The benefits and challenges of online professional-patient interaction: Comparing views between users and health professional moderators in an online health community

Computers in Human Behavior 83 (2018) 106e118

Contents lists available at ScienceDirect

Computers in Human Behavior journal homepage: www.elsevier.com/locate/comphumbeh

Full length article

The benefits and challenges of online professional-patient interaction: Comparing views between users and health professional moderators in an online health community Sara Atanasova a, *, Tanja Kamin b, Gregor Petri ca a b

University of Ljubljana, Faculty of Social Sciences, Centre for Methodology and Informatics, Kardeljeva pl. 5, 1000 Ljubljana, Slovenia University of Ljubljana, Faculty of Social Sciences, Centre for Social Psychology, Kardeljeva pl. 5, 1000 Ljubljana, Slovenia

a r t i c l e i n f o

a b s t r a c t

Article history: Received 25 September 2017 Received in revised form 5 January 2018 Accepted 26 January 2018 Available online 3 February 2018

Online health communities (OHCs) have become new venues for online professional-patient interactions in which patients, as OHC users, can undertake online consultations with health professional moderators. This interaction has previously been investigated mainly from the user's perspective, whilst neglecting the insights of health professional moderators. The aim of this study is to explore and compare the benefits and challenges of online professional-patient interactions for users and health professional moderators and the effects on face-to-face medical encounters. The study employed a qualitative research design, with in-depth, semi-structured interviews conducted with users (n ¼ 8) and health professional moderators (n ¼ 7) from the largest OHC in Slovenia. Data analysis utilised inductive thematic analysis and principles of grounded theory. The results of this small study demonstrate that the OHC enabled users and health professional moderators to overcome weaknesses of face-to-face medical encounters. Both users and professionals view the primary benefits of online professional-patient interaction as delivering informational and emotional support for users' health-related needs. The main challenges for users and health professional moderators stem from the limitations of computermediated communication (CMC). Users and health professional moderators expressed different and ambivalent attitudes toward the OHC and its effect on face-to-face medical encounters. © 2018 Elsevier Ltd. All rights reserved.

Keywords: Internet Online health community Online professional-patient interaction Social support Online supportive communication Qualitative study

1. Introduction Online health communities (OHCs) have become one of the most important sources for searching and exchanging healthrelated information, experiences, advice, support and opinions (Johnston, Worrell, Di Gangi, & Wasko, 2013). As Internet-based platforms, OHCs connect various groups of individuals with similar health-related interests; thus, they represent important venues for connecting people with similar health conditions and sometimes access to health professionals (Johnston et al., 2013; van der Eijk et al., 2013). Generally, OHCs can be divided into two types: First are OHCs, which are mainly devoted to peer support groups and are usually referred to as online support groups (Coulson, Buchanan, & Aubeeluck, 2007). The second type, which are most

* Corresponding author. E-mail addresses: [email protected] (S. Atanasova), tanja.kamin@fdv. uni-lj.si (T. Kamin), [email protected] (G. Petri c). https://doi.org/10.1016/j.chb.2018.01.031 0747-5632/© 2018 Elsevier Ltd. All rights reserved.

commonly associated with the term of OHC, refer to online platforms that include both patients and health professional moderators that are usually health care professionals or doctors. In the latter type of OHCs, health professional moderators deliver health consultations and offer professional and reliable health-related information and advice to OHC users (Johnston et al., 2013; Petrov ci c & Petri c, 2014; Vennik, Adams, Faber, & Putters, 2014; Zhao, Ha, & Widdows, 2013; van der Eijk et al., 2013). Most popular OHCs usually offer both online support groups and integrate health professional moderators (i.e. PatientsLikeMe, WebMD, MedHelp). The importance of OHCs is growing and have been increasingly studied in the recent years, yet it is surprising that the research currently does not give much attention to the fact that OHCs are also new venues of communication and interaction between patients or caregivers on one hand and health professionals (doctors) on the other (Vennik et al., 2014). OHCs have broadened and diversified channels for professional-patient interactions, which has transformed the perceptions of face-to-face medical

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

encounters (Guo, Guo, Vogel, & Li, 2016; Wu & Lu, 2017). Patients, as OHC users, are now aside to interaction with their personal doctors able to consult also with other health professionals (i.e. health professional moderators) and can thus receive additional information, before or after medical encounter with their personal doctor (Li, Orrange, Kravitz, & Bell, 2014; Umefjord, Petersson, & Hamberg, 2003). Online professional-patient interactions in OHCs have been primarily researched from the users' perspectives (Himmel, Meyer, Kochen, & Michelmann, 2005; Peng, Sun, Zhao, & Xu, 2015; Umefjord et al., 2003; Vennik et al., 2014; Yang, Guo, & Wu, 2015). Also the effects of online professional-patient interactions on face-to-face medical encounters in health care settings have been so far focused mostly on how these effects were perceived by patients (Broom, 2005; Petri c, Atanasova, and Kamin, 2017; Rupert et al., 2014; Wicks et al., 2010). How both parties (users and health professional moderators) perceive online professional-patient interactions in OHCs and their effects on faceto-face medical encounters in health care settings, by contrast, have remained under-researched. We believe that this is an important shortcoming that needs to be addressed by studying both OHCs' users' and health professional moderators’ perspectives. 1.1. The benefits and challenges of OHCs for users and health professional moderators Researchers have examined online professional-patient interaction in OHCs from various perspectives, often focusing on benefits and challenges for users as patients (Himmel et al., 2005; Peng et al., 2015; Rupert et al., 2014; Umefjord et al., 2003; Vennik et al., 2014; Yang et al., 2015) and less frequently on benefits and challenges for professionals (Atanasova, Kamin, and Petri c, 2017; Guo, Guo, Zhang, & Vogel, 2017; Guo, Guo, Fang, & Vogel, 2017). Existing research shows that consultation with health professional moderators in OHCs provide the users with many benefits: a convenient, accessible, geographically independent and reliable source for informational and emotional support (Himmel et al., 2005; Peng et al., 2015; Umefjord et al., 2003; Vennik et al., 2014). OHC users often perceive online professional-patient interaction as beneficial for their health outcomes, health-related knowledge, management of personal health issues, competence in relationship with their doctors and the use of health services (Peng et al., 2015; Vennik et al., 2014). Himmel et al. (2005) have demonstrated that interaction with health professional moderators in OHCs can increase users' informational and emotional support when confronted with health-related issues and distress. The exchange of evidence-based medical knowledge provided by health professional moderators was most valued by OHCs' users, as it importantly contributes to their health-related knowledge and management of their own disease (Vennik et al., 2014). These studies have mainly focused on exchange of social support in OHCs with emphasizing users’ perspectives and behaviours. Recent research indicates that OHCs provide benefits also for health professional moderators; they can gain professional recognition and respect, access additional education and research, social and even economic resources (Atanasova et al., 2017; Guo, Guo, Zhang, et al., 2017; Guo, Guo, Fang et al., 2017). Online supportive communication, which refers to the social support resources produced through online interpersonal communication aiming to provide assistance to another person in need (Bambina, 2007; Burleson & MacGeorge, 2002; Chang, 2009; Chuang & Yang, 2010; Oh, Ozkaya, & LaRose, 2014), presents additional important part of online professionalpatient interactions (Peng et al., 2015). Health professional moderators can provide social support resources to users, which can meet various health-related needs and potentially bring about beneficial and/or even challenging health-related outcomes

107

(Chang, 2009; LaCoursiere, 2001). Interactions in OHCs are not without challenges. Studies of the effects of online peer support groups revealed that users are confronted with high amount of information, which can be misleading, confusing and can guide users to problematic self-diagnosis and/or self-treatments (Bartlett & Coulson, 2011). Although in OHCs health professional moderators provide clinical expertise and reliable health-related information to users' queries, users' nevertheless rely on information from different sources in OHCs, which are not necessarily screened and verified by professionals (Vennik et al., 2014). Because of the availability of online health delivery service in OHCs users often have high expectations of receiving rapid responses from health professional moderators (Yang et al., 2015), which can be a challenging task especially when health professional moderators are confronted with users’ serious and complicated health-related situations (Atanasova et al., 2017). OHCs can thus have a disempowering effects also for health professional moderators. In the study of Atanasova et al., 2017 health professional moderatos reported about several disadvantages related to their participation in OHCs, such as feelings of overload, overcommitment, uncertainty, and lack of control over their personal life as well as their professional role. 1.2. The effects of online professional-patient interaction on face-toface medical encounters Professional-patient interaction in OHCs can have effects also on face-to-face medical encounters in offline health care settings. Studies thus far mainly focused on user's perspective, demonstrating that users' online interactions with health professional moderators increased users satisfaction with their subsequent care, improved their involvement in personal health care and improved relationships with their personal doctors (Himmel et al., 2005; Peng et al., 2015; Petri c et al., 2017; Umefjord et al., 2003; Yang et al., 2015). Users emphasised that interactions with health professional moderators were especially useful for addressing unmet needs by their personal doctor (Himmel et al., 2005). Participation in OHCs has been related to the increased motivation for users as patients to actively collaborate with their personal doctors (Bartlett & Coulson, 2011) and to the empowering outcomes for patients in the professional-patient relationship (Petri c et al., 2017). Health professional moderators' perspective on the impact of OHCs on professional-patient relationship has been thus far (to the best of our knowledge) completely overlooked and thus presents a significant research gap that should be addressed. We need to acknowledge that some research reported challenges of health professionals in face-to-face medical encounters with “Internet-empowered” patients (Seale, 2005), but such analysis were focused on health professionals in general, not on those who participate as moderators in OHCs. Health professionals perceived the use of Internet and OHC-based information in faceto-face medical encounters as burdensome interference, manifested in patients’ unrealistic expectations, tendencies toward selfmedication and tensions because of the transformation of traditional roles in the professional-patient relationship (Ahmad, Hudak, Bercovitz, Hollenberg, & Levinson, 2006; Rupert et al., 2014; Sommerhalder, Abraham, Zufferey, Barth, & Abel, 2009). Health professionals reported also some beneficial outcomes of the use of OHC-based information in face-to-face medical encounters, such as assistance in decision-making process, empowering patients and increasing their sense of control (Broom, 2005). Views between OHC users and health professionals reflect different and even conflicting understanding of the impact of OHCs on face-to face medical encounters. Health professional moderators’ perspectives on the effects of online professional-patient

108

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

interaction on face-to-face medical encounters in health care settings could shed better light on such differences. 1.3. The aim of the study The ways that both users and health professional moderators experience their interaction in OHCs remain obscure, as does the impact of online professional-patient interactions on face-to-face medical encounters. A comprehensive approach to simultaneously study users' and health professional moderators' perspectives on online professional-patient interaction and its effects is crucial, since both parties play an important role in the success of face-to-face medical encounters and in the efficient implementation of OHCs in health care settings in general. The main aim of this study is to provide insights into online professional-patient interactions and their effects on face-to-face medical encounters in health care settings. We designed a small qualitative study to explore and compare the perceived benefits and challenges of interactions between OHC users and health professional moderators. We studied experiences and meanings of the participation in online health consultations in Med.Over.Net, the largest OHC in Slovenia. We conducted semi-structured interviews with users (n ¼ 8) and health professional moderators (n ¼ 7) of Med.Over.Net community and applied inductive thematic analysis approach and principles of grounded theory in order to seek answers to the following research questions: What are the benefits and challenges of online professional-patient interactions in OHCs, as viewed by OHC users on one hand and health professional moderators on the other? What are the effects of online professional-patient experiences in the OHC on face-to-face medical encounters in health care settings as viewed by users and health professional moderators? 2. Materials and method 2.1. Study setting Users and health professional moderators were recruited for this qualitative study from Med.Over.Net, the largest OHC in Slovenia. This OHC was established in 2000 and is one of the most visited online communities in Slovenia, with more than 400,000 monthly visits and, on average, more than 70,000 monthly users. Med.Over.Net offers around 130 moderated online discussion forums (i.e. social forums, online support group forums, and online counselling forums). Online counselling forums, which are the main aim of this study, are moderated by around 150 different health professionals, who are health care experts (medical doctors and specialists), psychotherapists, psychologists, and medical staff employed in public and private health institutions in Slovenia and participate independently as volunteers in this OHC. This type of forums cover topics ranging from acute or chronic health conditions to medical specialties handling particular diseases and medical states (e.g. dermatology, gynaecology, oncology, psychiatry, preventive medicine, etc.). The online counselling forums are structured in a question-and-answer (Q&A) format, where questions are posted by users and then answered by health professional moderators. However, the moderator controls the extent to which the structure of the discussion strictly follows the Q&A dynamic and how much additional discussion between the forum's users is allowed and encouraged. 2.2. Recruitment process and sampling The study participants were recruited via an online expressionof-interest form. We asked Med.Over.Net community managers for

permission to approach potential participants and for their assistance with the recruitment process. The community managers supported our study by publishing the link to the users' online expression-of-interest form on online discussion forums and by sending an email to all health professional moderators involved in the OHC containing the link to the expression-of-interest form and a request to apply to participate in the study. The users' and moderators' expression-of-interest forms explained the purpose of the study and the participants’ rights and requested their contact information. From the 47 user applicants, we chose eight participants using mixed purposeful sampling approach composed of both criterion and maximum variation sampling. Based on this approach, we chose only users of Med.Over.Net who had actively participated in the OHC in the last three months, had posted at least one message and had diverse demographic characteristics. Similarly, we used a mixed purposeful sampling approach, composed of both convenience and snowball sampling, to recruit seven health professional moderators who participated in Med.Over.Net and who were willing to participate in the in-depth interviews. The sample size follows the guidelines proposed by Braun and Clarke (2013) for thematic analysis, wherein the sample size suggestions are categorised by the type of data collection and the size of the project. For this small-scale project, we followed the guideline of including 6e10 participants in the interviews for both users and health professional moderators. 2.3. Data collection The data were collected by conducting in-depth, semi-structured, face-to-face interviews with users and health professional moderators from Med.Over.Net. Following the recommendation for increasing validity of responses in qualitative research (Creswell, 2013), researcher conducting all the interviews made sure that participants have a clear understanding of the nature of the study. In the interviews, the users and health professional moderators were asked to share their views and experiences concerning the following topics: the start and reasons for participation, opinions and views about Med.Over.Net OHC, benefits and challenges of participation in the OHC, relationships and interactions with other users and health professional moderators of the OHC, the role of the moderators, and the role of the OHC in the health care system. Participants were offered an incentive in the form of a 20 V gift card before participation in the interviews. All interviews except one were conducted one-on-one in person in quiet and secure rooms at the authors' offices, participants’ workplaces, at their homes or at remote and quiet spots in public places. One participant was hearing-impaired and undertook the interview via email, as an interpreter was not available. All interviews, except for the one conducted by email, were audio recorded with the permission of the participants and transcribed verbatim. The interviews conducted with users lasted, on average, 1 h and 2 min, with a mean length of each interview conducted with health professional moderators of 1 h and 8 min (excluding the one conducted via email). All interviews were conducted in January and February 2015. The personal characteristics of the participants were anonymised to guarantee confidentiality, and pseudonyms were used to preserve anonymity. During data collection process researcher recorded all observations and reflections from the interviews in observation notes, which were used throughout the whole research process. In observation notes researcher reflected on participants’ experiences and narratives in relation to personal perspectives and potential biases that might influence the data analysis procedure. Data saturation was indicated by the point when researcher felt that no

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

new information and potential themes were emerging in the last few interviews conducted and by the overall thematic data replications evident during data analysis procedure. 2.4. Ethical considerations Throughout the research process, we followed the code of ethics for researchers of University of Ljubljana (2014). The study was retrospective, so no institutional ethics approval was needed. The study was also conducted in line with the World Medical Association (WMA) Declaration of Helsinki on ethical principles for medical research involving human subjects (2013). 2.5. Participants 2.5.1. Users The average age of the users participating in the study was 39 years, and ranged between 27 and 50 years. All users but one were employed, and all except one held an undergraduate degree. Users included in the study had been participating at the Med.Over.Net OHC from 8 months to 9 years (average 4.2 years). All users were in relationships at the time of the interview; two of them were married. The motives for starting the active participation at the Med.Over.Net were mainly searching for health-related information, seeking and exchanging other types of information, exchanging opinions or just having fun. Half of the included users reported being diagnosed with a chronic condition (e.g. lymphoma, breast cancer, infertility and mental health issues) and half had occasionally experienced acute health issues (e.g. vaccination side effects, bone fractures, treatable infectious diseases, etc.). 2.5.2. Health professional moderators Health professional moderators were, on average, 55 years old, ranging between 42 and 94 years. Two moderators were male and five were female. All except one were employed. Two health professional moderators held an undergraduate degree and five of them had completed a postgraduate degree. Each had been involved with the Med.Over.Net OHC for an average of 8.7 years, ranging from 1 to 13 years. The main motives for becoming a health professional moderator were similar to those identified in previous studies (Coulson & Shaw, 2013; van Uden-Kraan, Drossaert, Taal, Seydel, & van de Laar, 2010) and included altruistic (e.g. provision of access to health-related information) and intrinsic (e.g. the opportunity for knowledge exchange, promotion of their professional field or themselves as experts) reasons. These participants moderated a broad range of health-related topics in the OHC, including cardiology, general practice, public health, medical genetics, psychotherapy and psychology.

109

in grounded theory (Strauss & Corbin, 1998): open coding, axial coding, and selective coding. Each of the stages of the coding process are described below. Open coding: Prior to the coding process, the entire set of interview transcripts was first read systematically several times to increase the familiarity with data. The analysis was data-driven and no coding scheme was set up prior to the data analysis process to avoid imposing data into pre-existing categories. The analytic process was thus conducted as an inductive and iterative open coding analysis, starting with the identification of distinct concepts in the data related to individual research questions. The first analytical step was to ascribe codes to meaning units (groups of words, sentences or statements that share some common meaning). We developed a definition for each code and established clear distinctions between them. In this stage of coding procedure we mainly identified descriptive codes with explicit meaning of the data. Axial coding: After the generation of initial codes, the analysis incorporated different codes with shared commonalities into initial sets of themes. The descriptive codes identified in the previous stage of analysis were thus merged into initial themes with interpretative, broader meaning and implications. This process continuously refined the coding scheme. Each initial theme was verified alongside the transcripts of the interviews to ensure that themes were accurate reflection of participants’ views evident in their replies. Selective coding: The analysis continued with revision of the initial themes by searching for coherent patterns, followed by a process that defined and named the themes. In this stage a final set of themes was created by selecting main themes and their subthemes and then determining the meaning and relationships between them. The interviews were analysed in turns, starting with each user's interview. This provided a better insight into the views and experiences of both types of participants and prepared the comparison between them. However, if a new code emerged in an interview, the data set already coded was reviewed and examined again. Thus, the analysis was an iterative process and the emerging codes were constantly challenged and further refined at each step of the process. Code saturation was achieved with nine interviews (five user and four moderator interviews). Transparency of the coding process was ensured by noting and documenting the overall coding procedure, potential themes, observations, ideas and patterns in the data in memos. The coding process, framework and results were discussed and elaborated among the authors, and any disagreements and discrepancies were resolved with the purpose of preserving the reliability of the findings. 3. Results

2.6. Data analysis The interviews were analysed using inductive thematic analysis according to the guidelines provided by Braun and Clarke (2006). In addition, we followed the coding process principles of grounded theory by Strauss and Corbin (1998). The data analysis was assisted with Nvivo v11.0 software. A member of the research team (SA) who conducted all the interviews also conducted the analysis. The aim of the coding procedure was to identify the main benefits and challenges of online professional-patient interaction in the OHC experienced by the users and health professional moderators. This coding procedure was further aimed at identifying the main perceived effects of online professional-patient interaction in the OHC for face-to-face medical encounters in health care settings, as viewed by the users and health professional moderators. The coding procedure followed three stages as defined

With the coding procedure guided by our research questions we identified two main themes: (1) experienced benefits and challenges of online professional-patient interactions, and (2) perceived effects of online professional-patient interactions on face-to-face medical encounters in health care settings. The results are structured around these two main themes. 3.1. Benefits and challenges of online professional-patient interactions Within the first main theme that included descriptions of users' and health professional moderators' experienced benefits and the challenges of online professional-patient interactions, we identified six subthemes (see Table 1): 1) Users' benefits and challenges related to the informational social support, 2) Health professional moderators

110

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

Table 1 Identified sub-themes of the benefits and challenges of online professional-patient interactions by type of social support from the perspective of online health community (OHC) users and health professional moderators. Type of social support OHC users Benefits

Health professional moderators Challenges

- information overload - receiving trustworthy - receiving contradicting information information - time to think about relevant - delayed response questions - receiving instant response - patient expertise

Emotional

-

Network

Challenges

- lack of key information about - clinical expertise users - granting exchange of patient expertise - avoiding answers by referrals - raising awareness to doctors - ethics and data protection - adapting medical terminology - confronting the downsides - opportunity of providing consolation - unrealistic expectations of the a disease and encouragement

Informational

receiving consolation feeling less alone mutual help access to health professionals - sense of community

Benefits

- commercial persuasions

benefits and challenges related to the informational social support, 3) Users' benefits and challenges related to the emotional social support, 4) Health professional moderators' benefits and challenges related to the emotional social support, 5) Users' benefits and challenges related to the network social support, and 6) Health professional moderators' benefits and challenges related to the network social support. First and second subthemes of users' and health professional moderators' benefits and challenges related to the informational social support refer to different views on providing and receiving advice, useful information, guidance and suggestions for coping with health issues or management of health conditions. Third and fourth subthemes of users' and health professional moderators' benefits and challenges of emotional social support comprise different expressions of empathy, understanding, affection, acceptance, care and encouragement when dealing with difficult health situations. Users' and health professional moderators' benefits and challenges of network social support (fifth and sixth subthemes) consist of various views on connecting with others, broadening social networks and access to new individuals, engaging with them in similar activities and developing relationships and a sense of belonging. Each subtheme is presented with representative quotas from the interviews in the following subsections. 3.1.1. Users’ benefits and challenges related to the informational social support We observed that OHC users identified four key benefits in receiving informational support in online professional-patient interaction: Receiving trustworthy information: In searching for and understanding health-related information, the perceived benefit most often mentioned was receiving trustworthy and reliable information from the health professional moderators. The respondents emphasised the professional background of the health professional moderators, which they felt eliminated the possibility of receiving misleading information: “Sometimes you look for information all over the Internet and you never receive a concrete answer. There are some articles, but you never know if the information there is trustworthy or not. In most cases, it is not. But if you go into the online counselling forums, you know that a professional will answer your question and that the information is reliable.” (U8, female, aged 27 years) Time to think about relevant questions: Another important benefit of online professional-patient interactions was having time

- sense of community

- conflicts

to prepare meaningful questions and to narrow down the focus of specific topics of interest to the user. Users also reported that the health professional moderators have more time in online professional-patient interactions to provide them with an elaborated, focused and comprehensive response, which is often lacking in face-to-face medical encounters due to time constraints: “The benefit was that I had more time to think about my question. What I want to say is that my questions were more focused, which also meant that the responses were more relevant compared to those from my personal doctor, as time is very limited during an appointment.” (U3, male, aged 50 years) Receiving instant responses: Users emphasised that an advantage of engaging in interaction with health professional moderators in the online counselling forums was the possibility of receiving health-related information immediately or very shortly after asking the question. Instant communication with health professional moderators in many cases also eliminated the users’ need to visit their personal doctors: “I think that health professional moderators answer questions very fast … when I posted a question, I always got a reply. My question was never left unanswered.” (U5, female, aged 35 years) “You don't have to pay for a visit to your personal doctor for every detail that interests you. You just come [to the online counselling forum], write and ask.” (U8, female, aged 27 years) Patient expertise: The possibility to receive patients’ expertise is not directly related to the professional-patient interaction in the OHC, but the views of other users are mediated through the history of publicly available posts previously communicated between users and health professional moderators in the online counselling forums. Many users perceived the insights, opinions and experiences from other users in the online counselling forums as valuable sources of information. This information often focused on strategies for coping with personal health issues and on tips that stemmed from their personal experiences: “Maybe users can't describe something in professional and clinical terms, but he/she can explain his/her opinion and experiences and sometimes this means more to me than health professional moderators' views.” (U7, male, aged 34 years) Based on the analysis of the interviews we noted that users

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

reported four key challenges regarding the level of informational support perceived in the interaction with health professional moderators in the OHC: Information overload: Some users reported that looking for health-related information included reading the history of previous discussions between other users and the moderators. In many cases, this resulted in being confronted with large amounts of information that were overwhelming: “I follow the forum a lot, but still didn't read everything there is. There is so much information, it is so difficult to read everything …” (U5, female, aged 35 years) Receiving contradicting information: Based on information provided in the online counselling forums by the health professional moderators, some users reported finding the moderators’ advice and information contradictory to that received from other sources, such as their personal doctors. In these situations, the main challenge was making an appropriate decision: “Umm, sometimes they [health professional moderators] can help you, but sometimes they can make you even more confused, because sometimes, in medical expertise, the answers can be quite diametrical. But there is no one to tell you ‘Look, this is right, and this is wrong’, which means that it is up to the user to decide.” (U6, female, aged 47 years) Delayed response: Most participants complained about occasionally having to wait for health professional moderators to respond to their questions. This challenge was related to anticipation that access to desired information must be immediate in online contexts. Many users understood the wait and attributed it to the busy schedules of the health professionals; however, at the same time, they emphasised the importance of immediate responsiveness in health-related matters: “I noticed that health professional moderators don't answer questions regularly and I was in a hurry to find out the needed information, I cannot wait for three days …” (U4, female, aged 46 years)

3.1.2. Health professional moderators’ benefits and challenges related to the informational social support Regarding the level of providing informational support, we noted that the health professional moderators emphasised the following three key benefits of online professional-patient interactions: Clinical expertise: All health professional moderators reported that the primary benefit of online professional-patient interactions is that users can ask specific health-related questions and receive reliable information, explicit facts and opinions that are supported by official medical and healthcare knowledge, research and training:

111

users' access to information provided by other patients who were going through similar experiences. Most health professional moderators in the online counselling mentioned the importance of enabling the expression of users’ knowledge gained from their own experiences: “Sometimes users also add posts to my answers and I think that's O.K …. of course, there is a difference between our answers, because mine are somewhat more structured than theirs, but other users' posts also have value … As a matter of fact, they are experts too, especially those who went through similar experiences.” (HPM2, female, aged 55 years) Raising awareness: Many health professional moderators mentioned that the interaction with users in the OHC gives them an opportunity to inform a wide group of people about specific healthrelated causes, conditions or activities, thereby increasing public understanding of particular health matters: “Online counselling forums also provide a great opportunity to raise awareness and inform people about certain information that some people cannot even receive from public health institutions or doctors.” (HPM6, female, aged 43 years) We also observed that the health professional moderators pointed out four challenges regarding online professional-patient interactions perceived for the level of providing informational support to users: Lack of key information about users: Most health professional moderators reported often finding themselves confronted with insufficient amounts of information to obtain an overall impression of the users and give a knowledgeable reply that meets the users’ health-related needs: “Umm, in most cases, when I answer as a health professional moderator I often don't have detailed background information, which means that I really need to pay attention to how I form my answer … and sometimes this can be difficult.” (HPM5, female, aged 56 years) Avoiding answers by referrals to doctors: Because of insufficient users’ information, health professional moderators expressed uneasiness at providing a specific answer to users. Instead, they advise them to make appointments with their personal doctors. However, users are keen to receive straight answers and are usually not satisfied with vague advice or redirections to their doctors: “Sometimes users are not prepared to discuss personal things on this type of forum. In these circumstances, it makes sense to tell them to see their doctors and discuss it with them. This response might look like lazinessdlike you don't want to answer themdbut it's not. Sometimes answers on specific questions are just too complicated …” (HPM1, female, aged 62 years)

“Users told me that they like to read my posts, because they receive information … I don't think that people would use this service if they didn't get anything from it. I think that these online counselling forums benefit all of us.” (HPM3, male, aged 94 years)

Ethics and data protection: Almost all health professional moderators noted the need for awareness of ethical principles and for guaranteeing personal data protection in each interaction with users. They reported that following ethical principles was not just a basic obligation of their profession, but it also represents an awareness that health-related communication can have an important effect on users’ decision-making in the treatment process:

Granting exchange of patient expertise: Although health professional moderators emphasised the importance of users receiving information offered by health professionals, they equally valued

“We find ourselves in delicate situations. I don't mean delicate as in morally problematic, but delicate in the sense that we

112

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

should avoid getting ourselves into situations where we might lead someone to decide that he or she would medicate himself or herself at home …” (HPM7, male, ages 44 years)

me, and back then I couldn't give them anything in return. This means that I received something from someone; now, others receive something from me.” (U3, male, aged 50 years)

Adapting medical terminology: Some health professional moderators indicated the challenge of adjusting medical terms and specific professional terminology when explaining about diagnoses or specific indications of health conditions to users. In some situations, health professional moderators struggled to bring the language of the response to a level appropriate to the users’ understanding:

We also noticed that users highlighted the following challenge of receiving emotional support from health professional moderators in the OHC: Confronting the downsides of a disease: Users diagnosed with a specific chronic illness found online counselling forums and reading about possible negative side effects emotionally difficult and even intimidating:

“… I noticed that people wanteddneededdsimpler answers. But I must say, medicine is not that simple. Maybe I was unable to simplify my answers to be understood by people, because people were asking about serious health problems of their relatives and the answers weren't simple. I found this very demanding.” (HPM1, female, aged 62 years)

“I intentionally didn't read everything there is, because sometimes what you find out is frightening.” (U4, female, aged 46 years old)

3.1.3. Users’ benefits and challenges related to the emotional social support In discussing their online professional-patient interaction experience in the OHC, we noted that users consistently identified three benefits of emotional support received from health professional moderators: Receiving consolation: Users concerned about specific health issues received solace and comfort from health professional moderators. They received reassurances and confirmations about their health problems that eventually helped them reduce health-related anxiety and facilitated them in their decision-making process: “[Asking questions in online counselling forums] helped to improve my psychical state of health … and eventually my health condition. It was easier for me to accept things and make a decision and I found confirmation for accepting things as they are.” (U3, male, aged 50 years) Feeling less alone: The majority of users reported that interacting with the health professional moderators, participating in the online counselling forums and reading posts from other users made them feel less alone in their difficult health situations. They reported finding recognition and understanding in coping with their health problems: “I would assess the information in online counselling forums as being worth its weight in gold, just because you see … umm, that you are not the only one with this problem.” (U7, male, aged 37 years) “… I didn't have any friends and I didn't know anyone that had the same problem, which made me feel so alone. Then I found the Med.Over.Net forums and I felt much better when I saw that I was not the only one who was dealing with these health problems.” (U1, female, aged 29 years) Mutual help: Some users noted that the help they received for health problems from the health professional moderators encouraged them to provide similar help to other users; thereby giving back to the OHC. In some cases, the users also reported that helping other users was part of their obligation of being an OHC member: “This became a habit of mine and it feels appropriate for me to help others that I can in counselling forums, because, one day, when I needed help, the health professional moderators helped

3.1.4. Health professional moderators’ benefits and challenges related to the emotional social support In discussing about interacting with other OHC users, health professional moderators noted the following benefit for addressing the provision of emotional support: Opportunity of providing consolation and encouragement: Health professional moderators, in many cases, noted that users often seek encouragement, confirmation, care and empathy, in addition to information and practical advice. Health professional moderators perceived that they have more opportunities to address these users’ health-related needs in online interactions than in face-to-face medical encounters: “In counselling forums, I think it is good that, umm, for instance, when I worked at [institution's name], I felt that I needed to give a person my academic and professional knowledge, and give counselling from this perspective. Here, in the counselling forums, I'm a person first. O.K., I have all my professional knowledge and I use it all here, but I can act in a more personal way.” (HPM2, female, aged 55 years) We also observed that some health professional moderators reported challenges regarding provision of emotional support in online professional-patient interactions: Unrealistic expectations: Some health professional moderators mentioned that they find themselves confronted with demanding and false users’ expectations. Some users enter the interaction anticipating that health professional moderators will agree with their opinions, confirm their health-related decisions and emotionally support them. As emphasised by the health professional moderators, in some situations, this type of support is neither possible nor appropriate: “Some of them [users] don't like the answer, because they don't want to hear that they have some kind of anxiety and not a physical condition which can be treated with a pill. Some of them also expect that you will write a whole dissertation around their case and then you just write two lines … umm, some of them are unsatisfied with the whole planet and just want to hear confirmation for their anxiety that the world is really as ugly as they think it is.” (HPM7, male, aged 47 years)

3.1.5. Users’ benefits and challenges related to the network social support Based on the data analysis we noted that users emphasised three key benefits of the network support provided in the

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

interactions with the OHC's health professional moderators: Access to health professionals: A majority of users reported that the OHC provides them with the feeling of constant presence of a service and access to a health professional's advice when they need it. They emphasised that this accessibility to professionals provided them with the feeling that their needs will be met by the availability of health professional moderators and their support received in the online counselling forums: “Online counselling forums are great. Currently, I don't need them, but maybe in a year I will need something and I know that I can find a health professional that will answer my question.” (U8, female, aged 27 years) Sense of community: All users emphasised that participating in the counselling forums and interacting with health professional moderators over time have led to the development of feelings of belonging, a shared sense of personal relatedness, emotional connection and commitment to the OHC: “Med.Over.Net is a part of my life. I'm there every day, I read posts and I respect certain health professional moderators very highly. Some of them I have also met personally. I feel part of a big family.” (U1, female, aged 29) We also observed that most users were positive about the network support received in the interactions with the health professional moderators, but one challenge was also mentioned: Commercial persuasions: Some users noted that, in some cases, the health professional moderators intentionally did not reveal important information, but instead tried to persuade users to visit their private practices and clinics: “… when it comes to health professional moderators, sometimes I get a little bit sceptical, because everyone wants to bring grist to the mill. I sense that they don't share every detail of information, but they invite you to come to their practices.” (U7, male, aged 34 years)

3.1.6. Health professional moderators’ benefits and challenges related to the network social support One key benefit of network support in online professionalpatient interactions in the OHC emerged among health professional moderators: Sense of community: Health professional moderators, similar to users, reported that engagement in the counselling forums had allowed them personally to develop a sense of membership with the OHC and feelings of acceptance and belonging: “I feel highly involved in the community. There, I'm a part of a family … I'm a part of it and [the OHC] is a part of me.” (HPM4, female, aged 44 years) We also noted that another challenge experienced in the health professional moderators’ interactions with users was discussed: Conflicts: Several health professional moderators reported experiencing differences in opinions with users, which often led to disagreements and arguments on professional and personal levels: “There will always be people who will not change their opinion and my intention wasn't to convince people that antidepressants are great pills, because they are not. They have their own side effects and that's it. I don't see a lot of drama about the topic, but some people compare them to the anti-vaccination

113

companies, saying that we are prescribing antidepressants to help the pharmaceutical industry make money.” (HPM4, female, aged 44 years)

3.2. Perceived effects of online professional-patient interactions on face-to-face medical encounters in health care settings Sub-themes of the perceived effects of online professional-patient interactions on face-to-face medical encounters in health care settings theme were identified on the interpretative level of analysis, where deeper meanings and implications were investigated (Boyatzis, 1998; Braun & Clarke, 2006). Based on users' perspectives, we identified four interpretative sub-themes that demonstrate users’ views on online interactions with health professional moderators and their experiences with personal doctors. For health professional moderators, we identified three interpretative sub-themes that demonstrate their views on the impact of their online interactions with users of the OHC on their face-to-face medical encounters with patients in health care settings (see Table 2). The main reported users’ motive for searching for additional health-related information in the OHC was often derived from dissatisfaction, disappointment and a doubt regarding the sufficiency of information, clarification and advice related to treatments and prescriptions provided by their personal doctors: “I went to my doctor and he gave me only one box of medication and this amount was completely insufficient for one cycle, and although he is a professional, he doesn't know what dosages he should prescribe for me. Later on, I saw on [health professional moderator name's] forum what dosage I should be prescribed, and it was strange to me why I hadn't received the same amount.” (U5, female, aged 35 years) We noted that verification of the received information in faceto-face medical encounters with their personal doctors was often linked to the lack of time that doctors have per appointment with a patient. The users think they need more time with their doctors to obtain a better understanding of the decisions about their treatments, procedures or prescribed remedies: “You can come to your doctor with a list of questions, but as soon as you want to discuss it with him, you don't know which question is relevant and which one isn't. You would need to make a selection of questions and, in most cases, you are not capable of doing that while you are talking to him, because there is no time.” (U3, male aged 50 years) These experiences encourage more active engagement by the users in their health management and in decision-making processes about their health conditions and issues. They also prompt users to inform themselves about treatment options, remedies, side-effects and other important information relevant to their personal health. We noted that the intention of becoming more informed about their health issue and actively involved in self-care (see Table 2) was more evident among users who reported being diagnosed with chronic health conditions. For this type of user, acting as an “informed patient” also presented a mechanism to prepare themselves for further face-to-face medical encounters with their personal doctors. As U4 (female, aged 46 years) explained: “When you are confronted with a certain illness, you don't know much about it; but, doctors treat you like you do. You don't

114

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

Table 2 Sub-themes pertaining to effects of online professional-patient interactions in the OHC setting on face-to-face medical encounters in health care settings.

OHC setting

Health care setting

OHC users

Health professional moderators

searching for additional health-related information intention of becoming more informed about their health issue and actively involved in self-care using received information in face-to-face medical encounters (maintaining) trust in personal doctors

opportunity for building cooperative relationship with patients

know what to expect and what it is going to happen, so you check forums to see what you should know and what to ask at the next appointment.” The majority of users also actively used the received information in online professional-patient interactions in face-to-face medical encounters, usually as a basis for further discussions with their personal doctors; the information helped them to form specific questions in relation to their health conditions, issues, treatments and remedies. Users expressed that information received in online interactions with health professional moderators had value; however, in most cases, they did not discuss the origin of the gathered information with their personal doctor. In the users' opinions, disclosure of the source of the health-related information would upset their personal doctors and interfere with the doctors’ authority, thereby representing a possible threat to the established relationships with their personal doctors. We observed that they reported using different communicative strategies to avoid revealing that they had received information in the OHC: “Uh, no, I never pointed out where I found it [information], I just said that I saw or read it somewhere … and they never asked … but if they had, I would have said that I received it from another doctor …” (U3, male, aged 50 years) We also noticed that users, in many cases, reported that they received more detailed information, in-depth knowledge and understanding about their health-related needs by reading or directly asking health professional moderators in the OHC; however, these experiences did not weaken their trust in their personal doctors or remove the need for face-to-face medical encounters. The following quotation expresses the importance of medical encounters in health care settings: “… I still trust doctors and medicine; my opinion about them hasn't changed. I think that it has even increased my trust, but still I think it's great that you have a second opinion within a hand's reach. O.K., I believe and trust doctors, but if there is something that I would like to know, I think it's great that I can find it online.” (U1, female, aged 29 years) By contrast, health professional moderators perceived online counselling forums and the OHC as a great opportunity for building cooperative relationship with patients (see Table 2). We observed that the majority of these health professional moderators reported that their role as moderators opened up the possibility to improve the perception of the partnership between health professionals and patients, enhance the trust in the relationship by giving users an opportunity to discuss their health issues, expand their access to care and promote shared decision-making: “I think that we are more accessible, practically accessible, for anyone, and I think that this can have an influence on the general relationship between doctors and patients and on the users'

confrontation with new demands in face-to-face medical encounters feeling uncertain about co-responsibility approach in their relationships with patients

overall opinion about health care. It may even help in the long term.” (HPM7, male, aged 44 years) We also noted that most health professional moderators agreed about the value of the OHC's opportunity for face-to-face medical encounters with patients. However, they also perceived that the access to a great amount of online health information, increasingly informed patients and active patient involvement in their self-care confronted health professionals with new demands in face-to-face medical encounters. The health professional moderators viewed informed and active patients as usually more cooperative, but requiring more clarifications, reassurances and validations, which takes more time in face-to-face medical encounters. However, we observed that new demands are not only reflected in a lack of time in medical encounters, but also as requirements for professionals to be constantly up to date with medical novelties and advancements. As HPM1 (female, aged 62 years) explained: “A doctor just needs to stay updated regarding ongoing research, whereas I need to say that problem I see is that people read a lot of information, which they don't comprehend … A patient understands certain things in a certain way, so you need to explain what is actually meant and that they misunderstood it. This requires additional time, which is not efficient.” Thus, the health professional moderators expressed feelings of uncertainty about the co-responsibility approach in their relationships with patients emerging in the OHC and affecting face-to-face medical encounters in health care settings. The health professional moderators reported that the OHC could be perceived as a domain that intensively promotes a “self-care” approach in relationships with patients. We noted that the health professional moderators considered that users often seemed to be left alone to make their own decisions about health management and care. Thus, many health professional moderators expressed concerns about transferring health-related responsibilities and decisions to the users. These concerns can be further reflected in the face-toface medical encounters in health care settings as reconciling with patients’ decisions that are not in accordance with medical recommendations: “There are doctors who wouldn't agree with this, because, hmm, how can I explain this? Patients do not usually have enough education to make responsible decisions, and I think that sometimes too much responsibility is put on their shoulders in comparison to the level of knowledge that they have, and I think this is problematic … For me, it is not a problem to explain possible side effects and indications, and if someone doesn't want to take a medication, I tell them the possible consequences, and in those situations you mustn't look at them as if they are making a mistake; it his/her life and he/she has a right to make a wrong decision.” (HPM4, female, aged 44 years)

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

4. Discussion In this study, we explored the key benefits and challenges faced by users and health professional moderators in online professionalpatient interactions and how they view the impacts of these interactions on face-to-face medical encounters. On the basis of results of our study we can discern several important findings. 4.1. Online professional-patient interactions compensate for the weaknesses of face-to-face medical encounters We discovered that online professional-patient interactions as viewed by users and health professional moderators have rolespecific expectations directed toward compensating the characteristics of face-to-face medical encounters. OHCs and online counselling forums can be viewed as human service settings that present opportunities to receive and provide social support that brings about direct or indirect beneficial and/or challenging effects on psychosocial well-being, especially for the users. Based on the division of roles in the relationship between health professionals and patients, the users emphasised receiving social support from health professional moderators with regard to their health-related needs. By contrast, the health professional moderators tended to report about provision of social support for addressing OHC user health-related needs. Both users and health professional moderators were likely to compare online professional-patient interactions in the OHC with face-to-face medical encounters in health care settings. Users and health professional moderators revealed how online professionalpatient interactions compensated for and/or overcame the weaknesses of face-to-face medical encounters in health care settings. According to Lee and Hawkins (2010), unmet needs are the key reasons patients use the Internet and online social support services as a coping mechanism, especially needs related to informational and emotional support. Similarly, Tustin (2010) revealed that dissatisfaction with personal health providers often leads to a preference among cancer listserv users for receiving health information via the Internet. By contrast, the described challenges demonstrated shortcomings related to the specific characteristics of the online context and online communication practices that, according to the users' and the health professional moderators’ views, limited the potential of the online professional-patient interaction. Drawing upon the expectation-confirmation theory (Oliver, 1980), the experiences of the online professional-patient interactions that exceeded the expectations of interactions in face-toface medical encounters led both users and health professional moderators to value the OHC and online professional-patient relationship more highly. Conversely, when the experiences of online professional-patient interactions did not outperform faceto-face medical encounters or when they even added new challenges in achieving particular health-related needs, users and health professional moderators expressed negative disconfirmation of beliefs, thereby indicating important disadvantages of the perceived performance of the OHC. Several differences and similarities were identified between users' and moderators’ expectations and experiences of online professional-patient interactions due to the specific social roles of the users and health professional moderators in online professional-patient interactions. 4.2. Informational and emotional supportive communication as the most common benefits and challenges of online professional-patient interactions The benefits and challenges of the received and provided

115

informational support appeared to be most commonly reported by both users and health professional moderators. This is not surprising, since the features of informational support are among the primary tasks of (online) professional-patient interactions (Ong, De Haes, Hoos, & Lammes, 1995). The prevalence of benefits and challenges related to informational support within the present data is consistent with the findings of other studies on online health care services (Eichhorn, 2008; Sommerhalder et al., 2009; Umefjord et al., 2003). Searching for health information is one of the most frequently presented reasons for participation in OHCs (Peng et al., 2015; Vennik et al., 2014). With the assistance of health professional moderators, OHCs provide opportunities for users to receive online trustworthy health-related information, take more time to overview important questions and receive instant responses with patient and clinical expertise. The range of expertise in OHCs affords opportunities for users to receive factual consultations and medical advice about treatments, remedies or procedures, as well as to receive personally meaningful explanations and psychosocial treatments for health-related issues from other users with similar health-related experiences (Vennik et al., 2014). Peer-patient support plays an important role in coping with health issues. However, the benefits of emotional support received from health professional moderators also appear to be an important function of online professional-patient interactions; many users view the emotional support received as an important component of their participation in the OHC. The health professional moderators viewed the online professional-patient interactions as offering more opportunities to provide users’ with emotional consolation and encouragement than was possible in face-to-face medical encounters in health care settings. These findings are supported by previous research investigating (online) health care delivery services (Himmel et al., 2005). Receiving emotional support, having the chance to communicate feelings about health-related issues and being heard, acknowledged and understood are important users' expectations of (online) professional-patient interactions. Therefore, in agreement with previous research on online medical consultations (Umefjord et al., 2003), the online professional-patient interactions have a function of compensating for often omitted or unaddressed users' emotional health-related needs. Mutual help presents the only identified subtheme pointing to the users' role as providers of social support. This enactment of social support gives users the feeling of gratification and constitutes ‘helper-therapy’, in which offering help to others serves as an important therapeutic process that can lead to increased feelings of self-esteem and self-efficacy in managing their own health conditions (Coulson & Shaw, 2013; Reisman, 1965). The complementary nature of online professional-patient interactions was perceived by users through immediately received responses, additional health-related information, emotionally supported replies, access to a variety health professionals and the possibility of connecting with other users or patients. These benefits of online professional-patient interactions were particularly helpful for users diagnosed with chronic health conditions, as the identified benefits of online supportive interactions appear to play an important function in facilitating the management of health conditions, engagement in coping strategies and preparations for medical encounters with their personal doctors. The health professional moderators perceived the online professional-patient interactions as offering opportunities to focus on building trust, collaboration and partnerships with the users. The OHC gives the possibility of more consistently addressing the users’ emotional health-related needs and focusing on the usual identifications of treatments, remedies and procedures, as well as on health promotion and education, developing care pathways, and

116

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

becoming an important source for information and empowerment of patients. Research has shown that online communities, particularly those that offer health-related social support, may provide conditions for the development of interactions with hyperpersonal communication potential (Turner, Grube, & Meyers, 2001; Walther, 1996). The combination of OHC attributes (such as experiencing common identity and goals, physical separation, the possibility for managing self-presentation, and limited numbers of social cues), coupled with various characteristics of other outlets of social support, may contribute to the development of hyperpersonal communication between the users and health professional moderators (i.e. communication that exceeds face-to-face interaction experiences) (Walther, 1996). This may help to explain why users and health professional moderators perceive online professionalpatient interactions as more socially desirable and satisfying than face-to-face interactions, since they provide users and health professionals moderators with more time to ask and reply to questions, receive and provide consolation and empathy, access health services, etc. Our findings also identify a number of challenges to the online professional-patient interactions in the OHC. The majority were indirectly related to the characteristics of computer-mediated communication (CMC). Challenges related to the provided or received informational support, such as information overload, contradicting information, delayed responses, lack of key information, referrals to doctors, provision of ethics and data protection, and adaptation of medical terminology, were closely related, for both users and health professional moderators, to the limitations of CMC and the structure of online counselling forums. The lack of nonverbal social cues, interactivity and immediacy of conversation, long discussion posts and threads, and users’ anonymity may lead to disconnection and barriers in communication between users and health professional moderators (Coulson & Knibb, 2007), which may importantly affect the quality and satisfaction with online professional-patient interactions and this type of health counselling. For example, anonymity can assist users in overcoming identity boundaries and encourage them to speak more freely and openly, especially when it comes to disclosing intimate healthrelated experiences, but it can also minimise social pressure and cause users to more easily express disagreements and dissatisfaction and even initiate conflicts (Suler, 2004). Health professional moderators perceive these behaviours as a challenge when providing network support, because they experience it less often in face-to-face medical encounters in health care settings. However, the anonymity of users may also encourage the health professional moderators to use OHCs less subtly for marketing and selfpromotion, which users perceived as challenging in terms of received network support. 4.3. Online professional-patient interaction effects on face-to-face medical encounters Our findings, in agreement with previous research (Li et al., 2014), suggest that online professional-patient interactions present primarily a source for additional health-related information for the users that was not available or was poorly provided in faceto-face medical encounters. These interactions encourage users to become more intensively involved in self-care and more engaged in their own medical treatments and health management. This also means that OHC users are exposed to higher levels of health topics, which eventually can make them more assertive, knowledgeable, demanding and aware of their own rights as patients in face-to-face medical encounters (Kavcic, Pahor, & Domajnko, 2015). Health professional moderators perceive OHCs and online professionalpatient interactions as representing an opportunity to build trust,

partnership and collaboration between health professionals and patients. However, they were also highly aware that their online professional-patient interactions contribute to changes in relationships with patients that might result in higher demands in face-to-face medical encounters. These findings are in line with previous studies (Ahmad et al., 2006; McMullan, 2006; Rupert et al., 2014), which suggest that health professionals often associate “Internet-informed” patients (Seale, 2005) with additional workloads, new responsibilities and obligations that further restrict the already limited time for face-toface medical encounters. Health professionals also often perceive online health information as potentially misleading for patients (Ahmad et al., 2006; Broom, 2005; McMullan, 2006). The disclosure of information obtained online in face-to-face medical encounters by patients can trigger questions among health professionals about their roles in medical encounters, their responsibilities in decisionmaking processes and the future development of relationships with patients. Our findings, however, demonstrated that health professionals with experience in moderating OHCs do not worry much about the role of OHCs in the potential spread of misinformation and confusion among patients. They are aware of their primary role in the production of health-related knowledge in the OHC, since they represent the main source of online health-related information for the OHC users. However, health professional moderators are still uncertain about the transfer of health-related responsibilities and decision-making processes mainly to users. They believe that this transfer is promoted by the OHC, since the possibility of following users’ health-related decisions and health outcomes is often unfeasible in the OHC. This is also the reason why health professional moderators associate uncertainty in coresponsibility approaches to health care with new demands in face-to-face medical encounters. Thus, health professional moderators have rather ambivalent attitudes toward OHCs and online professional-patient interactions. On the one hand, they perceive OHCs as a venue for building collaborative relationship with patients, whereas, on the other hand, they feel uncertain about co-responsibility approaches and limited control over users' decision-making process. This ambivalence may indicate the ongoing confrontations between paternalistic health care approaches and increased patient autonomy approaches that have arisen in contemporary health care systems and are implied by OHC users who express uneasiness in sharing their online professional-patient experiences with their doctors. Similarly, as suggested by research on online health information use in face-to-face medical encounters with personal doctors (Tan & Goonawardene, 2017), OHC users felt restricted from speaking openly about their online professional-patient interactions as additional resources for health-related information with their doctors in medical encounters. They perceived that this revelation could erode the reciprocal trust developed in the relationship with their personal doctor. This finding is supported by previous research (Rupert et al., 2014), which demonstrated that merely half patients, who visited OHC, revealed the source of their information to their personal doctors; but those that did cite OHCs as their source of information mostly received negative reactions by their healthcare provider. The findings from our and previous studies might further suggest that users in face-to-face medical encounters do not unconditionally trust their personal doctors, giving them limited mandates of trust (i.e. entering into interactions with different degrees of openness and thus restricting the trust in areas in which they feel uncertain) (Skirbekk, Middelthon, Hjortdahl, & Finset, 2011). The OHC users' limited trust in sharing the source of additional health-related information in face-to-face medical encounters, however, did not affect the users' willingness to accept their personal doctors' medical

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

judgements in matters concerning the users’ health. 4.4. Practical implications This study has at least four important practical implications. First, the study reveals the experiences of both OHC users and health professional moderators. We identified several challenges in online professional-patient interactions that OHC managers might want to address to eliminate barriers that users and health professional moderators experience in online interactions. These challenges, in many cases, pertain to the attributes of the sociostructural properties of OHCs and computer-mediated context. Thus, online community managers could find more adequate technical solutions in OHCs that could assist and overcome potential barriers for users and health professional moderators, such as developing communication systems for consultations between health professional moderators in the OHC, improving the management of forum threads with similar topics, etc. Second, our findings indicate that OHC health professional moderators play a crucial role in addressing users' health-related needs. This emphasises the importance of the way that health professional moderators communicate and interact with users and how they use OHCs to deliver services directed toward satisfying users' healthrelated needs. Based on the challenges reported by these moderators, online community managers could develop guidelines containing sets of recommended skills, competence and training that health professional moderators could use in online professionalpatient interactions. Third, the findings demonstrated that both users and health professional moderators emphasised the importance of building personal bonds and a sense of belonging to the OHC, which has important implications for OHC managers. As also highlighted by Wang, Zhao, and Street (2017), exchanges of network support maintain the engagement of users and health professional moderators in the OHC and importantly affect the OHC's sustainability and success. Therefore, these types of discussions should be encouraged by OHC managers. Fourth, the results suggest the importance of cooperation between OHCs, health care providers and health care organisations. As OHCs present an additional channel for communication about health issues, they could also contribute to patient and health professional satisfaction with (general) health care systems. Thus, OHCs should be viewed as platforms for limitless co-creation opportunities, like co-creation of knowledge about health services, products, designs and research. 4.5. Limitations This study has several limitations. First, in the interviews, users and health professional moderators were asked to reflect on their past and present experiences in the OHC; this introduced a bias, as they likely reported their more prominent experiences. Second, the study was conducted on a small sample, which limits the generalisation of the findings. Although the data allowed us to reach saturation, more conclusive findings could be drawn by utilising bigger sample, various national contexts, and their comparison. A quantitative study involving a larger sample of users and health professional moderators might be appropriate for validating our results. Third, the included users were self-selected and thus active participants in the OHC, suggesting that they had a higher interest in health and health management. However, users that had adverse experiences in the health care system might have been more vocal about their health needs and more willing to participate in the study. Future research could more closely investigate the differences between users' experiences in relation to their satisfaction with their personal doctors and healthcare systems in general. Finally, whilst this study included a broad range of health-related

117

topics covered by the health professional moderators (from cardiology to psychotherapy), a relative bias still exists towards health conditions. Differences in health professional moderators’ views with regard to their medical fields were not evident in the data; however, future work may seek to extend the types of health professional moderators participating in the study. 5. Conclusions In contrast to existing research of OHCs, this study investigated two-way online professional-patient interactions and demonstrated that users and health professional moderators perceive OHCs and online professional-patient interactions as a valuable supplement to the face-to-face medical encounters in health care settings. In online professional-patient interactions, both users and health professional moderators primarily try to overcome the shortcomings usually experienced in face-to-face medical encounters. Interactions in the OHC setting present several benefits, especially in the area of receiving and providing informational and emotional support for users' health-related needs; however, online professional-patient interactions are not without their limitations. Potential pitfalls stem primarily from the limitations of CMC, which should be a relevant issue for OHC community managers, administrators and developers. OHCs and online professional-patient interactions should not be seen as venues that present a threat to, or a substitution for, face-to-face medical encounters but as important spaces that contribute, complement and advance interactions between health professionals and patients. The potential of OHCs lies in the improvement of addressing patients’ healthrelated needs and compensating for weaknesses of face-to-face medical encounters. Moreover, OHCs have the potential to encourage co-creation of interaction and communication approaches between health professionals and patients, which might lead to active co-creation of healthcare services, products and technologies. Conflicts of interest The authors declare that there is no conflict of interest. Funding The authors acknowledge the financial support from the Slovenian Research Agency (Research Programme P5-0168, Young Researcher Funding). References Ahmad, F., Hudak, P. L., Bercovitz, K., Hollenberg, E., & Levinson, W. (2006). Are physicians ready for patients with Internet-based health information? Journal of Medical Internet Research, 8(3), e22. Atanasova, S., Kamin, T., & Petri c, G. (2017). Exploring the benefits and challenges of health professionals' participation in online health communities: Emergence of (dis)empowerment processes and outcomes. International Journal of Medical Informatics, 98, 13e21. Bambina, A. (2007). Online social support: The interplay of social networks and computer-mediated communication. Amherst, NY: Cambria Press. Bartlett, Y. K., & Coulson, N. S. (2011). An investigation into the empowerment effects of using online support groups and how this affects health professional/ patient communication. Patient Education and Counseling, 83(1), 113e119. https://doi.org/10.1016/j.pec.2010.05.029. Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code development. London: Sage. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77e101. https://doi.org/10.1191/ 1478088706qp063oa. Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners. London: Sage. Broom, A. (2005). Medical specialists' accounts of the impact of the Internet on the doctor/patient relationship. Health, 9(3), 319e338.

118

S. Atanasova et al. / Computers in Human Behavior 83 (2018) 106e118

Burleson, B. R., & MacGeorge, E. L. (2002). Supportive communication. In M. L. Knapp, J. A. Daly, & G. R. Miller (Eds.), Handbook of interpersonal communication (3rd ed., pp. 374e424). Thousand Oaks, CA: Sage. Chang, H. J. (2009). Online supportive interactions: Using a network approach to examine communication patterns within a psychosis social support group in Taiwan. Journal of the American Society for Information Science and Technology, 60(7), 1504e1517. Chuang, K. Y., & Yang, C. C. (2010). Helping you to help me: Exploring supportive interaction in online health community. Proceedings of the American Society for Information Science and Technology, 47(1), 1e10. Coulson, N. S., Buchanan, H., & Aubeeluck, A. (2007). Social support in cyberspace: A content analysis of communication within a Huntington's disease online support group. Patient Education and Counseling, 68(2), 173e178. Coulson, N. S., & Knibb, R. C. (2007). Coping with food allergy: Exploring the role of the online support group. CyberPsychology and Behavior, 10(1), 145e148. Coulson, N. S., & Shaw, R. L. (2013). Nurturing health-related online support groups: Exploring the experiences of patient moderators. Computers in Human Behavior, 29(4), 1695e1701. https://doi.org/10.1016/j.chb.2013.02.003. Creswell, J. W. (2013). Qualitative inquiry & research Design: Choosing among five approaches. London: Sage. Eichhorn, K. C. (2008). Soliciting and providing social support over the Internet: An investigation of online eating disorder support groups. Journal of ComputerMediated Communication, 14(1), 67e78. van der Eijk, M., Faber, M. J., Aarts, J. W., Kremer, J. A., Munneke, M., & Bloem, B. R. (2013). Using online health communities to deliver patient-centered care to people with chronic conditions. Journal of Medical Internet Research, 15(6), e115. Guo, S., Guo, X., Fang, Y., & Vogel, D. (2017b). How doctors gain social and economic returns in online health-care communities: A professional capital perspective. Journal of Management Information Systems, 34(2), 487e519. https://doi.org/ 10.1080/07421222.2017.1334480. Guo, X., Guo, S., Vogel, D., & Li, Y. (2016). Online healthcare community interaction dynamics. Journal of Management Science and Engineering, 1(1), 58e74. https:// doi.org/10.3724/SP.J.1383.101004. Guo, S., Guo, X., Zhang, X., & Vogel, D. (2017a). Doctorepatient relationship strength's impact in an online healthcare community. Information Technology for Development, 1e22. https://doi.org/10.1080/02681102.2017.1283287. Himmel, W., Meyer, J., Kochen, M. M., & Michelmann, H. W. (2005). Information needs and visitors' experience of an Internet expert forum on infertility. Journal of Medical Internet Research, 7(2), e20. Johnston, A. C., Worrell, J. L., Di Gangi, P. M., & Wasko, M. (2013). Online health communities: An assessment of the influence of participation on patient empowerment outcomes. Information Technology & People, 26(2), 216e235. https://doi.org/10.1108/ITP-02-2013-0040. Kav ci c, M., Pahor, M., & Domajnko, B. (2015). User involvement in Slovenian healthcare. Journal of Health Organization and Management, 29(5), 595e610. LaCoursiere, S. P. (2001). A theory of online social support. Advances in Nursing Science, 24(1), 60e77. Lee, S. Y., & Hawkins, R. (2010). Why do patients seek an alternative channel? The effects of unmet needs on patients' health-related Internet use. Journal of Health Communication, 15(2), 152e166. Li, N., Orrange, S., Kravitz, R. L., & Bell, R. A. (2014). Reasons for and predictors of patients' online health information seeking following a medical appointment. Family Practice, 31(5), 550e556. McMullan, M. (2006). Patients using the Internet to obtain health information: How this affects the patientehealth professional relationship. Patient Education and Counseling, 63(1), 24e28. Oh, H. J., Ozkaya, E., & LaRose, R. (2014). How does online social networking enhance life satisfaction? The relationships among online supportive interaction, affect, perceived social support, sense of community, and life satisfaction. Computers in Human Behavior, 30, 69e78. Oliver, R. L. (1980). A cognitive model of the antecedents and consequences of satisfaction decisions. Journal of Marketing Research, 17, 460e469. Ong, L. M., De Haes, J. C., Hoos, A. M., & Lammes, F. B. (1995). Doctor-patient communication: A review of the literature. Social Science & Medicine, 40(7), 903e918. Peng, X., Sun, D., Zhao, Y. C., & Xu, W. (2015). What trigger people use physicianpatient interactive OHCs? An empirical research based integration model. PACIS 2015 Proceedings. Paper 2. Petri c, G., Atanasova, S., & Kamin, T. (2017). Impact of social processes in online

health communities on patient empowerment in relationship with the physician: Emergence of functional and dysfunctional empowerment. Journal of Medical Internet Research, 19(3). e74. Petrov ci c, A., & Petri c, G. (2014). Differences in intrapersonal and interactional empowerment between lurkers and posters in health-related online support communities. Computers in Human Behavior, 34, 39e48. https://doi.org/10.1016/ j.chb.2014.01.008. Reisman, F. (1965). The “helper” therapy principle. Social Work, 10, 27e32. Rupert, D. J., Moultrie, R. R., Read, J. G., Amoozegar, J. B., Bornkessel, A. S., O'Donoghue, A. C., et al. (2014). Perceived healthcare provider reactions to patient and caregiver use of online health communities. Patient Education and Counseling, 96(3), 320e326. Seale, C. (2005). New directions for critical internet health studies: Representing cancer experience on the web. Sociology of Health & Illness, 27(4), 515e540. Skirbekk, H., Middelthon, A. L., Hjortdahl, P., & Finset, A. (2011). Mandates of trust in the doctorepatient relationship. Qualitative Health Research, 21(9), 1182e1190. Sommerhalder, K., Abraham, A., Zufferey, M. C., Barth, J., & Abel, T. (2009). Internet information and medical consultations: Experiences from patients' and physicians' perspectives. Patient Education and Counseling, 77(2), 266e271. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. London: Sage. Suler, J. (2004). The online disinhibition effect. International Journal of Applied Psychoanalytic Studies, 2(2), 184e188. Tan, S. S. L., & Goonawardene, N. (2017). Internet health information seeking and the patient-physician relationship: A systematic review. Journal of Medical Internet Research, 19(1). doi: 10.2196/jmir.5729. Turner, J. W., Grube, J. A., & Meyers, J. (2001). Developing an optimal match within online communities: An exploration of CMC support communities and traditional support. Journal of Communication, 51(2), 231e251. Tustin, N. (2010). The role of patient satisfaction in online health information seeking. Journal of Health Communication, 15(1), 3e17. https://doi.org/10.1080/ 10810730903465491. van Uden-Kraan, C. F., Drossaert, C. H., Taal, E., Seydel, E. R., & van de Laar, M. A. (2010). Patient-initiated online support groups: Motives for initiation, extent of success and success factors. Journal of Telemedicine and Telecare, 16(1), 30e34. https://doi.org/10.1258/jtt.2009.001009. Umefjord, G., Petersson, G., & Hamberg, K. (2003). Reasons for consulting a doctor on the Internet: Web survey of users of an Ask the Doctor service. Journal of Medical Internet Research, 5(4), e26. University of Ljubljana. (2014). Code of ethics for researchers at University of Ljubljana. Retrieved from https://www.uni-lj.si/mma/Eti%C4%8Dni%20kodeks%20za %20raziskovalce%20UL/20141211104120/. Vennik, F. D., Adams, S. A., Faber, M. J., & Putters, K. (2014). Expert and experiential knowledge in the same place: Patients' experiences with online communities connecting patients and health professionals. Patient Education and Counseling, 95(2), 265e270. Walther, J. B. (1996). Computer-mediated communication impersonal, interpersonal, and hyperpersonal interaction. Communication Research, 23(1), 3e43. Wang, X., Zhao, K., & Street, N. (2017). Analyzing and predicting user participations in online health communities: A social support perspective. Journal of Medical Internet Research, 19(4). https://doi.org/10.2196/jmir.6834. Wicks, P., Massagli, M., Frost, J., Brownstein, C., Okun, S., Vaughan, T., … Heywood, J. (2010). Sharing health data for better outcomes on PatientsLikeMe. Journal of Medical Internet Research, 12(2), e19. World Medical Association. (2013). World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Journal of the American Medical Association, 310(20), 2191e2194. https://doi.org/ 10.1001/jama.2013.281053. Wu, H., & Lu, N. (2017). Online written consultation, telephone consultation and offline appointment: An examination of the channel effect in online health communities. International Journal of Medical Informatics, 107, 107e119. https:// doi.org/10.1016/j.ijmedinf.2017.08.009. Yang, H., Guo, X., & Wu, T. (2015). Exploring the influence of the online physician service delivery process on patient satisfaction. Decision Support Systems, 78, 113e121. Zhao, J., Ha, S., & Widdows, R. (2013). Building trusting relationships in online health communities. Cyberpsychology, Behavior, and Social Networking, 16(9), 650e657. https://doi.org/10.1089/cyber.2012.0348.