To the Editor: Health, wellness, and full participation in life activities take on new meaning in the 21st century, when community is no longer simply defined by neighborhood boundaries, racial or ethnic background, or social class and when health care is no longer characterized by a visit to the doctor or the hospital. New media technologies, Web environments, and mobile devices provide access to virtual opportunities for active information seeking and shaping, real-time interaction and relationship building, and collaborative community involvement (1).
Although the Internet and the participatory media culture provide support for patient-driven health care, innovative patient communities, and the development of new health care models (2), these media may present additional barriers and thus contribute to emerging disparities in health and health care and further community disenfranchisement for individuals with serious mental illness. These individuals, who are at high risk of health conditions that shorten their lives considerably, may benefit most from access to online health education information, treatment guidelines, advocacy materials, and peer support and networking opportunities.
However, as Borzekowski and colleagues (3) reported in the September 2009 issue, only a third of the 100 participants with serious mental illness in their study used the Internet, and only a small percentage had ever gone online to find pertinent health information. Data for the study, which were obtained from patients at community treatment sites, are consistent with earlier findings from the Pew Internet and American Life Project that only half of persons who were living with a disability or chronic disease had gone online, compared with 74% of those with no chronic condition (4). The Pew study found that far fewer individuals with disabilities had searched for mental health-related information (30%) than for information about a specific disease or general medical problem (73%). Taken together, these findings suggest that individuals disabled by serious mental illness may be least likely among persons living with disability or chronic disease to use the Internet as a tool for health promotion.
We applaud Borzekowski and colleagues' conclusion that challenges such as the cost of access and lack of training must be overcome for people with serious mental illness to take full advantage of the Internet (3). However, we would like to underscore further, as the authors briefly suggest, that individuals with serious mental illness are particularly disadvantaged by the lack of accommodations in Web design that would allow them to overcome barriers to Internet use that result from possible illness-related impairments in cognition, concentration, executive function, and motor control. The work of Rotondi and colleagues (5) suggests that Web applications must be developed with the needs and challenges of individuals with serious mental illness in mind. Design considerations include the benefits of a flat hierarchy, explicit labeling, lower-level modules, familiar phrasing, and text presented at a lower reading level (5).
Findings from studies of Internet use suggest the need for design accommodations if further disparities in access to health information, intervention resources, and peer supports are to be avoided. As Web-based applications involve increasingly more complex skills, opportunities for health promotion may be lost. Individuals with serious mental illness may become even less able or less likely to participate in the community provided by the world online.
Dr. Nicholson is affiliated with the Department of Psychiatry and Family Medicine, University of Massachusetts Medical School, Worcester. Dr. Rotondi is with the Department of Critical care Medicine, University of Pittsburgh, and the Veterans Affairs Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, Pittsburgh.
Jenkins H: Confronting the Challenges of Participatory Culture: Media Education for the 21st Century. Chicago, MacArthur Foundation, 2006
Swan M: Emerging patient-driven health care models: an examination of health social networks, consumer personalized medicine and quantified self-tracking. International Journal of Environmental Research and Public Health 6:492–525, 2009
Borzekowski DLG, Leith J, Medoff DR, et al: Use of the Internet and other media for health information among clinic outpatients with serious mental illness. Psychiatric Services 60:1265–1268, 2009
Fox S: E-patients With a Chronic Disability or Chronic Disease. Washington, DC, Pew Internet and American Life Project, 2007
Rotondi AJ, Sinkule J, Haas GL, et al: Designing websites for persons with cognitive deficits: design and usability of a psychoeducational intervention for persons with severe mental illness. Psychological Services 4:202–224, 2007