are searched, allowing for rapid retrieval of specific information. We contacted the providers of such services, requesting that our Home Page be included in their search databases. Following is a list of those contacted:

Table 1 [not available online]

The above mechanisms allowed us to potentially target a global audience of millions of people. In order to specifically target Victorian Internet users we wrote to Mr Gary Hardy of the Victorian State Library who maintains VICNET, the Victoria Home Page on the Internet. After reviewing our Home Page he added it to the 'health' section of VICNET. In addition, we wrote to many medical-related sites (eg. MedWeb) requesting that they add a link to our Home Page. We also wrote to The Age in Melbourne to enquire if they would publicise our site in the Computer Age; the results of this are still pending.

Another method of publicity used was Internet Newsgroups, which consists of a collection of messages on a particular subject. We posted mail publicising our new Home Page in many health and medical related newsgroups. We also posted e-mail to staff of the Monash Department of Medicine and Monash Medical Informatics announcing the establishment of the Home Page.

The limitation of most of the above methods is that we are restricting publicity to people who use the Internet. It was beyond the scope of this Health Promotion Project to publicise the Internet itself and consequently attract people to use it and attain health-related information. Nevertheless, our potential audience within the Internet is huge.

Evaluation Plan

The Internet provides an innovative means of evaluating the success of a community project. As our project is accessible to the global community, 24 hours a day, evaluation of its impact can be assessed continually. Via a few key strokes, the user can instantaneously send their feedback.

In order to evaluate the community impact of our project, two methods were adopted:

Access log. A log of all people who accessed our Home Page was generated so that we could gauge the community interest. Moreover, details such as country and place of access could be ascertained from this log.
On-line questionnaire. An on-line questionnaire was developed so that users could give specific feedback regarding the content and quality of the Home Page.

The objectives of the on-line questionnaire were to:

Obtain demographic details of the people who visited our Home Page. This was done to assist further development of this page so that people best targeted for health promotion on the Internet can be identified.
Specifically identify the health issues of interest to users. This was done so that we could verify that we had chosen appropriate health issues. It will also enable appropriate modifications to be made in the future.
Ascertain major sources of information on health related issues. As we are using a new media for health promotion, this information was of interest.
Determine if the structure and content of our Home Page was beneficial to the priority population.
Allow the user to send additional comments and suggestions.

To entice the user into completing the questionnaire we offered subscription to a "health promotion mailing list". This mailing list will allow the registered user to enjoy free notification of the publication of new electronic journals as well as important changes to the Home Page.

Results

1. Access Logs

From collating and analysing the Monash University World Wide Web logs for the period of 15 Sept 95 to 6 Oct 95 the following results were discerned (see Appendix C for an example of such a log):

385 visits to our Home Page were recorded. Notwithstanding that our Home Page was recently established, this figure is quite high and indicates wide community interest in the service provided.
Our logs also recorded the country of origin from which our site was visited. Figure 4 below displays these results by region:

Figure 4

2. On-line Questionnaires

The on-line questionnaire was completed by 66 people. This number was hampered by differing computer standards, preventing some people from successfully submitting the questionnaire. The results were as follows:

Demographic details. Results were consistent with those obtained from the GVU survey (see Priority Population, p5). 70% of respondents were male, 30% were female. Figure 5 below illustrates the age distribution of respondents:

Figure 5

Health issues. The areas showing most interest were alternative medicine, general and men's health. This is probably due to the lack of emphasis placed on these health issues in the past.

Figure 6

Major sources of information on health related issues. Our results showed that people tend to use many forms of media to obtain their information on health. Among self-declared "expert" Internet users, the Internet rated highly as a source of information.
Structure and content of the Home Page. The nature of the feedback received was positive. 85% said they would recommend the Home Page to others while 84% believed that an adequate range of health issues was covered. The database of Victorian support groups did not rate highly almost certainly because of poor wording of the question as the majority of users who accessed the page were not Victorian. Figure 7 below summarises these results:

Figure 7

Discussion and Conclusions

The Internet is fast becoming the preferred media for accessing vast sources of information. As a medium for health promotion advantages include:

The potential audience is large, encompassing most countries (see statistics in Priority Population). It is well suited to promoting health issues which are relevant to the community at large. Our results clearly demonstrate how a project can quickly reach the global community.
It provides the ability to gain access to new information virtually instantly, without having to wait for a paper to be published via conventional means. It's size virtually guarantees that no matter how obscure the information being sought after, there is a very high probability that someone has published information concerning it.
It is a multimedia platform allowing for text, pictures, sound and video. No other media can combine these elements with such ease. Moreover, it provides an interactive source of information allowing users to quickly obtain the information they desire and respond to it.
It provides easy access to archives of information, thus empowering people to make better informed decisions.
The cost of implementing a health promotion project via the Internet is considerably less than other mediums while maintaining the above advantages.

However, the Internet currently has a few disadvantages and limitations:

Some computer knowledge is a prerequisite to accessing the Internet. Nevertheless, general computer know-how is increasing while software is becoming more 'user friendly'.
There is still limited access to the Internet. Requirements include a computer with an Internet connection and therefore lower socioeconomic groups may be disadvantaged. However, with more schools, libraries and community centres continually being connected, this obstacle is being overcome.
Literacy is a requirement for health promotion on the Internet. Therefore, it may not be suitable for targeting low socioeconomic groups as well as third world populations. Moreover, the majority of information provided on the Internet is in English, although, this is rapidly changing to encompass many other languages.
There exists an imbalance between the number of males and females using the Internet (see Priority Population for statistics). The trend is now, however, towards an equal balance between the sexes.

Community Impact and Recommendations

Our project had significant community impact. We feel that the Internet is a new and exciting medium for health promotion which can not be ignored. There were 385 visits to our page over a three week period from numerous countries while the service created will be available for many years to come. We received numerous appraisals from people who accessed our page.

An infrastructure for health promotion on the Internet has been successfully created. This forms a basis for modifications that could be implemented in the future. The possibilities are infinite and could include:

Creating an interactive, world-wide support group on-line for specific health issues.
A more extensive database of health resources, including a larger database of support groups that could encompass states other than Victoria.

Acknowledgements

We are indebted to the following people:

Dr Bridget Hsu-Hage (Department of Medicine MMC) for her tireless assistance and enthusiasm during the conduction of our project. Specifically, Dr Hsu-Hage provided guidance with respect to structuring of the Home Page.
Dr Adrian Vanzyl, Dr Branko Cesnik and Wendy McPhee (Monash Medical Informatics) for providing us with the computer resources required for initially establishing our Home Page on the Internet.
Ms Sue Steele (Main Library), the Monash 'Webmaster', for further assisting us in the maintenance of the Home Page.

References

Graphic, Visualization, & Usability Center's (GVU). 3rd WWW User Survey, May 1995.
Collective of Self Help Groups. Directory of Self Help and Social Action Groups, May 1994 (7th ed.).
Heslop B and Budnick L. HTML Publishing on the Internet for Windows: create great-looking documents online: home pages, newsletters, catalogs, ads & forums, Chapel Hill: Ventana Press, 1995.
Ford A. Spinning the Web: How to Provide Information on the Internet, London: Internal Thomson Publishing, 1995.
Graham S. The HTML Sourcebook, New York: Wiley, 1995.
December, J. The World Wide Web Unleashed, Indianapolis: Sams Publishing, 1995.
Hsu-Hage BH-H and Jones KV. Student Workbook: Health Promotion, Department of Medicine, Monash University, 1995.
Egger G, Spark R, Lawson J. Health Promotion Strategies and Methods, Sydney: McGraw-Hill Book Co., 1990.

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