Health Promotion and New Information Technologies

Health Promotion and New Information Technologies - Page 3

4.1.3 Health Promotion and Social Development Offices (HPSDO), Health Canada

Various methods were used to obtain information from regional HPSDOs, including e-mailed and faxed questions, telephone consultations, and a focus group. Views and information were obtained from the Atlantic, Ontario, Manitoba/Saskatchewan and British Columbia HPSDOs. It appears that there is significant variation in the extent of use of the internet by HPSDOs, and it appears that there may be some differences between regional directors and their staff in the types of potential uses that are highly valued.

The Ontario office appears to be among the most advanced. It uses an e-mail discussion group to link the regional director with sub-region managers. In addition, various projects are underway and under development that involve such things as using the internet for sharing information among health promotion funding organizations and facilitating information sharing between health promotion projects for children in Alberta and Ontario. On the other hand, attempts to communicate to the Toronto office by e-mail failed repeatedly and the regional director indicated that there were problems with junk mail and obtaining timely access to the internet connection. It is clear that in the Ontario case cooperation between the HPSDO and organizations like the Ontario Prevention Clearinghouse and local community based groups is helping to test the road ahead for the use of this new technology in health promotion.

There is clearly some confusion about what the internet has to offer and what it means to have access to the internet. As best we can determine, all offices can use the internet for e-mail and should be able to subscribe to listserv's. However, it is not clear that staff are aware of this. Ability to surf the net via a World Wide Web browser appears to be confused with the more limited but still powerful internet e-mail. While internet knowledge and experience appears to be relatively low, most HPSDO managers and staff had a strong sense that the internet could bring great efficiencies in accessing information and in facilitating networking. They see themselves facilitating capacity building by funding projects that make use of the internet and have an internet training capacity. Training and access are issues for themselves and for the health promotion and community groups and organizations they attempt to enable, facilitate and inform.

The advantages to using internet are clear -- simplified networking. In a region like the Atlantic where the cost of travel is prohibitive, the potential of Internet is enormous. The disadvantage at the moment is that not everyone uses the technology. The barriers to using the technology seem to be financial, lack of knowledge of the usefulness of internet and how to use it, and lack of time to use the new technology.

Internet in the future needs to be part of our knowledge development and information sharing strategies. We will be able to use internet for support groups, focus groups, consultations, etc. To ensure this can happen, groups need the technology and the training to use the technology. Groups need to work together to avoid duplication of resources on the internet. (HPSDO - Atlantic).

There is great variation in the ability of groups we work with to access the internet. We need to provide support and training to avoid increasing inequality. (HPSDO - B.C.)

As a private contractor who works with provincial government, the relatively low level of sophistication in HPSDO internet capacity is a surprise. Increasingly, provincial governments are using e-mail as a standard method of communicating with contractors and for sending and receiving draft reports and other information. If this possible differential in sophistication becomes a demonstrable reality of significant proportions, and if the federal government continues to emphasize capacity building in the community without enhancing its own capacity, and while cutting back on program funding, it will become very hard to justify the continuation of HPSDOs. On the other hand, given the mandate, means and skill to link with colleagues, groups and organizations across the country HPSDOs could continue to be a much needed facilitator of local action to promote health and to take action on the determinants of health.

RECOMMENDATION:

Thus it is recommended that:

Health Canada take action to develop the capacity of HPSDOs so that they can serve as key links in a national system for health promotion, and in consultation with provinces and other key stakeholders, develop initiatives to implement the recommendations regarding access for all and the availability of health promotion information and resources in a manner sensitive to unique regional needs and conditions.

4.1.4 Public Health Associations

Our effort to obtain information from public health associations was disappointing. Because of time constraints we were forced to attempt to make contact by fax and request a written faxed reply. This appears to have placed too high a response burden on most associations. In the final analysis we were able to have telephone discussions of the new IT and health promotion with representatives of the Canadian Public Health Association, and the provincial association representatives from Nova Scotia, New Brunswick, Ontario, and British Columbia. A written response was received from Saskatchewan, and a focus group was held with the Public Health Association of British Columbia.

The level of usage is almost universally low, with the possible exception of New Brunswick, where an energetic facilitator for the Community Health Promotion Network - Atlantic appears to be helping many health promotion and public health advocates get on-line. Getting boards on e-mail for cost saving and easy of communication seems to be a priority for a number of associations, and several associations have taken concrete action to achieve this goal, such as creating directories and developing guidebooks for the use of e-mail.

It appears that Associations are inclined to want a Web-site for visibility and for disseminating their views on various health policy issues. Some consideration is being given to using the internet for the sale and distribution of publications. At this stage there appears to be little interest in using the internet for two-way communication with members. There is serious concern by associations that they will not be able to handle the demand for information and interaction that opening themselves to two-way communication on the internet entails. Few if any can afford the staff to develop a Web site, let alone spend time responding on demand to members.

More investigation is needed before any recommendations can be made that relate directly to these associations.

4.1.5 University Health Promotion Centres

A 1995 national survey on the use of computer technology in 650 US colleges and universities provides some indication of the rapid growth in the use of new computer mediated communication and access to information. According to the survey,

". . . the use of information technology ... grew dramatically this past year, as did the number of students and faculty routinely using the Internet and World Wide Web (WWW).... the percentage of college courses using e-mail and multimedia resources more than doubled, with the use of computer simulation and commercial courseware increased by more than 50 percent. Further, more than seven million college students and faculty routinely use the Internet and WWW as part of their daily and weekly activities."

Canadian post-secondary institutions are paralleling their American cousins in developing a presence on the internet and the world wide web. Most Canadian University-Based Health Promotion Centres are attempting to move in step with their parent institutions. One has the sense that it has become a requirement for any University Centre to have a home page. Home pages promote the Centre and the University, and attract the attention of students.

All six Centres for which we contacted representatives have internet connections. There are significant variations in the use and vision each centre has for the internet and its applications. In addition, there are substantial variations in the amount of information supplied by our contacts. This, coupled with an absence of information on the access levels within each institution, make it hard to generalize about Centres' use of the internet. Some clearly are primarily concerned about the internet's potential for furthering research, while others are much more concerned about the implications for networking between researchers and external communities. Others in the academic health promotion community are placing their emphasis on using the internet for distance education. All, however, have in common the fact that they are scrambling fast to have internet capacity and to figure out how they want to use it. Further, most are viewing the internet and its accessories as simply new technology that makes it easier to do the things that are usually done at university centres -- research and teaching. Future plans generally take the form of improving the reliability and accessibility of the new information technology, training of staff, and finding an efficient way to deal with the overload of information that comes in over the internet.

RECOMMENDATION:

In view of these common concerns and the Centres' expertise in research, it is recommended that:

Health Canada consider providing assistance for a national Health Promotion Centres workshop to share information on overcoming shared problems in using the internet, and to explore Centres' role in ensuring that public and community health promotion practitioners have access to research findings and resources on the internet.

A number of the informants from university-based centres provided fairly extensive information in response to our inquires. What follows are some informative excerpts from these responses. They are presented to give the reader a feel for the information that underlies our observations.

How do you use the internet and its applications?

We have our own home page and therefore share a lot of info about the Centre and its work on that. We have hooked into other health promotion centres via our home page. At this point short periods of time have been used to search out info. This is mostly due to lack of time. We search for info on particular subjects, perhaps contact other researchers, hook in to discussion groups and other home pages to monitor what others are doing. Consideration would be given to taking courses or conferencing on the internet.

The [name of centre] has not used the internet extensively to date but I see this changing in the future as more health promotion information is included on the Net and as more people working in the field learn how to use it. The 2 computers at our Centre are both on a network, and internet access is easy (but sometimes slow). You may be interested to know that our Centre's Advisory Board recently recommended that [name of centre] establish its own home page where research information and results could be shared. We currently post information (upcoming lectures, job opportunities, conferences, workshops, etc. on [name of another organization] home page under research and coming events. E-mail is used extensively at the centre.

The thinking we have been doing on this connects to several of our projects. [two research projects described] Both are expected to produce results that will deserve to be disseminated in ways that go beyond the usual peer reviewed publications and professional conference presentations. Internet is one of the possibilities we have been exploring and have been engaging with other SIRP investigators across Canada in a network set up by the federal SIRP office in Health Canada.....[Uses of internet] We obtain information through Internet by remote retrieval through the WWW and other information retrieval databases; sharing information by making announcements of our products on various listservers; correspondence through daily e-mail internally and externally; dissemination of information through e-mail, listservers and a www homepage we are experimenting with now. [future use] Depending on the demand and selectivity of visitors to our home page, we anticipate giving increased emphasis to those items of information that are in highest demand, and give greater publicity to those that are in lower demand on the homepage but that might be of greater interest to potential users who are not using our homepage.

To date we have only used internet for correspondence and sharing information using a memo format, e.g. alerting our research associates to opportunities for research funding, etc. Since many are still not on the net, this only reaches a portion of the network, and we have to supplement with fax -- not a great solution. [future use] We are actively pursuing development of a home page through which we could make available our newsletter, our publication list, our video library/loan service and access to the homepages of related centres.

We have mostly used it [the internet] to communicate with individuals via e-mail, although we now have a Home Page which apparently has had over 100 visitors and have put some of our reports on it. We intend to continue using the internet in these ways and in fact increase our use. In addition, we will probably use it more for conferencing.

What barriers have been encountered?

The net is only accessible to a few people. There honestly isn't always time to spend time on the net although when you get on it, it is very worthwhile.

Language is a big barrier for the non-English speaker. ASCII is not friendly to any language that uses accents. There is also problem of the lack of a well-developed internet infrastructure in parts of Europe and in developing countries.

The programming time required to set up and maintain a WWW homepage has been significant. Time spent responding to the increased volume of correspondence on e-mail has been partially compensated by the increased efficiency over typing and mailing formal letters and playing telephone tag, but the point of diminishing returns on that compensation is fast approaching. Solution: unsubscribe to some of the listservers cluttering our inboxes, which means living without some of the good stuff that occasionally comes across them. Another is to assign different listservers to different staff, fellows and students in the [name of centre] to forward items they think might be of interest to others.

Not all of our associates are on the net, so this makes it hard to use the net for communications.

Big thing is people need to realize work, time, effort and ongoing resources are needed to set up and use the internet properly. It just won't happen by setting up a web-page. The Internet has to operate almost as a LAN for related groups. Need to focus efforts of project teams or organizational work groups. I see lots of reaching out to everyone (i.e. the web) by using Listservs without defining the purpose. we need to use more front-end work and use the Internet as a communications group device in specific ways with certain people to do certain things. Once it is setup, understood and parameters set out it can be effective.

In terms of problems, I find the software to be a pain in the butt as you can tell from this attempt to communicate with you. Our attempts at conferencing have not been great because no one seems to want to keep them rolling. There is also a lot of crap that you have to wade through. The solutions are better software, assign a coordinator or chair to flush the crap.

What role do you see for the internet and its applications in the future of health promotion?

More information will be accessible to John and Mary Public and that is good, but sometimes the info is not reliable or correct. How will we filter out the hoaxes from the true stuff? There can be an overwhelming amount of information and it is hard to filter out what we really need. It dissuades real face to face communication and may lead to isolation. At the same time we (the professionals) have to be more accountable to the public and that is a good thing.

I would like to think that the internet could be used for training, professional development, conferencing, and much easier access to documentary resources. But I think we have quite a way to go before this happens, because too many players are not yet on the ?net . . . . There are also many situations in which one might be tempted to rely on the internet when there is, in fact, no substitute for personal conversation. It is hard to develop trust on the screen; also, relative few users are quick enough on the keyboard for ideas to flow as quickly as they can using speech. And the time it takes to "surf" the net for browsing through possibly interesting sources is something that a lot of people don't have.

I think that the key to success in using the internet for health promotion is a commitment to training. The day-to-day demands of the job often don't allow extra time to learn new skills such as this; however if this is the way of the future (and it undoubtedly is), more time, effort and training resources should be devoted to the use of the internet.

It [the internet] is shaping it [the future of health promotion], whether we like it or not, whether we even know it or not. Studies such as yours can help us get a handle on the ways it is shaping us in the absence of much organization or coordination. The approach just now is to let a thousand lotus blossoms bloom and see which ones become self-supporting or self-sustaining. These criteria of utility, popularity and viability follow a market model of growth and sustainability. We need, in addition, some government-sponsored think tank reviews and consensus building on other ways to ensure the equitable distribution of some of those rewards that would not otherwise flow to people with less access to the Internet.

4.1.6 National NGOs

The investigation of national NGOs has been extensive and has, in effect, resulted in a report within a report. Credit for the draft writing and the investigatory work belongs to Mr. Barry George and Mr. Chad Nelson.

Two methods were used to gain a sense of the trends in internet use by Non-Governmental Organizations. First, we consulted by telephone with a number of national non-governmental organizations that we felt would have a significant influence on the future of the health promotion field. The aim was to gain a deeper understanding of their use of the internet and the issues they associated with its use. This analysis looked at 17 national NGOs.

Second, we examined web sites and homepages for each of the 206 organizations identified in Health Canada's "Directory of National Organizations and Associations involved in Health Promotion" (summer 1995). We also searched for other health promotion web sites using key words such as health promotion and public health. This process identified and analyzed forty-two Canadian health promotion related web sites, not including federal government sites. Only 39 (19%) of the 206 health promotion related organizations noted in the directory had web sites at the time of our study. From the consultation we undertook with national NGOs we know that many have sites under development or at least under consideration. Of the 39 sites, we were able to access only 30 (15%) for more detailed examination. Of these, 19 were national NGOs, five of which were among those consulted by telephone.

Our discussion and analysis reflects two broad ways that organizations can use the internet at this time. The first is as a tool for accessing information and communicating with other individuals and organizations. This encompasses accessing the internet to conduct research, obtain files and information, learn about the activities of other organizations, etc., and to make use of the e-mail capabilities of the internet.

The second way organizations use the internet is to provide information or services to external users, usually by establishing a WWW site for the organization, or even for a branch or program within an organization. This can encompass listing information about the organization or program, databases, publications, access to individuals, and a wide range of pro-active methods of sharing information and linking people.

The direct consultation with national NGOs examined both internal and external use of the internet. The examination of health promotion sites focused exclusively on the provision of information and services to external users by health promotion organizations. Both forms of internet use are discussed in more detail below.

Accessing information for use by the organization

Most national organizations with health promotion functions have at least a few people who use the internet in the course of their work. The internet is used as a vehicle for e-mail, for identifying and accessing information, for developing contacts, and for other purposes, including subscribing to or participate in discussion groups, listservers, chatlines, and newsgroups.

The developers of sites are especially motivated to use the internet. Those authoring pages using a HyperText Markup Language (HTML), for example, use the internet to find examples of pages and information presentation to inspire their own work. They also look for sites with which their own pages could be linked.

Current uses of the internet include:

1. Identifying and obtaining information

This has become second nature to many people who need access to research or a route to make contacts with other organizations. National health promotion organizations vary in providing their workers with access to the internet. In some cases only a few have access; in others all have access.

2. Sharing information

Some staff of health promotion NGOs are participants in discussion groups, or use listserv's or newsgroups. Sometimes the organization as a whole has a subscription, which can be accessed by having interesting or relevant items forwarded to the appropriate staff person using the internal network.

3. Internal information

A number of organizations use their own public pages as a source of information for their staff (e.g. staff directories). Internet host software can be used with internal systems entirely disconnected from external links. This is particularly useful where the cost or quality of a firewall between confidential internal information and external accessors is an issue.

Providing information access to external users

The uses of the internet are undoubtedly expanding far beyond provision of access to databases, e-mail and conferencing applications. Videophone and computer-based financial transactions are emerging as viable internet applications, although problems with both remain to be worked out. Expansions in volume and types of applications are occurring daily. We can look forward to rapid and continuing evolution of internet applications as technical solutions fall in cost. Competition among telephone companies, cable companies and specialized providers will lower access costs and drive innovation.

Over the past year, many health promotion organizations have established or planned sites on the internet. Within this short period, the environment has changed significantly. New versions of authoring languages have appeared, along with new standards at the leading edge. Advanced sites now offer sound, video, outstanding graphics, and stimulating, easy-to-use pages.

For now, health promotion organizations in Canada are making use of only some of the available technologies. Most, for example, do not use FTP (file transfer protocol) to make high speed downloading of documents, data sets, and programs convenient for external users. Few, if any, use video. Some provide still graphics. Most sites use or plan to implement the provision of links to related sites -- one of the outstanding features of the internet.

Current uses of the internet include:

1. Information on the organization

Home pages contain mission statements, vision statements, and information on mandates and programs. Our site review found only 11% of sites provided only limited or summary information of this type; most offered detailed outlines of services or information in report form.

2. Access to the organization

Sites often include directories of offices or staff members, with e-mail addresses, telephone, fax, mail and location information. Message forms or e-mail contacts may be provided so that messages can be immediately posted. The review of sites found that 95% offered at least minimal opportunities to provide feedback to the organization (through e-mail to a system operator or other staff person). About a quarter offered more extensive access to several or many individuals within the organization.

3. Links to other information sources

This very convenient feature of the internet has been implemented by most health promotion providers. Co-operation in linking sites is an area where rapid expansion can be expected in the near future. About two thirds of the NGOs in the site review had direct links to other web sites. It is hard to determine, but it appears that a higher proportion have links from other web sites, and this increases as the site becomes better known. Most NGOs do not yet have links to major internet search engines, or internal database search capability, but a few do.

4. Access to other people or organizations with similar interests

A much cited advantage of the internet is the development of communication among individuals and organizations. The internet provides quick and easy access to staff lists, program information, e-mail, chats and file transfers. These strengthen and promote relationships, information sharing and knowledge transfer.

In our direct consultations there was only one example of electronic discussion groups hosted/edited by a Canadian health promotion non-government organization. This was the physician's network of the CMA. The site review identified 3 of 19 sites offering listserv's, but only one regional NGO with a chat line.

5. Substantive information in a variety of formats

This is the core of most organizations' use of the internet to share information. They provide reports, statistical summaries, access to detailed publications and databases, and information on current events and activities -- in short, most things they disseminate through other means, but packaged conveniently and accessibly using the internet. Specific types of information and ways of packaging it include:

• Catalogues to access information
• Directories and phone listings
• Conferences and Events
• Courses and workshops
• Reports, papers, statistical summaries
• Newsletters
• Electronic journals
• Data for secondary analysis Emerging and Future Issues

Information technologies continue to change rapidly. It has become normal to expect change to continue. While the changes bring new opportunities, the changes themselves consume resources, displace other activities, and bring an array of challenges. Some of the issues raised by the key informants are as follows:

Appropriate information for Canadians

The proliferation of US information sources provides another area in which Canadians may be influenced by concerns and perceptions that are inappropriate to their context. In the direct consultation, comments were made on the differences in food content, labelling, lifestyle, institutions, cultural context (crime rates, inequality of access to medical care, poverty), and other matters. Comments were made about the absence of Canadian content, context and analysis on the internet. Thus, while many useful and respected foreign sources were cited, it was also stated that Canadians need easily accessible and highly visible Canadian sources.

Credibility of information

While the internet is a route to useful information, it is also known as a platform for bizarre, misleading and biased thought. Canadian government and NGO sources could counteract dangerous providers by making available carefully evaluated information to Canadians and users from other countries. In some places, both governments and NGOs have credibility problems of their own. Openness and completeness in information provided on the internet can do much to enhance the reputation of Canadian organizations and reinforce the considerable good-will still enjoyed by the Canadian government and Canadian organizations in the health promotion field.

Advertising

The government emphasis on cost recovery for services has led some organizations to use the internet only to the extent that this use can be supported through advertising incorporated in their pages, or cost-recovery through selling products or information.

User charges

User charges vary. Larger amounts are appropriate for items for which expensive and individual delivery is expected (such as data sets, journal subscriptions, major documents). On the other hand, small amounts should be charged for items that are to be distributed to large audiences. A mechanism is needed to automatically obtain minor user fees without creating cost access barriers.

Widening Audience

Some national organizations now interact with and provide information primarily to professionals and organizations in their domain. Once an internet site is established, however, it becomes almost inevitable that the constituency of users will increase. It will come to include organizations and professionals in other fields and in other countries. Interested non-experts will also gain access, including those people whose health is being promoted or discussed. This provides an opportunity to widen the audience for information and to hasten the spread of new information throughout society.

Those organizations with sites know from inquiries and by acquisition of new members that the internet has widened access to their organization. In other cases, simple usage statistics suggest that interest extends beyond the initial target audience.

Given the broadening audiences, health promotion organizations may wish to expand the kinds of information they provide. They may also wish to employ additional resources to help make information more accessible. Internet technology facilitates this kind of undertaking. Information can be readily edited for a general audience. Internet hypertext facilities make it natural to link glossaries and supportive background information. Interactive quizzes can be added. Voice, graphics and video can make sites more attractive sources of information for some users.

Evaluation

Many organizations with web pages gain basic statistics on usage (number of hits). Some gather occasional feedback through e-mail messages to their addresses or invite feedback through comment forms. When the primary clientele is members or member organizations, other routes for feedback undoubtedly exist.

As yet, there has been no extensive evaluation of the effectiveness of presenting health promotion information electronically. For example, while an organization may know that a page was accessed, they do not know whether the accessor captured and kept the text, read it, or eventually made use of it. Without further study, a casual browser cannot be distinguished from someone who actually benefits from the information. Some participants expressed uncertainty about the value of their efforts to provide information electronically because of the lack of evidence of effectiveness.

Barriers to Use

Increasing sophistication of technologies, capabilities and expectations

Every generation of technology seems to bring with it changes in expectations. Just as monospaced typewriter text has been replaced by proportionate fonts in variable sizes, expectations are drifting away from plain text and toward multimedia presentations.

Unfortunately, multimedia require special facilities and experience, with start-up costs beyond those needed for basic internet sites. Several organizations worried that meeting the expectations of public and professional users would tax their ability to package information attractively. While many functions can clearly be provided without multimedia enhancements, pressure to use multimedia may clearly result from competition from sites in the US and elsewhere financed by larger resource bases, including sites produced by major entertainment and media conglomerates.

Purchasing information and security of information

Because provision of credit card information is still risky over the internet, and financial transaction facilities have not been widely implemented, use of credit cards has not been implemented by health promotion organizations. When this problem is solved, delivery of documents and purchased services can take place immediately.

Expertise, accessibility and expanding responsibilities

There are economic, technical and cultural barriers to the use of e-mail, remote databases and the net. Many component organizations of the national organizations may not have the equipment or expertise to participate; only some constituent organizations can receive or send information electronically. For some, limitations of in-house technology are a barrier. Computers, displays, printers, modems, and software adequate for other purposes may not be adequate for use with the net, especially when graphics are involved. Many organizations still contain people who resist the use of computers, including many managers who still regard direct use of computers as a task primarily for those in subordinate positions. Others feel that use of the net is too time-consuming.

A final caveat about our studies of national NGOs

It would be unfair to read in a great deal about health promotion organizations based upon their accomplishments in using the latest information technologies at the time of these surveys. Change is occurring so rapidly that in mere weeks any inferences would be obsolete. Indeed, many sites changed significantly in the short time period during which the research was done.

The list of national NGOs and individuals contacted through direct consultation is attached as Appendix B. The detailed results of the site review are discussed in a separate companion report "Health Promotion on the Internet: Surfing and Searching for the Potential of the World Wide Web."

4.2 Realizing the Potential: Reinventing Health Promotion's Infrastructure

There are a number of ways of thinking about the potential of the internet for health promotion. Individuals, groups and organization tend to think about this potential in terms of the things they must do or want to do. Thus some see the internet as a cheap or more efficient way of communicating. They may see it supplementing or replacing current technology to carry out the communication and information functions they have always carried out. Others may see the new IT as providing an opportunity to expand the range and volume of information they can take in and put out, as well as enabling them to begin thinking about launching totally new types of information and communication services. Most of the discussion in the section above dealt with visions of these types.

Some health promotion stakeholders are going further to think about how they want to work and how the new information technologies can facilitate new ways of working. Notions of improving groups and social development processes by supplementing them with e-mail and a listserv to deal with things that are time-consuming and do not require face-to-face interaction are surfacing. Other ideas like creating and linking pockets of expertise on-line to support work on a project, and linking projects via closed conferences so that they can share information to aid each others' development are emerging. Health promotion practitioners as advocates of inclusiveness, sharing, public participation, empowerment, holistic thinking and cross-sectoral cooperation find no end of ways to use a technology that promises to remove the barriers of time and space to participation. One very contemporary example of this kind of use of the new IT is described below. Summaries of others are presented in Appendix A.

I see it [new IT] as central to making information about any topic more accessible. Creating defined spaces as they are required to achieve specific ends . . . for example, ....... and I are running a listserv in advance of a session at CPHA conference in July for the purpose of covering a lot of content prior to the session, which is only an hour and a half. The idea being we will tap into what people are using it for now, what their plans are and how they would like the session designed to maximize the benefit of the face-to-face session. We do this regularly in the project I coordinate, which has enhanced our use of time in meetings for things which are better served by having a chance to read all communication cues, not just those accessible through the net. As the pipelines become larger the use of other media (audio/video) may be very useful.

Another way of thinking about the potential of the internet it to think about its ability to change the distribution of power and the relationships among the key players in the field. At the moment the infrastructure of health promotion is weak. Policy makers and spin doctors play with words like "population health" and "health reform" while people and dollars disappear from government units that helped put health promotion on the map both nationally and internationally. The disappearance of a distinct Health Promotion Directorate within Health Canada, the reduction of federal health promotion spending, spending cut backs in Ontario, and the disappearance of the Office on Health Promotion within the B.C. Government, are all signs that health promotion's infrastructure is in transition. At the same time the elimination of government core funding for many if not most health and health promotion NGOs has put severe limits on how far these organizations can go in providing support and linkages to local community groups and grassroots organizations. It is a milieu in which new technologies that promise to transcend the barriers of time and space are immediately attractive as a means of doing more with less.

One option for restructuring the field that seems to have attracted a fair amount of attention is put forward in Nancy Milio's article Creating Community Information Networks for Healthy Communities. In this model, Computer Mediated Communication is used to link and support networking among a broad array of community-based groups and organizations that have links to all sectors of the community, including the less privileged sectors. Health and medical professionals have a place in this model, but the communication network is not built around them but instead is centred in the networked, community-based organizations. Milo's model appears to fit very well with much of the work being done by the Community Health Promotion Network Atlantic and by the Ontario Prevention Clearinghouse.

A second model seems to fit government and many national NGO's. Here centres of expertise supply information and facilitate knowledge development and communication among communities of interest as opposed to geographic communities. An important limitation to this model is the tendency to privatize components of the internet, and to put a price on the flow of information. At the same time, government is under pressure to pursue policies of cost recovery. This means increased emphasis on producing and selling information to those who have the money to buy it. In health, the people with the money to purchase information are the medical professionals, the medical institutions and to some extent the various communities of interest (e.g. Heart and Lung Society, Cancer Society). In these circumstances more reflection on how the futures of the internet and health promotion are entwined is merited.

These two models meet to some extent in regional offices of Health Canada, in Health Promotion Research Centres, and Provincial Public Health Associations. The internet and the new technologies are immensely flexible, and may be able to accommodate both models. But strong intermediary organizations are essential to help facilitate inter-community collaboration and sharing, and to aggregate local groups' interests into demands for change from governments and powerful private sector interests. Without strong higher level organizations to link them, local health promotion networks will find themselves always at a disadvantage in lobbying for local health promoting change that threatens, as it often does, the interests of powerful forces within and outside of the community. Further, at the community level there is a need to create new methods and resources for gathering and sharing information using the new technologies on a continuing, non-project basis. This is critical if community residents are to know each others' wants and needs, network, and mobilize local resources to promote their own and their community's health.

RECOMMENDATION:

In view of the foregoing discussion, it is recommended that:

Health Canada begin a series of discussions with other levels of government and representatives of local, provincial and national NGOs to determine a method for providing secure on-going funding for intermediary organizations and for local networking and organizing activities.

A clear hope for many is that the internet's capacity to allow two-way communication unencumbered by the usual time and geographic barriers would result in a fundamental change in the way decisions that affect people's health are made. So far this does not seem to have been the case. Innovative projects are for the most part confined to information sharing and networking within the narrow boundaries of the project. Health Canada and provincial health ministries, for example, appear not to have experimented with shared decision-making within projects, and have not opened their own strategic planning and decision-making processes to external participation through the new IT. Politicians do not have on-line dialogues with constituents on health policy (although some are interested in polling).

Even when it comes to information exchanges not tied to policy or program decisions, the promise of two way communication has not been well realized. While government, universities and national NGO's are showing increasing interest in having web pages for marketing themselves and the information and services they provide, there is little evidence that these organizations use the internet to work collaboratively as partners in health promotion or to increase their staff's responsiveness to health promotion practitioners. Although more thorough study is needed, our review of web sites and our consultations suggest that local organizations and groups are much more likely than national or provincial organizations to use the internet to interact and share information among themselves and to welcome dialogue with practitioners and the public. Some national and provincial organizations are very supportive of networking and information sharing by others, and provide on-line chat facilities and listserv's to aid this. However, very few provide facilitators and moderators for their discussion groups and listserv's, or sufficient technical support to aid use of their sites.

For government, one way flow messaging via the mass media is still the preferred method of communication to the public on health and health promotion issues, as is evidenced in budget allocations. This is complemented by a strategy that major NGOs also use. This is the strategy of using the internet to disseminate health and health promotion information to intermediaries such as doctors, researchers, voluntary organizations, public health workers, project leaders and community groups, and letting it trickle or flow down to the public from these information nodes. It appears that at this stage, communication by internet has been seen as way to cut the cost of communicating to intermediaries by replacing face-to-face meetings, conferences, travel, and hard copy mailouts, but not as a way to directly reach the public at large, nor as a vehicle for unmediated two way communication with the public.

We anticipate that governments and other major organizational players in the health promotion field may soon find it appropriate to place more emphasis on using the internet as a vehicle for direct communication to and from the public. As more people come on-line, one of the key rationales for working through the mass-media and intermediaries will disappear, especially if Health Canada and others take effective action to facilitate access for all. It is important to anticipate such possible changes of policy, as they have major implications for the structure of power and influence within the field.

NGOs derive much of their power and influence with government through their ability to consult, represent and mobilize significant constituencies. In turn, NGOs' ability to represent and maintain the loyalty of their constituencies lies in their ability to carry and interpret information from government and other major stakeholders to their own members. Moving to increase the public's and individual health practitioners' access to government information and information from other major organizations will likely weaken the ability of practitioners to influence the public, and the ability of various intermediary organizations to influence both practitioners and the public. On the other hand, small grass root organizations may find that they can be much better informed and as a consequence, more effective in dealing with local issues. This said, the previous points about the need for strong intermediary organizations remains. However, we anticipate that such organizations are going to have to make some major shifts in the way they do business in order to emphasize their role in aggregating interests, facilitating local groups in networking, and simply developing in the case of disadvantaged groups. Intermediaries can also play a major role in facilitating access for all.

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