Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care 119

IMPACT OF HEALTH INFORMATICS ON PATIENTS'

PERCEPTION OF HEALTH CARE SERVICES: TRENDS OVER
TIME OF HEALTH INFORMATION TECHNOLOGY USE.
Safa Elkefi1, Onur Asan1 and Thy Do2
1
Stevens Institute of Technology, Hoboken, USA
2
The University of Western Australia
selkefi@stevens.edu, oasan@stevens.edu, thy.do@health.wa.gov.au
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024

Abstract: Despite the increase in the availability of online technology, the trend of patients’ adoption of
health information technology is not yet clear. This study aims to track the temporal evolution of
technology adoption among patients. It focuses on studying the impact of technology use on health care
services perspective using the self-efficacy theory. We conducted analysis to evaluate trends over time
using Nationally representative data. We found that the more people use technology over time, the less
effective they perceive health care services. Their use of technology consists of seeking more information
online and communicating more with health care providers. Efforts need to be made in order to guide the
use of technology as a complement to clinical health care services to ensure a supervision of health
behaviors and a framing of health pathway. Future studies should look at the possible designs and concepts
that may provide a suitable solution that both satisfy patients and providers’ needs involving technology but
keeping traditional health services respectable.
Key Words decision making, technology, health information technology, support groups, communication,
moral support, information exchange, self-efficacy theory, patient-centered care, health services perception,
traditional healthcare.
increasing utilization has provided a better opportunity for
INTRODUCTION people to search for health information online, which was not
easily available to them in the past, regardless of its
Background credibility, accuracy, and reliability (Y. Y. Chen et al., 2018;
Finney Rutten et al., 2019). Provided the opportunity to decide
Health care has been facing a revolutionary transformation by themselves for their health-related matters through Health
through the digitalization efforts that have been made in the Information Technology (HIT), the patients’ perception
last decade (M. Chen & Luo, 2020). Health care experts, towards the services provided may change. The purpose of
policymakers, payers, and consumers have considered health this study is to explore patients’ use of health information
information technologies, such as electronic health records technologies over the years and understand the impact of these
and computerized provider order entry, to be critical to trends on their satisfaction with health care services provided.
transforming the health care industry (Chaudhry et al., 2006) We used the self-efficacy theory to predict the perception of
While the benefits of health information technology are clear patients towards the traditional health services. Self-efficacy
in theory, the success of the systems in healthcare settings theory is a subset of Bandura's (1986) social cognitive theory
does not meet the expectations (Valdes, Kibbe, Tolleson, (Bandura, 1986). According to this approach, the two key
Kunik, & Petersen, 2004). In fact, there is a long history of determinants of behavior are perceived self-efficacy and
technology-oriented research that showed positive outcomes outcome expectancies (Suttona, 2004). In this study, we test
in health care (ElKefi & Asan, 2021; Elkefi, Yu, & Asan, the direct impact of self-efficacy and outcomes expectations
2021). For example, computerized drug order entry reduced seen in the way patients are using technology on their
costly and harmful medication prescribing errors (Bates et al., perception of traditional health services.
1998). However, focusing on research in how digital health
technologies can optimize both clinical care delivery and METHODS
clinical research is still slow to develop (Holland, 2014)
despite the significant opportunities (Sharma et al., 2018). Data
From a consumer perspective, technology has enhanced
patients’ self-management (Calthorpe, Smith, Gathercole, & Data was derived from a public data set. We utilized cross-
Smyth, 2020). With the actual technology invasion, large sectional surveys from the Health Information National Trends
amounts of health information can be accessed online (Y. Y. Survey collected between 2016-2020, HINTS5 Cycle 1 (2016-
Chen, Li, Liang, & Tsai, 2018). Just several decades ago, 2017) and HINTS5 Cycle 4 (2019-2020) published in 2021.
people relied solely on traditional media to obtain health HINTS include U.S. residents who are 18 years and above,
information, for example, reading newspaper and magazines, and the survey gathers information on U.S. resident’s
listening to radio, watching television, and seeking physicians’ requirements for access to and utilization of health-related
advice. With the dramatical growing in access to Internet, its data and health-related practices, insights, and awareness.
 Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care
There are 3285 survey participants from HINTS5 Cycle 1 and
3865 survey participants from HINTS5 Cycle 4. We used the
weighted sample sizes to explore the relationship between
technology use in healthcare and the traditional care settings
perception accounting for the complex sampling design and
deriving population-level estimates. Information regarding the
sampling design and survey procedures are available at
http://hints.cancer.gov. (HINTS). This study does not involve
patient participation, and no personal patient information has
been revealed. All analysis was conducted using anonymized
data which is publicly available. We conducted all the
analyses using Python 3.7.6.
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024
Covariates and Measures
Self-efficacy & outcomes expectations:
Technology use questions, have been utilized by various
studies in different ways, including the creation of composite
scores by converting questions to 0–100 scale (Blanch-
Hartigan et al., 2016), using the average score of Health
Information Technology use questions. Considering the
technology use as a factor that expresses the self-efficacy
perception of patients to find the needed information and
guide themselves towards satisfying their outcomes
expectations of a better quality of care, we used 10 questions
representing the technology use practices on the Figure 1
represents the variables used.
Figure 1. Technology use practices
The score of use of technology is calculated as follow:
Use_of_technology = (1)
Having:
(2)
And:
xi = Population having the score ai.
ai = An individual’s score of use of technology
120
ψi= Factor, equal to 1 if i=j for j in the set of the 10 technology
use practices stated above.
bj = Technology use practice for j in the list of the 10
practices.
n= population of the study
This score was used to assess for the outcomes’ expectations
and self-efficacy of patients through their practices: when
patients seek information online it reflects that they are
expecting more information from their health care provider,
and they are trying to find it on their own.
Traditional Health Services Perception as behavior:
The perception of patients towards the traditional health care
services defines the opinion of patients towards engaging in
in-person doctor-patient health care instead of telehealth and
online provided services. For that we used these variables to
assess for their behavior.
- Variable 1: How confident is a patient that he can take care
of himself and does not need a doctor for that: “Yes” or “No”.
-Variable 2: How satisfied a patient is about healthcare
services: “Yes” or “No”.
Statistical Analysis
We followed similar methodologies as in prior studies when
developing analytical plans published HINTS data (Swoboda,
Walker, & Huerta, 2021). We analyzed, first, the trends for the
2 cycles to track the temporal changes of the technology use
between 2016 and 2021 and its impact on the health
perception. All analyses were completed using R statistical
packages (mainly: survey and lme4 package) imbedded in
Python.
RESULTS
As shown in Figure 2. From 2016 to 2020 technology use
increased from a score of 49.58 to 55.54 which shows that,
with time, more adoption of technology by patients in shown.
With that, the healthcare quality decreased from 96.95 in
2016-2017 to 95.58 in 2019-2020 as shown in Figure 2. Also,
the need of doctors to take care of them decreased from 81.5
to 69.66 in 2019-2020. So, the more patients use technology
the more they tend to negatively perceive the traditional health
settings.
 Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care 121

Figure 2. Trends of use of technology and health perception

over time.
For the last years (2017 to 2020), technology use is
significantly discouraging patients trust in traditional
healthcare settings and encouraging technology use. We
confirmed by that the self-efficacy theory hypothesis (Figure
3).
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024
DISCUSSIONS
This study explored the association between their way of using
technology for healthcare purposes and their perception of in
person healthcare services. Our hypotheses were that
technology use is associated with patients’ satisfaction with
health care services and their perceived need to resort to
doctors. Over the past decade, the explosion of online
communication in the community has motivated patients to

explore opportunities to use these modes of communication in

addition to their health care provides (Katz & Moyer, 2004).
Figure 3. Self-efficacy Theory validation. Technology has been changing health care, and with each new
technological advancement—be it telephone, e-mail, Internet,
We then decorticated the technology use practices in order to electronic health records (EHRs), personal health records
understand what people tend to use technology for exactly, (PHRs), mobile health (mhealth) or social media-there has
and what in the technology is making them feel self-effective been efforts to promote its acceptance and use by both patients
and in no need for doctors to assess the information and make and doctors (Earnest, Ross, Wittevrongel, Moore, & Lin,
the health-related decisions on their own. Table 1 below 2004). If technology were well-implemented and well-
represents, for each technology practice, the percentage of presented, it would hold the potential to improve the
patients that adopt it during the 12 months prior to answering individual and organizational health outcomes (Grant et al.,
the survey. 2008) because there are numerous barriers facing the
implementation and acceptance of information communication
Table 1. Trends of technology use practices over time. technology in healthcare, going from financial to cultural to
2016- 2019- political barriers in addition to concerns about
Technology use practice
2017 2020 understandability of the information exchanged and control
Information seeking: 49.81 52.10 over the situation (Cowan, 2010). From a patient perspective,
Using technology to participate in their concerns towards healthcare services include the
online forums / support groups for 10.58 13.48 uncertainty, perceived social support, perceived usability,
people with same medical issues. perceived self-efficacy, perceived difficulties of health
provider access as well as fear and anxiety (Cowan, 2010).
Using technology to look for general
89.05 90.71 Support groups are a popular resource for people looking for
health or medical information.
information and support from peers to help them cope with
Decision making: 55.47 50.86 their condition and provide them with emotional support
Using technology to help decide about (McCaughan, Parahoo, Hueter, Northouse, & Bradbury,
55.47 50.86
how to treat an illness or condition. 2017). Cancer support groups and forums, for example,
Access to information: 94.25 75.21 provide a significant means that meets the social support
Using technology to access health or requirements of cancer patients helping them to control their
61.22 70.81
wellness Apps. emotions and enhancing their problem-solving skills and
Using technology to download health coping methods (Ursavas & Karayurt, 2017) which explains
83.94 69.89
information to personal device. why patients resort to it more than they used to. Doctors and
Using technology to look up medical health care stuff that are in contact with the patients need to
82.12 84.94 help patients deal with uncertainty while explaining things
test results.
Communicate with HCPs: 61.62 68.49 more clearly to them. Technology can be a good opportunity
Using technology to communicate with to help foster their knowledge decreasing their uncertainty
73.97 78.80
a doctor or doctor’s office. about several health-related topics (ElKefi & Asan, 2021;
Using technology to help discuss with Elkefi et al., 2021). Doctors should use technology solutions
53.28 57.75 available to assure a good quality of information flow gets to
health care provider.
Using technology to share health their patients training them how to deal with uncertainty and
69.26 75.33 anxiety. Furthermore, technology is shifting knowledge (e.g.,
information with a health professional.
Using technology to securely message patients can access guidelines for care on the Internet or read
50.00 62.10 their own EHRs) and power (e.g., social media sites allow
health care provider or staff.
patients to share information about care and providers)
So, patients use technology more for information seeking and (Cowan, 2010). Patients find in technology a 24/7 source that
to communicate with their health care providers. But they use they can access from anywhere to find any information they
it less than they used to, in decision making and accessing need reducing by those different burdens like cost and
medical results online. transportation (ElKefi & Asan, 2021). This way of searching
 Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care
information provides them with empowerment and self-
confidence. So, their needs are not only knowledge and
information access anymore, but it is also empowerment of
their self-efficacy what they are looking for which they cannot
always find in traditional healthcare settings (Earnest et al.,
2004). The medical professions require doctors to be both
clinically competent and empathic towards the patients, in
practice. However, accommodating both requirements can be
difficult for physicians. The image of the technically skillful,
rational, and emotionally detached doctor dominates the
profession, and inhibits physicians from engaging emotionally
with their patients and their own feelings which may make
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024
patients look for emotional support from support groups and
for guidance from websites (Kerasidou & Horn, 2016). The
results of this study support the fact that technology should
complete this role not taking place of doctors. Patients still
trust doctors more than Health Information Technology as
they still use it to communicate with their health care
providers, exchange messages and health results with them but
not to make their own decisions. But the quality of health care
depends on successful communication between health
professionals and patients (Santana et al., 2010). The
availability of online medical records and health information
technology would not only impact the way patients
communicate with their doctors (Goodyear-Smith, Wearn,
Everts, Huggard, & Halliwell, 2005) but would also influence
their choice of health care provider to some extent (Beckjord
et al., 2007). For many patients, using online communication
appears a better option than more traditional modes (Katz,
Moyer, Cox, & Stern, 2003). Online communication is also
appealing to physicians. They navigate an increasingly
fragmented communication environment that forces them to
communicate through several disparate modes: face-to-face
encounters, phone messaging, e-mail, digital beepers, and of
course, the paper chase. This fragmentation, adding more
workload to their work, can result in delays or omissions of
important information, yielding lower provider satisfaction
and quality of care (Baker, 2001). For this and other reasons,
patients were shown in this study to have doubts concerning
which doctors to trust and their frequency of visits. As the use
of online tools becomes more pervasive in health and
medicine as represented by the concepts Health 2.0 and
Medicine 2.0 (Hughes, Joshi, & Wareham, 2008), and patients
become more empowered by technology finding it to fill the
gap of routine healthcare settings’ problems, all parties need to
adjust to a new form of participatory health care. Expected
outcomes are not only improved health but also more
efficiency in the use of scarce resources, improved trust
between stakeholders, and greater convenience (Santana et al.,
2010),the essence of quality health care. Four axes need to be
addressed, the health care provider’s education, the patients’
education, the traditional healthcare practices’ correction
together with the design of the health-related technologies to
be able to control their adoption once implemented. Doctors
and health staff are the key factor that drives the patients to
decide whether to trust health services provided or mistrust
them. The role of doctors is becoming different. Doctors
should be trained to do different work then they used to. With
technology invading healthcare the role of doctors is
122
becoming more than just prescribing medicines, translating
results of tests, and following up with patients, patients are
watching videos because they need to understand more the
results communicated to them and get more information about
it. Patients do not need doctors that tell them what to do but
who explained to them why they do it. People are looking for
emotional support and real health-related discussion with an
understandable language. that is why they are more engaged in
discussion groups and forums. In all this, doctors need to ask
themselves how they can embrace technology in relationships
with patients and use it to improve their communication with
them revising their definition of patient-centered care adding
more personalized care to the services they are providing.
From a patients’ axis, the confusion that they have about
health-related issues may be addressed with technology but a
misuse of online provided tools or solutions may misguide
their health and curing pathway. Thus, patients need to be
guided, controlled, and understood. Guided so that they are
provided with the right information and that they make the
right decisions. Controlled so that they do not fall in radical
perspectives about health processes and follow clear
guidelines and understood so that their needs are satisfied and
that they always feel that they have to resort to doctors and
that technology can only facilitate healthcare services and not
replace health care providers. Another dimension that varies
across patients over time is the context in which patients and
clinicians communicate. Early adopters of technology in
clinical settings will likely be younger, more highly educated,
and healthier than the general clinic population (Katz et al.,
2003). These users of technology-based solutions are not the
only users and do not have the same needs as typical primary
care patients that tend to be older, less educated, and more
burdened by chronic diseases. The communication needs
differ, and the interaction requirements differ with it. That
being mentioned, the technical and operational challenges of
building and integrating technology in healthcare motivate the
need for a clear vision of how these new communication tools
will meet larger organizational goals and address unmet
patients’ needs. Patient portals and web-based can meet these
goals in several ways and should be adapted to those needs for
a better control over the patients’ use of technology improving
the service delivery by improving the efficiency of
communication (Baker, 2001). Features of services can be
personalized, prioritizing the needs of patients, and providing
them with the possibility to communicate with other patients
having similar health issues under supervision of healthcare
professionals. Another important feature to be highlighted is
the patient-stuff and patient-provider communication.
Designers need to compete with other models of
communication that have been improved and enriched over
years. For a communication strategy to be successful, a
communication strategy must contain patient-centered care
options from patient and provider perspectives. In
consideration of time workload, some questions can be
automatically answered with embedded automatic chatbots
and forums. Furthermore, the communication management
strategy used should also consider educating patients and
manage their expectations to address appropriate
communicated content (White, Moyer, Stern, & Katz, 2004).
 Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care
For instance, the choice of what to tell, how to tell it, which
words to include in the message, how far to go with details,
how to inform about urgent and complex issues, how many
communications to do and who will respond to the questions
among other details should be considered and predefined, not
left to the luck. Finally, a technology communication and
information system is never perfect and is never forever
suitable. Technology is evolving rapidly and with the
evolution, patients’ needs change as well as their expectations
and for the health care services to be up to date a continuous
evaluation and follow-up are needed. On the other hand, the
health care system should have alternative plans to maintain
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024
quality online visits with these patients.
This study has limitations. First, the nature of HINTS data is
cross-sectional and relies on subjective responses and the low
response rate might raise some bias concerns, especially
related to nonrespondents and sampling strategy. We should
note that the sampling and weighting strategy used by HINTS
administrators helps minimizing biases and improve national
representativeness and generalizability of findings.
Nonetheless, some local studies with more detail and a higher
response rate should be conducted to validate the findings.
CONCLUSION
This study showed the evolution over time of patient’s use of
technology in healthcare and its impacts on the health services
perspective. The findings show that there is an increased rate
of technology use for each year compared to previous years
for the period from 2016 to 2020. The use is more focused on
help with information seeking, access to information, moral
support through the support groups and communication with
doctors and exchange of information and messages with less
help in self-decision-making support. We gave some feedback
that may help to improve the technology-based solutions
based on this study’s findings. Future studies should also look
at in cancer risk patients and cancer survivors’ perceptions and
how technology is impacting their clinical pathways as it may
consist of a good opportunity for those patients in critical
situation. We also acknowledge that the recent COVID-19
pandemic had shifted the culture of virtual visits and online
healthcare technology use. Future studies should look at the
possible designs and concepts that may provide a suitable
solution that both satisfy patients and providers’ needs
involving technology but keeping traditional health services
respectable.
REFERENCES
Baker. (2001). Crossing the Quality Chasm: A New Health
System for the 21st Century. In Crossing the Quality
Chasm: A New Health System for the 21st Century.
Washington (DC).
Bandura, A. (1986). Social foundations of thought and action:
A social cognitive theory. Social foundations of
thought and action: A social cognitive theory.
Englewood Cliffs, NJ, US: Prentice-Hall, Inc.
Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen,
L. A., Teich, J. M., . . . Seger, D. L. (1998). Effect of
123
computerized physician order entry and a team
intervention on prevention of serious medication
errors. JAMA, 280(15), 1311-1316.
doi:10.1001/jama.280.15.1311
Beckjord, E. B., Finney Rutten, L. J., Squiers, L., Arora, N.
K., Volckmann, L., Moser, R. P., & Hesse, B. W.
(2007). Use of the internet to communicate with
health care providers in the United States: estimates
from the 2003 and 2005 Health Information National
Trends Surveys (HINTS). J Med Internet Res, 9(3),
e20. doi:10.2196/jmir.9.3.e20
Blanch-Hartigan, D., Chawla, N., Moser, R. P., Finney Rutten,
L. J., Hesse, B. W., & Arora, N. K. (2016). Trends in
cancer survivors' experience of patient-centered
communication: results from the Health Information
National Trends Survey (HINTS). J Cancer Surviv,
10(6), 1067-1077. doi:10.1007/s11764-016-0550-7
Calthorpe, R. J., Smith, S., Gathercole, K., & Smyth, A. R.
(2020). Using digital technology for home
monitoring, adherence and self-management in cystic
fibrosis: a state-of-the-art review. Thorax, 75(1), 72-
77. doi:10.1136/thoraxjnl-2019-213233
Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W.,
Roth, E., . . . Shekelle, P. G. (2006). Systematic
review: impact of health information technology on
quality, efficiency, and costs of medical care. Ann
Intern Med, 144(10), 742-752. doi:10.7326/0003-
4819-144-10-200605160-00125
Chen, M., & Luo, D. (2020). A CRISPR Path to Cutting-Edge
Materials. N Engl J Med, 382(1), 85-88.
doi:10.1056/NEJMcibr1911506
Chen, Y. Y., Li, C. M., Liang, J. C., & Tsai, C. C. (2018).
Health Information Obtained From the Internet and
Changes in Medical Decision Making: Questionnaire
Development and Cross-Sectional Survey. J Med
Internet Res, 20(2), e47. doi:10.2196/jmir.9370
Cowan, M. (2010). Millennial transformation for primary care.
Mil Med, 175(6), 379-381. doi:10.7205/milmed-d-10-
00184
Earnest, M. A., Ross, S. E., Wittevrongel, L., Moore, L. A., &
Lin, C. T. (2004). Use of a patient-accessible
electronic medical record in a practice for congestive
heart failure: patient and physician experiences. J Am
Med Inform Assoc, 11(5), 410-417.
doi:10.1197/jamia.M1479
ElKefi, S., & Asan, O. (2021). How technology impacts
communication between cancer patients and their
health care providers: A systematic literature review.
Int J Med Inform, 149, 104430.
doi:10.1016/j.ijmedinf.2021.104430
Elkefi, S., Yu, Z., & Asan, O. (2021). Online Medical Record
Nonuse Among Patients: Data Analysis Study of the
2019 Health Information National Trends Survey. J
Med Internet Res, 23(2), e24767. doi:10.2196/24767
Finney Rutten, L. J., Blake, K. D., Greenberg-Worisek, A. J.,
Allen, S. V., Moser, R. P., & Hesse, B. W. (2019).
Online Health Information Seeking Among US
Adults: Measuring Progress Toward a Healthy
 Proceedings of the 2022 International Symposium on Human Factors and Ergonomics in Health Care 124

People 2020 Objective. Public Health Rep, 134(6),
617-625. doi:10.1177/0033354919874074
Goodyear-Smith, F., Wearn, A., Everts, H., Huggard, P., &
Halliwell, J. (2005). Pandora's electronic box: GPs
reflect upon email communication with their patients.
Inform Prim Care, 13(3), 195-202.
doi:10.14236/jhi.v13i3.597
Grant, R. W., Wald, J. S., Schnipper, J. L., Gandhi, T. K.,
Poon, E. G., Orav, E. J., . . . Middleton, B. (2008).
Practice-linked online personal health records for
type 2 diabetes mellitus: a randomized controlled
trial. Arch Intern Med, 168(16), 1776-1782.
Copyright 2022 by Human Factors and Ergonomics Society. All rights reserved. 10.1177/2327857922111024
Women. J Breast Health, 13(2), 54-61.
doi:10.5152/tjbh.2017.3350
Valdes, I., Kibbe, D. C., Tolleson, G., Kunik, M. E., &
Petersen, L. A. (2004). Barriers to proliferation of
electronic medical records. Inform Prim Care, 12(1),
3-9. doi:10.14236/jhi.v12i1.102
White, C. B., Moyer, C. A., Stern, D. T., & Katz, S. J. (2004).
A content analysis of e-mail communication between
patients and their providers: patients get the message.
J Am Med Inform Assoc, 11(4), 260-267.
doi:10.1197/jamia.M1445

doi:10.1001/archinte.168.16.1776
Holland, W. W. (2014). How to improve our health services.
Clin Med (Lond), 14(3), 223-224.
doi:10.7861/clinmedicine.14-3-223
Hughes, B., Joshi, I., & Wareham, J. (2008). Health 2.0 and
Medicine 2.0: tensions and controversies in the field.
J Med Internet Res, 10(3), e23.
doi:10.2196/jmir.1056
Katz, S. J., & Moyer, C. A. (2004). The emerging role of
online communication between patients and their
providers. J Gen Intern Med, 19(9), 978-983.
doi:10.1111/j.1525-1497.2004.30432.x
Katz, S. J., Moyer, C. A., Cox, D. T., & Stern, D. T. (2003).
Effect of a triage-based E-mail system on clinic
resource use and patient and physician satisfaction in
primary care: a randomized controlled trial. J Gen
Intern Med, 18(9), 736-744. doi:10.1046/j.1525-
1497.2003.20756.x
Kerasidou, A., & Horn, R. (2016). Making space for empathy:
supporting doctors in the emotional labour of clinical
care. BMC Med Ethics, 17, 8. doi:10.1186/s12910-
016-0091-7
McCaughan, E., Parahoo, K., Hueter, I., Northouse, L., &
Bradbury, I. (2017). Online support groups for
women with breast cancer. Cochrane Database Syst
Rev, 3, CD011652.
doi:10.1002/14651858.CD011652.pub2
Santana, S., Lausen, B., Bujnowska-Fedak, M., Chronaki, C.,
Kummervold, P. E., Rasmussen, J., & Sorensen, T.
(2010). Online communication between doctors and
patients in Europe: status and perspectives. J Med
Internet Res, 12(2), e20. doi:10.2196/jmir.1281
Sharma, A., Harrington, R. A., McClellan, M. B., Turakhia,
M. P., Eapen, Z. J., Steinhubl, S., . . . Peterson, E. D.
(2018). Using Digital Health Technology to Better
Generate Evidence and Deliver Evidence-Based
Care. J Am Coll Cardiol, 71(23), 2680-2690.
doi:10.1016/j.jacc.2018.03.523
Suttona, S. (2004). Health Behavior : Psychosocial Theories.
Swoboda, C. M., Walker, D. M., & Huerta, T. (2021). Odds of
Meeting Cancer Prevention Behavior
Recommendations by Health Information Seeking
Behavior: a Cross-Sectional HINTS Analysis. J
Cancer Educ, 36(1), 56-64. doi:10.1007/s13187-019-
01597-0
Ursavas, F. E., & Karayurt, O. (2017). Experience With A
Support Group Intervention Offered to Breast Cancer