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This may be seen as mirrored on their sites, which appeared simple and reduced in terms of Web design and menu navigation and lacked interactive elements, evoking a do—it—yourself charm. This recalls the study by Oudshoorn and Somers , who similarly showed that patient organisations had to face constraints in terms of providing interactive elements and more elaborated Web site features due to financial barriers. The PR manager of the pharmaceutical company producing insulin and medical devices, on the contrary, straightforwardly said that the company primarily uses their Web site as an advertising platform.

Besides biomedical information on diabetes, the site provided a virtual tour of the company, professional images of insulin injection pens and other products, as well as recent news on diabetes. The design of the site appeared professional and expensive, because it had been created by a professional Web design agency as part of the international corporate group, as the interview partner explained. In this context, the PR manager referred to the economic dimension of the Web:. According to her — and her role as PR and marketing agent for the company — commercial dynamics pervade all topical areas on the Web, including medical ones.

Like the doctor, the pharmaceutical company was not allowed to explicitly advertise their drugs by name. However, text on the site mentioned groups of drugs and their substances, most particularly on their partner site primarily designed for patients; this text was written in a comprehensible language. On this partner site, hardly any information about the company providing the site could be found, apart from the copyright section. This is significant as it created the possibility of implicitly advertising new drugs without mentioning either the company or the brand of the drug, a common practice amongst pharmaceutical companies, according to the interviewee.

This clearly shows that commercial dynamics deeply pervade online health information. Similarly, Web site providers profiting from their sites referred to the economic dimension of medical Web information. The director of the general health portal and the journalist offering the semi—commercial diabetes site both said that they run their sites as a business, on a very different scale. The director of the health portal employed a number of people ranging from medical professionals, journalists, to technical staff, to assure the quality of the largely biomedical information communicated to patients.

The journalist ran the portal together with his business partner, with whom he previously owned a PR agency, and aimed at offering experiential diabetes information from a patient perspective. The primary goal of these sites was to generate income by informing patients about diabetes and other health—related issues. Corresponding to their goals, these providers designed their sites as informational products. Having no pre—Internet health institution in the background, they only briefly presented themselves on their homepages with slogans.

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Instead, their homepages were filled with different features, such as teaser stories and snippets of longer text, images evoking a good feeling, and quizzes, movies, a forum where patients could exchange experiences, and advertising. While the health portal can be seen as offering a high—quality informational product where content and advertising were strictly distinguished, according to its director, the site offered by the journalist resembled a tabloid, where content and commerce intermingled strongly.

To both Web site providers, however, user traffic was very important since they financed their sites through advertising and aimed at making a profit, which requires sufficient traffic to the site.

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Besides content, the appearance, design, and navigation of their sites were considered as very important features to keep users satisfied. In the case of the health portal, next to the top—down menu, teaser stories and other hypertext elements were provided, enabling users to navigate through their sites in multi—directional ways. This analysis shows that the different motivations and aims in providing a diabetes—related Web site, as well as financial motives and technical know—how, strongly shaped the ways in which diabetes information was structured, designed and formatted.

Web site providers from non—profit institutions built and designed their sites in simple, straightforward ways within their small budgets. Web site providers from companies and media businesses, in contrast, designed their sites in a much more elaborated way with visual features, interactive parts such as patient forums, and more flexible navigation structures, thanks to in—house technical experience and financial resources. These differences demonstrate that off—line power relations and commercial dynamics have a crucial impact on the way Web site providers design their sites, but also position them in the online health information landscape, as I discuss in the next section.

The diabetes association and doctor providing a non—commercial Web site mainly relied on collaborative networking strategies to position their sites and attract users. The first step to gain visibility, these providers said, was to contact Web site providers with whom they had social relations with and propose to connect their respective sites through hyperlinks. This way, each site would benefit from other linked sites, as users would be channelled from one site to another by hyperlinks. In this interpretation, links mirror social networks.

Accordingly, the Webmaster of the diabetes self—help group immediately started to talk about the sites surrounding his own site when I showed him the network map illustrated as Figure 2. According to the interviewee, the network primarily displays sites of institutions the self—help group collaborated with mirroring the lively diabetes self—help scene that developed in Austria blue nodes on top of the image.

Further, the network shows links from patient groups to pharmaceutical companies nodes on the edge of the network on top , illustrating that companies financially support patient movements. Pharmaceutical companies, however, are not interlinked indicating a different linking, or rather non—linking, style, discussed later in this paper.

Finally, Austrian self—help sites heavily interconnected their sites with German and international sites, primarily self—help sites green and orange nodes at the bottom of the network. In issue networks, links may be seen as recommendations to users. I do not want to somehow relate our empowered patients with, with something like charlatanism. While the self—help group excluded sites representing institutions they had trouble with, the director of the general health portal and the pharmaceutical company denied linking on general principles.

This shows that collective strategies of gaining visibility end where competition starts. Link exchanges supposed to create mutual pathways between Web sites may turn into one—way streets when the size and traffic of sites differ too greatly, according to him. The visibility generated this way did not pay off relative to the number of users potentially lost. Further, losing users would also mean losing appeal to sponsors, threatening his business success. This underlines that the provider of the health portal perceived himself in a competitive relationship with other Web sites.

Similarly, the PR manager of the pharmaceutical company did not link to other corporations in the field of diabetes, she said, mirroring off—line dynamics. While Web sites in competition with each other hardly employed links to gain visibility, they strongly employed individual techniques of search engine optimisation SEO.

In talking about the way users reached their sites, all Web site providers mentioned search engines rather than links. The director of the health portal, for example, referred to the amount of links pointing to the site, keywords, and text as central elements co—determining the position of Web sites in organic search engine results as opposed to paid links, which all site providers included in the study neglected.

Extensive link exchanges with other sites may thus be seen as serving the goal of gaining visibility in search engine results as well, as the provider of the semi—commercial site argued.

The provider of the health information portal, however, mainly invested funds to gain visibility in search engine results. To be able to maintain a professional health portal, it is obligatory to get technical support from professional SEO agencies, ranging from basic adjustments of links and metatext to sophisticated audience analysis, he explained. Similarly, the PR manager of the pharmaceutical company said that the technical side of the Web site was maintained by the headquarters of the corporation in a professional way.

This indicates that for—profit medical sites gamed search engine algorithms on a large scale. Providers of non—profit Web sites, in contrast, associated the strategy of gaining visibility by deliberately trying to climb up the Google result list with manipulating their sites and off—line services that appeared tightly intermingled with their sites. When the Webmaster of the diabetes association was asked whether he cared about SEO, he said:.

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He further added that putting extra links on the site to please Google would run counter to his basic approach to links as recommendations for users. This shows that there is a certain tension between serving users and serving search engines that for—profit Web sites are more willing to accept due to their primary goal of raising user traffic and money. Finally, some providers followed the strategy of extending their online presence by observing users.

Both the PR manager of the pharmaceutical company and the doctor said that they use statistics like those generated by Google Analytics to figure out what search terms users chose to reach their sites and adapt their content accordingly. Providers offering medical Web sites to make a profit were particularly interested in the number of users coming to their sites. In addition to site statistics, the director of the health portal said that they conducted online surveys with their users on a regular basis.

None of the investigated Web sites made use of social media such as Facebook or Twitter at the time of our analysis. Since the initial study, both the professional health portal and the semi—commercial diabetes site have Facebook and Twitter buttons on their sites, indicating their desire to use social media to attract additional users. All of the other sites still do not use any of these services. This underlines once again that the two sites operated as businesses have the greatest motivation to increase user traffic, not the least to satisfy their advertising clients.

How the use of Facebook, Twitter and co. This paper investigated how different types of diabetes—related Web sites — ranging from professional to self—made pages, commercial to non—commercial information sources, expert to lay sites — are designed, formatted and positioned in the mass of online health information. In line with Oudshoorn and Somers , it has shown that the different goals Web site providers follow, but also their resources in terms of technical expertise and budget have a crucial impact on the way their sites are configured and made available to users.

The increasing dominance of search engines in user practices led to a battle for attention amongst Web site providers. All site providers examined in the study employed a variety of strategies to gain visibility in search engine results. Particularly large sites with sufficient manpower and technical know—how aggressively tried to climb up Google results, by trying to tweak the PageRank algorithm, rather than their users.

Together with self—perpetuating effects that search engines trigger Diaz , this leads to centralising tendencies partly mirroring off—line power relations and hierarchies. Moreover, these tendencies leading to the commodification of medical Web information challenge the democratic ideal of the Web. Only when going further down search results or employing more specialised keywords will users reach smaller, non—profit sites, such as those by the patient association or the doctor [ 14 ].

The Web should thus not be seen as entirely removed from the off—line environment. Rather, off—line power relations are translated into the online environment, strengthening large and popular medical institutions and viewpoints, while silencing actors with less prominent voices and counter—cultural approaches. These power relations can be seen as crucially contradicting the notion of the Web as a public sphere, populated by speakers with equal opportunities to reach a global audience.

Censorship and deletion practices in Chinese social media. First Monday, 17 3. Another Hong Kong election, another pro-Beijing leader-why it matters. Brookings Institute.

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Governance, 16 2 , Chen, C. Growing social unrest and emergent protest groups in China. Chen, X. Social protest and contentious authoritarianism in China. Cambridge University Press.

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