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In Search of Quality Health Information

Published:January 18, 2010DOI:https://doi.org/10.1016/j.pedhc.2009.11.001

      Key words

      Jennifer D'Auria, PhD, RN, CPNP
      University of North Carolina at Chapel Hill
      School of Nursing
      Chapel Hill, North Carolina

      Why this department?

      Ninety percent of individuals expect their health professional to refer them to reliable online sources for health information (

      Health On the Net Foundation. (2005). Analysis of 9th HON survey of health and medical Internet users (Winter 2004-2005). Retrieved from http://www.hon.ch/Survey/Survey2005/res.html

      ). Respondents reported that online health information improved both their knowledge and the quality of communication with their health professional. The editors of JPHC determined that a column dedicated to online educational and informational resources would help pediatric nurse practitioners (PNPs) guide children and their families to reliable health resources on the Web. On the Web will be published three times a year as a 1- to 2-page column in the Online Only Content section of the JPHC. It will be interactive and link to reliable health information on the Web that PNPs may incorporate into their practice regimens.

      Searching for health information

      The most recent findings from the Pew Internet & American Life Project (

      Fox, S., & Jones, S. (2009, June). The social life of health information (Pew Internet & American Life Project). Retrieved from http://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information.aspx?r=1

      ) indicated that 61% of American adults go online to locate health information. Survey respondents indicated that the results of online health information searches had a strong effect on how they managed their own health or the health of someone else. More findings from this study about online health information include the following (

      Fox, S., & Jones, S. (2009, June). The social life of health information (Pew Internet & American Life Project). Retrieved from http://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information.aspx?r=1

      ):
      • 60% say the information found online affected a decision about how to treat an illness or condition
      • 56% say it changed their overall approach to maintaining their health or the health of someone they help take care of
      • 53% say it led them to ask a doctor new questions or to get a second opinion from another doctor
      • 49% say it changed the way they think about diet, exercise, or stress management
      • 38% say it affected a decision about whether to see a doctor
      • 38% say it changed the way they cope with a chronic condition or manage pain
      Few studies have evaluated the outcomes for patients or individuals who use online health information, Web-based interventions, and support groups (
      • Christensen H.
      • Griffiths K.M.
      • Farrer L.J.
      Adherence in Internet interventions for anxiety and depression.
      ,
      • Griffiths K.M.
      • Calear A.L.
      • Banfield M.
      Systematic review on Internet support groups (ISGs) and depression (1): Do ISGs reduce depressive symptoms?.
      ). In the HON survey (2005), only 3% of the consumer respondents reported knowing of someone who was harmed by medical or health advice they received on the Web. More than 70% of health professionals participating in the survey reported that they found it helpful to refer patients to high-quality health Web sites. However, they reported worries about the effect of online health information on self-treatment, adherence, and challenging of medical authority. Health professionals also reported concern with the impact on patients of health information shared in online support groups.

      Evaluating the quality of health information

      A variety of approaches have been used to educate Internet users about how to evaluate the quality of health information on the Web. These initiatives include criteria guidelines and user education.
      General evaluative guidelines for assessing the credibility of online health information commonly include such criteria as authority of the site, accuracy of content, currency of information, design, disclosure, and ease of use.
      Quality criteria guidelines have been an important resource for professionals and consumers to aid in evaluation of credible health information (
      • Eysenbach G.
      • Powell J.
      • Kuss O.
      • Sa E.R.
      Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review.
      ). General evaluative guidelines for assessing the credibility of online health information commonly include such criteria as authority of the site, accuracy of content, currency of information, design, disclosure, and ease of use. Web sites that offer ideas on how to evaluate quality health information on the Web are found in the Box.
      Resources for evaluating the quality of health information on the Web
      Several associations and organizations evaluate the information on health Web sites using their own published guidelines and provide access to consumers. Governmental health organizations like HealthFinder (http://www.heathfinder.gov) and MedlinePlus (http://www.medlineplus.gov) provide free access to a catalog of educational health information that may guide patients in their health decision making. The Medical Library Association publishes A User's Guide to Finding and Evaluating Health Information on the Web (http://www.mlanet.org/resources/userguide.html). This guide includes a “Top Ten” list of consumer Web sites with links to many quality Web sites focused on cancer, diabetes, and heart disease. The Consumer and Patient Health Education Section of the Medical Library Association regularly publishes the “Top 100 List” (http://caphis.mlanet.org/consumer/index.html), which is a rich resource for quality health information.
      User education is another strategy that has had some success in teaching health consumers how to evaluate the quality of online health information. The DISCERN Internet Project (http://www.discern.org.uk) focused on helping health consumers evaluate the quality of health information regarding treatment choices (
      • Charnock D.
      • Shepperd S.
      Learning to DISCERN online: Applying an appraisal tool to health websites in workshop setting.
      ). The DISCERN instrument is a 15-item questionnaire for appraisal of evidence. A health care consumer must be able to interpret quality criteria, have the motivation to fill out the survey, and interpret the score. The DISCERN tool has shown some potential as a valid indicator of quality health information (
      • Griffiths K.M.
      • Christensen H.
      Website quality indicators for consumers.
      ). The Brief DISCERN (6 items) was recently constructed and tested (
      • Khazaal Y.
      • Chatton A.
      • Cochand S.
      • Coquard O.
      • Fernandez S.
      • Khan R.
      • Zullino D.
      Brief DISCERN, six questions for the evaluation of evidence-based content of health-related websites.
      ). Study findings supported that this tool facilitated the identification of evidence-based information on health Web sites.
      Another endeavor to guide the consumer in the appraisal of health sites was the Judge Project (

      Childs, S. (2004). Developing health website quality assessment guidelines for the voluntary sector: outcomes from the Judge Project. Health Information and Libraries Journal, 21(Suppl. 2), 14–26.

      ). Focus groups and surveys were used to collect data from health consumers and members of support groups regarding: (a) concerns about the Web and (b) help they needed to evaluate online health information. The Judge Guidelines for health care consumers and a set of guidelines for Web publishers resulted from the findings of this study.

      Safeguarding the quality of health information

      Accreditations developed by third-party organizations are another mechanism to safeguard the quality of health information on the Web. The HON (http://www.hon.ch) and URAC (http://www.urac.org) (original name: Utilization Review Accreditation Commission) have been leaders in monitoring the quality of online health information. Participation of a Web site in these organizations is voluntary. These accreditations guarantee that organizations use a set of standards and processes that promote credible and reliable health information on Web sites. The quality labels or seals of approval for these organizations generally are located on the home page of a site. Both organizations have online directories of accredited sites.
      The HON Foundation Code of Conduct (HONcode) was the earliest quality initiative to guide consumers and health care professionals to reliable sources of health information on the Web. The HONcode logo indicates that health Web sites hold to eight ethical standards to improve the reliability of health information published on their sites. More than 6800 Web sites are certified by HON, and sites must be re-accredited annually. The HON site includes several services to guide users to reliable health information, including the search engines MedHunt and HONcodeHUNT.
      URAC is an accreditation body originally founded in 1990 by the American HealthCare Accreditation Association. URAC accredits many types of health care organizations, including call centers and health plans. In 2001, it was the first organization to expand accreditation to health Web sites. The URAC Health Web Site Accreditation program specifically evaluates health content editorial processes and evidence-based information.

      Credibility of health web sites

      Credibility refers to the quality of being believed. According to

      Fogg, B. J., Soohoo, C., Danielson, D. R., Marable, L., Stanford, J., & Tauber, E. R. (2003). How do users evaluate the credibility of Web sites? A study with over 2,500 participants. Proceedings of the 2003 Conference on Designing for User Experiences (pp. 1–15). New York, NY: ACM Press.

      , the perception of credibility is based on a perception of both trustworthiness and expertise. Research findings support that consumers and health professionals evaluate the credibility of online information in different ways.

      Stanford, J., Tauber, E., Fogg, B. J., & Marable, L. (2002). Expert vs. Online Consumers: A Comparative Credibility Study of Health and Finance Web Sites. Retrieved from http://www.consumerwebwatch.org/dynamic/web-credibility-reports-experts-vs-online.cfm.

      found that consumers ranked design, information focus, and information design as their top three priorities when judging the credibility of health Web sites. In contrast, health care professionals ranked the reputation of the site publisher, information source, and company motive as their top three priority items.
      The findings of several other studies have supported that the visual design of a site may influence the assessment of health information by Internet users. Using regression analysis,
      • Barnes M.D.
      • Penrod C.
      • Neiger B.L.
      • Merrill R.M.
      • Thackeray R.
      • Eggett D.L.
      • Thomas E.
      Measuring the relevance of evaluation criteria among health information seekers on the Internet.
      found that design and aesthetics was one of six significant predictors participants used to identify quality information on health Web sites. The other predictors included content, currency of information, and contact details. In a large study focused on the credibility of Web sites, 41% of consumers reported the design of a Web site was an important factor for determining the credibility of a health Web site (

      Fogg, B. J., Soohoo, C., Danielson, D. R., Marable, L., Stanford, J., & Tauber, E. R. (2003). How do users evaluate the credibility of Web sites? A study with over 2,500 participants. Proceedings of the 2003 Conference on Designing for User Experiences (pp. 1–15). New York, NY: ACM Press.

      ). Study participants viewed health Web sites as more credible if they provided useful information and had a clear focus.
      Other studies also have supported the finding that the design of a Web site is important to the individual who searches for online health information.
      • Robins D.
      • Holmes J.
      • Stansbury M.
      Consumer health information on the Web: The relationship of visual design and perceptions of credibility.
      investigated the relationship of consumer preferences for the visual presentation of health information to the credibility ratings of that information on 31 health information Web sites. Their findings supported that when participants gave higher ratings for visual design, they also rated the information on a health Web site as more credible. Participants also judged the credibility of health Web sites higher if the sponsor was reputable and sites were not-for-profit.

      Where do internet users look for health information on the web?

      The popularity of Web sites is another mechanism for identifying potential sources of online health information. Alexa: The Web Information Company (http://www.alexa.com) provides information and traffic details about Web sites by country and by category. Use of the following search trail on Alexa will result in a list of the top child health sites ranked by popularity (number of visitors and pageviews) for the past month: Top Sites>(By Category) Health>(by sub-category) Child Health.
      On October 26, 2009, the top child health Web site as calculated by Alexa was a highly reputable site, Kidshealth (http://kidshealth.org), created by the Nemours Foundation. Alexa also provides a link to each Web site with a brief description about the site, including the publisher of the site and user reviews (by both consumers and health professionals). Reading what Internet users have to say about a site will provide further insight into what they evaluate and value on a health Web site.

      In the eye of the beholder

      A first step in guiding children and their families to quality health information is to provide tips for identifying a quality Web site.
      The Web has become an important source of health information for parents who go online.

      Allen, K., & Rainie, L. (2002). Parents online (Pew Internet & American Life Project). Retrieved from http://www.pewinternet.org/Reports/2002/Parents-Online.aspx?r=1

      found that 62% of parents who use the Internet were concerned about the reliability of health information; however, most parents did not routinely check the information sources or sponsorship of the Web sites they visited. Quality is in the eye of the beholder. A first step in guiding children and their families to quality health information is to provide tips for identifying a quality Web site (Table). A second step is to search the Web for health information that is useful and relevant to the children and families in your practice setting. Start searching today!
      TableQuality criteria and clues to evaluate health information on the Web
      CriteriaClues
      Authority
       Author, credentials/qualificationsURL/domain
       SponsorLast updated
       Advisory board membersAbout us
       Contact detailsSponsor policy
       AwardsCopyright statement
       Date of siteGoogle the author, organization, or site
      PurposeURL/domain
       AudienceAbout us
       Intent of the siteWriting tone
       Relevance and usefulnessSponsor policy
       Balanced, unbiased informationPrivacy policy
       Privacy and disclosure policiesTerms of use
      Advertising policy
      Design
       Appealing designHome button
       Easy to navigateNavigation buttons
       Easy to readSite maps
       Pages download quicklyAttractive color, fonts
       LinksInternal search engine
       Internal search capabilityNo broken or dead links
       Interactivity (feedback mechanisms)Notifies user when leaving site
       Advertisement policiesAdvertisements clearly labeled
      ContentLast updated: site, pages, content
       Accurate and completeProper references
       Currency of informationFirst-hand information
       Evidence basedGood writing style, level; proofread
       Sources of information documentedReview cycle or content update policies
       Editorial review processesLinks to quality external sites
       Health disclaimerWho links to site (Google search)
       Contact information: Help, questionsCertifications: HON, URAC
      HON, Health on the Net Foundation; URL, uniform resource locator.
      Please note: All readers are encouraged to submit questions, ideas, and potential manuscripts for this column.

      References

      1. Allen, K., & Rainie, L. (2002). Parents online (Pew Internet & American Life Project). Retrieved from http://www.pewinternet.org/Reports/2002/Parents-Online.aspx?r=1

        • Barnes M.D.
        • Penrod C.
        • Neiger B.L.
        • Merrill R.M.
        • Thackeray R.
        • Eggett D.L.
        • Thomas E.
        Measuring the relevance of evaluation criteria among health information seekers on the Internet.
        Journal of Health Psychology. 2003; 8: 71-82
        • Charnock D.
        • Shepperd S.
        Learning to DISCERN online: Applying an appraisal tool to health websites in workshop setting.
        Health Education Research. 2004; 19: 440-446
      2. Childs, S. (2004). Developing health website quality assessment guidelines for the voluntary sector: outcomes from the Judge Project. Health Information and Libraries Journal, 21(Suppl. 2), 14–26.

        • Christensen H.
        • Griffiths K.M.
        • Farrer L.J.
        Adherence in Internet interventions for anxiety and depression.
        Medical Internet Research. 2009; 11: e13https://doi.org/10.2196/jmir.1194
        • Eysenbach G.
        • Powell J.
        • Kuss O.
        • Sa E.R.
        Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review.
        Journal of the American Medical Association. 2002; 287: 2691-2700
      3. Fogg, B. J., Soohoo, C., Danielson, D. R., Marable, L., Stanford, J., & Tauber, E. R. (2003). How do users evaluate the credibility of Web sites? A study with over 2,500 participants. Proceedings of the 2003 Conference on Designing for User Experiences (pp. 1–15). New York, NY: ACM Press.

      4. Fox, S., & Jones, S. (2009, June). The social life of health information (Pew Internet & American Life Project). Retrieved from http://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information.aspx?r=1

        • Griffiths K.M.
        • Christensen H.
        Website quality indicators for consumers.
        Journal of Medical Internet Research. 2005; 7: e55https://doi.org/10.2196/jmir.7.5.e55
        • Griffiths K.M.
        • Calear A.L.
        • Banfield M.
        Systematic review on Internet support groups (ISGs) and depression (1): Do ISGs reduce depressive symptoms?.
        Journal of Medical Internet Research. 2009; 11: e40https://doi.org/10.2196/jmir.1270
      5. Health On the Net Foundation. (2005). Analysis of 9th HON survey of health and medical Internet users (Winter 2004-2005). Retrieved from http://www.hon.ch/Survey/Survey2005/res.html

        • Khazaal Y.
        • Chatton A.
        • Cochand S.
        • Coquard O.
        • Fernandez S.
        • Khan R.
        • Zullino D.
        Brief DISCERN, six questions for the evaluation of evidence-based content of health-related websites.
        Patient Education and Counseling. 2009; 77: 33-37
        • Robins D.
        • Holmes J.
        • Stansbury M.
        Consumer health information on the Web: The relationship of visual design and perceptions of credibility.
        Journal of the American Society for Information Science and Technology. 2009; ([Published online October 2, 2009]. doi:10.1002/asi.21224)
      6. Stanford, J., Tauber, E., Fogg, B. J., & Marable, L. (2002). Expert vs. Online Consumers: A Comparative Credibility Study of Health and Finance Web Sites. Retrieved from http://www.consumerwebwatch.org/dynamic/web-credibility-reports-experts-vs-online.cfm.

      Biography

      Jennifer P. D'Auria, Associate Professor, The University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC.