#61054: Health 2.0: Implications for Care

As is increasingly evident, the Internet is not only rapidly changing public life but professional and private life as well. The first wave of Internet technology, referred to as Web 1.0, launched in 1993, focused on the functionality of accessing information through search engines and hyperlinks—a top-down approach [1,4]. The second wave, beginning around 2003, or Web 2.0, refers to a second generation of Internet technology that uses applications to facilitate interactions, collaborations, and collection and dissemination of information [4]. The impact of Web 2.0 has extended into many fields, including health care and mental health. In fact, it is believed Web 2.0 will revolutionize how health care is provided, leading to the use of such terms as Health 2.0 or Medicine 2.0. Consumers of healthcare services are increasingly utilizing technology to seek information about health and to connect with others through social networking sites. For example, consumers using Facebook may share evaluations of physicians, potentially resulting in more informed decisions when choosing a healthcare provider [2]. Practitioners may also use Web 2.0 applications to discuss cases and problem solve collaboratively.

Web 2.0 allows for the accumulation of a vast amount of information, generated by both experts and the general public, and makes it instantly available to anyone with access to the technology. Health information can be accessed at any time using cellular phones and smartphones, which has resulted in the democratization of health information. Individuals who are emotionally or physically distressed can use web logs (blogs) and social networking sites to tell their stories, seek support, and gain empowerment. These technologies have the potential benefits of being not only educational but also therapeutic [3]. However, there is also a downside. With the amount of information readily available, it can be difficult for consumers to critically evaluate the numerous claims and make informed decisions. In some cases, individuals may rely too heavily on Internet technologies, possibly hindering earlier detection of problems or delaying access to more appropriate support and professional services [3].

Web 3.0 represents the next generation of the Internet. As of 2024, it has not fully launched and is thought to be more of a set of ideas [5]. The goal is to decentralize the Internet, rather than largely being controlled by big companies like Alphabet (e.g., Google) or Meta (e.g., Facebook) [5].

The goal of this course is to provide an overview of the roles and functions of Web 2.0 in the healthcare, social work, nursing, and mental health fields. Examples of specific Health 2.0/Medicine 2.0 technologies will be provided. It will explore how practitioners, educators, and clients/patients are using Web 2.0 to educate, provide support, and seek health information and how this ultimately influences health decisions.

As of 2018, 85.3% of American households had an Internet subscription, and as of 2021, 77% of households had broadband Internet access [8,12]. There appears to be no gender differences in Internet usage, with 89% of men and 88% of women reporting Internet use [8]. Individuals 18 to 29 years of age are the most likely to use the Internet (100%), while adults 65 years of age and older are the least likely (75%) [8]. With Web 2.0, people have increasingly used social networking sites and are creating and viewing podcasts, vodcasts, and blogs. In 2021, 72% of adults were using social networking sites, with 18 to 29 year olds leading at 84% [71]. In 2020, 97% of Americans owned a cellphone of some kind, and 85% owned a smartphone [72]. Among adults 65 years of age and older, 61% owned a smartphone [72].

Podcasts or vodcasts are audio or video digital media files that can be downloaded from the Internet. In December 2020, there were 41.9 million podcasts according to Apple [9]. As of 2023, there are more than 4 million podcasts registered around the world [9]. According to the Pew Research Center, 64% of Americans have ever listened to a podcast, which is a dramatic increase compared with 2006 (11%) [98]. Generally, men download podcasts more often than their female counterparts, and adults 18 to 49 years of age are the most likely of all age-groups to have downloaded a podcast [6].

It is estimated that 12 to 26.4 million Americans blog and 57 to 94 million read information from blogs [7]. The number of bloggers in the United States was estimated to be 31.7 million in 2020 [99]. On average, 120,000 blog entries are generated each day, and approximately 500 million blogs existed in 2019 [22]. Blog content ranges from very personal to professional.

Social networking sites include Facebook, Instagram, Snapchat, X (formerly Twitter), TikTok, and LinkedIn. In 2021, 69% of Americans 18 years of age and older used Facebook, 81% used YouTube; 40% used Instagram (a Facebook company), 31% used Pinterest, 28% used LinkedIn, and 23% used Twitter [97]. This is astounding considering that only 38% of Internet users were social networking in 2005 [10].

In the past, consumers preferred to seek health information from their physicians, but more consumers are taking advantage of Internet technologies to obtain health-related information [11]. Online health information-seeking refers to the active process of filling gaps in health-related knowledge [100]. Today, the Internet is typically the public's first source for health information [109]. In one study, 20% of Americans reported consulting TikTok for health information before going to a healthcare provider [157]. An estimated 70% of adults in the United States searched online for information on COVID-19, and more than 30% had shared or posted information about COVID on social media [157].

This trend is the result of several factors. First, there is a growing interest in preventive medicine and self-care, which promotes a healthcare model that is more patient-centered and consumer-oriented. Second, The breadth and depth of available health information is daunting, even for healthcare professionals. Finally, there is an increased interest in alternative approaches to health and well-being [129]. These factors all tend toward rejection of the physician or healthcare professional as the only source of health and wellness information.

In a study of adults (18 years of age and older) in California, 65% of Internet users reported searching for medical information online [101]. In a national study, 40% of adults used the Internet to search for health information and 3.7% used online health chat rooms [102]. Older adults are also using the Internet more frequently to seek health information. The proportion of adults 65 years of age and older who sought health information online increased from 14.5% in 2011 to 43.6% in 2020 [158]. Use of health apps has also grown, with $8.21 billion in revenue in 2023; this amount is expected to grow to $35.7 billion by 2030 [159].

A study with 569 Internet users found that there are four types of health information that consumers tend to seek online: medical treatment, difficult to discuss health topics, family health, and methods to improve health [11]. In a focus group study on health-related use of the Internet conducted with 19 adults, participants reported using the Internet for symptom troubleshooting, searching for information before an appointment, and searching for health information for someone else (e.g., a family member or friend) [73]. In general, people tend to conduct searches related to the symptoms of various health conditions [74]. One study using analytic data of website queries on the Mayo Clinic's consumer health information website found that the most common health queries were about symptoms, followed by the "causes" of conditions and treatment and drugs [74]. Research indicates that adults typically seek online medical information on specific diseases, medical treatments, and healthy behaviors [103]. In one study, more than two-thirds of participants preferred to use general search engines (e.g., Google) and another one-fifth reported that they employed Wikipedia for information about mental disorders and medications rather than going to the websites of hospital or professional organizations [130]. One study found a decline in online health information seeking between 2002 and 2012, which researchers attributed to the public's concern about the validity and reliability of health information online [103]. In addition, consumers are increasingly searching online for information about healthcare providers, experimental treatments, health insurance, medications, fitness, and nutrition. However, it appears that purchasing medications or medical devices is less common. According to a 2009 study of 1,428 adults in the United States, only 6.4% had purchased prescription drugs and 2% had purchased medical equipment over the Internet [13]. A study conducted between 2005 and 2008 using 4,008 respondents from the Washington University School of Medicine confirmed this trend [75]. They found that the primary source of obtaining medications/drugs was through dealers, friends and relatives, and physicians' prescriptions; only 3% reported obtaining drugs through the Internet [75]. A study of 1,959 Internet users found that participants most often searched for pharmacies, symptoms of medical condition, and pain [131].

It is estimated that every day 6 million people in the United States search for information about a health-related topic online [14]. Internet health information seekers maintain that the Web 2.0 improves the way they access health information, which ultimately assists in promoting a healthier lifestyle.

One digital marketing firm found that 34% of online health seekers use social media resources (such as Wikipedia, online discussion boards, social networking sites, blogs, and synchronous chat rooms) to obtain their information [15]. Much of this involves disease education rather than information about specific healthcare providers, care facilities, or insurance. In a study conducted in Saudi Arabia, the most common social media platforms for health-related use were WhatsApp, YouTube, and Twitter/X [160].

People are most likely to start searches for medical information with Google, MedlinePlus, and/or WebMD. Google is perceived to be easy to use and reader-friendly information, and MedlinePlus is viewed as a credible source [104]. An estimated 7% of searches on Google are health related, which translates to 1 billion health-related queries daily [161]. Furthermore, 58% of individuals with chronic illnesses are enthusiastic about sharing medical information and their experiences with others [16]. In a 2010 study conducted by the Pew Research Center's Internet and American Life Project, the researchers noted that individuals with chronic illnesses, even after controlling for demographic factors, are more likely to blog, use mass email (e.g., Listserv), and participate in online health discussion boards than those without chronic illnesses [17,104]. A comprehensive literature review of articles published between 2011 and 2016 found that individuals primarily seek information about specific diseases or illnesses and public health issues on social media sites [132]. The primarily motivations are emotional support and a desire to interact with other like-minded people. Internet technologies allow patients to obtain in-depth information about a health topic and to reach out to others using the Internet as a communications tool.

Using cellular phones to access online health information is also becoming increasingly popular. In general, mobile applications have been used for communication, education, and tracking and monitoring health and symptoms [105]. The Pew Internet Project and the California HealthCare Foundation found that 17% of cellular phone owners have used their phones to search for health information, with the highest rates of this usage among adults 18 to 29 years of age (29%) [18]. Furthermore, 15% of individuals in this age group have an application on their cell phones to monitor their health. Interestingly, Hispanic cellular phone owners are more likely to use their phones to access health information compared to non-Hispanic white users (25% vs. 15%) [18]. Healthcare providers have also reported benefits of using cell phones or smartphones to disseminate health information. In a study examining the use of cell phones or smartphones by community health advisors (paraprofessionals) in the African American community, providers reported that communicating through apps or texts enhanced their ability to reach underserved populations and provide information related to cancer screening, awareness raising, and concrete services [76].

Gender appears to influence Internet health-seeking patterns. Compared to men, women tend to be more likely to search for health and medical information online [13,131]. At least one study found that women were three times more likely to look for health information online than men [133]. In particular, women are more likely to search for information regarding mental health and psychiatric issues such as depression (26%) than men (19%) [19]. Mothers with young children tend to use the Internet to seek pediatric health information on specific health conditions and symptoms [20]. In a study of 360 parents, mostly mothers, who had visited the pediatric emergency department in an Australian hospital, 43% had used the Internet to seek health information for their child in the 6 months prior to the visit. Unfortunately, 31% reported using Google to obtain the information rather than a specific authoritative health website, such as a government source [21]. A separate study of data from the National Cancer Institute found that gender, particularly being a woman, consistently predicted use of e-health tools [77].

There are some findings that indicate racial and ethnic differences in online health information seeking and attitudes regarding the usefulness of obtaining health information on the Internet. Studies of racial/ethnic differences in health-seeking online have found that white users are more likely to use the Internet to search for health information compared to their Hispanic and African American counterparts [78]. Similar findings were reported in a study of 2,780 adults (18 years of age and older) [23]. In this study, Hispanics were less likely to search on the Internet for health information (28.9%) compared to whites (35.6%). Attitudes about online health information were also different between the two groups. Hispanics were less likely to agree that online health information can improve the lay public's understanding about medical conditions and their treatments, give people a greater sense of empowerment and confidence when interacting with healthcare providers, and assist patients to obtain appropriate treatment. However, Hispanic individuals were more likely to agree that online health information could prevent a physician office visit [23].

Some argue that these differences can be attributed to the digital divide, or disparities in the access to the Internet due to socioeconomic differences. A 2014 study failed to find any racial/ethnic differences in e-health usage, although it did note the role of socioeconomic status and education as predictors of the use of e-health tools [77]. Patients with lower levels of education were less likely to search for a healthcare provider online, to track their personal health information, or to use websites to track health outcomes. Higher literacy level is a positive predictor of online health information seeking [134]. In a study conducted with South Asians in Canada, being older, being female, having less than high school education, and desiring to have health information written in a language other than English predicted non-Internet or digital health usage [162]. Research indicates that those with lower levels of education are more likely to engage in online health communities to obtain factual information about a condition or different treatment options compared with those in higher socioeconomic levels [104]. Individuals with higher e-health literacy scores are more likely to have a smartphone and more willing to use the Internet to obtain health information [106].

Due to the stress and time constraints of daily clinical practice, it can be difficult to incorporate new technologies and spend time learning about different Web 2.0 applications. However, it is crucial to do so. Health consumers today are technologically and digitally savvy and will likely be using these applications themselves.

Digital literacy refers to an individual's proficiency and competency with the use of digital technologies, including mobile devices, personal computers, recording devices, the Internet, and Web 1.0 and 2.0 platforms [81]. However, digital literacy goes beyond an individual's degree of competence in the use of or access to technologies. It also includes the ability to effectively evaluate digital information [165]. According to the U.S. Department of Commerce, it is not clear whether the minority of persons in the United States who do not use the Internet due to a lack of skills or a lack of financial resources to obtain Internet access, or if there are other factors involved [82].

Many adults may be categorized as what is termed "digital immigrants," meaning they did not grow up in the digital world and are trying to learn and adapt to this new environment [33]. Digital immigrants may employ technology, but tend to be less familiar with its potential, although they do acknowledge its importance for some tasks [34]. On the other hand, adolescents and young adults are generally considered "digital natives," as they were raised using digital technology and have no difficulty using new technological mediums with ease and familiarity [33]. Digital natives tend to use technology for numerous tasks and adapt as the tools change [34]. It is likely that the majority of health and mental health practitioners fall into the category of "digital immigrants," and many clients, particularly adolescents and young adults, are "digital natives." Consequently, many younger consumers will access health and mental health information and make health decisions based on information from Web 2.0 applications.

However, it is important to not assume all younger practitioners will adopt Web 2.0 tools in clinical practice. A survey of Millennial nursing students (i.e., those who have been raised in the era of digital technology) found that they were less positive in their views of telehealth activities than in their views of common nursing activities [112]. The authors caution making the statement that all digital natives will want to incorporate Web 2.0 tools and technology into practice.

In order to ensure that consumers are receiving the best possible information and care, practitioners will require a solid understanding of the different pathways to health and mental health services via these applications. Furthermore, the next generation of health, counseling, social service, and mental health practitioners will be proficient in using these applications in the work environment [35]. Many Web 2.0 tools can be integrated into the day-to-day operations of the organizational structure to minimize costs and maximize employee productivity [35]. For example, a facility may use online calendars to schedule meetings or an intranet to edit documents, eliminating the need to constantly email documents back and forth. Supervisors can more readily provide updates and announcements on a blog that employees can access anytime and from anywhere [35].

It can be overwhelming for providers to implement Web 2.0 into practice [92]. Sharma, Kilian, and Leung recommend considering the following issues prior to initiating use of a Web 2.0 platform [93,120]:

The American Nursing Association provides broad general guidance, emphasizing the importance of nurses being aware of the audience and their employer's social media policy, placing appropriate privacy settings on one's own profiles, avoiding derogatory comments, and sharing only accurate and credible information [70].

In focus groups, marketers who used Web 2.0 for health promotion suggested that using simple, lay-friendly language was important. In addition, content should be easily searchable and retrievable using tagged categories [92]. The HIPAA Journal offers a free checklist for HIPAA compliance using social media, and the World Health Organization offers a social media toolkit for health practitioners (Resources).

In order for patients to obtain health information online, many skills are needed. At the most basic level, technical skills related to the use of a computer (operations) and Internet searching (navigation) are required in order to effectively access the Web [94]. A higher level of proficiency, including cognitive critical thinking skills, is necessary in order to evaluate the tremendous amount of information retrieved and to choose the most relevant and valid recommendations.

In a 2013 study, researchers recruited adults to complete a set of tasks related to retrieving information from the Internet pertaining to rheumatic diseases [94]. The participants all had experience searching on the Internet, but they were less familiar with using Web. 2.0 tools. The majority could not complete the tasks, experiencing difficulties navigating the Internet in general, using search strategies effectively, evaluating the accuracy of the content, and protecting their privacy [94]. In an integrative review, researchers found that healthcare professionals' digital skills must be continuously updated [151]. Technology changes rapidly, and full workplace implementation of these technologies are a function of healthcare professionals' attitudes, confidence, and proficiency.

Health literacy refers to the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services that they need to make appropriate health decisions" [50]. More specifically, it involves being able to navigate from lower to higher stages of critical thinking [121]. According to the 2003 National Assessment of Health Literacy, 14% of individuals in the United States have "below basic" health literacy, which means they lack the ability to understand health information and make informed health decisions [51,52]. A systematic review of more than 300 studies showed that an estimated 26% of patients had inadequate literacy and an additional 20% had marginal literacy [53]. Health literacy varies widely according to race/ethnicity, level of education, and gender, and clinicians are often unaware of the literacy level of their patients [54,55]. Predictors of limited health literacy are poor self-rated reading ability, low level of education, male gender, and nonwhite race [55,56]. Low health literacy makes patients vulnerable to poor health outcomes, including medication errors, rehospitalization, and noncompliance to medical interventions [122].

E-health literacy has been defined as ability to seek, evaluate, and apply health information from online and other digital sources to a health problem [152]. There are several subcategories of e-health literacy [133]:

e-HEALS is an instrument that consists of eight closed-ended items to measure e-health literacy. This brief instrument is valid and reliable and can be used by providers to assess patients' self-perceived comfort and knowledge in locating, assessing, and applying online or digital health information [153].

Of course, health literacy is affected by overall literacy rates in the United States. According to the National Adult Literacy Survey, 11 million adults in the United States are nonliterate in English; 36% of these adults speak/read a language other than English [52,57]. Practically speaking, individuals who are nonliterate are not able to answer simple written test questions.

However, health literacy is not merely about being able to read the information but includes social components and the creation of meaning [58]. Informational competence, for example, involves appropriately evaluating the validity and authority of health information. Autonomous competence, the ability not only to evaluate the information but also apply it within the context of one's life, is also a part of health literacy [58]. Health literacy also includes an individual's ability to navigate the health system, communicate with their providers, follow prescribed treatment plans, and evaluate health information and evidence [95]. Health literacy can be organized into three categories [125]:

An individual's literacy level and competence in navigating health information can promote or impede health decision making, and readability of the health information is hugely important. In general, patient/client education materials should be written at no higher than an 8th grade reading level; yet, printed materials are often written above this level [59]. In a study of 10 cancer brochures from various cancer organizations, the average reading level was 12.1, ranging from 9 to 15, well above recommended guidelines [60]. In another study of online brochures created for children and adolescents about mental health issues, the average reading grade level of the brochures was 13.23, ranging from 11.1 to 14.8 [61]. A study of fact sheets on the websites of state domestic violence coalitions indicated the materials were written at an average of an 11th grade reading level [62]. In a study about the readability of e-cigarette information on health websites, all the test was determined to be written at a higher grade level than that recommended for the general public [123]. In a 2022 study, that reading level of online information related to chronic health conditions was consistently higher than recommended [126]. Furthermore, 15.8% of the online information contained complex words of three or more syllables.

The rise of smartphones has made the readability of online health information and functionality of apps for mobile devices even more important. In a study that explored 270 mobile websites targeted to health conditions, 15.9% were not fully optimized for readability [124]. Generally, government websites are not as mobile-friendly as commercial sites.

As discussed, the amount of health information available online and the collective wisdom garnered from others in using Web 2.0 tools can certainly be empowering for consumers of health and mental health services. However, it is vital that consumers have the skills necessary to evaluate, interpret, and apply this information, as the quality can vary tremendously. In one study, researchers searched the Internet for "weight loss diets" using the Excite search engine and analyzed the first 50 websites returned as search results [64]. The authors then compared the content on these websites to published clinical guidelines for obesity. They found that only three websites offered sound dietary advice; most promoted diet aids (e.g., diet replacements and supplements). Because the benefits and risks of these types of products are unclear, consumers must be able to critically evaluate health information for applicability and bias.

Individuals tend to use multiple heuristics simultaneously to assess online health information [154]. Heuristics are mental short cuts used to make rapid decisions for problem-solving, and they tend to be employed in situations in which there is a tremendous amount of information and uncertainty, producing cognitive overload. However, heuristics can be self-confirming or based on perceived endorsement, which can reinforce myths and/or biases [154].

In a focus group study, participants placed high importance on the reputation of the website [73]. The perceived reputation was based primarily on name recognition and on lack of advertising, with more ads signaling greater commercial interest and focus on profits [73]. In another study, researchers examined whether the credibility of sources for online health information had any effect on consumers' judgment of the quality of the health information [65]. Ideally, if the health information was from a highly credible source, consumers would rate the information to be of high quality compared to health information from a source with low to no credibility. For the purpose of this study, the three "credible" sources of information were the websites of the National Cancer Institute, the American Lung Association, and the American Cancer Society. All of the participants were given information originating from one of these sources, but only some were told the information came from highly respected organizations. Other participants were only told that the information came from a "webpage." Findings indicated that participants who were given the content and told the information was from a credible source did not judge the information to be any more trustworthy or valid compared to the participants who were told the information simply came from a "webpage;" credibility of the source did not influence judgments about trustworthiness of information. A similar pattern was observed among participants in a survey, which found that consumers tended to use the most popular websites returned in Internet searches and did not recognize that the quality of the health information might vary between online sources [14]. In general, health websites that end with .gov, .edu, or .org are perceived to be more credible and valid. However, research indicates that users with low literacy are more likely to distrust these types of websites, perhaps because they do not trust these types of institutions [155].

In an observational study of online search behaviors for health information, researchers found that participants tended to rely on what information they could locate rapidly rather than searching for more credible sources, relying mainly on information found on search engines such as Yahoo or Google [66]. They will not often verify the information. The majority of the participants also relied on the first five search results to obtain the information. Other research has found that participants tend to judge results of health information searches based on position or rank or based on other users' comments [121]. This speaks to the necessity for practitioners to educate consumers regarding the importance of gaining informational and autonomous competency [58].

Prior to the current Internet era, consumers of health, wellness, and mental health information and services were forced to rely mainly on the medical establishment for education. However, the Internet has altered the healthcare landscape. Web 1.0 gave consumers the opportunity to search for information using tools like Yahoo, Google, and health directories, but the second generation, Web 2.0, has promoted the collaboration, interaction, and sharing of information and continues to revolutionize the healthcare industry. Patients are using Web 2.0 applications to share stories, provide emotional and informational support to one another, and obtain more health information than ever before. Meanwhile, practitioners are utilizing Web 2.0 tools to discuss cases, share resources, and provide consultation with one another. Researchers, scholars, and guideline authors have also joined online conversations to disseminate newly found information regarding clinical regimens and interventions. This is not to say there are no downsides of Health 2.0. Issues and concerns regarding patient/client privacy and confidentiality, professionalism, intellectual property, and accountability of information are still being debated and discussed. Certainly, how the forces of technology change will inevitably impact how practitioners provide health care and interact with patients/clients in the coming decades.

The following websites are examples of Web 2.0 applications. They may be explored for more insight into the benefits and possible uses of Web 2.0 technology.