Greg: As I explain in the article, there is a common belief that mass media outlets, and especially online mass media outlets, often portray government in a negative light in an effort to pique the interest of readers. This tendency of media outlets to engage in ‘bureaucracy bashing’ is thought, in turn, to detract from the public’s support for their government. The basic assumption underpinning this relationship is that the more negative information on government there is, the more negative public opinion. However, in my analyses, I found evidence of a positive indirect relationship between citizens’ use of online mass media outlets and their levels of trust in government. Interestingly, however, the more frequently citizens used online mass media outlets for information about their government, the weaker this association became. These findings challenge conventional wisdom that suggests greater exposure to mass media outlets will result in more negative perceptions of the public sector.

Ed: So you find that that the particular positive or negative spin of the actual message may not be as important as the individuals’ sense that they are aware of the activities of the public sector. That’s presumably good news — both for government, and for efforts to ‘open it up’?

Greg: Yes, I think it can be. However, a few important caveats apply. First, the positive relationship between online mass media use and perceptions of government tapers off as respondents made more frequent use of online mass media outlets. In the study, I interpreted this to mean that exposure to mass media had less of an influence upon those who were more aware of public affairs, and more of an influence upon those who were less aware of public affairs. Therefore, there is something of a diminishing returns aspect to this relationship. Second, this study was not able to account for the valence (ie how positive or negative the information is) of information respondents were exposed to when using online mass media. While some attempts were made to control for valance by adding different control variables, further research drawing upon experimental research designs would be useful in substantiating the relationship between the valence of information disseminated by mass media outlets and citizens’ perceptions of their government.

Ed: Do you think governments are aware of this relationship — ie that an indirect effect of being more open and present in the media, might be increased citizen trust — and that they are responding accordingly?

Greg: I think that there is a general idea that more communication is better than less communication. However, at the same time there is a lot of evidence to suggest that some of the more complex aspects of the relationship between openness and trust in government go unaccounted for in current attempts by public sector organizations to become more open and transparent. As a result, this tool that public organizations have at their disposal is not being used as effectively as it could be, and in some instances is being used in ways that are counterproductive–that is, actually decreasing citizen trust in government. Therefore, in order for governments to translate greater openness into greater trust in government, more refined applications are necessary.

Ed: I know there are various initiatives in the UK — open government data / FoIs / departmental social media channels etc. — aimed at a general opening up of government processes. How open is the Korean government? Is a greater openness something they might adopt (or are adopting?) as part of a general aim to have a more informed and involved — and therefore hopefully more trusting — citizenry?

Greg: The South Korean Government, as well as the Seoul Metropolitan Government have gone to great lengths to enhance their openness. Their strategy has made use of different ICTs, such as e-government websites, social media accounts, non-emergency call centers, and smart phone apps. As a result, many now say that attempts by the Korean Government to become more open are more advanced than in many other areas of the developed world. However, the persistent issue in South Korea, as elsewhere, is whether these attempts are having the intended impact. A lot of empirical research has found, for example, that various attempts at becoming more open by many governments around the world have fallen short of creating a more informed and involved citizenry.

Ed: Finally — is there much empirical work or data in this area?

Greg: While there is a lot of excellent empirical research from the field of political science that has examined how mass media use relates to citizens’ perceptions of politicians, political preferences, or their levels of political knowledge, this topic has received almost no attention at all in public management/administration. This lack of discussion is surprising, given mass media has long served as a key means of enhancing the transparency and accountability of public organizations.

Read the full article: Porumbescu, G. (2013) Assessing the Link Between Online Mass Media and Trust in Government: Evidence From Seoul, South Korea. Policy & Internet 5 (4) 418-443.

Greg Porumbescu was talking to blog editor David Sutcliffe.

Gregory Porumbescu is an Assistant Professor at the Northern Illinois University Department of Public Administration. His research interests primarily relate to public sector applications of information and communications technology, transparency and accountability, and citizens’ perceptions of public service provision.

Individuals often have little knowledge about the actual risks, and single instances of breaches are exaggerated in the media. Key to successful adoption of Internet-based health records is, however, how much a patient places trust in the technology: trust that data will be properly secured from inadvertent leakage, and trust that it will not be accessed by unauthorised strangers.

Situated in this context, my own research has taken a closer look at the structural and institutional factors influencing patient trust in Internet-based health records. Utilising a survey and interviews, the research has looked specifically at Germany – a very suitable environment for this question given its wide range of actors in the health system, and often being referred to as a “hard-line privacy country”. Germany has struggled for years with the introduction of smart cards linked to centralised Electronic Health Records, not only changing its design features over several iterations, but also battling negative press coverage about data security.

The first element to this question of patient trust is the “who”: that is, does it make a difference whether the health record is maintained by either a medical or a non-medical entity, and whether the entity is public or private? I found that patients clearly expressed a higher trust in medical operators, evidence of a certain “halo effect” surrounding medical professionals and organisations driven by patient faith in their good intentions. This overrode the concern that medical operators might be less adept at securing the data than (for example) most non-medical IT firms. The distinction between public and private operators is much more blurry in patients’ perception. However, there was a sense among the interviewees that a stronger concern about misuse was related to a preference for public entities who would “not intentionally give data to others”, while data theft concerns resulted in a preference for private operators – as opposed to public institutions who might just “shrug their shoulders and finger-point at subordinate levels”.

Equally important to the question of “who” is managing the data may be the “how”: that is, is the patient’s ability to access and control their health-record content perceived as trust enhancing? While the general finding of this research is that having the opportunity to both access and control their records helps to build patient trust, an often overlooked (and discomforting) factor is that easy access for the patient may also mean easy access for the rest of the family. In the words of one interviewee: “For example, you have Alzheimer’s disease or dementia. You don’t want everyone around you to know. They will say ‘show us your health record online’, and then talk to doctors about you – just going over your head.” Nevertheless, for most people I surveyed, having access and control of records was perceived as trust enhancing.

At the same time, a striking survey finding is how greater access and control of records can be less trust-enhancing for those with lower Internet experience, confidence, and breadth of use: as one older interviewee put it – “I am sceptical because I am not good at these Internet things. My husband can help me, but somehow it is not really worth this effort.” The quote reveals one of the facets of digital divides, and additionally highlights the relevance of life-stage in the discussion. Older participants see the benefits of sharing data (if it means avoiding unnecessary repetition of routine examinations) and are less concerned about outsider access, while younger people are more apprehensive of the risk of medical data falling into the wrong hands. An older participant summarised this very effectively: “If I was 30 years younger and at the beginning of my professional career or my family life, it would be causing more concern for me than now”. Finally, this reinforces the importance of legal regulations and security audits ensuring a general level of protection – even if the patient chooses not to be (or cannot be) directly involved in the management of their data.

Interestingly, the research also uncovered what is known as the certainty trough: not only are those with low online affinity highly suspicious of Internet-based health records – the experts are as well! The more different activities a user engaged in, the higher the suspicion of Internet-based health records. This confirms the notion that with more knowledge and more intense engagement with the Internet, we tend to become more aware of the risks – and lose trust in the technology and what the protections might actually be worth.

Finally, it is clear that the “who” and the “how” are interrelated, as a low degree of trust goes hand in hand with a desire for control. For a generally less trustworthy operator, access to records is not sufficient to inspire patient trust. While access improves knowledge and may allow for legal steps to change what is stored online, few people make use of this possibility; only direct control of what is stored online helps to compensate for a general suspicion about the operator. It is noteworthy here that there is a discrepancy between how much importance people place on having control, and how much they actually use it, but in the end, trust is a subjective concept that doesn’t necessarily reflect actual privacy and security.

The results of this research provide valuable insights for the further development of Internet-based health records. In short: to gain patient trust, the operator should ideally be of a medical nature and should allow the patients to get involved in how their health records are maintained. Moreover, policy initiatives designed to increase the Internet and health literacy of the public are crucial in reaching all parts of the population, as is an underlying legal and regulatory framework within which any Internet-based health record should be embedded.

Read the full paper: Rauer, Ulrike (2012) Patient Trust in Internet-based Health Records: An Analysis Across Operator Types and Levels of Patient Involvement in Germany. Policy and Internet 4 (2).

Is this aim of achieving user empowerment realistic? In their examination of health queries submitted to the NHS Direct online enquiry service, John Powell and Sharon Boden find that while patient empowerment does occur in the use of online health services, it is constrained and context dependent. Policymakers wishing to promote greater choice and control among health system users should therefore take account of the limits to empowerment as well as barriers to participation. The Dutch government’s online public national health and care portal similarly aims to facilitate consumer decision-making behavior and increasing transparency and accountability to improve quality of care and functioning of health markets. Interestingly, Hans Ossebaard, Lisette van Gemert-Pijnen and Erwin Seydel find the influence of the Dutch portal on choice behavior, awareness, and empowerment of users to actually be small.

The Internet is often discussed in terms of empowering (or even endangering) patients through broadening of access to medical and health-related information, but there is evidence that concerns about serious negative effects of using the Internet for health information may be ill-founded. The cancer patients in the study by Alison Chapple, Julie Evans and Sue Ziebland gave few examples of harm from using the Internet or of damage caused to their relationships with health professionals. While policy makers have tended to focus on regulating the factual content of online information, in this study it was actually the consequences of stumbling on factually correct (but unwelcome) information that most concerned the patients and families; good practice guidelines for health information may therefore need to pay more attention to website design and user routing, as well as to the accuracy of content.

Policy makers and health professionals should also acknowledge the often highly individual strategies people use to access health information online, and understand how these practices are shaped by technology — the study by Astrid Mager found that the way people collected and evaluated online information about chronic diseases was shaped by search engines as much as by their individual medical preferences.

Many people still lack the necessary skills to navigate online content effectively. Eszter Hargittai and Heather Young examined the experiences a diverse group of young adults looking for information about emergency contraception online, finding that the majority of the study group could not identify the most efficient way of acquiring emergency contraception in a time of need. Given the increasing trend for people to turn to the Internet for health information, users must possess the necessary skills to make effective and efficient use of it; an important component of this may concern educational efforts to help people better navigate the Web. Improving general e-Health literacy is one of several recommendations by Maria De Jesus and Chenyang Xiao, who examined how Hispanic adults in the United States search for health information online. They report a striking language divide, with English proficiency of the user largely predicting online health information-seeking behavior.

Lastly, but no less importantly, is the policy challenge of addressing the issue of patient trust. The study by Ulrike Rauer on the structural and institutional factors that influence patient trust in Internet-based health records found that while patients typically considered medical operators to be more trustworthy than non-medical ones, there was no evidence of a “public–private” divide; patients perceived physicians and private health insurance providers to be more trustworthy than the government and corporations. Patient involvement in terms of access and control over their records was also found to be trust enhancing.

A lack of policy measures is a common barrier to success of eHealth initiatives; it is therefore essential that we develop measures that facilitate the adoption of initiatives and that demonstrate their success through improvement in services and the health status of the population. The articles presented in this special issue of Policy & Internet provide the sort of evidence-based insight that is urgently needed to help shape these policy measures. The empirical research and perspectives gathered here will make a valuable contribution to future efforts in this area.

Helen Margetts: Editorial

Stephan G. Grimmelikhuijsen: Transparency of Public Decision-Making: Towards Trust in Local Government?

Jesper Schlæger: Digital Governance and Institutional Change: Examining the Role of E-Government in China’s Coal Sector

Fadi Salem and Yasar Jarrar: Government 2.0? Technology, Trust and Collaboration in the UAE Public Sector

Mike Just and David Aspinall: Challenging Challenge Questions: An Experimental Analysis of Authentication Technologies and User Behaviour

Ainė Ramonaite: Voting Advice Applications in Lithuania: Promoting Programmatic Competition or Breeding Populism?

Thomas M. Lenard and Paul H. Rubin: In Defense of Data: Information and the Costs of Privacy