The aim of this chapter is to consider the impact of the Internet and related technologies on health care, in terms of the availability of health‐related information, support and treatment. We begin by examining the types of people who are more likely to search for online health information and why they do so, as well as the potential negative impact of this on the individual, in the form of ‘cyberchondria’. Following this, we look at online forums as places of knowledge and support for those with health‐related issues. Use of the Internet for therapy has been around since the early days and so, importantly, we discuss online therapy (or e‐therapy) and evaluate its effectiveness. Finally, we present examples of the ways in which immersive virtual environments are being used as treatments for a number of health‐related conditions.
The Internet has changed our relationship with health‐related information, for, although research typically shows that health‐care professionals continue to be the preferred contact point for the majority of people with health concerns (Berle et al., 2015; Fox, 2011), online resources such as health searches and forums (where one can seek advice from peers and/or ‘informed others’) have nevertheless become a significant source of health information, particularly in the US (Fox, 2011). It is therefore no exaggeration to state that ‘the Internet is bringing about a structural transformation of the cultural practices and organization of health systems’ (Rossi, 2006, p. 9). In support of this claim, in 2003, Eysenbach and Kohler reported that up to 6.75 million health‐related Internet searches were made every day worldwide on Google. In addition, Rossi (citing the Pew Internet & American Life Project) reported that, at the turn of the twenty‐first century, 55% of people in the US with Internet access (equating to 52 million people) had used the Internet to obtain health‐related information or had used online health services (the average across European countries at that time was lower: around 23%). Of these, 92% reported finding the information useful. By 2008, the proportion of Americans searching for online health information had risen to an estimated 75–80% of those with Internet access (Fox, 2008). More recently, Lauckner and Hsieh (2013) reported that Google had announced that general‐health‐related sites had an estimated combined unique monthly visitor tally of around 117.8 million and that WebMD had likewise claimed to receive 111.8 million unique monthly visitors.
As part of this changing relationship to health‐related information, Powell (2011) makes the point that young people who have grown up with the Internet – sometimes referred to as ‘digital natives’ – are fundamentally different from previous generations in terms of how they communicate, seek information and generally interact and entertain themselves because of their familiarity with, and reliance on, digital technology (as discussed in Chapter 7). As such, they have ‘expectations that public services such as healthcare will be digital’ (Powell, 2011, p. 368; see also Owens et al., 2012). In response, social media is now being incorporated into health‐care settings by providing, for example, emergency alerts, as well as by helping to monitor patient care. The World Health Organization likewise uses social media (Twitter and YouTube, among others) as a means of keeping the population up to date with the latest health‐related news (Catford, 2011). The Internet should therefore be considered a source of health‐related benefit to patients and health professionals alike (Wright, 2012).
Who is more likely to engage in online searches and what motivates this activity? According to Lee and Hawkins (2010), those with health problems tend to look for information to help them understand their diagnosis, prognosis and treatment; but, equally, those who consider themselves to be healthy also look for health‐related information in order to learn more about their physical well‐being (we will consider psychological/mental well‐being in more detail later when discussing e‐therapy). Similarly, Rice (2006), after analysing a number of US databases, concluded that those most likely to search for health‐related information via the Internet are individuals who have just been diagnosed with a medical condition or who are seeking to help others cope with their medical problems (e.g., a friend or parent, or some other family carer, caring for a child who has a chronic illness). Rice also found that employed women are among those most likely to seek out health‐related information online. In short, based on the growth of health‐related websites and the findings of a number of studies carried out across Europe and North America (e.g., Health on the Net Foundation, 2001; Skinner, Biscope, Poland & Goldberg, 2003), what all of this means is that the Internet is used by large numbers of people to obtain information on illnesses, treatments and support (Horgan & Sweeney, 2010; Ybarra & Suman, 2006).
Those seeking health‐related information online may begin simply by typing key words into a search engine, or perhaps directly consult the websites of professional health organizations (e.g., NHS Choices in the UK). In conjunction with consultations with health‐care professionals, research has shown that such a relatively simple strategy can make one feel more at ease with the information received from professionals (Parker et al., 1999; Ybarra & Suman, 2008). Similarly, seeking online health content in this way has been shown to have a positive effect on one’s adherence to medication (Samal et al., 2011) and one’s ability to make informed decisions about health care (Seckin, 2010). Importantly, though, while there are clearly benefits associated with this kind of information seeking, such an approach is not without its problems. Helft, Eckles, Johnson‐Calley and Daugherty (2005) report that cancer patients taking part in their study had a negative experience of reading online cancer information: one third felt more confused, and nearly a quarter more nervous, anxious or upset.
More generally, a common motivation for online medical searches is to gain reassurance that there is nothing medically wrong, or at least nothing seriously wrong (Baumgartner & Hartmann, 2011; Muse, McManus, Leung, Meghreblian & Williams, 2012). Reducing the discomfort caused by uncertainty is therefore a major reason people engage in Internet searches for health‐related information. Yet online medical searches have been associated with increased depression in the general population (Bessière, Pressman, Kiesler & Kraut, 2010) and, as Fergus (2013) notes, they can often result in multiple medical possibilities, some more threatening than others. White and Horvitz (2009) found that those using general search engines (e.g., Google) to try to self‐diagnose were disproportionately exposed to information about serious illnesses. Specifically, about 70% of those who used general search engines to self‐diagnose common and innocuous symptoms ended up searching for rarer, more serious conditions (McManus, Leung, Muse & Williams, 2014). Such behaviour, which often leads to increased uncertainty rather than reassuring the person concerned, can exacerbate the situation, thereby increasing health‐related anxiety, particularly if the individual has an intolerance for uncertainty (Fergus, 2013; Norr, Albanese, Oglesby, Allan & Schmidt, 2015). Increased anxiety as a result of Internet searches for health‐related information has come to be known as ‘cyberchondria’, which is construed not only as a form of reassurance seeking but also as a manifestation of health anxiety and hypochondriasis (Starcevic & Berle, 2013).
McManus et al. (2014) argue that expressions of cyberchondria are consistent with cognitive behavioural models of health anxiety. As noted, repetitively checking sources of medical information online acts as a form of reassurance seeking; unfortunately, this activity is a factor in maintaining individuals’ health anxiety, not reducing it. McManus et al. cite a number of studies (e.g., Haviland, Pincus & Dial, 2003; Lemire, Paré, Sicotte & Harvey, 2008; Muse et al., 2012) that report that those who are more health anxious search for health information online more often but, importantly, add that searching for health information more frequently has the potential to increase their health anxiety. Presumably, this increases the frequency with which they seek to be further reassured and search for online health information, and so the anxiety‐provoking cycle continues.
Cyberchondria has been measured using the multidimensional Cyberchondria Severity Scale (McElroy & Shevlin, 2014; see also Fergus, 2014; Norr, Allan, Boffa, Raines & Schmidt, 2015, for reviews of the scale). Items on the scale are designed to assess levels of compulsion, distress, excessiveness, reassurance and mistrust of medical professionals. These factors are measured using a five‐point Likert scale indicating frequency (1: never; 2: rarely; 3: sometimes; 4: often; and 5: always), which participants use in response to 33 statements, such as (adapted from McElroy & Shevlin, 2014):
When seeking out health‐related information, in addition to more general Internet searching, more and more people are making use of health‐related discussion forums (Tanis, 2008). In the age of the Internet, such virtual communities are growing into an ever more common form of health communication. Let us therefore consider this type of online activity further.
Liang and Scammon (2011) note how, in today’s health‐care environment, it is not always easy, or indeed possible, for patients to obtain all the information and support they need through face‐to‐face communication with their doctor in what tends to be a relatively short consultation. As a consequence, since the turn of the century, SNSs have started to emerge in the form of virtual communities – sometimes referred to as self‐help or social support groups – consisting of ‘friends’ or those more informed (perhaps through first‐hand experience) about a particular health‐related matter, which may be anything from irritable bowel syndrome (Coulson, 2005) to infertility (Malik & Coulson, 2008) to miscarriage (Gold, Boggs, Mugisha & Palladino, 2012) to depression (Griffiths et al., 2012) to HIV/AIDS (Mo & Coulson, 2008), and so on. Within these forums, people can ask for help and advice (Sillence, 2013). This often develops into a thread consisting of a series of responses to the initial question and/or discussion around these responses. It may also involve someone recounting a relevant anecdote that is informative or that at the very least conveys the message that there are others available – ‘experiential experts’ – who have an empathic understanding based on prior experience of what the particular individual is going through (Donelle & Hoffman‐Goetz, 2009), which is perhaps more than can be said for others in the person’s offline social network. In addition, Tanis (2008) describes how these forums can be good places to pick up useful information on treatments or coping strategies, or can simply be a place for encouragement and support that provides a sense of belonging. This may help an individual to feel more in control of, or at least less uncertain about, their condition, particularly if recently diagnosed. It may also be a place where they can feel more at ease discussing issues relating to what they are going through – compared to, say, being in the presence of colleagues or even friends and family – especially if they feel embarrassed or fear being stigmatized (Berger, Wagner & Baker, 2005; Webb, Burns & Collin, 2008). The potential and likely diversity of the forum members also means that there could be a rich vein of diverse information available that would be less accessible offline. Such diversity may go some way to help cater for different individuals’ needs, for, as Liang and Scammon (2011) note, research on health communication supports the view that the most effective health communication is tailored health communication. Health‐related information and communication should therefore be tailored to meet an individual’s needs and characteristics, skill set and abilities (e.g., reading and comprehension, computer literacy), and motivation.
The usefulness of online forums in meeting the aim of tailored communication must be tempered, of course, with the fact that information may not always be reliable or medically sound (Owens et al., 2012). After all, such forums are not necessarily, or in any way required to be, frequented by medical experts. Horgan and Sweeney (2010) report concerns over the quality of health‐related information obtained via the Internet. In support of this claim, they cite Eysenbach, Powell, Kuss and Sa’s (2002) review of 79 research studies that evaluated the quality of health information online. While there is concern over the quality of some of these original studies (and therefore their findings), Eysenbach et al. nevertheless report that 70% concluded that there was a problem with the standard of health‐related information available online.
That said, a number of studies looking at the impact of health‐related forums on their users have reported positive effects. Kramer et al. (2015), for example, researched online peer‐support forums for those bereaved by suicide, many of whom presented with depressive symptoms and issues relating to well‐being. They described how two thirds of those who took part in the study found the forums beneficial, particularly in terms of social support. They also found that, in general, there was a small to medium improvement in the participants’ depressive symptoms and sense of well‐being one year later (although some were still struggling with their mental health). Jones et al. (2011), as part of their survey focusing on an online forum for those who self‐harm, found that participants valued being able to communicate anonymously with strangers about their self‐harm issues. They found disclosure in this way easier to do than talking to someone in person or on the telephone. The participants also reported learning more about their condition from the forum than from online information sites, and felt they had benefitted from interacting with others who had similar feelings to them. Kirk and Milnes (2015) looked at the effectiveness of online support forums for young people with cystic fibrosis and their parents. Those with cystic fibrosis said that the online community meant they had a safe place in which to share experiences, exchange experientially derived advice and views on how to manage their treatment as well as their lives more generally, including their emotions, their relationships, their identities and the support they received from health services. The parents of children with cystic fibrosis, for their part, sought and received advice on managing their child’s health, including specific therapies. Kirk and Milnes also described how the forums were able to supplement professional support and help parents and children to develop the expertise to empower themselves when interacting with health‐care professionals.
Owens et al. (2012) were interested in the possible benefits of inviting health‐care professionals to join in with discussions on online forums supporting young people who self‐harm. They reported initial interest during the recruitment of those health professionals who agreed to take part, but this was followed by a reluctance to actively engage with the forums. Some of the reasons suggested for this were a lack of confidence on the part of the professionals in engaging in this type of exchange, issues relating to private–professional boundaries, and the need for role clarity given the implications for duty of care and accountability. What Owens et al.’s failed attempt at inviting health‐care professions into the informal and anonymous world of online support‐group discussion highlights is the issue (perhaps problem) of integrating these two mechanisms of information and support into a workable whole.
In concluding this section, it should be evident that ‘the mechanisms within an online support group are the same as those created within a traditional group (mutual problem solving, swapping of information, expressing of experiences, catharsis, mutual help and assistance, empathy, etc.)’ (Rossi, 2006, p. 11). Online forums have the advantage, however, of being much more accessible to those individuals who have difficulty accessing offline support groups, perhaps owing to some form of physical disability or other practical difficulty (e.g., time/distance) – difficulties that also feature in making e‐therapies a more attractive option for some people.
The term ‘e‐therapy’ refers to any form of psychological therapy that takes place online as opposed to face to face (Skinner & Latchford, 2006). More specifically, e‐therapy has been defined as:
a licensed mental health‐care professional providing mental health services via e‐mail, video conferencing, virtual reality technology, chat technology, or any combination of these. (Manhal‐Baugus, 2001, p. 552)
Or, more recently, it has been said to constitute:
a new therapeutic modality aimed at assisting clients to resolve life and relationship issues through electronic means, synchronous or asynchronous. [It is] a process of interacting with a therapist online in ongoing conversations over time when the client and counselor are in separate or remote locations and utilize electronic means to communicate with each other. (Olasupo & Atiri, 2013, p. 408)
Of course, the phenomenon of therapy over distance is not new. During the seventeenth and eighteenth centuries, for example, physicians would often form diagnoses based on patients’ written descriptions of their symptoms, rather than physical examinations (Spielberg, 1999). Moreover, in the nineteenth century, Freud engaged in therapeutic practices via letter (Brabant, Falzeder & Giampieri‐Deutsch, 1993). E‐therapies, however, began to emerge as a delivery method within the practice of counselling psychology in the 1980s (Alleman, 2002; Oravec, 2000; Skinner & Zack, 2004). They incorporate a variety of electronic media compatible with the Internet and should be thought of as a form of therapy delivery rather than as a form of therapy per se (Sucala, Schnur, Brackman, Constantino & Montgomery, 2013).
Text‐based sessions, for example, may involve email, chat rooms and text messaging (Andersson, Sarkohi, Karlsson, Bjärehed & Hesser, 2013; Hucker & McCabe, 2014). Non‐text‐based therapy may involve voice‐only communication or video conferencing (Dunstan & Tooth, 2012; Nelson & Lillis, 2013; Santhiveeran, 2005). Each of these can be synchronous (occurring in real time, thus providing immediate feedback) or nonsynchronous (involving a time delay and so a lack of immediate response). At the turn of the century, only about 10% of therapists reported using some form of online media to communicate with their patients/clients (VandenBos & Williams, 2000; Wright, 2002). This was found to have increased to 45% in a more recent study carried out in Norway (Wangberg, Gammon & Spitznogle, 2007).
Depending on the precise medium used, in addition to confidentiality, e‐therapy affords a higher level of anonymity compared with face‐to‐face treatment. For some, this may provide additional appeal (Hucker & McCabe, 2014; Qian & Scott, 2007; Rains, 2014; Tanis, 2008). Moreover, Prabhakar (2013) informs us that research has been shown to support the view that ‘clients are more honest and cooperative in online sessions than face‐to‐face therapy, and tend to explore deeper concerns in a shorter time period’ (p. 213; although see discussion below on potential risks by way of a caveat to this claim). Further advantages of e‐therapy include (adapted from Olasupo & Atiri, 2013):
According to Recupero and Rainey (2005), patient preference may be one of the clearest indicators of the benefit of e‐therapy. Postel, de Jong and de Haan (2005), for example, after carrying out research in the Netherlands, found that e‐therapy was considered a more attractive means of treating alcohol problems by those who were reluctant to engage in offline (face‐to‐face) therapy. The ability to traverse otherwise difficult distances is also a benefit. E‐therapy has been used, for example, to treat military personnel in remote areas (Jerome et al., 2000). Some patients may also perceive e‐therapy as affording them increased privacy, although, as we will see below, this may not always be the case, as online therapy is not immune to risks relating to confidentiality. Recupero and Rainey also note that, for some, the removal of a face‐to‐face interaction may facilitate self‐disclosure and honesty (again, see below for a discussion on potential risks based on increased inhibition). For Skinner and Latchford (2006), the ubiquity and convenience of the Internet, alongside the increased opportunity for anonymity, make it an ideal medium for counselling. That said, e‐therapy is not without its disadvantages, which include (adapted from Olasupo & Atiri, 2013):
Potential disadvantages of e‐therapy are often seen as synonymous with new ethical concerns. In response to the increased presence and utility of e‐therapy, and in recognition of some of the additional ethical challenges specific to this medium, the American Psychological Association’s (2002) ethical guidelines were modified so as to be more inclusive of Internet therapy. In addition, the International Society of Mental Health Online (2009) provides a useful accompaniment to the American Psychological Association’s guidelines. Together, they provide insight into the ethical nuances faced by e‐therapists (Lee, 2010), some of which are discussed below.
One of the potential risks inherent within most forms of e‐therapy is the lack of facial expression cues. Consequently, text‐based communication may lower an individual’s inhibitions (known as the disinhibition effect; Suler, 2004; see also Chapter 3). Given the increased likelihood of inhibition, according to Recupero and Rainey (2005), ‘a shy patient may be more likely to disclose suicidal ideation in a chat room than in a therapist’s office [meaning that] the e‐therapist must now be concerned with the safety of a patient who may be far away’ (p. 322). To help safeguard against such an eventuality and so improve the chance of offline crisis intervention, the e‐therapist may decide to restrict online treatment to local patients. In fact, Recupero and Rainey (2006) report that some websites render ineligible certain prospective clients/patients (e.g., those with ‘suicidality’). There is also the risk of misdiagnosis, especially given the fact that psychotherapists traditionally rely on nonverbal cues when making their diagnoses. Videoconferencing may reduce the chance of this, of course, but, as Santhiveeran and Grant (2006) found after surveying 73 e‐therapy websites, the majority of treatment on these sites occurred in the form of email correspondence, with very few e‐therapists offering videoconferencing. Recupero and Rainey (2005) also note how the lack of visual cues may mean that any harmful side effects of medication may go unnoticed by the e‐therapist. As a result, some therapists will not prescribe medication online. Moreover, after studying 44 e‐therapy websites, Heinlen, Welfel, Richmond and O’Donnell (2003) concluded that ‘the number of psychologists offering e‐therapy is small, their services are diverse, and their compliance with established ethical principles is uneven’ (p. 112).
Evidence is available to support the effectiveness of e‐therapies for a variety of psychosocial problems (Barak, Hen, Boniel‐Nissim & Shapira, 2008; Rochlen, Zack & Speyer, 2004), but extensive research on its effectiveness is limited and findings can be mixed. Studies by Aardoom, Dingemans, Spinhoven and Van Furth (2013) and Dölemeyer, Tietjen, Kersting and Wagner (2013), for example, drew positive conclusions on the effectiveness of e‐therapy for the treatment of eating disorders. In contrast, Loucas et al.’s (2014) findings, based on a meta‐analysis of 20 studies, led them to conclude that the effectiveness of e‐therapy for eating disorders cannot be described as ‘promising’, nor is there any firm basis for the claim that e‐therapy is an effective alternative to face‐to‐face treatment, at least as far as eating disorders are concerned.
An issue to be resolved in the study of e‐therapy effectiveness is how to operationalize ‘adherence’, so that one can measure the relationship between adherence to the treatment programme and treatment outcomes with a greater degree of confidence. Donkin et al. (2011) performed a systematic review of various e‐therapy interventions. They noted a large variation in the reporting of adherence and its association to outcomes, which could have contributed to the variation in research findings. Donkin et al. therefore suggest using a composite measure of adherence that encompasses time online, activity completion and active engagements with the intervention.
In addition, Sucala et al. (2013) have raised the issue of ‘therapeutic alliance’ and the potential difficulty that exists when trying to develop this within an online environment. Therapeutic alliance is defined as ‘the nature of the working relationship between patient and therapist’ (Sucala et al., 2013. p. 283). In face‐to‐face sessions, Sulcala et al. tell us, research indicates a robust positive correlation between therapeutic alliance and treatment outcome (see, e.g., Horvath, Del Re, Fluckiger & Symonds, 2011; Lambert & Barley, 2001). There is little research on this relationship in the context of e‐therapy, however. What little work has been done (e.g., a systematic review of the literature by Sucala et al. in 2012) indicates that, while no firm conclusions can yet be drawn on the nature of the therapeutic alliance in e‐therapy – owing to the paucity of research – there nevertheless does seem to be some indication that it is at least equivalent to face‐to‐face therapy. Sucala et al. (2013) were also interested in clinicians’ perceptions of the importance of therapeutic alliance in an e‐therapy context. They found that:
Clinicians’ ratings of the importance of alliance in face‐to‐face therapy were higher than their ratings of the importance of alliance in E‐therapy, a result which might indicate that clinicians are less aware of the potentially important role of the therapeutic alliance in E‐therapy. (p. 290)
From this, they conclude:
This result seems to reflect the current state of E‐therapy literature, in which the therapeutic relationship has been very rarely studied … It is possible that clinicians’ perceptions of the importance of the alliance in E‐therapy will change if the E‐therapy literature catches up to and begins to mirror the general psychotherapy literature in terms of recognizing the role that therapeutic alliance plays in the therapeutic process. (p. 290)
In concluding this section, the view of Castelnuovo, Gaggioli, Mantovani and Riva (2003) seems pertinent. For these authors, the introduction of new online technologies should not be thought of as signalling a new theoretical approach to psychotherapy, nor as an alternative treatment. Instead, this technology should be treated simply as a resource that complements the traditional psychotherapeutic approach. As they state:
E‐therapy could represent a useful integration between technological tools and traditional clinical techniques and protocols in order to improve the effectiveness and efficiency of therapeutic process … [Yet,] to enhance the diffusion of e‐therapy, further research is needed. More evaluation is required of clinical outcomes, organizational effects, benefits to health‐care providers and users, and quality assurance. To date, the empirical research is not strong enough to objectively evaluate all the benefits and limits of e‐therapy. (pp. 380–81)
In fact, based on the level of research presently available on the effectiveness of e‐therapies, Loucas et al. (2014) perhaps best sum up the current situation, both in terms of e‐therapy’s inevitable development and the need for safeguards:
The treatment of mental health problems is likely to change markedly over the next 10–20 years, as a result of the widespread availability of the Internet and of mobile‐device applications (apps), and their ability to deliver direct to the user certain psychological treatments. This change will greatly increase the availability of these treatments, but it will be associated with risks, a major one being the promulgation of ineffective or even harmful interventions. Clinicians and the public alike will therefore need access to authoritative and up‐to‐date guidance regarding the empirical status and clinical utility of the many online and app based interventions. (p. 122)
To end, it is worth noting that digital technologies in the form of ‘immersive virtual environments’ are being employed more and more as tools for the treatment of various psychological problems. Such immersive environments are capable of simulating numerous real‐world situations, thereby allowing the patient to experience them in a real way but from within the relative safety and control of a digital simulation.
To illustrate: major cognitive and subsequent behavioural impairment can often follow traumatic brain injury and stroke. As part of their rehabilitation, patients need to be assessed on how well they are able to engage with the activities of daily life. Lee et al. (2003) designed an immersive virtual environment in the form of a supermarket to help assess patients’ level of rehabilitation (assessing the extent to which patients navigate around the virtual supermarket, picking up items and opening or closing doors, etc.). Cárdenas, Munõz, González and Uribarren (2006) likewise reported the usefulness of immersive virtual environments for the treatment of agoraphobia (see also Alcañiz et al., 2003; Martin, Botella, Garcıá‐Palarios & Osma, 2007). As part of the treatment, the patient can be exposed (virtually) to the feared situation (a simulation of an open space, in this case). Freeman (2008), for his part, found such immersive technology useful as a means of controlling schizophrenic patients’ social environment (having to interact with virtual characters on a tube train): a major step, Freeman claimed, in the understanding of psychosis, including paranoid fear (see also Freeman et al., 2008; Ku et al., 2007). Immersive virtual environments have also been used to aid in the treatment of (among other things) spider phobia (Carlin, Hoffman & Weghorst, 1997), tobacco dependence (Culbertson, Shulenberger, De La Garza, Newton & Brody, 2012), the control of pain in a dental surgery (Hoffman et al., 2001), social phobia (Roy et al., 2003) and pain reduction in those experiencing phantom limbs (Murray, Patchick, Pettifer, Caillette & Howard, 2006). Immersive virtual environments have also been used to aid prolonged exposure therapy, whereby a patient suffering from post‐traumatic stress disorder (PTSD) is required to re‐experience the traumatic event (rather than seeking to avoid it). In the case of war veterans suffering from PTSD as a result of combat, patients are required to experience battlefield simulations, including exploding mines, being ambushed and having to treat casualties.
The Internet is proving to be a useful supplement to traditional care and support for patients. The full implications and scope of the Internet and related virtual technologies on health and health education are not fully known, however, nor have they been fully tested. What the Internet does offer is the possibility of increased user access to medical knowledge and support, thereby enabling increased collaboration and care.