The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0022-0418.htm
JDOC
68,6
826
Received 27 January 2012
Revised 18 April 2012
Accepted 19 April 2012
Journal of Documentation
Vol. 68 No. 6, 2012
pp. 826-851
q Emerald Group Publishing Limited
0022-0418
DOI 10.1108/00220411211277064
Discourse structure differences in
lay and professional health
communication
Jennie A. Abrahamson and Victoria L. Rubin
Faculty of Information and Media Studies,
Language & information Technology Research Lab (LiT.RL),
University of Western Ontario, London, Canada
Abstract
Purpose – In this paper the authors seek to compare lay (consumer) and professional (physician)
discourse structures in answers to diabetes-related questions in a public consumer health information
website.
Design/methodology/approach – Ten consumer and ten physician question threads were aligned.
They generated 26 consumer and ten physician answers, constituting a total dataset of 717 discourse
units (in sentences or sentence fragments). The authors depart from previous LIS health information
behaviour research by utilizing a computational linguistics-based theoretical framework of rhetorical
structure theory, which enables research at the pragmatics level of linguistics in terms of the goals and
effects of human communication.
Findings – The authors reveal differences in discourse organization by identifying prevalent
rhetorical relations in each type of discourse. Consumer answers included predominately (66 per cent)
presentational rhetorical structure relations, those intended to motivate or otherwise help a user do
something (e.g. motivation, concession, and enablement). Physician answers included mainly subject
matter relations (64 per cent), intended to inform, or simply transfer information to a user
(e.g. elaboration, condition, and interpretation).
Research limitations/implications – The findings suggest different communicative goals
expressed in lay and professional health information sharing. Consumers appear to be more
motivating, or activating, and more polite (linguistically) than physicians in how they share information
with consumers online in similar topics in diabetes management. The authors consider whether one
source of information encourages adherence to healthy behaviour more effectively than another.
Originality/value – Analysing discourse structure – using rhetorical structure theory – is a novel
and promising approach in information behaviour research, and one that traverses the lexico-semantic
level of linguistic analysis towards pragmatics of language use.
Keywords Health information seeking, Information sharing, Provision of information,
Information behaviour, Internet discussion groups, Diabetes, Information use, Pragmatic use of language,
Information exchange, Internet
Paper type Research paper
An earlier version of this paper was presented at the 2011 Canadian Association for Information
Science conference.
The authors wish to thank the Everydayhelth.com forum participants whose publicly available
questions and answers illuminate new perspectives on lay and professional health communication.
The authors are also grateful for suggestions offered by anonymous reviewers for the CAIS/ACSI
2011 Conference and for Journal of Documentation. The authors thank Tatiana Vashchilko for her
help with peer debriefing; her participation was partly funded by the New Research and Scholarly
Initiative Award (10-303) awarded to Dr Victoria Rubin. Jennie Abrahamson’s work was supported
in part by a Graduate Research Scholarship from the University of Western Ontario.
Introduction Discourse
Researchers and clinicians have long acknowledged that the majority of health care structure
takes place in everyday life environments, well beyond the threshold of the formal,
clinical health care system (Kleinman et al., 1978). Pursuing health in contemporary differences
everyday life is both an opportunity and a challenge. Health information seekers or
“consumers”[1], have a variety of sources to choose from when seeking information. As
the availability and use of online health information continues to grow (Fox, 2011a; 827
Diefenbach et al., 2009), internet resources have become the top health and wellness
information source people report choosing in the US (Elkin, 2008). A recent US survey
found that 80 per cent of internet users seek health information online (Fox, 2011a).
Despite the availability and purported interest in health and wellness information,
people’s adherence rates for recommended treatment or preventive health care
regimens rarely rise above 50 per cent globally (World Health Organization, 2011).
DiMatteo (2004, p. 200) defines adherence as people doing “what their health
professionals recommend.” Adherence originates in the clinical setting of the health
care system, but is enacted by consumers as part of their “mastery of everyday life”
(Savolainen, 2008). The current study expands the former biomedically-based
definition of adherence to encompass the information and self-care practices people
engage in to learn how to live with, or prevent chronic disease[2] in their everyday
lives. Adherence is particularly important in chronic disease care, where complying
with prescribed or recommended medication regimens or lifestyle changes (such as
dietary practices or physical exercise) often must become lifelong activities to ensure
quality or length of life.
Good and Del Vecchio Good have described health care and related discourses as
fundamentally “social” activities because, regardless of whether care takes place in a
clinical or everyday setting, it is “the product of human beings interacting and
communicating with one another” (Good and Del Vecchio Good, 1981, p. 187). In the
contemporary online social environment, one in four American internet users living
with chronic diseases such as high blood pressure, diabetes, heart or lung conditions,
or cancer go online to “find others with similar health conditions” (Fox, 2011b, p. 2),
and internet discussion forums are among the most popular social media sources they
use (Sarasohn-Kahn, 2008).
The second most common source Americans seek health information from is
physicians (Elkin, 2008). People turn to physicians or other health professionals for
“practical advice in coping with day-to-day health situations” almost as often as they
choose to turn to their peers or significant others (Fox, 2011b, p. 4). Nonetheless,
physicians frequently express concern regarding the effects of consumer information
seeking and sharing (Ferguson, 2002). Yet, research has confirmed that participation in
online support groups such as discussion forums can improve health outcomes
(Neuhauser and Kreps, 2010). However, little is known about how such improvement is
achieved.
This study explores the communication spaces between consumers, and between
physicians and consumers interacting via a US-based consumer health information
website. We consider whether one source of information (consumer or physician)
encourages adherence to healthy behaviour more effectively than another. This work
addresses recent library and information science (LIS) calls for more research in
information sharing, use, and effects (Savolainen, 2009). This research also addresses a
JDOC critical need identified in health care and health communication for investigations of
68,6 the impact of consumer-to-consumer communication on medication adherence
(Diefenbach et al. (2009) and “what people are doing when they are trying to carry
out their (personal health care) regimens” (McCoy, 2009, p. 128). Adherence is
essentially a goal-based activity, in which consumers and/or their health care
professionals (i.e. physicians, nurses, dieticians or physical therapists) identify goals
828 for various health behaviours such as taking medication, exercising or making dietary
changes (Christensen, 2004).
We depart from previous LIS health information behaviour research by utilizing a
computational linguistics-based theoretical framework for this study. The framework,
rhetorical structure theory (RST), supports studying the goals and effects of human
communication (Mann and Thompson, 1988). Using RST facilitates research at the
pragmatics level of linguistics, which enables the comparison of
consumer-to-consumer and physician-to-consumer communication in online
question-and-answering diabetes discourses. We accomplish this by first considering
the context of chronic disease and diabetes, then reviewing adherence and its
relationship to information sharing, both within health care and the LIS literature. We
then position our work at the linguistic level of pragmatics, and discuss the empirical
study methodology, major findings, and implications.
This work informs consumer-centred health communication and promotion, and
carries theoretical value in LIS due to its contributions to the understanding of
information sharing and use, and due to its application of RST methodology to
information behaviour research.

Literature review
Context: chronic disease and diabetes
Chronic diseases account for 60 per cent of deaths worldwide (World Health
Organization, 2011). As chronic disease rates and associated human and societal costs
climb throughout the world at an alarming pace, it is becoming increasingly urgent to
understand how to support chronic disease prevention and treatment (World Health
Organization, 2011).
Approximately one in 13 adults currently has diabetes; this figure is expected to
grow to one in ten adults, or 552 million worldwide by 2030 (International Diabetes
Federation, 2011). The related annual global health care expenditure for diabetes is
currently 499 billion in international dollars (ID), a figure anticipated to increase to 654
ID in 2030 (International Diabetes Federation, 2011). Living with or preventing
diabetes and other chronic diseases requires information about illness management
and preventive regimens to try to adopt or maintain medication and other treatment
protocols such as dietary changes and exercise. These lifestyle changes affect the
everyday life of consumers, their family, friends, and coworkers (Hunt and Arar, 2001;
Christensen, 2004). The physical consequences of adherence failures in diabetes are
serious, and include potentially irreversible damage to eyes, kidneys, and nerves
(Vermeire et al., 2005) and a possible 80 per cent increase in risk of death (Elliott, 2009).

Adherence and information sharing in LIS and health care literature

Non-adherence to prescribed treatments has been widely studied as a health care
problem. High non-adherence rates persist and few effective solutions have been found,
even though several possible causes have been identified such as medication cost, Discourse
cultural issues including conflicting health beliefs or patient/treatment preference structure
mismatches, literacy challenges; forgetfulness as well as unsatisfactory
patient-provider communication (Christensen, 2004; Elliott, 2009). Most adherence differences
challenge assessments focus on patient responsibility or failures, rarely considering
the role of the physician, or a joint role between patient and physician (Hunt and Arar,
2001). 829
Information sharing and use is a recurrent theme in the adherence literature in
health care. While physicians often believe that they spend adequate time educating
patients about various treatments including medications, observational studies reveal
that they spend less than one minute discussing new treatment regimens, if that. Even
when physicians share health information with patients intended to facilitate patient
recovery or health maintenance, patients frequently report that this information is
“confusing” or “inadequate” (Alexander et al., 2006, p. 330).
Few LIS researchers have focused on treatment or medication adherence and
information sharing. Sligo and Jameson (2000) advocated for adherence research in
their report on New Zealand Pacific Islander immigrant women’s information
behaviour related to screening recommendations for cervical cancer. Sligo and Jameson
concluded that further everyday life studies related to adherence and how people’s
environment “structures their capacity to accept and interpret new knowledge is called
for” (Sligo and Jameson, 2000, p. 860). More recent work has begun to consider
information use and adherence-related behaviour in chronic disease and health
information behaviour studies. In a study of “health information mastering” in a
Finnish population, Ek and Widén-Wulff (2008) observed that most health promotion
communication is predicated on an information transfer model, based on “the
assumption that health promoting knowledge and corresponding behaviour are
automatically created as people are subjected to [. . .] information” (p. 74). Ek and
Widén-Wulff cautioned that “information is not synonymous with knowledge, neither
is the transformation of knowledge into behaviour a simple linear process” (Ek and
Widén-Wulff, 2008, p. 74). Palsdottir considered multiple aspects of how Icelanders’
information behaviour and health beliefs are related to preventive health behaviour
(Palsdottir, 2008).
Several studies have examined peer-to-peer information seeking and sharing in both
electronic and offline environments. Oliphant (2010) and Neal and McKenzie (2011)
studied the relationship of cognitive authority to information practices among patients
experiencing depression or endometriosis, respectively. LIS studies on HIV/AIDS have
begun to more directly integrate the study of adherence and information use in their
research. Hogan and Palmer (2005) described adherence as an information intensive
activity. Veinot (2009) highlighted the interplay of health information exchange and
emotional support sharing and identified HIV/AIDS information seeking as a social
process carried out between people with HIV/AIDs and their friends or family members.
Veinot also observed the importance of experiential information to her participants as
they developed “ongoing health management routines” (Veinot, 2010, n.p.).
Ferguson found that consumers identified online patient groups as being more useful
than health professionals for the majority of health care needs studied (Ferguson, 1999;
Fox, 2011b, p. 13). Several researchers have surveyed this environment in studies of
peer-to-peer information behaviour or advice giving (see, for instance, Savolainen, 2011a;
JDOC Oliphant, 2010; Neal and McKenzie, 2011). Savolainen (2011b) and Kouper (2010) provide
68,6 recent comprehensive reviews of related work. Kouper states that prior research in
advice giving has focused on “issues of social support [. . .] trust, credibility (with an
emphasis on peer-to-peer communication) [. . .] and the linguistic aspects of
professional-to-public advice” (Kouper, 2010, pp. 3-5). Kouper studied both the
solicitation and giving of advice amongst participants in a motherhood community blog,
830 with a focus on pragmatic linguistic aspects of expressions of politeness or hedging
(e.g. expressions of uncertainty). Savolainen (2011b) compared peer-to-peer information
needs and information sharing expressed in question and answering in blogs and
discussion forums for consumers “coping with depression” (p. 2). Savolainen also notes
that prior LIS work in online support communities has focused on peer-to-peer rather
than physician-to-consumer communication.
Health care researchers have also begun to advocate for studying the social aspects
of diabetes patients’ lives and how patients’ social networks may affect their adherence
(e.g. Van Dam et al., 2005). Bissell et al. identify the space between consumers and
health professionals (such as physicians) as a space where the expertise of both should
combine to achieve “mutually agreed goals” (Bissell et al., 2004, p. 851).

Characteristics of lay versus professional health discourse

Little is known about pragmatic differences between lay and professional discourses in
health communication. It is clear that lay people and health care professionals often
express themselves differently, but the majority of the differences have been attributed
to lexico-semantic choices (such as complex medical terms and abbreviations), and for
instance, to physician preference for lengthy words and sentences (Zethsen and
Akehave, 2006). However, consumer health vocabulary research finds that consumer
vocabulary may be more similar than different from health professional vocabulary
(Smith and Stavri, 2005). Calling it physician “adaptability” in language use, or “lexical
entrainment” Bromme et al. (2005) found that advanced medical students adapt their
level or content of language to the language found in patient questions posed (p. 572).
Prior research suggests that “the difference between the lay (consumer) and
professional (e.g. physician) knowledge base of health and disease is likely to extend
beyond simple term labels, into the underlying concepts that are the basis for (the use
of) these terms” (Keselman et al., 2008, p. 496). Patel and Kaufman (1989) suggest that
such conceptual level uses may be related to pragmatic versus semantic characteristics
and uses of language in health communication.

Current study
Objectives
This study analyses and compares consumer and physician answer discourses on a
public consumer health internet portal, and furthers LIS research by incorporating the
level of pragmatics in linguistic analysis and extending the use of Rhetorical Structure
Theory (Mann and Thompson, 1988) to consumer and physician perspectives. The
main linguistic premise in this study is that language is typically used to achieve
various goals in human communication (Bonvillain, 2008). Speakers (or writers)
generally convey various information or meaning to those who listen (or read) with a
goal in mind. We equate speakers/writers to “information providers or sharers”, and
listeners/readers – to “users” in LIS.
 The pragmatic level of discourse specifically seeks to explain the meaning of Discourse
linguistic messages or information in terms of the context of use (Leech and Weisser, structure
2004). Pragmatics facilitates consideration of how each information sharing group uses
language “to convey desires, beliefs, and intentions” (Bickmore and Giorgino, 2006, differences
p. 557) and to achieve goals, akin to the conveyance of prescribed medication, other
treatment, and lifestyle changes such as diet and exercise in everyday health care and
health promotion. Successful communication is essential to consumer adherence. 831
Based on a review of prior consumer health information seeking and use studies as
well as on our preliminary analysis of health forum threads, we hypothesise that
consumer and physician answers discourses may differ in their pragmatic use of
language and in their communicative goals. We posit the following research questions:
(1) What are the general characteristics of physician versus consumer discourses at
the pragmatics level?
(2) How do the consumer and physician discourses differ in their goals for health
communication?

Analytical framework: rhetorical structure theory

Developed by Mann and Thompson (1988), rhetorical structure theory (RST) has had
two principal uses: discourse analysis and automatic text generation, and has been
extensively empirically tested (Taboada and Mann, 2006). In RST each sentence or its
part, called elementary discourse units (EDUs), stands in a certain kind of relation to its
surrounding EDUs in context. For instance, an EDU might elaborate on the statement
in the preceding EDU (as in elaboration relation). The overall rhetorical structure of
discourse is revealed after each individual relation is identified and labelled.
The basic elements of a standard RST relation are a nucleus – the main point of the
text, which can stand alone as comprehensible, and a satellite – supplementary text that
augments or refers to the nucleus and cannot stand alone. There are two general RST
relation types: subject matter and presentational. Subject matter relations are primarily
descriptive in nature: they identify or describe situations, problems, solutions, while
presentational relations have a goal and are intended to precipitate various effects on the
reader (Taboada, 2004). Table I lists both types of relations in the first and second column

Subject matter relations Presentational relations Multinuclear relations

Circumstance Antithesis Contrast

Condition Background Joint
Elaboration Concession List (structured)
Evaluation Enablement Sequence
Interpretation Evidence
Non-volitional cause Justify
Non-volitional result Motivation
Otherwise Restatement
Purpose Summary
Solutionhood
Volitional cause Table I.
Volitional result Rhetorical structure
theory relation
Source: Adapted from Mann and Taboada (2010) classification
JDOC respectively. Some relations, the multinuclear relations, do not contain satellites; their
68,6 nuclei are considered comparable in importance (Table I, third column). Table I contains
the total of 25 RST relations used in this study as a codebook for discourse analysis.
Descriptive titles of RST relations such as circumstance or condition, are often
supplemented with definitions that place certain constraints on the parts of relations
(on the nucleus, satellite, or a combination of the two) and further identify an effect on
832 the reader intended by the writer (Mann and Thompson, 1988). Mann and Thompson
detail the following intended effects of six of the presentational relations on readers:
(1) Motivation – increases desire (to do something).
(2) Antithesis – increases positive regard.
(3) Background – increases ability.
(4) Enablement – increases belief.
(5) Justify – increases acceptance.
(6) Concession – increases positive regard (Mann and Thompson, 1987, p. 18).

Table II illustrates the presentational relation Motivation with an excerpt from our
dataset: the writer urges the reader to action (stated in the nucleus EDU) and provides
motivation in satellite.
An RST analysis is often performed graphically, by connecting and labelling
relations identified in discourse, using a specialized tool or manual approach. Figure 1
demonstrates a manual analysis of six EDUs from a physician’s answer to a consumer
question about blood test recommendations. The physician uses elaboration and joint
relationships to expand on several factors that influence the frequency of blood tests.

Methodology
Data source
The data for this study were obtained from a freely and publicly available consumer
health information website, Everydayhealth.com, that hosts both consumer discussion

Constraints on either Constraints on both

satellite or nucleus nucleus and satellite
Name (individually) (together) Intention of writer

Motivation On nucleus: nucleus is Comprehending Reader’s desire to

(presentational relation) an action in which satellite increases perform action in
reader is the actor reader’s desire to nucleus is increased
(including accepting an perform action in
offer), unrealized with nucleus
respect to the context of
nucleus
Example 1 (ID: Cons_ Nucleus [Email me at (address omitted)]
Ans_4.2.2-3-4-5_P3) Satellite [and I will forward a glycemic index and a boatload of very useful
information.
Table II. The information will explain how to use the table and other meal planning
Motivation relation help.
definition and example The information may help you avoid becoming diabetic.]
 Discourse
structure
differences

833

Figure 1.
Sample segment of a
graphical rhetorical
structure theory analysis
of a physician’s answer

forums and “ask a physician” sections. On this popular “HON code certified” site,
consumers can seek and share information about preventive health care and treatment
for a variety of health conditions, utilising both professional and peer information
resources, such as blogs, support groups, and a variety of articles written by health
educators or health care providers. This study utilises the site’s consumer discussion
forum for diabetes, described as one of the most popular groups on the site (Alexa.com,
2011), as well as the corresponding “ask a professional (physician)” question-answer
sections for diabetes. Most site users are English speaking, and female; 83 per cent of
users are from the US. Users typically visit the website from home, report having a
college or “some college” education and belonging to either of the three predominant
age groups (in descending order 55-64, 65 þ , and 45-54 years of age) (Alexa.com,
2011).
The site supports the consumer information seeking scenario utilised in this study
– that of the consumer searching or sharing health information about chronic health
conditions from both laypeople (consumers) and professionals (physicians).

Dataset
Our dataset consists of consumer-to-consumer question-answers conceptually aligned
with consumer-to-physician question-answers. Alignment was performed by the first
author utilizing content analysis (Krippendorf, 2004) of both questions and answers
found on the consumer discussion forum area and the “ask a professional” areas of the
site during a two-week period in early autumn 2010. Questions from the
consumer-to-consumer section were selected first, their corresponding consumer
answers were identified, captured in vivo and archived for later analysis. Then, moving
sequentially through the “ask a professional” diabetes pages of the website,
JDOC consumer-to-physician questions were selected and matched with
68,6 consumer-to-consumer questions, if they were judged to share common themes, as
exemplified in Table III.
The second author reviewed and agreed upon these and similar alignment choices in
all cases. Using questions solely for alignment purposes, we focus on the two types of
answers to matched questions which constitute the consumer and physician discourse
834 samples for this study. Sample texts, similar to consumer and physician answers in
Table III, were analysed within RST framework and compared (pair-wise, within- and
across-group) in terms of their discourse structure and communicative goals.

Analytical framework application

Mann and Thompson based the development of RST on a set of 24 relations, yet
emphasised that these relations could be expanded, depending upon research needs, to
accommodate text conditions not identified in their original research. These relation
sets function as codebooks, where relation definitions are used to assign relations to
analysed data. As listed in Table I, we used a total of 25 relations: the original 24
relations set, the most empirically tested set (Taboada, 2004) plus the relation list (used
here as structured list) added later by Mann and Thompson (see Mann and Taboada
(2010) for complete list of relation definitions).

Example 2a-b. Consumer-to-consumer Example 2c-d. Physician-to-consumer

communication communication

2.a. Consumer question 2.c. Consumer question

“My daughter is 6 years old and was diagnosed
with diabetes this July. Does anyone know of
alterante (sic.) medicine options for her? Herbs,
vitamins, massage therapy, homeopathy, etc.”
2.b. Consumer answer (excerpt)
“At her age she is likely type I. That means that
her pancreas is not producing any insulin. There
are no reliable alternatives to taking insulin. I
have heard about things like boiling green beans
and using the water as a substitute for insulin.
But such experiments are risky. It will help you
greatly to find a holistic doctor. Other doctors
have virtually no training in nutrition. Diabetes
is a diet based disease. They will address
everything with pharmaceuticals, which will
cause long term damage to her liver.
The best thing that you can do for her (type I or
II) is to get her off of pro-oxidant foods like high
fats, prepared foods (nearly anything in a box or
Table III. can), caffeine, sodas or colas, artificial
Sample consumer sweeteners except xylitol or stevia, high
questions and related glycemic index foods, and processed flour
answers provided by a products . . . ”
consumer and a
physician
“I’ve heard a lot of conflicting information about
using dietary supplements to help lower my
blood glucose levels. What’s the deal? Do any of
them really work?”
2.d. Physician answer (excerpt)
“The short answer is, we’re not yet sure . . . some
of the studies have shown that Cocinia indic,
konjac mannan, and American ginseng can
lower glucose levels. Ipomoea batatas,
Momordica charantia, nopal, aloe vera,
vanadium, Gymnema sylvestre, and fenugreek
require further investigation to determine their
effect on glucose. Alpha lipoic acid, magnesium,
chromium, L-carnitine, and vitamin E have not
been found to be effective for lowering glucose.
As a doctor trained in Western medicine, I’ll
admit that my response to you is biased. It relies
on evidence from rigorous and replicable
scientific research (or lack thereof), and the kind
of evidence I’d like to see is not available for
many of the dietary supplements. While this
doesn’t mean that all supplements are
ineffective, there isn’t sufficient evidence at this
time to recommend their use to lower glucose
levels . . . ”
RST analysis procedures Discourse
Rhetorical structure theory relations from the inventory of 25 (Table I) were assigned structure
via manual annotation by the first author, following the steps in a classic RST analysis
(Mann and Thompson, 1987): differences
(1) The answers in the dataset are segmented into sentences or clauses:
“elementary discourse units,” or EDUs.
(2) RST relations are assigned by looking at EDUs and EDU neighbours, if 835
relations are clear.
(3) Larger structural elements are assigned, if applicable.
(4) The analysis is iteratively continued until all text units are analyzed.
(5) Each marked relation is verified to have satisfied nucleus/satellite constraints
and writer intentions/reader effects requirements.

With elementary discourse units identified in the data, frequency counts and percentage
occurrence of relations within each discourse were calculated. To supplement the RST
analysis, quantitative lexical analyses with the Natural Language Processing Toolkit or
NLTK (Bird et al., 2009) were used to compare and report such measures within each
discourse group as the overall data size and average sentence length.
Rhetorical structure theory analysis can be applied at various levels of text
structure granularity for the RST relations, from text segments and clauses
paragraphs (Taboada, 2004; Taboada and Mann, 2006; Bateman and Delin, 2006),
based on research objectives. We used the elementary discourse unit (EDU) as the unit
of analysis with which certain complications can arise. For instance, in the physician
data, structured lists, signalled by either numerical or bulleted headings for list
elements, were separated in our procedures into several EDUs constituting a structured
list. We counted structured lists because we saw them as representing intent (an
important aspect of our research questions) on the physician’s part to present
information in a certain way (by list). Though no Structured Lists were found in the
consumer data, some of consumer data included unstructured enumerations, running
in text. For instance, “[. . .] problems such as burning feet, kidney problems, eye
problems, and other problems [. . .]”(excerpt ID: Cons_Ans_5.4.7_P10)[3]. Such
embedded lists were not separated into separate EDUs due to their noun phrase
granularity, adhering as closely as possible to classic RST analysis, which omits lists.

Study scope, assumptions, and data exclusion criteria

Though RST has been previously used in the analysis of some visual media, the scope
of this study was limited to text found within answers to questions posted in
discussion threads. For instance, we excluded some website content (such as outward
hyperlinks) and imagery (including emoticons). Other exclusions were threads
containing commercial advertisements, regardless of format, solicitations for finding
“friends with diabetes,” or research project recruitments.
The greetings in each post (such as “Hi” or “Dear” (as an opening form of address)
and closing signatures (including names at the end of a message, etc.) were deemed to
have no rhetorical relation function regarding text organisation with surrounding text,
as per Mann et al. (1992). Instead, these greetings and signatures are simply
“conventional properties of the (post)” (p. 24).
JDOC We also assumed that each question is related to its answers, on a meta-level, as a
68,6 Solutionhood relation (defined as a solution to a problem or question stated or implied)
(cf. Abelen et al., 1993). Taking questions for granted we only accounted for frequencies
and distribution of the RST relations found within the body of the answers. A
necessary inclusion criteria was an answer to the original question posed in the thread.
Using our research questions to guide the level of our analysis, we focused on
836 identifying goals and intentions in each text, which resulted in a pragmatic macro-level
analysis, in order to attend to the “writer’s overall purpose” (Abelen et al., 1993, p. 339).

Reliability and validity or trustworthiness procedures

In addition to undertaking careful data collection and archiving procedures, several
measures helped to ensure the reliability and validity, or trustworthiness of the present
research (Lincoln and Guba, 1985). The first author, who had four months experience
with RST analysis prior to commencing study data analysis, conducted close and
repeated readings of the data over a period of several weeks. Data and corresponding
analyses were reviewed at least two times to ensure trustworthiness of the primary
analysis. This afforded immersion in the data, utilizing the constant comparative
method, as advocated by Lincoln and Guba (1985). A recent investigation of slimming
blogs served as a model for the present study (Savolainen, 2011a). Iterative checks
(both within and across analysed texts) were performed to safeguard consistency in
coding of the dataset with RST relations
Intracoder reliability agreement of an average of 78 per cent was achieved based on
the 10 per cent of the data (82 per cent agreement for consumer, 70 per cent – for
physician data). The first author re-coded 10 per cent of the final dataset after having
spent several weeks away from the data. Related intracoder consistency measures
included checking data for negative case analysis (i.e. when no relations for a particular
relation definition were found). For example, the initial coding of the data identified no
Motivation relations for the physicians. Data were therefore reviewed specifically for
possible evidence of Motivation relations. This procedure was repeated for other
negative coding instances, including otherwise, circumstance, structured list, sequence,
and contrast in both discourses. Some RST relations such as background and elaboration
presented specific challenges for disambiguation. Close reading of the relation definitions
for each, re-reading of the data, along with consulting prior RST research and coding
manuals (cf. Mann and Thompson, 1987; Taboada, 2004) facilitated resolution of coding
ambiguities. A notable difference between the two was resolved: the Background relation
was deemed to explain why or how something described in text exists or occurs, while
elaboration was found to simply provide additional or straightforward descriptive
information (describing more what something is, rather than why or how it exists or
operates) (Mann and Taboada, 2010). These observations were incorporated in the
codebook. In addition, another researcher familiar with RST analysis served as a peer
debriefer during the final stages of data analysis.

Results
Dataset characteristics and participant demographics
Twenty pair-wise aligned consumer questions with their corresponding answers were
collected. The dataset includes 26 consumer answers (about three answers per question
on average), and ten physician answers (with a one-to-one questions-to-answers ratio).
Initially, 13 diabetes consumer-to-consumer discussion threads were collected from the Discourse
website. Based on our exclusion criteria outlined in Methods, three of these threads structure
were eliminated. The study was centred on the remaining ten threads, which covered
topics such as questions related to being new to diabetes, avoiding diabetes through differences
prevention, how to count carbohydrates, etc. From these ten threads, 41
consumer-to-consumer answer posts were originally collected and were reduced to
the final set of consumer-to-consumer answers directly relevant to the original 837
questions was 26 postings in total. Some of the excluded posts contained no answers to
the original question at all, discussed tangentially related issues, or started a new
embedded thread.
Physician answers were found in the consumer-questions with a physician-answer
or “ask a doctor” area. At the time of data gathering the website included 78 physician
answers to consumer questions (64 for type-two diabetes, and 14 for less common
type-one diabetes). Ten answers from these data were matched with the ten consumer
answers as described in the methodology section above.

Participant demographics
The consumer answers were contributed by 14 unique authors (two answers on average
per consumer) with 11 single answers and three productive authors. The physician
answers were contributed by a single, female physician, a diabetes specialist. Limited
participant demographics were available (see Table IV), though participants nearly
matched the majority user profile for the Everdayhealth.com website (Alexa.com, 2011).
Most of participants reporting their gender were females, aged between (in descending
order) 55-64; 65 or over; or 45-54 years. Mean participant age was 58 years.

Consumer versus physician discourse distributions

Aided by NLTK data processing (Bird et al., 2009), general dataset distributions are
shown in Table V by number of characters, words, and elementary discourse units
(EDUs). Note the comparability of physician and consumer discourses on almost all
measures. Particularly interesting is how close the total numbers of words between the

n %

Gender
Female 8 57
Male 3 21
Unknown 3 21
Age (yrs)
18-24 0 0
25-34 1 7
35-44 0 0
45-54 2 14
55-64 5 36
65 þ 4 29
Unknown 2 14
Ave: 58 Table IV.
Consumer participant
Note: n ¼ 14 demographics
JDOC
Data measurements Consumer answers Physician answers
68,6
Number of characters
(excl. spaces) 18,482 17,876
Words 4,051 3,494
Number of EDUsa 423 294
838 Ave., words per EDU 9.6 11.9
Min, words per EDU 3 1
Example: shortest EDU “I have both.” [referring to diabetes “Congratulations!”
or lupus problems]
Max, words per EDU 30 34
Example: longest EDU “. . . like high fats, prepared foods “Here’s why: As your blood glucose
(nearly anything in a box or can), rises above the normal level, your
caffeine, sodas or colas, artificial risk of developing damage in the
sweeteners except xylitol or stevia, body’s small blood vessels, and
high glycemic index foods, and ultimately your risk of a heart attack
processed flour products.” [referring or stroke, also rises.” [referring to
Table V. to pro-oxidant foods] blood sugar level numbers that are
Comparative data not in the diabetic range]
description per type of
answers Note: aEDUs: elementary discourse units (unit of analysis in the dataset)

two discourses are, given the fact that consumer data included 26 answers, while
physician data included ten answers. The number of consumer EDUs is 129 higher
than their number in the physician data. Consumer discourse is known to be more
diffuse, which this difference may reflect. On average, physician EDUs contain
approximately two more words per EDU than the consumer EDUs do. This finding is
consistent with known physician preference for lengthy words and/or sentences
(Zethsen and Akehave, 2006).
A total of 717 elementary discourse units were identified, including 291 rhetorical
relations. Table VI demonstrates that the consumer answers contained fewer identified
discourse units on average (16.3 as compared to 29.4 – in physicians’ answers), as well
as fewer average rhetorical relations within each answer (6.7 compared to 11.8).

Units of analysis Data types Counts Ave., per question Ave., per answer

Questions Consumers 10 n/a n/a

Physicians 10 n/a n/a
Combined 20 n/a n/a
Answers Consumers 26 2.6 n/a
Physicians 10 1.0 n/a
Combined 36 1.8 n/a
Table VI.
Dataset description: Elementary discourse units, EDU Consumers 423 42.3 16.3
collected questions and Physicians 294 29.4 29.4
answers, identified Combined 717 35.9 19.9
elementary discourse Rhetorical relations Consumers 173 17.3 6.7
units, and rhetorical Physicians 118 11.8 11.8
relations Combined 291 14.6 8.1
Twenty-four of the 25 relations used were present in the dataset overall. Neither group Discourse
used the otherwise relation. Table VII demonstrates the 23 relations used by the structure
consumers, distinctly missing structured list and otherwise, and 20 relations used by
physicians with five absent – circumstance, otherwise, purpose, joint, and sequence. In differences
Table VII, zeros in consumer and physician answers (highlighted in grey) indicate the
categories that are not present in the corresponding type of answers.
The last column in Table VII (on the right) also depicts the relations distribution, 839
starting from the types of relations that were used more frequently by physicians at the
top, and ending with the relations used more frequently by consumers (at the bottom).
The negative numbers indicate that physicians used the rhetorical relations more times
than the consumers; positive numbers indicate that consumers used more of that relation
types. For instance, the relation of elaboration (listed first in Table VII), was used 20
times less by the consumers than physicians (11 2 31 ¼ 220), while Motivation (listed
last) was used 38 times more by the consumers than physicians (42 2 4 ¼ þ38). Note
that the elaboration with a structured list structure was not found in the consumer data.

Absolute difference
between consumer
Consumer Physician and physician
No. RST relations answers answers answers

1 Elaboration 11 31 220
2 Evaluation 3 10 27
3 Condition 7 13 26
4a Structured list 0 4 24
4b Elaboration and structured list 0 4 24
5 Interpretation 3 6 23
6 Antithesis 3 5 22
7 Non-volitional result 2 4 22
8 Solutionhood 3 5 22
9 Background 11 13 22
10 Volitional cause 1 2 21
11a Otherwise 0 0 0
12 Non-volitional cause 1 1 0
13 Summary 2 2 0
14 Restatement 3 2 1
15 Purpose 2 0 2
16 Contrast 4 1 3
17 Volitional result 4 1 3
18 Circumstance 5 0 5
19 Joint 5 0 5
20 Evidence 8 2 6
21 Sequence 7 0 7 Table VII.
22 Justify 12 2 10 Distribution of rhetorical
23 Enablement 15 2 13 structure theory relations
24 Concession 19 4 15 in consumer and
25 Motivation 42 4 38 physician answers (per
Total: 173 118 Ave. ¼ 2.5 discourse type), sorted by
pair-wise difference
Note: aNeither group (consumers or physicians) used the relation otherwise; Categories on top are between total identified
used more by physicians, on bottom by consumers relations
JDOC The five most common relations found in each discourse type are reflected in
Table VIII; they account for 90 and 95 per cent of relations in consumer and physician
68,6 answers, correspondingly. The consumer data includes predominately presentational
relations (66 per cent of consumer relations identified), while the physician data
includes mainly subject matter relations (64 per cent of physician relations identified).
All but one of the top frequent relations in the consumer data are presentational
840 relations. Conversely, all but one of the most common relations found in physician data
are subject matter relations. Recall that subject matter relations are those whose
“intended effect” is, basically, information transfer (Mann and Thompson, 1987, p. 18),
and the reader can easily recognise the relation’s purpose or effect. Presentational
relations are those whose “intended effect” is more complex, intended to “increase some
inclination in the reader” (Mann and Thompson, 1987, p. 18).

Most frequent relations found in each discourse

We now present and exemplify the three most frequent types of relations identified
within each discourse type (per Table VIII). In the sample texts below, each EDU is
separated by a “pipe” symbol (i.e. “j“) with square brackets around the nuclei and
satellites for each relation (see also [3]).

Consumer relation #1. Motivation (presentational)

The most frequently found relation in the consumer data is motivation (Table VII). The
effect of motivation is to increase the reader’s “desire to perform an action in the
nucleus” Mann and Taboada, 2010, n.p.). Motivation is found in 24 per cent of
consumer relations, but only 3.5 per cent of the physician relations:
Example 3: Motivation:
Nucleus [Make certain that she gets some form of daily exercise that elevates her heart ratej]
Satellite [to repair damage to her vascular system due to high blood sugarsj] (ID:
Cons_Ans_3.1.17-18_P3)
In the consumer data, motivation was frequently associated with encouraging language:
Example 4: Motivation:
Nucleus [Email me at (address omitted)j]

Consumer Physician
answers answers
Top consumer relations n % Top physician relations n %

1. Motivation (P) 42 24 1. Elaboration (S) 31 27

2. Concession (P) 19 11 2a. Background (P) 13 11
3. Enablement (P) 15 9 2b. Condition (S) 13 11
4. Justify (P) 12 7 3. Evaluation (S) 10 9
5a. Background (P) 11 6 4. Interpretation (S) 6 5
5b. Elaboration (S) 11 6 5a. Antithesis (P) 5 4
5b. Solutionhood (S) 5 4
Table VIII. Subject matter (S) total, consumers 24 Subject matter (S) total, physicians 64
Top five rhetorical Presentational (P) total, consumers 66 Presentational (P) total, physicians 31
structure theory relations
in consumer and Notes: P ¼ Presentational; S ¼ Subject matter; n ¼ 173 for consumer relations; n ¼ 115 for
physician discourse types physician relations
 Satellite [and I will forward a glycemic index and a boatload of very useful informationj Discourse
The information will explain how to use the table and other meal planning help.j
The information may help you avoid becoming diabetic.] (ID:Cons_Ans_4.2.2-3-4-5_P3) structure
The nucleus above presents a possible action, to email the writer, and the satellite
differences
offers motivation or encouragement for the reader to do so (that he will share “useful
information”).
An example from the physician data encourages or motivates the reader to do 841
something (“take control of the disease”). While the overall effect is similar for
Motivation relations found in the consumer data, there are subtle differences between
the two discourses:
Example 5: Motivation:
Satellite [Because diabetes involves something that is so basic to our existence – foodj
– it can seem to control our lives.j]
Nucleus [But the challenge – and your goal – is to take control of the disease instead.j] (ID:
Dr_Ans_7.1.5-6-7)
Note how the physician shows empathy and decreases the distance between herself and
her reader in the satellite text by stating how diabetes “can seem to control our lives.” In
the nucleus, the physician identifies the reader’s goal for them, as “(their) goal,” and then
distances herself further by referring to diabetes abstractly, as “the disease.”

Physician relation #1. Elaboration (subject matter)

The most frequently found relation in the physician data is the Elaboration relation (27
per cent physician relations; 6 per cent consumer relations, Table VIII). Elaboration’s
effect is that the reader “recognises the satellite as providing additional detail for the
nucleus [. . .] (also), the reader identifies the element of subject matter for which (the)
detail is provided” Mann and Taboada, 2010, n.p.):
Example 6: Elaboration:
Nucleus [you can probably prevent the onset of diabetes and other complications,j]
Satellite [such as coronary artery disease.j] (ID: Dr_Ans_8.1.17-18)
The reader can easily connect “coronary artery disease” in the satellite as an
elaboration of “other complications” referred to in the nucleus.

Consumer relation #2. Concession (presentational)

The second most common consumer relation is concession, found in 11 per cent of
consumer relations and 3.5 per cent of physician relations. The effect of Concession is
that the “reader’s positive regard for (the) nucleus is increased” (Mann and Taboada,
2010, n.p.). Concession is also recognised as a relation that exhibits politeness, a
pragmatic linguistic tool in communication that has the effect of softening the
interaction, and allowing the reader/hearer to “save face” (Taboada, 2004). In example
7, the specific effect is to allow the reader to choose among the suggestions the writer is
offering:
Example 7: Concession:
Satellite [Maybe your doctor could give you a diet,j]
Nucleus [or maybe some good books from the Diabetes Section at the book store can helpj]
(ID: Cons_Ans_4.1.2-3_P13)
JDOC Physician relation #2a. Background (presentational) and -#2b. Condition (subject matter)
68,6 Background and condition tie for the second most common physician relations (11
percent of physician relations each), while in consumer discourse both are used less
prominently (6 and 4 percent, respectively). The effect of background is the “reader’s
ability to comprehend (the) nucleus increases” (Mann and Taboada, 2010, n.p.). In
example 8 the reader is told in the nucleus that “prevention is key.” The function of the
842 satellite is background information because it tells the reader why prevention is key:
Example 8: Background:
Nucleus [Now that you’ve been diagnosed with prediabetes,jprevention is key.j]
Satellite [Prediabetes is characterized by either impaired fasting glucose (IFG) or impaired
glucose tolerance (IGT).j
Both of these terms refer to the level of sugar in the bloodstream,j
and they’re both ways of saying that you have prediabetes.j] (ID: Dr_Ans_8_1_3-4-5-7)
The effect of condition is that the “reader recognizes how the realization of (the) nucleus
depends on the realization of (the) satellite” (Mann and Taboada, 2010, n.p.). Example 9
comes from the same answer as the Background Example 8. The nucleus depends
upon the reader having a certain fasting glucose level: “If you have [. . .]” Note that an
elaboration relation is embedded in the example below as the parenthetical text in the
satellite “(a test in which [. . .])” decoding for the reader what a fasting glucose level is:
Example 9: Condition:
Satellite [If your fasting glucose level (a test in which blood is drawn after six hours without
food) is between 100 and 125 mg/dl,j]
Nucleus [you have IFG.] (ID: Dr_Ans_8_1_8-9)

Consumer relation #3. Enablement (presentational)

Enablement is the third most common consumer relation. It increases the “reader’s
potential ability to perform the action in (the) nucleus” (Mann and Taboada, 2010, n.p.).
The nucleus in example 10 is part of a larger text that encourages the reader to go to
the website stated in the nucleus, and then tells the reader how to use the website:
Example 10: Enablement:
Nucleus [http://www.joslin.harvard.edu/diabetes_information.html.j]
Satellite [Then click on the left bar under Joslin Clinical guidelinesj
and read the section of the PDF about glucosej](ID: Cons_Ans_6.1.3-4-5_P4)

Physician Relation #3. Evaluation (subject matter)

The third most common physician relation is evaluation. The reader can use the text in
the satellite to assess the claim made by the writer in the nucleus with the potential
effect of strengthening the claim or assigning value to the nucleus statement:
Example 11: Evaluation:
Nucleus [The good news is that laboratory studies have determined mechanisms by which
some dietary supplements might reduce glucose levels,j
including increasing insulin secretion from the pancreas, decreasing the rate of carbohydrate
(glucose, or sugar) absorption from the gut, and speeding the rate of glucose entry into cells.]
Satellite [However, many of the studies, which examined the effect of specific dietary supplements
on glucose levels, do not meet standards for conclusive trials or have not been replicated.j
As a result, the conclusions from these studies are not sufficient to recommend the use of these
supplements.] (ID: Dr_Ans_3_1_3-4-5-6)
Discussion Discourse
RST relations and the semantic-pragmatic levels of communication structure
In this study, we tentatively connect adherence behaviour with RST relation effects and
call for further empirical tests of the idea. Our findings suggest that consumer answers differences
may be more effective at facilitating healthy behaviour in fellow consumers than
physicians, based on considering the “effects” of the most common relations found in
each discourse. The finding that the majority of consumer answer discourse relations 843
were presentational suggests that the consumer answers may be more able to trigger a
response action in readers or users of shared information. For example, the significance
of the most prevalent consumer discourse relation, Motivation, is that it represents
textual information that may increase the reader’s desire or inclination to perform an
action (Mann and Taboada, 2010), such as a healthy behaviour, like walking.
Other researchers have found that consumers report that finding internet health
information lead them to change their behaviour (Neuhauser and Kreps, 2010). Also,
there may be a relationship between RST and self-efficacy, a health behaviour theory
that a consumer’s belief in his or her ability to achieve a given goal will result in greater
goal achievement (Bandura, 1997). Increasing people’s self-efficacy can also lead to
their “active participation” and “better disease management” (Allen et al., 2008, p. 107).
RST presentational relations, because of their emphasis on increasing readers’ desire,
belief, or ability to perform actions, may therefore be useful in increasing self-efficacy.
Mann and Thompson (1988, 1987) suggest that, on the linguistic level, RST subject
matter relations are mostly semantic (i.e. putting forth a factual level argument, or
fulfilling the purpose of information acquisition), whereas the presentational relations
are pragmatic (i.e. contributing to the achievement of a goal, or information use). In LIS
research, connections may be possible between semantic or subject matter relations as
examples of the information transfer model, and pragmatic relations as examples of the
constructionist theoretical approach in LIS (Savolainen, 2008).
Our introductory question about the ability of one source of information to encourage
adherence to healthy behaviour more effectively than another (consumer versus
physician) – is partly answered here. The presence of more presentational relations in
consumer discourse than in physician discourse suggests that the consumer discourse is
more goal-oriented than the physician discourse. In other words, laypeople/consumers
may be more effective at inspiring healthy behaviour. In particular, the predominance of
the Motivation relation in consumer versus physician data (24 per cent versus 3.5 per
cent) suggests that the consumers are more encouraging of behaviour or actions reflected
in the analysed texts. The second and third most common consumer discourse relations
also demonstrate that the consumer discourse is more polite due to the frequency of the
concession relation (11 per cent of consumer; 3.5 per cent of physician relations), and
more enabling (in the sense of making actions/decisions more feasible or possible by
supplying means, knowledge or opportunity) due to the enablement relation (9 per cent
of consumer; 1.7 per cent of physician relations).
The prevalence of elaboration relations in the physician data compared to the
consumer data (27 per cent versus 6 per cent) suggests that the physician discourse
could be more factual. The physician discourse is perhaps more literally informative, in
that it provides more information, though not about how to use or integrate that
information into everyday life. This also suggests that the physician discourse is more
rooted in the information transfer model of communication than the consumer
JDOC discourse. The prevalence of the condition relation, the second most common physician
68,6 relation compared to findings in the consumer discourse (11 per cent versus 4 per cent)
indicates that the physician discourse is more reliant on establishing or sharing facts
for developing or couching (literally, conditioning) arguments or shared information.
The frequency of the other second most common physician relation, the background
relation (11 per cent in physician; 6 per cent in consumer data), demonstrate physician
844 intention to help (or concern about the need to help) consumers comprehend health
information.
Hartzler and Pratt’s (2011) recent findings, drawn from comparing patient (lay) and
clinician (professional) expertise, appear to corroborate our results regarding the
prevalence of pragmatic versus semantic relations in consumer versus physician
discourses. Hartzler and Pratt found that patient shared expertise/information
emphasised “actionable advice,” delivered in narrative style, while clinician expertise
emphasised “prescriptive action strategies,” rich in “direct instructions” rather than
“personal stories” (n.p.).
The occurrence of structured lists in physician data and their absence in consumer
data may reflect physician training and use of “problem lists” to guide patient care in
practice (Hunter, 1991, p. 84). Physicians generate these lists during patient care and
use them to carry out treatment plans for their patients. These physician findings
signify a more professional approach to communication, with a characteristic
emphasis on hedging (couching or qualifying communication), providing facts or
evidence, and simplifying health communication (Zethsen and Akehave, 2006).

Value of pragmatics level analysis

Situating this and future research at the pragmatics level of linguistics allows us to
examine language use and meaning in context, an important topic within LIS, and in
information behaviour studies in particular (Courtright, 2007). This approach enabled
us to see that presentational (pragmatic) linguistic relations appear to increase readers’
desire to act, believe or accept shared information, such as treatment or prevention tips.
Subject matter (semantic) linguistic relations emphasise more formal language aspects,
and appear less capable of conveying deeper levels of meaning which can lead to
action-oriented use of information (Mann and Thompson, 1988). This work extends
prior health information LIS investigations by focusing more on argument structure
and how shared information may affect information use, rather than on the content or
types of information shared (affective, personal, etc.) in online discourse in particular.
The use of RST for information behaviour research appears to be limited to our
study and another study that used RST to develop search templates for users to input
guided searches based on desired relation effects (Vechtomova and Zhang, 2009). We
have demonstrated that RST offers a new approach to discourse analysis for
information behaviour and practice studies, and recommend incorporating it in further
studies. RST could prove particularly helpful in producing tailored health information
and communication, both online (utilizing computational linguistics or artificial
intelligence approaches), and in-person, from a more user-centred perspective than is
currently the norm (Alpay et al., 2009). RST research involving consumers directly
(through in-person interviews) or indirectly (through analysis of consumer texts) may
increase our understanding of how to improve treatment adherence in diabetes and
other chronic diseases.
 Findings regarding the prevalence of linguistic politeness in the Discourse
consumer-to-consumer discourse suggest that the scope of further research could be structure
expanded to compare politeness in lay and professional communication. Such work
could draw on and inform research on practice of reference transactions, and differences
specifically, on politeness aspects of greeting and closing rituals in information
services (cf. Park et al., 2010).
845
Implications
Our findings suggest that RST is a helpful theory for studies in the areas of everyday
life information seeking (ELIS) and health information use. McKenzie (2003), Talja and
Hansen (2006), and Veinot (2009), among others in LIS, have advocated for more such
“user-to-user” information behaviour and information retrieval work in everyday life
research. In the peer-to-peer information sharing and use domain, RST research seems
promising for the subdomain of lay information mediary behaviour (LIMB)
(Abrahamson et al., 2008). Applying RST utilizing the LIMB theoretical framework,
which considers how people seek or share information, from or on behalf of others, can
facilitate studying aspects of information seeking and sharing, and communication in
groups such as families and other close-tie, everyday life social networks. Bickmore
and Giorgino (2006) note that such multivocal dialogue is “understudied in both
linguistics and computational linguistics”, yet such groups can play key roles in
adherence (p. 569).
Savolainen’s findings (2011b) that some health bloggers report fewer needs for
factual information and greater needs for opinion or experience-based issue evaluation
support an argument that consumers prefer a consumer discourse compared to the
physician discourse (see also Veinot, 2010, and Neal and McKenzie, 2011, regarding
such preferences). However, human communication is a complex act. Physicians and
other clinicians have also been found to prefer peer-to-peer communication over other
forms of communication (see, for example, Forsythe et al., 1992). Our findings may
extend beyond the consumer-to-consumer health information sharing domain, and
relate to a more general peer-to-peer discourse or knowledge translation and
communication model. The prevalence of presentational rhetorical relations,
particularly Motivation relations, could apply to discourse among peers of any kind
(e.g., lay or professional), not just health information consumers. Confirming this
hypothesis is beyond the present study scope, but doing so could provide direction for
future research which seeks to understand information source roles and the effects of
information exchange in knowledge translation and information use across varied
domains.
This study is descriptive in nature, and its results should not be interpreted
prescriptively without considering the broader pragmatic situation and the desired
perception. Pin-pointing and detailing discourse structure differences between lay and
professional language may invite attempts at mimicking, accommodating, and
ultimately mis-representing a lay or professional identity, especially in online
environments. Keeping both benevolent or malevolent intentions in mind, Rubin (2010)
cautions against the adverse effects of intentional deception as it often “renders
information unreliable” when detected, and “it ruins trust and credibility” which are
“essential to successful communication” or information seeking.
JDOC Limitations
68,6 This work addresses Alpay et al.’s (2009) call for research that can “(bridge) the gap
between access to information and information understanding” in future consumer
health information system development. Alpay et al. (2009) describe the future of such
work as one “shaped by an increase in the aging population, who are prone to chronic
conditions and are in need of more involvement in the self-management of their chronic
846 diseases” (p. 2). While our results reflect such an aging population, they are not
generalizable, due to small study design and lack of triangulating methodology.
However, though our total participants and sample size were limited, participant
demographics (age and gender) reflect average user demographics for the website
studied.
We did not ask users for direct feedback regarding whether effects observed in RST
relations yield actual effects they experienced. While RST has been used widely in
research in multiple domains (Taboada and Mann, 2006), few studies to date have
incorporated participant feedback regarding relations found, with the recent exception
of Vechtomova and Zhang (2009). This is recommended in future research as a means
for triangulating results. Findings regarding presentational versus subject matter
relations and possible user effects are compelling, but some users/readers may actually
prefer the physician answer discourse, precisely for its more descriptive nature. Since
consumer-to-consumer discussion forum participants are more likely to be consumer
discourse-oriented, they represent a possible source of study bias. It will also be
important in future work to include multiple physician “voices” in the physician
discourse. Further related research would be also strengthened by taking a more
international approach to explore possible culturally-based or country-specific health
communication differences.

Conclusions
The present study compares lay (consumer) and professional (physician) discourses in
health information sharing on a consumer health diabetes website. We find
preliminary evidence of differences between discourses at the pragmatics level of
linguistics, using rhetorical structure theory to guide our analysis.
Based on analysed RST definitions, information consumers share, and how they
share it with other consumers appears to be more motivating, or activating, and more
polite (linguistically) than what, or how physicians share information with consumers
online in similar topics in diabetes management. More research is needed to provide
more in-depth and generalizable results.
Living with or preventing chronic disease requires “nearly continuous decision
making and adjustments to changing circumstances (or contexts)” by consumers
(Wagner et al., 2005). Our results cross the threshold of the health clinic towards
“home”, and everyday life environments, where health information is dynamically
processed yet its use is understudied (Mattingly et al., 2011). Such research contributes
to our understanding of the process of knowledge translation in health care and other
domains, where professional information is shared in various settings, yet ultimately
applied or used in lay or everyday life environments.
Because RST was employed in prior studies to inform system design via automatic
text generation, summarisation, and other algorithmic-based information science
applications, the present study can also contribute to future integrated information
behaviour and information retrieval system research. We hope that such studies can Discourse
eventually facilitate the design of information systems that draw in a more balanced
manner on both approaches (Järvelin and Ingwersen, 2004), thus taking user-centred
structure
information system design to a new level. differences
Notes
1. The term “consumer(s)” here encompasses both patients who are experiencing illness, and 847
people who are well, but seeking or sharing health information for various purposes. This
term is controversial, but is commonly used in the health information seeking and
informatics literature. A challenge to such terminology is beyond the scope of this research
(cf. Lewis et al., 2005).
2. The US National Center for Health Statistics defines “chronic disease” as “(a disease) lasting
3 months or more.” This definition includes cancer when it fits this duration.
(MedicineNet.com definition of “chronic disease,” available at: www.medterms.com/script/
main/art.asp?articlekey ¼ 33490 (accessed 10 December 2011).
3. Each example carries an identification number from the dataset with consumer answers
marked as “Cons_Ans” and physician as “Dr_Ans”.

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About the authors

Jennie A. Abrahamson is a Doctoral Student in Library and Information Science at the Faculty of
Information and Media Studies, and a member of the Language & information Technology
Research Lab (LiT.RL) at the University of Western Ontario, London, Canada. Jennie has an
MLIS from the University of Washington iSchool, Seattle, WA, USA. She also earned a Master of
Biomedical Informatics (MBI) from the School of Medicine at Oregon Health and Science
University, Portland, OR, USA, while completing a US National Institutes of Health/National
Library of Medicine-funded research training fellowship. Jennie’s experience working in
academic and community reference and information services inspires her research interests in
how people seek and use information to solve problems in everyday life, how information affects
health outcomes, and connecting user- and system-centred research to improve information
systems. She focuses on interpersonal and secondary information seeking via the study of lay
information mediary behaviour (“LIMB”, or people seeking information from, or on behalf or
because of others in everyday life). Adjunct interests include integrated research methods, health
information seeking, consumer health informatics, information disparities, and social and ethical
aspects of ICT design and use.
Victoria L. Rubin is an Assistant Professor at the Faculty of Information and Media Studies
and the Principal Investigator of the Language & information Technology Research Lab
(LiT.RL) at the University of Western Ontario, London, Canada. She received her PhD in
Information Science and Technology in 2006, her MA in Linguistics in 1997 from Syracuse
University, NY, USA, and a BA in English, French, and Interpretation from the Kharkiv National
University, in 1993. Dr Rubin’s research interests are broadly in information organisation and
information technology. She specializes in information retrieval and natural language processing
techniques that enable analyses of texts to identify, extract, and organize structured knowledge.
She investigates complex human behaviours that are, at least partly, expressed through
language such as certainty, emotions, credibility, trust, and deception. The language in each case
exhibits subtle but discernible properties that can be identified and traced computationally. Her
lab focuses on modelling these phenomena and developing methodologies for acquiring
appropriate and reliable cues for identification, classification and detection, first manually than
computationally, based on natural language processing and machine learning techniques.
Victoria L. Rubin is the corresponding author and can be contacted at: vrubin@uwo.ca

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