The audio-taped interviews were transcribed, and the resulting text subjected to a qualitative analysis using a coding system developed through the application of NVivo software.
Results
The women who took part in the study ranged in age from twenty to eighty-two years (with a mean age of forty-six). Many were well-educated; two-thirds reported that they had completed some post-secondary education, and another 20 percent had completed high school. Half of the women reported family income of less than $30,000 (Canadian dollars) per year, and fewer than 20 percent had a family income of more than $60,000. Sixteen women were mothers, nine of whom had young children living at home at the time of the interview.
Fifty-five percent of the participants lived in one of the small towns in the county, 25 percent were village-dwellers, 15 percent lived on a working farm, and 5 percent lived on a rural nonfarm property. Most were born in the province of Ontario; 20 percent in the immediate or adjoining county; and another 57 percent elsewhere in the province. Four women were born outside Canada.
The digital divide was very much a factor for many of the women who took part in this study. Two reported that they do not have telephones; nine women told the interviewer that they don’t use the Internet because they don’t own or use computers; and another three reported that, even though they have computers at home, they don’t have Internet access.
Situational Context
Urgency of Concern
As noted earlier, situational context is a key determinant of information-seeking behavior. An important contextual variable when it comes to health is the severity of the inquirer’s health concern. Depending on whether they were faced with an urgent health situation or coping with a nagging health concern, the women anticipated using different strategies (see table 1). For urgent concerns, the strategy most often described was to visit a hospital emergency department, whereas for a chronic or nagging problem, the most frequently mentioned option was to look for information on the Internet.
Although the majority of women said they would turn to hospital emergency and nurse telephone advisory services if they had to cope with an immediate, potentially urgent health concern, it is interesting to consider the responses of women who did not cite these sources when describing what they would do in this situation. Some said, for example, that they would self-medicate and wait until the morning to call their family doctor, or that they would rely on information they could find in their personal collections of medical and home remedy books.
Rurality
Many of the women who took part in the study are heavily influenced by the realities of living in a rural area. Indeed, nearly half mentioned aspects of rural life when describing their experience of searching for health information. Several raised concerns about the health impacts of living in a rural area, particularly because of such agricultural practices as spraying and intensive hog farming. Others mentioned the lack of services in rural areas, raised issues with respect to confidentiality, and questioned the competence of local healthcare providers, especially physicians. A number of women explained that their decisions about whether to visit a local physician or go to the hospital were affected by the distances they needed to travel, especially during the winter.21 For example, one remarked, “Out in the country, it’s a lot easier to try to work out the symptoms in my Doctor’s Book of Home Remedies than having to get in the truck and go to the hospital.”
Small Town Libraries
As well as relying on the Internet for health information, several women said they would find libraries useful if they were dealing with a chronic or nagging health concern. When describing their experiences of searching for health information either for themselves or on behalf of others, more than half said they had or would consider using the library. One woman explained that she took comfort in the library’s print resources:
It’s been really helpful for me. It’s a tool that I feel a degree of confidence in, in terms of something in print. … I think I’m getting closer to that confidence with the Web, but I think I still have a higher degree of skepticism about the information on the Web as opposed to what I might get out of an encyclopedia or out of a book at [the] library.
For some, the library is an important resource because it provides Internet access that is not available at home or because the women don’t know how to retrieve information from the Internet on their own. One respondent said that if she were dealing with a nagging or chronic health problem, “I would be going straight to the library and the Internet, because we don’t have a computer or the Internet here [at home] and I would resort to the Internet and any library books I could get.”
Another woman who visits the library in order to use the Internet appreciates the help of library staff when she searches because “there’s just so overwhelmingly much on the Internet.” Others who commented on the importance of help from library staff said, “The girls up there are good if you can’t find anything. They’ll help you. Help you look up, you know, what you’re looking for.” Another commented, “The library in town, if you can’t find it they’ll help you find it. Usually you get what you’re looking for. If not, you’ll get it from a different library in the county.” Others noted:
You can go in there and ask them about certain books. They’ll tell you if they have it or not. They have a good computer system up there and they can tell you, “okay, we can get this book from this other county but it’s going to take a day or so.” You know, they’re very helpful.
I just go to the girls at the library and they just get the information … the ladies that work there are usually very up to date with things, so I assume, because they always call me five minutes after with something.
Some women were not convinced about the value of rural libraries when it comes to finding health information. For instance, one woman said while the library might have useful resources or access to them, she wouldn’t rely on it because of concerns about confidentiality. “Well, in a small town, I mean, the librarian here is a great gal, but I’m not about to go talk about … you know …”
Another said she wouldn’t rely on the library for books about health because, “you have to return them and that’s not going to do you.” On the other hand, because she doesn’t have a computer at home, the same woman also reported that she uses the computer in the library to search for health information.
Several women had concerns about the age of materials available in local libraries, suggesting a lack of awareness of the current, electronic resources to which the public library subscribes to on behalf of its patrons. Their comments included:
The information, of course, gets dated very quickly, and, especially in rural areas, I don’t think they always have a lot of up-to-date books on subjects like health.
I would rely on the local library for a health topic that wouldn’t change much over the years.
Chances are it might not be as up to date as I’d like it to be in the library, but it would give you a good foundation about some of the tried-and-true treatments and people who are possibly expert in the field.
[The library] has been helpful. Maybe not 100 percent, but it has been helpful. I think they need to update it more. In the rural communities, um, I think they get the information last, the good books last. And by the time they get them they’re outdated.
Some participants regard the Internet as a replacement for libraries (again, not recognizing the Web-based services provided by the local public library system). As one woman put it, “a lot of the library stuff is on the Internet now.” Another observed that “the Internet is like having a library right in your house.”
Relying on the Internet
Ah well, sometimes I’ll just refer to the Internet if it’s something that I’m not sure of what to do about. Well, if my mother was still alive I probably would have called her and asked her thoughts on what I should do but I think nowadays I look to the Internet quite a bit for information on health matters, whether it’s what prescriptions I’m taking or a medical condition. It’s a starting point to get more information. When I see something about something I will then go further and look for further information either on the Internet or it’s a treatment or medication I’m interested in I will then maybe go further and ask my doctor. But the Internet [is most helpful over time] because it’s available immediately when you need it.
As this woman’s comments make clear, the ease of access to, or the proximity of, the Internet makes it a valuable tool when she is trying to retrieve health information, although it doesn’t replace the personal information exchanges she had with her mother. In contrast, one young woman was very enthusiastic about the Internet precisely because it did provide an opportunity for a personal relationship:
I looked up [a site] and [it] had a specific doctor and you can chat with him, like live, and ask him a question … and you can even have him send you an e-mail as to when he’s going to be on next. I thought that was really awesome.
Another respondent had more trust in the Internet than she did in the pharmacy when making decisions about medications:
I’m more inclined to read it on there [the Internet] than to read the information they give you at the pharmacy. I’ll also look to see if there’s an alternative medication or therapy that I could be taking instead of what I’m currently taking.
Others were less sanguine about the value of the Internet and appeared to have a limited understanding about how to use it. One woman told the interviewer that she used a doctor disk on her sister’s computer and explained that, “We just punched in my symptoms and it came up [with a diagnosis] and it turns out that was not what was wrong so I probably won’t turn to the Internet again.”
Consistent with findings reported elsewhere, of the women who had used the Internet to locate health information, most reported that they rely on keyword searches using popular search engines, and few had any particular recollection of the sites they’d consulted.22 Comments included, “I’d just type in maybe women’s health, probably women’s health …” “I would start with typing in the issue, doing a search on the issue. I tend not to go to the medical sites; I tend to plug in the issue and see what comes up.” “I usually just type in whatever I’m looking for and see what comes up.”
Interestingly, with respect to the impact of government e-health initiatives, in spite of a media campaign underway at the time of the interviews that was designed to raise public awareness about the provincial government’s new consumer health portal, only four of the participants in the study had any recollection of visiting the site, and those who had did not find it particularly valuable.23
Health Literacy
The volume and complexity of health information available, especially via the Internet, posed significant challenges for the study’s women. One said:
What I would say about health information? I’m just overwhelmed. It’s almost like doing a master’s thesis to try and sort out which part of it is pertinent to oneself. … A big problem is the ability of a highly educated person to talk down to the person who is the patient.
Another remarked, “It’s tough on the Internet because there’s just too many options.”
One woman explained that when she uses the Internet she searches for “a general consensus” by “bringing up a medical term” then decides whether she can “understand what they are telling me”: “Sometimes they give you terms that, as a layperson, a lot of it I do understand, but some of it I don’t.”
Another cautioned that when using the Internet “you have to be careful” because there are problems with quality of information and there is “too much.” A woman told the interviewer that she finds the Internet to be “fairly helpful,” although:
[Y]ou really have to weed through what you’re reading and be careful, you know, not to take everything they say because, I mean, I could publish an article on how grass grows and I know nothing about how grass grows, so you really need to weed through it and see what’s reputable.
Others faced challenges when using the Internet because of limited search skills. One explained, “I’ve used the Internet and tried to go searching but always by myself. I’m not too good at it.”