Title: THE EFFECTIVENESS OF INTERNET-BASED TREATMENT A thesis submitted to the National University of Ireland, Galway as partial fulfilment of the requirements for degree of Master of Medical Science By [ABDULRAZAQ MUSALLAM L ALATAWI] School of Medicine, Clinical Science Institute, National University of Ireland, Galway Head of Department: Dr Sean Dinneen Submitted: August 2017 Supervisor: [Dr. MICHEAL NEWELL] Certificate of Authorship - Final Thesis Submission Masters in Medical Science School of Medicine, National University of Ireland, Galway Student Name: ABDULRAZAQ MUSALLAM L ALATAWI Date of Submission: August 2017 Title of Submission: THE EFFECTIVENESS OF INTERNET-BASED TREATMENT Supervisor Name: Dr. MICHEAL NEWELL Certification of Authorship: I hereby certify that I am the author of this document and that any assistance I received in its preparation is fully acknowledged and disclosed in the document. I have also cited all sources from which I obtained data, ideas or words that are copied directly or paraphrased in the document. Sources are properly credited according to accepted standards for professional publications. I also certify that this paper was prepared by me for the purpose of partial fulfilment of requirements for the Degree Programme. Signed Thesis Coversheet Student Name: ABDULRAZAQ MUSALLAM L ALATAWI Address: 8263 al qadsiyyah, Tabouk, Saudi Arabia Zipcode: 4709 E-mail Address: [email protected] Student ID Number: 15232529 Title of Award: Masters in Medical Science Exact Title of Thesis: THE EFFECTIVENESS OF INTERNET-BASED TREATMENT Name of Thesis Supervisor, contact details: Supervisor Name: Dr. MICHEAL NEWELL E-mail: [email protected] Discipline School of Medicine University National University of Ireland, Galway Head of Department Professor Sean Dinneen External Examiner Declaration to be signed by candidate: I submit this abstract for inclusion in any list of theses published by the University or in any publication to which the University may decide to contribute a list of N.U.I. theses accepted for Higher Degrees. Signature: _________________________________ Date: ________________ Office use only: Internal Examiner(s) Signed: Date: External Examiner(s) Signed: Date: NUI Galway Library Form To the College Librarian: I give permission for my thesis entitled: THE EFFECTIVENESS OF INTERNET-BASED TREATMENT to be made available: Immediately (after Graduation) (Delete or complete above as appropriate) Signed: _______________________________________ Date: ________________________   Acknowledgements Table of Contents Title: i Certificate of Authorship - Final Thesis Submission ii Thesis Coversheet iii NUI Galway Library Form iv Acknowledgements v List of Tables viii List of Figures viii Abbreviations ix Abstract x Introduction 11 Purpose of this Study 14 Literature Review 15 Negative Aspects of Online Diagnosis and Treatment Options 15 Laypeople are not able to provide adequate information for a correct diagnosis. 15 Some conditions cannot be diagnosed without additional testing. 16 Internet diagnoses give users a false sense of security. 17 Positive Aspects of Internet Diagnosis and Treatment Options 18 For users who already have a correct diagnosis of a minor issue, self-cure can help save money. 18 For illnesses which could be treated either naturally or with drugs, Internet solutions help prevent the unnecessary use of prescription drugs. 19 Many non-psychotic psychological illnesses can be helped with easily taught methods. 19 Medical Conditions Most Often Researched Online in Saudi Arabia 20 Bladder, kidney, and colon issues. 20 Gynecological issues. 21 Mental health issues. 22 Anxiety. 22 Depression. 23 Posttraumatic stress disorder. 23 Counseling. 23 Drug and alcohol issues. 24 Stress-Related Disorders. 25 Heart disease. 25 Asthma. 26 Obesity. 26 Depression and Anxiety. 26 Gastrointestinal Issues (GI). 27 Alzheimer's disease. 27 Accelerated aging. 27 Premature death. 27 Methods 28 Ethical Consideration 28 Pilot Study 28 Study Sample 28 Study questionnaire 28 Statistical Analysis 29 Results 33 Section 1 Demographics: 33 Age and Gender of the participants: 33 Education level 33 Income level 34 Section 2 Respondents views about using Internet in the diagnosis 35 Section 3 Future view about using Internet in the diagnosis 37 Summary of Results 41 Discussion 43 Conclusion 46 Limitations of the Study 47 Recommendations 49 References 52 List of Tables: Table 1: Age and Gender of the participants 33 Table 2: Using the internet in the future for medical diagnosis 38 List of Figures: Figure 1: The Study Questionnaire 31 Figure 2: Level of Education 35 Figure 3: Income Level 36 Figure 4: Online Treatment/Diagnosis Queries 36 Figure 5: Reasons for using the internet for diagnosis 37 Figure 6: Online medical resources preference 37 Figure 7: What is your preferred web resource for medical diagnosis? 38 Figure 8: Using the internet in the future for medical diagnosis 40 Figure 9: Was the internet diagnosis correct? 41 Figure 10: Will you repeat diagnosis using the internet in the future again? 41 Abbreviations   Abstract The healthcare industry has witnessed the growth of a new trend courtesy of the technological innovation that led to an increase in the use of the internet. The internet provides access to a vast database of information to individuals with suitable devices and working data plan. While the benefits of such innovation are undoubtedly positive, they also hold an alarming level of danger for the healthcare industry. The enormous data volumes about medical conditions, medical practices, and other online services are available to every person who can access the internet. Such conditions have led to the growing trend in the industry where individuals engage in self-diagnosis and self-medication. The risky behavior or approach to medical care exposes those who practice it to grave danger emanating from factors such as misdiagnosis and wrongful self-medication. The menace documented above necessitates a systematic research of the factors that influences such behavior among members of society. The results obtained in the study below should provide sufficient insightful information regarding this volatile trend to enable retrospective action against its continued practice. The scope of the study allows it to establish the demographical information of the population in Tabuk City who partake in the unethical practice explained above. Ultimately, this research should reveal the reliability of online medical services and any relevant information regarding the practice. The results of this research should provide sufficient foundational information for future research excursions to understand the use of the internet in the healthcare industry.   Introduction Over the years, the use of the Internet has significantly increased as people have realized that through the web they can find information on almost any topic. Among the various useful data that can be obtained from the Internet is health information (Diagnosing disease from the comfort of your own home 2008). Approximately 88.5 million people around the world currently use the Internet to gather medical and treatment information, as well as to communicate with different healthcare providers (Ventola, 2014). Those numbers represent over a sixth of the total world population today. Physicians and other healthcare institutions project that the number will rise in the coming years due to the high level of trust that many people have in information obtained on the Internet (Diagnosing disease from the comfort of your own home 2008). What many people do not recognize, however, is that there are many different types of medical sites, ranging from those set up and run by reputable medical agencies to those which do not require any medical knowledge at all to leave one’s opinion (Ventola, 2014). The reason that the Internet is so popular is that using the Internet allows any patient during this digital age to access any treatment information from any location without having to go through the trouble of making a doctor’s appointment and attending visits and checkups, and enduring long and often expensive treatment processes (Buckjun, 2012). However, the main issue at hand is whether or not the information that can be found on the Internet is reliable or helpful for the majority of people who seek it out (Ventola, 2014). There have been arguments that Internet-gained medical information can be very helpful, if provided by a reputable website; however, not all websites are reputable or even tied to a legitimate healthcare agency (Fink & Beck, 2014). The problem is that many people seeking advice on the Internet do not know the difference (Buckjun, 2012). Gathering health information and general treatment information from the Internet means that patients avoid the trouble of going to visit the doctors at various healthcare facilities. This means that the information available on the web does not originate from a person that the patient knows, or an individual that the patient can contact if he needs further information (Buckjun, 2012). Despite the lack of one-on-one communication when patients opt to use the Internet to seek out treatment, the use of Internet information is currently on the rise (Cima, Anderson, Larson, Dozois, Hassan, &Sandborn, 2007). There have been numerous claims that the treatment received through the web may not be accurate because there are times when the patient may not be sure of the ailment that he is suffering from (Fink & Beck, 2013). This is mainly because different diseases share similar symptoms, but the cause and mode of treatment are entirely different (Fink & Beck, 2013). Incorrect diagnosis and treatment can make a medical situation worse, and in extreme cases, patient deaths have been reported (Fink & Beck, 2013). “According to doctors, such incidences can be easily avoided if patients could only take treatment strictly prescribed by the doctors through one-on-one communication” (Schwartz, Roe, Northrup, Meza, Seifeldin, & Neale 2006 p. 42). The reason provided is that treatment goes beyond symptoms and signs as doctors also check the physical condition of the patient before prescribing any medication, determines whether the patient needs surgery or if prescribing drugs alone would be adequate. Physicians will also attempt to determine whether the disease being treated needs only one or a combination of treatments. Hence, the doctor can provide an informed treatment that would not harm the patient but rather improve the situation. There have been countless cases of patients who received treatment through the Internet and were completely cured (George, Rovniak, &Kraschnewski, 2013). However, some patients fear seeking Internet treatment and will only receive treatment from doctors in actual healthcare facilities. According to TephanieBuckjun (2012) concerning what doctors think about online health searches, most doctors discourage the use of the Internet for treatment purposes. Her report states that with such contradicting statements, experiences and facts, it is hard to determine the best way that patients should receive treatment (Buckjun, 2012). While the use of Internet searches to self-diagnose and self-cure has skyrocketed recently, this does not mean that all information found on the Internet is reliable. Even if the information is posted by a reputable physician or medical service, if a patient misdiagnoses his own condition, he might be treating himself for the wrong condition, with potentially disastrous results (Ebel, 2015). The health and well-being of patients are of utmost importance to the healthcare industry. However, when the ultimate goal is in jeopardy or a dilemma, it means that a solution must be found by all means possible. The use of the Internet to seek treatment, where an individual searches for a particular illness by listing his symptoms and then follows online treatment advice, is definitely on the rise, but that does not mean that it has become more reliable (Rozental, Boettcher, Andersson, Schmidt, Carlbring, 2015). According to statistics, little or no research has been done to prove whether getting treatment information from the Internet is useful or not. Consequently, numerous people take the risk without really knowing the consequences that might follow. The majority of doctors share a feeling that it is a high and avoidable risk for patients when they seek treatment advice from Internet sources. It is also a risk that a majority of patients are not aware of: even reliable sites cannot say with any certainty what illness a person suffers from when relying only on self-report. Besides that, many sites simply are not reliable (Powell, Darvell, & Gray, 2003). Conducting this research and generating a report and solution to the dilemma will help many people to make an informed decision about whether it is advisable to seek out medical advice online. A dilemma exists as to whether the use of Internet works for all people, some people, or completely fails. The central objective of this research, therefore, is to determine if Internet- obtained treatment works for a majority of people who seek it out. According to many doctors, the most efficient way for patients to receive the best treatment is to visit a healthcare facility, get tested to verify the test results and receive a professional diagnosis from the doctors or health practitioners (Podichetty, Booher, Whitfield, &Biscup, 2006). From this argument, a second research objective would be to determine whether or not visiting healthcare facilities is the only effective way for patients to be sure they are receiving the best. Purpose of this Study The following study aims to reveal the rationale behind the increasing trend of self-diagnosis and self-medication across the globe by investigating the trend in Tabuk City. The research results should show the factors that catalyze such behaviors in the chosen population sample and the entire world through extrapolating the findings. Additionally, this research excursion should reveal the circumstances of self-diagnosis and medication that might be inconsequential as well as conditions that could deteriorate quietly into disability or death. Furthermore, the study results will reveal the value of disparity recorded regarding individuals who believe that the internet is a reliable diagnostic tool for medical conditions plaguing either gender. Finally, this report seeks to ascertain the grounds for future research regarding the role of the internet in the healthcare industry. Literature Review Since it became possible for individuals to attempt to self-diagnose and self-cure their medical problems by using Internet searches, a multitude of articles, news stories, and websites dealing with web-based medical care have become available. While the majority of literature discourages individuals from using the Internet as a primary form of diagnosis and/or self-cure, the reasons given by various sources vary in the reasons for this discouragement. Some cite the lack of reliable medical information available online, the general public’s inability to tell the difference between which are reliable and which are not, and also the layperson’s tendency to misread or not input the range of symptoms to reach a correct diagnosis. Others point to the fact that no matter how reliable the cite might be, it is no match for a qualified physician’s treatment, especially if an individual suffers from a medical condition which requires medication or surgery. Many sources claim that medical websites have a tendency to downplay what could be very dangerous conditions in order to sell “cures” offered by companies that advertise on their site. Negative Aspects of Online Diagnosis and Treatment Options Laypeople are not able to provide adequate information for a correct diagnosis. Anwar and Khan (2013) point out that when laypeople are not sure which symptoms are important to report, they might report every symptom that they have, which lessens the likelihood of narrowing down the number of potential issues affecting them, and leading to a long list of illnesses that they might have, if every symptom they report is related to an illness or group of illnesses. This has led, in their words, to a generation of “Cyberchondriacs,” or hypochondriacs who are led by the web to believe they are afflicted with diseases that they do not actually have (Anwar & Khan, 2013; Buckjun, 2012). If these people then attempt to self-cure from these imagined illnesses, they could cause further harm to themselves or their health (Buckjun, 2012). On the other side of the coin are people who put in a partial list of symptoms because they do not realize that other, seemingly unrelated symptoms are relevant (Bednar, 2009; Farmer,Bernardotto, & Singh, 2011). For example, if an individual types in the following symptoms: blood in stool, pain upon defecating, and bleeding rectum, most Internet medical search sites would indicate that he has hemorrhoids, a usually minor and easily self-treated issue. If the additional symptoms are added: difficulty defecating, a feeling of abdominal fullness, and stomach discomfort or pain, the diagnosis can quickly change to that of irritable bowel syndrome or even colorectal cancer, both much more serious diseases for which the individual should seek immediate medical attention (Johnson, 2014; Cima, Anderson, Larson, Dozois, Hassan, &Sandborn, 2007). A similar situation would be if a nursing mother reported a painful lump on her breast; when input alone, this symptom would most likely indicate a clogged mild duct, an illness easily self-treated with hot compresses. If a bloody discharge is added to the symptom list, however, this might indicate mid-stage breast cancer (George, Rovniak, &Kraschnewski, 2013; Lynch, 2015). Some conditions cannot be diagnosed without additional testing. While some very basic illnesses are self-diagnosable and -treatable, the majority of major illnesses require not only a patient’s self-report of symptoms, but additionally testing by a qualified physician to determine an exact diagnosis (Yifeng&Haake, 2010). This is not to imply that the Internet does not have a place in diagnosing complicated illnesses. Many doctors will at times turn to the Internet when faced with an illness which is either new to them or is presenting itself atypically (Powell, Darvell, & Gray, 2003; Podichetty, Booher, Whitfield, &Biscup, 2006; Ventola, 2014; Schwartz, Roe, Northrup, Meza, Seifeldin, & Neale, 2006). New illnesses and diseases are discovered all of the time, as are new treatments for existing illnesses. However, physicians are knowledgeable enough to know which sites are reputable and which are to avoided; which treatments are realistic and which might cause further harm to their patients. The average person searching the Internet for diagnosis or treatment options is not so sophisticated (Layman, 2011). Coming to the incorrect conclusion regarding a diagnosis or choosing the wrong treatment option for even a correct diagnosis could make many illnesses worse, and in some cases, lead to death (Online advice sickens, 2005). And in extreme cases, the Internet is not enough to diagnose many medical issues, such as cancer or heart disease (Ebel,Stellamanns, Keinki, Rudolph, & Huebner, 2015). Physicians have a multitude of diagnostic tests available to them which the Internet just cannot replicate: bloodwork, stress tests, Electrocardiograms, and Angiograms are all used commonly to diagnose the extent of heart disease, and obviously nothing on the Internet is available to replicate the importance of these procedures. Internet diagnoses give users a false sense of security. When a person goes online and inputs his/her symptoms and receives a diagnosis which seems to be relatively minor, they are, of course, relieved (Ebel et al., 2015). What they may not consider is the accuracy of the symptoms which they entered, the accuracy of the diagnosis that they received, or the other conditions, many much more serious, that their symptoms might suggest. Leaving out even one symptom can make all the difference between receiving an accurate potential diagnosis and an inaccurate one (The online doctor will see you now, 2008). The real danger here is that upon receiving a diagnosis of a minor problem, the person seeking advice will proceed with any self-cure methods recommended for the issue and not question whether his diagnosis might actually be something more serious, which could lead to devastating consequences. A person diagnosed with hemorrhoids who actually has cancer, for example, will lose valuable treatment time as the cancer progresses in his body. It is well-known that cancer is more easily treated in its early stages, and that certain cancers spread and advance more quickly, making early detection vital to the survival of the patient. Any delay in diagnosis and treatment which might be caused by an incorrect online diagnosis decreases the odds the cancer will be treated effectively (Ebel et al., 2015). Positive Aspects of Internet Diagnosis and Treatment Options For users who already have a correct diagnosis of a minor issue, self-cure can help save money. Not all illnesses require a trip to a doctor or hospital. If a patient has had the same medical issue before, recognizes the symptoms, and has self-treated in the past successfully, a simple Internet search to see if there are new, better self-cure options available could be just as effective as an expensive trip to see a physician. In many cases, there are over-the-counter drugs or other natural remedies that work just as well, if not better, than prescription medication, at a fraction of the cost. Some illnesses do not really benefit at all from prescription medication, but might a patient might be given a prescription anyway (Ebel et al., 2015). One of the reasons experts point to in the prevalence of drug-resistant disease today is the over-prescription of drugs for illnesses that do not require them. The body naturally builds up a resistance to medication that it is exposed to many times; if a patient is over-prescribed antibiotics for such things as the common cold or influenza, which will cure themselves with a combination of time, fluids, and rest, the body will stop using antibiotics effectively when they are actually called for (Alumran, Hou, & Hurst, 2013). This problem is especially prevalent among children in such countries as Saudi Arabia, where parents often push for the use of antibiotics when they are not called for (Johnson, 2014). For illnesses which could be treated either naturally or with drugs, Internet solutions help prevent the unnecessary use of prescription drugs. Prescription drugs other than antibiotics are also sometimes both overprescribed by doctors or abused by the patients taking them. Antianxiety medication and painkillers are among the most abused legally prescribed drugs, and doctors tend to prescribe them quite readily to patients that request them. While patients who are actively drug-seeking, the option of seeking a non-drug solution to their issue online might not be an option, for those patients who are actually prescribed medication for a legitimate reason and become addicted, the option of an over-the-counter or natural remedy could save a great deal of problems in the long run. This is especially true for individuals who know themselves to have had an issue with abusing drugs or alcohol in the past, or that are known to their doctor for this problem. While most doctors will take a past problem such as chemical abuse into account when prescribing addictive medications to their patients, they might still prescribe a drug with the potential to be abused if the issue seems to be legitimate, even if an over-the-counter drug would suffice. Many non-psychotic psychological illnesses can be helped with easily taught methods. Many emotional or psychological illnesses can be treated with behavior-modification, breathing exercises, or positive imagery, all of which are techniques which can be taught as easily online as in a doctor’s office. Also, many people will avoid seeing a traditional medical professional for mental health issues because of the stigma involved in seeing a counselor or psychologist. Seeking help online helps to avoid this stigma, while still providing the necessary tools to help with the issue being addressed (Alumran et al., 2013). It is also important to note that behavioral methods tend to work fairly quickly, while the majority of antidepressants take up to six weeks to begin working, which makes Internet behavioral training a better option for many people that are in pain and need immediate help. Also, anxiety sufferers who do not necessarily need the help of antianxiety prescriptions to control their symptoms will almost certainly be better off avoiding the possible abuse and addiction issues common to this type of medication. Antianxiety medication is one of the most-often abused prescription drugs, and taking it for just a short time leads to physical dependency, making withdrawing from it a drawn-out process which requires more visits to the doctor and, therefore, further expense (Olivieri, Cantopher, & Edwards, 1986). Medical Conditions Most Often Researched Online in Saudi Arabia As in most areas, the medical issues most commonly researched for self-diagnosis and self-cure in Saudi Arabia are not what are considered serious life-threatening conditions such as heart disease or cancer (Yifeng&Haake, 2010). The issues most commonly researched are those which are ambiguous, thought of as easily treatable, and not overly serious. Unfortunately, some of these problems, if left untreated or treated in the wrong way, can be life-threatening, or can lead to more serious issues. Some extremely serious problems can also be misdiagnosed as an easily treated condition, which is another reason many doctors discourage their patients from self-diagnosing on the Internet (Rozental, Boettcher, Andersson, Schmidt, &Carlbring, 2015; Saeed, Alkhoshaiban, Ali, Mohammed, Long, 2014). Bladder, kidney, and colon issues. Bladder, kidney, and colorectal issues are researched a good deal on the Internet in Saudi Arabia (Alkhunaizi, 2016; Binsaleh, Al-Jasser, Almannie, &Madbouly, 2015). Kidney stones is the most often diagnosed medical problem in response to the symptoms listed (Alkhunaizi, 2016), and although this is an issue that can sometimes be resolved without qualified medical help, at times it could lead to the need for a doctor’s intervention (Binsaleh et al., 2015). Small kidney stones might pass through the urethra without the need of medication or surgery to break up the stones, but large stones could rupture the vessel while the patient attempts to pass them, leading to a potential hemorrhage and loss of life (Binsaleh et al., 2015). Despite this potential risk, the advice most patients with a diagnosis of kidney stones would receive on the Internet would be to drink additional fluids to encourage the passage of the stones in more frequent urination. This is just another example of the harm that could be done by even a correct Internet diagnosis. An incorrect diagnosis could be just as disastrous. Diseases with symptoms similar to those of kidney stones range from those as mild as influenza to as severe as appendicitis. Appendicitis, if left untreated, could lead to death due to a burst appendix. In women, Pelvic Inflammatory Disease also has similar symptoms to kidney stones, and should be treated by a physician. Gynecological issues. Issues related to pregnancy comprise a large portion of Internet medical-related searches. Many are as simple as questions regarding adequate nutrition (Al-Hakeem, 2012), while others are much more complex, involving treatment for such conditions as breast lumps during nursing and prolapsed uterus (Fageeh, 2011). The risk of any condition is increased during and immediately after pregnancy, and a pregnant woman seeking the majority of information online is in itself cause for concern. While nutrition might seem to be a non-crucial issue, inadequate caloric, vitamin, and/or mineral intake during pregnancy could increase pregnancy risk factors, as well as causing damage to the unborn child and mother. It is for this reason, among others, that most doctors advise all pregnant women to seek professional medical care rather than looking for answers on the Internet (Al-Hakeem, 2012). Other gynecological issues tend to deal with issues such as yeast infections, which are easily treatable without professional care, and Sexually Transmitted Diseases (STDs), including Pelvic Inflammatory Disease, which is the STD most often looked up. While Pelvic Inflammatory Disease is a fairly common illness in sexually active women, and does not cause serious disability on its own, it can lead to or be indicative of other illnesses which could lead to infertility, and should be brought to a doctor’s attention. While there is no cure for Pelvic Inflammatory Disease, it can be treated and monitored to ensure that it does progress to the point where it affects a woman’s fertility (Sweet, 2011). Mental health issues. Mental health problems researched on the Internet range from serious psychoses, which are more likely to be successfully diagnosed by a physician and are usually treated with antipsychotic medication, to less serious issues such as anxiety, depression, Posttraumatic Self Disorder, marital discourse, and substance abuse. While these problems should not be taken lightly, and can lead to serious consequences, they are often treatable without medication, which makes it possible, at least in theory, for them to be successfully treated by Internet advice. Anxiety. Anxiety is an ideal condition to be treated online, as many types of therapy involve methods such as self-guided imagery, breathing techniques, and positive thinking in order to alleviate symptoms, all of which can be taught in an online forum (Ameringen, Simpson, Patterson, &Turna, 2015). If feelings of anxiety do not get better with these methods, however, medication might be necessary, at which case it would be necessary to see a physician. Depression. It is important to recognize that there are many types of depressive disorders. From general depression to Major Depressive Disorder and Bipolar Depression, the level of symptoms and their severity vary by diagnosis. Some forms of depression, including mild general depression, can be treated with talk therapy, which can be provided in an online forum, while Bipolar Depression is a psychotic illness that responds best to medication. Major Depressive Disorder is best treated with a combination of talk therapy and antidepressant medication. Posttraumatic stress disorder. Whether or not it is appropriate to treat Posttraumatic Stress Disorder online depends primarily on the severity of the case, although it should be relatively accurately diagnosed online (Internet-based PTSD Therapy may help overcome barriers to care, 2007; Litz, Engel, Bryant, & Papa, 2007). PTSD includes elements of anxiety and depression, often with the presence of flashbacks, triggers which recall the trauma which led to the development of the disorder, and at times, suicidal or homicidal ideation (Litz et al., 2007). In serious cases, where the patient is either suicidal or homicidal, physician involvement is necessary, but in milder cases, the same online treatments which teach self-care for anxiety and depression could be useful in treating these patients. Counseling. Many fields of counseling have practitioners who offer services online. From behavioral counselors to Adlerian/Person-Centered Counselors, there are a multitude of licensed professionals who are willing to counsel either individuals or couples online, for a multitude of conditions (Dincyurek&Uygarer, 2012; Sorbi, Kleiboer, van Silfhout, Vink,Passchier, &Cephalalgia, 2015; Schover, Canada, Yuan, Sui, Neese, Jenkins,& Rhodes, 2011). While some good can obviously be gained by using Internet counseling over not attending counseling at all, there are several problems involved with the online counseling process. Confidentiality is difficult to maintain online, and as confidentiality is a core concept in any form of counseling, this is a serious problem. While online counselors for the most part make their clients aware of problems concerning confidentiality during the informed consent process, many clients might not fully understand the consequences of confidential information which falls into the wrong hands. Depending on the information which a client discloses to her counselor, having confidentiality breached could affect the client’s family or work situation. Clients tend to say things in the therapist or counselor’s office that they would not feel free to say at any other time; if things are made public, embarrassment could be the least of the consequences (Dincyurek et al., 2012). Another issue with online counseling is that many counselors rely largely on aspects other than what a client says in counseling to make a diagnosis or treatment plans. Body language is an important part of a trained counselor’s observation process, and this is an aspect that is not possible to employ while counseling online. Also, if a depressed patient were to become disheveled, stop bathing, or gain or lose a large amount of weight in a short period of time, an in-person counselor would assume that this was related to his issue; an online counselor would not even be aware of these changes. Drug and alcohol issues. While patients planning an initial withdrawal from either alcohol or certain drugs after long-term use should seek the help of a physician, after the initial withdrawal period, many cases can be treated with talk therapy and peer support, both of which are available online. Withdrawal can be fatal in the cases of alcohol and certain drugs, such as anxiety medication, while in the case of many other drugs, such as prescription painkillers or heroin, the withdrawal can be so painful or unpleasant that the patient is very likely to relapse. After withdrawal, however, many online sites offer links to support groups which offer the type of support which one would find at an Alcoholics or Narcotics Anonymous meeting, and these online “meetings” have many of the same features as in-person meetings. Similar to the statistics for people with alcohol and drug addiction issues are those for people attempting to quit smoking. Whether or not they are using an over-the-counter medication, they seem to benefit from the peer support which is available to them either in in-person groups or online (DeZee, Wink, & Cowan, 2013). Stress-Related Disorders. Heart disease. Researchers have long suspected that the stressed-out, type-A personality has a higher risk of high blood pressure and heart problems. Stress can directly increase heart rate and blood flow, and causes the release of cholesterol and triglycerides into the blood stream. It's also possible that stress is related to other problems--an increased likelihood of smoking or obesity--that indirectly increase the heart risks (Morgan, 2016). Physicians do know that sudden emotional stress can be a trigger for serious cardiac problems, including heart attacks. People who have chronic heart problems need to avoid acute stress--and learn how to successfully manage life's unavoidable stresses, and this can best be accomplished through behavior modification, which is available online. Asthma. Many studies have shown that stress can worsen asthma (Hicks, 2015). Some evidence suggests that a parent's chronic stress might even increase the risk of developing asthma in their children (Seeley, 2014). One study looked at how parental stress affected the asthma rates of young children who were also exposed to air pollution or whose mothers smoked during pregnancy. The kids with parents who were significantly more stressed had a higher risk of asthma than the other two groups did. Obesity. Excess fat in the belly seems to pose greater health risks than fat on the legs or hips, and unfortunately, that is where people with high stress tend to store it. "Stress causes higher levels of the hormone cortisol," claims Morgan (2016) "and that seems to increase the amount of fat that's deposited in the abdomen" (Seeley, 2014). Diabetes. Stress can worsen diabetes in two ways. First, it increases the likelihood of bad behaviors, such as unhealthy eating and excessive drinking. Second, stress seems to raise the glucose levels of people with type 2 diabetes directly (Morgan, 2016). Headaches. Stress is considered one of the most common triggers for headaches--not just tension headaches, but migraines as well. By avoiding stress, patients can avoid these headaches, and thus cut down on trips to the doctor’s office and on pain medication. Depression and Anxiety. It is probably no surprise that chronic stress is connected with higher rates of depression and anxiety (Hicks, 2015). One survey of recent studies found that people who had stress related to their jobs, such as demanding work with few rewards, had an 80 percent higher risk of developing depression within a few years than people with lower stress (Morgan, 2016). Gastrointestinal Issues (GI). Contrary to popular belief, stress does not cause or lead to ulcers. However, it can make existing ulcers worse. Stress is also a common factor in many other GI conditions, such as chronic heartburn (or gastroesophageal reflux disease, GERD) and irritable bowel syndrome (IBS) (Seeley, 2014). Alzheimer's disease. One animal study found that stress might worsen Alzheimer's disease, causing the brain lesions associated with the illness to form more quickly (Morgan, 2016). Some researchers speculate that reducing stress has the potential to slow down the progression of the disease. Again, behavioral therapy, which is available online, seems to be the best way to do this without direct medical intervention. Accelerated aging. There is evidence that stress can affect how an individual ages. One study compared the DNA of mothers who were under high stress from caring for a chronically ill child with women who were not (Seeley, 2014). Researchers found that a particular region of the chromosomes showed the effects of accelerated aging. Premature death. A study looked at the health effects of stress by studying elderly caregivers looking after their spouses--people who are naturally under a great deal of stress. It found that caregivers had a 63 percent higher rate of death than people of similar age who were not caregivers (Morgan, 2016). Methods Ethical Consideration Ethical approval was granted for this study by the local research ethics committee. The researcher explained to respondents the purpose of the study that participation was voluntary, and all data would be anonymous and would not be shared with any institution. Participants provided informed consent. Pilot Study An initial pilot study was conducted one month prior to the scheduled commencement date of the main research study. Thirty participants interviewed at random from Tabuk City participated in the pilot study. The aim of the pilot study was to determine the feasibility and practicality of the questionnaire. The pilot study highlighted some minor issues with the wording of questions. The questionnaire was subsequently revised to ensure clarity. Study Sample The research sampled three hundred (300) participants at random using a modified purposive sampling method. The target population were all residents of Tabuk City. The study was restricted to individuals who indicated that they had access to the web, had used the internet to seek either medical care or advice in the past, had a current medical issue, and were interested in the searching for medical advice, self-diagnosis and self-treatment, using the internet. Participants who had no access to the internet were excluded from the study. Study questionnaire The study questionnaire was divided into three sections. The first section collected demographic data of the respondents including their level of education, the age of the interviewees, economic level, and gender respectively. The second section recorded their views on using the internet for diagnosis of a medical condition. Respondents were asked to give their views and attitudes regarding experiences the use of the internet to diagnose medical issues. The third section recorded their opinions regarding using the internet to diagnosis in the future. A closed-ended questionnaire was used to collect data on the views and attitudes of the respondents towards using the internet for self-diagnosis and treatment. The questionnaire featured both short answer dichotomous (Yes/No responses) as well as polytomous scales (ranging from strongly agree to strongly disagree) to rate their level of agreement/disagreement to a series of statements (Figure 1). The researcher administered the questionnaires, offered technical advice and support to the respondents where necessary and checked them through after filling to ensure that all questions were answered. It took between 5 to 10 minutes for each participant to complete the questionnaire. Data was collected over a three day period. Statistical Analysis All statistical analysis was carried out using Statistical Processing for the Social Sciences (SPSS) Version 20. For categorical variables, test of association were performed to test for any association between factors of interests. Chi squared test (using a significance level of 0.05) was used if the underlying assumption relating to the expected values are deemed appropriate, otherwise Fishers Exact Test was employed. Analysis of variance testing was performed using Kruskal Wallis test and Mann Whitney test respectively. P-values will be reported for those comparisons of specific interest as opposed to comparing all levels of all variables. Figure 1: The Study Questionnaire Section 1: Demographics Please circle your answers in each section 1.1 Gender 1.2 Age 1.3 Education Level 1.4 Income Level ( 1 ) Male ( 2 ) Female ( 1 ) 15 to 29 ( 2 ) 30 to 44 ( 3 ) 45 to 59 ( 4 ) 60 & above ( 1 ) elementary ( 2 ) Intermediate )3 ) Secondary ( 4 ) undergraduate ( 5 ) post-graduate education ( 1 ) Low-income ( 2 ) Average-income )3 ) High-income Section 2: Respondents views about using Internet in the diagnosis Please choose one answer in each of the questions in this section 2.1- What kind of ailments do you obtain their treatment via online medical diagnosis? (1) - Minor issues such as pink eye, burn, allergies, upset stomach ... etc. (2) - Common ailment such as fever, headache, cold ... etc. (3) - Major issue such as paralysis, renal failure, cystic fibrosis ... etc. 2.2 - Why do you use the internet for diagnosis? (1) – The cost of visiting a doctor is expensive. (2) - The distance to travel to the doctor is far. (3) - Self-reliance because of enhanced technology 2.3- What types of Online Medical resources have you used? (1) - Video resources. (2) - website hosted by doctors. 2.4- What is your preferred web resource for medical diagnosis? (1) - General social networking sites. (2) - Communications with a doctor via social networking sites. (3) - From what I read of medical conditions in the media. Section 3: Future view about using Internet in the diagnosis Please give your opinion on the following statements. Select one answer for each statement Items strongly disagree disagree agree strongly agree 3.1 The results of the diagnosis on the Internet are reliable. 3.2 Using the Internet gives accurate results and useful tips for the patient. 3.3 Using the internet to diagnose stops having to go to the doctor. 3.4 Using the internet to diagnose has no side effects. 3.5 Medical condition could be diagnosed correctly using the internet. 3.6 Using the internet to diagnose could be a substitute for the future of medicine. 3.8- When you went to doctor, was the diagnosis via the Internet correct? (1) Yes (2) No 3.9- Will you use the internet in the future again for self-diagnosis? (1) Yes (2) No Results Section 1 Demographics: Results are presented as descriptive and inferential statistics and supported by tables and graphs were appropriate. Age and Gender of the participants: A total of 300 people participated in this study with 125 (42%) males and 175 (58%) females respectively. In total 73% of the sample were aged between 15-44 years with the other 27% between 45 to over 60 years respectively (Table 1). When comparing education levels according to gender, the majority of males (48%) were in the 30-44 age groups and the majority of females (57%) were in the 15-29 age group respectively. In total, 62% of males and 80% of females sampled were between 15-44 years of age. Of those over 60, 14% of males and 8% of females were internet users. Table 1: Age and Gender of the participants Gender Number (%) Age (years) 15-29 30-44 45-59 60+ Male 125 (42%) 17 (14%) 60 (48%) 30 (24%) 18 (14%) Female 175 (58%) 99 (57%) 41 (23%) 21 (12%) 14 (8%) Total 300 116 (39%) 101 (34%) 51 (17%) 32 (10%) Education level Participants were asked to indicate their highest level of education, ranging from elementary school to postgraduate education (Table 2). The category with the highest percentage was elementary level (34%), which represented 43% of females and 21% of males respectively. Chi square tests show that there was a significantly higher proportion (p=0.001) of females in the elementary category. Similarly, a significantly higher proportion of males (32%) had obtained a third level qualification compared to females (20%) respectively (Figure 2). Figure 2: Level of Education Income level Participants were asked to categorise their income according to low, average, and high income respectively. Overall, there is a similar pattern of distribution of income across the three categories with the majority (37%) in the high income category (figure 2). When income is assessed by gender there is a significantly higher proportion of males (52%) in the higher income category (p=<0.001) than females (26%). Similarly there is a higher proportion of females (35%) in the low income category than males (22%) respectively (p=<0.001) (Table 3). Figure 3: Income Level Section 2 Respondents views about using Internet in the diagnosis Responses for each of the individual questions are presented below. Q 2.1 What kind of ailments do you obtain their treatment via online medical diagnosis? The most frequent search online (45%) was for information regarding the treatment and diagnosis of major issues such as paralysis, renal failure, cystic fibrosis, etc. Minor issues (such as pink eye, burn, allergies, upset, etc.) accounted for 32%; with common ailments (such as fever, headache, cold, etc. representing 23% respectively. There was no association between gender and category of treatment query (p=0.21) with both males and females reporting similar patterns. Figure 4: Online Treatment/Diagnosis Queries Q 2.2 Why do you use the internet for diagnosis? The most frequent repsonse to this question regarding the use of the internet for diagnosis was that the distance to travel to the doctor was too far (48%). The cost of the doctor ranked second (39%) with 13% indicating that they used the internet because the technology was available to do so. The cost of attending a doctor was associated with income level (p<.001) particularly amongst the ower and higher income categories respectively (Figure 5). Figure 5: Reasons for using the internet for diagnosis Q 2.3 What types of Online Medical resources have you used? When asked what was their preferred choice of internet resource (Figure 6): videos, or websites hosted by doctors; the majority (57%) of respondents expressed a preference for video resources as opposed to doctor hosted web sites (43%). There was no association between the online resource preference and gender (p=0.288), or age (p=0.226), but there was a significant association (P=0.007) with the level of education and preference for video sites particularly for those whose highest award was elementary or secondary school respectively. Figure 6: Online medical resources preference Q 2.4- What is your preferred web resource for medical diagnosis? Participants were asked to indicate their preferred resource on the web for medical diagnosis. The frequencies were similar for the three categories of answers. Although the ‘from what I read of medical conditions in the media’ had a slightly higher proportion (36%) than the other categories (‘general social networking sites’, and ‘communications with a doctor via social networking sits’) the distribution was very similar overall. There was no significant association (p=0.66) between gender and preferred web resource or age and preferred web resource (p=0.143) respectively. Figure 7: What is your preferred web resource for medical diagnosis? Section 3 Future view about using Internet in the diagnosis In this section of the questionnaire respondents were asked to give their opinions on their view of using the internet in the future for diagnosis of medical conditions by indicating if they agreed or disagreed to a series of statements (Table 2). Table 2: Using the internet in the future for medical diagnosis Statement Strongly Disagree Disagree Agree Strongly Agree 3.1- The results of the diagnosis in the Internet are Reliable. 131 (44%) 68 (23%) 46 (15%) 55 (18%) 3.2- Using the Internet gives accurate results and useful tips for the patient. 132 (44%) 63 (21%) 52 (17%) 53 (18%) 3.3- Using the internet to diagnose stops having to go the doctor. 117 (39%) 80 (27%) 55 (18%) 48 (16%) 3.4- Using the internet to diagnose has no side effects. 109 (36%) 85 (28%) 47 (16%) 59 (20%) 3.5- Medical condition can be diagnosed correctly using the internet 112 (37%) 77 (26%) 60 (20%) 51 (17%) 3.6- Using the internet for diagnosis could be a substitute for the future of medicine. 128 (43%) 73 (43%) 48 (16%) 51 (17%) When the responses for each question were analysedaccording to gender (Figure 7) there were significant differences in the patterns of opinions expressed for some of the questions. For question 3.1, ‘The results of the diagnosis in the Internet are Reliable’, a significantly higher proportion of males (78%) disagreed with the statement compared to females (58%) respectively (p<0.01). The distribution of male and female responses were not significantly different with regard to their opinion on (Q3.2) the ‘Using the Internet gives accurate results and useful tips for the patient’ (p=0.590), or (Q3.3) Using the internet to diagnose stops having to go the doctor’ there was no significant difference between the two groups (p=0.143). Opinions differed significantly with regard to (Q3.4) ‘Using the internet to diagnose has no side effects’ (P=0.017) with a slightly higher proportion of females agreeing with this statement than males respectively. Similarly for the question (Q3.5) regarding ‘Medical condition can be diagnosed correctly using the internet’ there was a significant difference in opinion with 44% of females agreeing/strongly agreeing with the statement as opposed to 26% of males respectively (p=0.001). Likewise opinions differed between males and females with regard to the statement (Q6) ‘Using the internet for diagnosis could be a substitute for the future of medicine’ with a significantly higher majority of males (82%) disagreed/strongly disagreed versus 57% of females respectively (p<0.01). Figure 8: Using the internet in the future for medical diagnosis 3.8 When you went to doctor, did the diagnosis via the Internet was correct? Only 12% of all the diagnosis made by the individuals using the internet was confirmed by the medical doctor (Figure 8). Figure 9: Was the internet diagnosis correct? 3.9 Will you repeat diagnosis using the internet in the future again? When asked how likely a person was to use the internet again for future diagnosis of medical conditions/ailments the majority of respondents overall indicted that would not be in favour of using the internet again (57%). However when the data was analysed according to gender, the majority of males (53%) expressed a preference for using the internet for future diagnosis; and similarly a significantly higher proportion of females indicating that they would not use the internet for self-diagnosis again in the future (65% no; 35% yes) as opposed to males (47% no; 53% yes) respectively (P=0.002). Figure 10: Will you repeat diagnosis using the internet in the future again? Summary of Results • The results revealed that the most active group of internet users was individuals within the age group 15-29 years. The above age group was followed closely by individuals of the age range 30-44. The trend continues in a sloping manner as the individuals above 60years were the least number of internet users. The trends were consistent regardless of the gender categorization • The results also revealed that the education level varies between either genders with a significant number in the elementary level of education. Generally. The females who participated in the study attained lower levels of education in comparison to the men. • The income level statistics revealed that a majority the males earned a significantly higher salary while the rest faced disproportionate distribution of income. On the other hand, the females earned a fair proportionate income. • The research also revealed that a majority of individual made online diagnosis queries for major illnesses (45%) followed by minor issues (32%) and finally common ailments (23%). • A considerable majority of the respondents used video websites more that doctor hosted websites at a distribution of 57% and 435 respectively. These individuals cited the cost of seeking doctor consultation as their main reasons. Notable percentages cited the distance to be covered while other identified the ease of access as their reason for using online sources. Notable figure glean information from the internet followed others who communicate with doctors on social networking sites. • The results also indicated that only 12% of the internet diagnosis matched the doctor’s follow up diagnosis thus they affirmed that they would not utilize the same channel again. Discussion The outcome of the research reveals four distinct facts about the use of internet in the healthcare industry by unqualified civilians. The first act unveiled by the study was that a majority of the individuals had received substantial education levels that allowed them to make rational decisions based on the knowledge they possessed. Such people took up the initiative to use the internet with the knowledge that it goes against conventional practices of seeking medical attention. Additionally, the research revealed that the individuals who used the internet consistently did so out of choice rather than necessity. Such people choose to use the internet because they did not want to undertake the lengthy procedure of accessing a qualified medical practitioner. The said individuals cited the cost of the trip to the doctor as well as the medical cost of consulting a doctor as the barriers that directed their attention to the use of the internet. Ultimately, the research group also cited the ease of access and ease of use of the internet as the main reason behind their choice. The results mentioned above indicate a worrying trend in the form of misusing the online platforms and endangering their lives. The results suggest that health care is still too steep and inaccessible to most people regardless of their economic ability. Such results indicate that the government must take proactive action in improving access to medical services and qualified doctors in Tabuk City. An improvement in the distribution of doctors and increased number of health facilities will intervene in the cases where the patients found it cumbersome to access either option. The aim of such intervention means should be to ease the burden of accessing medical services from hospitals or doctors. Additionally, the ease of access and use of the internet also presents a challenge. While it is impossible to cap freedom of speech and access to information online, it is possible to realign the information to prevent misdiagnosis. It is possible to sanction websites that provide inaccurate information through prohibiting the issuing of online diagnosis regardless of the case. Considering the astounding percentage of individuals who actively use the internet for their medical services, it is only a matter of time before the fatalities reach a new high. The trends in internet use are damning because a majority of the individuals who disregard conventional practices are learned, people. The respondents interviewed for this research reveal a blatant disregard for their better judgment and their access to reputable knowledge. Instead, they rely on technology without much deliberation over their safety or the overall impact on their health status. The research reveals that the shocking trend transcends ages, economic status and social standing as evidenced by the diverse demographic factors unearthed by the responses to the probes in the questionnaire. As long as the access to the Internet endangers the lives of patients across the globe, then it is irrational and unethical to continue offering similar services on any online platform. The results reveal the need to improve the circulation of information to the public regardless of their demographical position. Furthermore, the results of the research bring into sharp focus the value of external intervention by the government or other concerned organizations. One of the available intervention methods entails conducting civic education to inform the public regarding the dangers of self-diagnosis and self-medicating. The research revealed that most of the respondents who took medical from online sources did so out of ignorance. The respondents relied on video sites that contained tutorials among other demonstrative techniques to communicate. The public must realize that such platforms are no substitutes for the hospital or expert advice from doctors. Such platforms also do not have the benefit of laboratories to conduct additional tests to confirm the doctor’s diagnosis. In light of such discrepancies, it is up to the authorities and the concerned parties to take up moral position to protect the civilians from reckless and costly practices. Conclusion In light of the findings of the research documented in this report, the practice of getting advice or medical directives from the internet represents a dangerous precedent. It is alarming that even the intelligent individuals take part in this risky and unethical practice. Despite the obvious dangers involved, the concerned authorities are yet to make any meaningful intervention to regulate this hazardous practice. The results obtained from the research in Tabuk City are applicable on a global scale since the problem is a worldwide occurrence that threatens to derail the quality of health care services. The results indicate online diagnosis have significant error margins that risk the life of the patient and the reputation of the medical practitioners. In retrospect, the concerned authorities must take more preemptive action to protect the public from the self-destructive tendency shown by such dangerous practices. Ultimately, the future of professional medical practice is in danger based on the result of this research. Limitations of the Study There are a few limitations to this study. These are detailed below. This study should be considered preliminary, with larger studies more able to determine the extent of the problems regarding access to healthcare. One of the limitations of this study is that it relies primarily on self-report, which can be subjective and unreliable. Some subjects may seek to participate in the study, and so might exaggerate the extent to which they use the Internet to seek diagnosis and/or treatment. Others may have a faulty memory regarding their experiences and might simply be unaware of how often they seek diagnoses using the Internet and what the outcomes have been. Another problem is that for participants who report seeking diagnosis on the Internet, but who subsequently seek treatment from a physician, it is likely that the doctor will perform tests that amount to a second diagnosis, effectively negating the diagnosis obtained online. Thus, participants may have believed that diagnoses obtained on the Internet were faulty even if they were eventually upheld by the physician, because the doctor did not accept the Internet diagnosis but would only support it if tests returned positive. In other words, the patients may have walked away from their physicians with the impression that the correct diagnosis via the Internet was due to chance, therefore not valid. Another limitation was that it is difficult to separate legitimate medical websites from non-legitimate ones, and capable physicians from non-capable ones, online or in real life. Our survey did not ask details about which websites were used, so this could not be determined by this study. Furthermore, there is the assumption that diagnoses and treatment provided in real life were the best possible, and any discrepancy between the Internet and real-life physicians proved a problem with the Internet. Researchers did not have funds to send participants for second opinions to independently verify any discrepancies. In future studies, we would recommend asking participants for a list of websites or physicians they used in their diagnoses and treatments, so that these issues can be minimized. However, it is likely that they will not be eliminated totally. Finally, this study is also limited in its generalizability. The participant pool was relatively small, and pulled from one particular area in one city of Saudi Arabia. Therefore, it might not be possible to generalize the study results to larger or different groups of people. Further studies would be necessary to determine the extent of Internet use in other areas and the results of this use. However, we believe that further studies are likely to show that there are substantial hazards in attempting to use the Internet to diagnose and treat medical conditions or illnesses, given the current Internet environment. Recommendations The Internet holds promise for assisting patients with their healthcare needs. It contains a wealth of information and, unfortunately, misinformation on every topic. It is currently not living up to its promise. To do so, we recommend the following changes: 1. Physicians, hospitals, clinics, and other healthcare providers should have lists of websites that provide reliable and science-based healthcare information in a format that is easily understood by patients without medical training. This may require testing of healthcare websites by physicians and other providers who are experts in their fields, to evaluate websites for accuracy. Each topic should have more than one professionally approved website. Then these websites should be rated by patients who have no special medical knowledge, to determine which are best understood. Given the difficulty in many parts of the world for patients to access doctors, these lists should be widely available in every community. 2. Patients need to understand the limits of Internet technology. In particular, the art of diagnosis will need to be employed mostly by healthcare professionals. Diagnoses are determined through a combination of personal health history, family history, physical examination, and laboratory tests. There are too many possibilities for most symptoms or even clusters of symptoms to determine a diagnosis without the full array of background information plus tests. If there are relatively simple illnesses and conditions that patients can determine themselves, with relatively unimportant consequences to misdiagnosis, then physicians should sort these out. But patients need to understand that if an illness or condition persists, they need to see a doctor for initial diagnosis and treatment, after which they may be able to follow up online. 3. Physicians and other healthcare providers may be able to help significantly more patients by establishing an online presence. They could provide general healthcare information on their own websites and/or with a list of approved websites. After initial diagnoses are established, they could also make themselves available via secure email for patients' follow-up questions. They could even use an interactive website like Skype to make observations at a distance. Once diagnoses are established, it does seem to us that most follow-up could be provided online, physicians could determine how treatment is progressing, and plans could be made for the future including treatment modifications, requiring a limited number of follow-up office visits. This could help significantly decrease patients' costs in time and travel, while keeping patients safe and helping them recover. Applications for Further Research As the Internet becomes more and more prevalent and accepted, it is likely that more people will seek out advice on medical issues online. It is necessary to determine the effectiveness of online diagnosis and treatment when compared to traditional medicine in order to give the best advice to those in need of quality medical advice. Learning where the Internet is lacking in terms of providing reliable advice can also help to improve the quality of medical websites on the Internet by determining where the Internet is already helpful and where improvements need to be made. Further research should focus on areas in which the Internet can be helpful to those seeking medical care and those in which it cannot. As the proposed study is relatively small in scope and will contain participants from a single region of Saudi Arabia, this is ample opportunity for larger, more inclusive studies to replicate this study’s results in larger, more diverse areas. It is the hope of study researcher that this research takes place. This study was designed strictly to learn about Internet use in medical situations in Tabuk, Saudi Arabia, but it would be interesting as well as informative to see if the results found in that area were similar or different from those found in other areas of the world. Internet access varies widely, as do primary-concern medical issues, so this study might not be representative of Internet use for medical reasons in other parts of the country or the world. It would be beneficial to learn how these differences affect the effectiveness of Internet-based treatment in many different cultures and areas of the world. References Al-Hakeem, M. M. M. K. (Jul 2012). Impact of education on knowledge and use of folic acid among Saudi women. Pakistan Journal of Medical Sciences 28(3): 686-690. Alkhunaizi, A. M. (Jan-Mar 2016). Urinary stones in Eastern Saudi Arabia. Urology Annals 8(1): 6-9. Alumran, A., Hou, X.-Y., & Hurst, C. (2013). Assessing the overuse of antibiotics in children in Saudi Arabia: Validation of the parental perception on antibiotics scale (PAPA scale). Health & Quality of Life Outcomes 11(1): 1-8. Ameringen, M. V., Simpson, W., Patterson, B., &Turna, J. (Dec 2015). Internet screening for anxiety disorders: Treatment-seeking outcomes in a three-month follow-up study. Psychiatry Research 230(2): 689-694. Anwar, S., & Khan, S. (Mar 2013). Risks of online self-diagnosing: Cyberchondriacs. British Columbia Medical Journal 55(2): 72-73. Bednar, J. (Jan 05, 2009). Digital diagnosis. BusinessWest 25(17): 33-40. Binsaleh, S., Al-Jasser, A., Almannie, R., &Madbouly, K. (Apr-Jun 2015). Attitude and perception of urology by medical students at the end of their medical school: An appraisal from Saudi Arabia. Urology Annals 7(2): 211-220. Buckjun, S. (2012). What Doctors Think about Your Online Health Searches. Retrieved from: http://mashable.com/2012/06/15/online-medical-searches/#dAsIgvHnEZqw Cima, R. R., Anderson, K. J., Larson, D. W., Dozois, E.J., Hassan, I., &Sandborn W. J. (2007). Internet use by patients in an inflammatory bowel disease specialty clinic. Inflammatory Bowel Disease 13(10): 1266-1270. DeZee, K. J., Wink, J. S., & Cowan, C. M. (Apr 2013). Internet versus in-person counseling for patients taking Varenicline for smoking cessation. Military Medicine 178(4): 401-405. Diagnosing disease from the comfort of your own home. (Dec 13, 2008). Inpharma Weekly 1668: 19-19. Dincyurek, S., &Uygarer, G. (Jul 2012). Conduct of psychological counseling and guidance services over the internet: Converging communications. Turkish Online Journal of Educational Technology – TOJET 11(3): 77-81. Ebel, M.D., Stellamanns, J., Keinki, C., Rudolph, I., & Huebner, J. (2015). Cancer patients and the internet: A survey among German cancer patients. Cancer Education. Fageeh, W. M. K. (Jun 2011). Different treatment modalities for refractory vaginismus in Western Saudi Arabia. Journal of Sexual Medicine 8(6): 1735-1739. Farmer, S. E. J., Bernardotto, M., & Singh, V. (Oct 2011). How good is Internet self-diagnosis of ENT symptoms using Boots WebMD symptom checker? Clinical Otolaryngology 36(5): 517-518. Fink, A., & Beck, J. C. (2015). Developing and evaluating a website to guide older adults in their health information searches: A mixed-methods approach. Applied Gerontology 34(5): 633-651. George, D.R., Rovniak, L. S., Kraschnewski, J. L. (2013). Dangers andopportunities for social media in medicine. Clinical Obstetric Gynecology 56(3):453-62. Hicks, K. F. (2015). Stress-related illness. Medical Diagnosis and Treatment 2(5): 112-127. Internet-based PTSD Therapy may help overcome barriers to care. (Nov 01, 2007). Science Update. Retrieved from: http://www.nimh.nih.gov/news/science-news/2007/internet- based-ptsd-therapy-may-help-overcome-barriers-to-care.shtml Johnson, J. (Nov 23, 2014). Local experts weigh the dangers, benefits of self-diagnosis via online sources such as WebMD. Grand Forks Herald (ND). Layman, T. (Aug 24, 2001). More self-diagnosing patients turn to Web for answers. Pacific Business News 39(24/25). Litz, B. T., Engel, C. C., Bryant, R., & Papa, A. (Nov 2007). A randomized controlled proof-of-concept trial of an internet-based, therapist-assisted self-management treatment for Posttraumatic Stress Disorder. American Journal of Psychiatry 164(11):1676-84. Lynch, J. (Sep 28, 2015).Ken Jeong: The Dr. Ken Star (and former real-life doctor) on the perils of self-diagnosing online. Adweek 56(32): 61-61. Morgan, O. G. (2016). 10 health problems related to stress that you can fix. WebMD. Retrieved from: http://www.webmd.com/balance/stress-management/features/10-fixable-stress-related-health-problems. Olivieri, S., Cantopher, T., & Edwards, J. G. (Dec 1986).Two hundred years of dependence on antianxiety drugs. Human Psychopharmacology: Clinical & Experimental 1(2): 117-123. Online advice sickens. (Jan 23, 2005). Sunday Herald Sun (Melbourne). Podichetty, V. K., Booher, J., Whitfield, M. &, Biscup, R. S. (2006). Assessment of internet use and effects among healthcare professionals: A cross sectional survey. Postgraduate Medicine 82(966): 274-279. Powell, J. A., Darvell, M., & Gray, J. A. (2003). The doctor, the patient and the world-wide web: How the internet is changing healthcare. Societal Medicine 96(2):74-76. Rozental, A., Boettcher, J., Andersson, G., Schmidt, B., &Carlbring, P. (2015). Negative effects of internet interventions: A qualitative content analysis of patients' experiences with treatments delivered online. Cognitive Behavioral Therapy 44(3): 223-236. Saeed, M. S., Alkhoshaiban, A. S., Ali A.W., Mohammed, Y., Long, C. M. (Oct-Dec 2014). Perception of self-medication among university students in Saudi Arabia. Archives of Pharmacy Practice 5(4): 149-152. Schover, L. R., Canada, A. L., Yuan,Y., Sui, D., Neese, L., Jenkins, R., & Rhodes, M. M. (Sep 26, 2011). A randomized trial of internet-based versus traditional counseling for couples. Cancer 118(2): 500-509. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1002/cncr.26308/pdf Schwartz, K.L., Roe, T., Northrup, J., Meza, J., Seifeldin, R., & Neale, A.V. (2006). Family medicine patients' use of the internet for health information: A MetroNet study. American Board of Family Medicine 19(1):39-45. Seeley, J. J. (2014). Psychological and stress-related diseases. Journal of Medical Treatment 8(12): 74-96. Sorbi, M.J., Kleiboer, A.M., van Silfhout, H. G., Vink, G., Passchier, J., &Cephalalgia, V. (Jun 2015). Medium-term effectiveness of online behavioral training in migraine self-management: A randomized trial controlled over 10 months. An International Journal of Headache [Cephalalgia] 35(7): 608-618. Sweet, R. L. (2011). Treatment of acute Pelvic Inflammatory Disease. Infectious Diseases in Obstetrics & Gynecology 2011(Special section): 1-13. The online doctor will see you now. (Nov 17, 2008). Toronto Star (Canada). Ventola, C. L. (2014). Social media and health care professionals: Benefits, risks, and best practices. Physical Therapy 39(7): 491-520. Yifeng, H., &Haake, J. (Apr/Jun 2010). Search your way to an accurate diagnosis: Predictors of Internet-based diagnosis accuracy. Atlantic Journal of Communication 18(2): 79-88.