Excerpt of the presentation


A descriptive analysis of strategies in Spain for internet biomedical content evaluation

García S, Montesinos E, Baujard V, Boyer C.
Health On the Net Foundation, Geneva University Hospital, Switzerland

Learning objective:
After this presentation participants should be able to understand the following points. How the coexistence of several quality seals certifying one website can influence internet users, health professionals as well as general public. To determine if the existence of a growing number of initiatives regarding health content quality is beneficial. And to determine if a closer interaction amongst these initiatives is needed.

Introduction and goals:
The number of health related websites is rapidly growing, as well as the number of internet users in search of health information. The number of initiatives aimed at improving the quality of the health information offered are growing as well. The health information offered is very diverse, trusted medical information, reviewed by health professionals can be found, as well as information with no scientific support or background. This has lead to the development of control and evaluation tools.

The goal of these initiatives is to guide internet users in there search of health information. This guidance is done by determining if a website follows certain quality criteria regarding authorship, website funding and the existence of conflict of interest.

Different Spanish speaking initiatives can be found. By means of a health website certification process they guide the internet user.
We will study each one of them, comparing the methods they use and evaluate the coexistence of the different quality seals in a website.

Study design:
-First phase: Description and observation of Spanish projects for the certification of health information websites, by independent research in three generic search engines, five specialized search engines, Medline database and Spanish Medical Index. Keywords used: "internet, quality, information, ethic code, certification". The HON Foundation is excluded as it is used as the "gold standard", this initiative has the largest number of certified Spanish speaking websites. The initiatives are selected after evaluating authorship, institutional support, existence of a quality seal, how authorization is given to display the quality seal, and a listing of the websites certified. Each initiative is compared with the quality criteria established by the Health on the Net Foundation and the European Commission.

-Second phase: Independent observation by two researchers of the homepage of all the websites listed by each initiative. In each homepage the presence of one or more quality seals has been evaluated. If the seal was not found in the homepage, it was found in sections such as "credits, certifications". For the HONcode quality seal, the certification process status page was reviewed as well.

Regarding statistical analysis, a descriptive listing of the data was used.

Results:
From April to June 2003, besides HON, 9 health specific initiatives were identified. Each one provided a description of the criteria used for evaluation, certification and authorization to display there quality seal. The list of the initiatives studied is:

1. http://wma.comb.es/cat/llistat.php (seal name: Web Médica Acreditada; n=235).
2. http://www.pwmc.org/pwmc.php3 (seal name: Web Médica de Calidad; n=62).
3. http://www.hipocampo.org/ (seal name: Web Recomendada; n=26).
4. http://www.webmastersanitarios.org/Asociadas/asociadas.asp (seal name: SWS Calidad Biomedicina; n=98).
5. http://www.aurasalud.com/ (seal name: Web de Interés Divulgativo; n=42).
6. http://www.portalesmedicos.com/premio/medicina/ganadores.htm (seal name: Premios Web; n=45).
http://www.portalesmedicos.com/premio/medicina/2001.htm http://www.portalesmedicos.com/premio/medicina/2000.htm
7. http://www.seei.es/certificados/paginascertificadas.htm (seal name: Certificado de calidad de páginas electrónicas; n=40).
8.http://aemir.org/ (seal name: Web de Utilidad en Formación Médica Continuada n=52).

One initiative was disregarded (http://www.cristosalud.com) as it was unavailable at the time of this study.

The number of websites reviewed by each initiative ranges from 26 to 233. The total number of websites reviewed by the 8 initiative is 600 (n=600). 174 websites (29%) were using more than one quality seal and 35 (6%) were websites not found by the server. The number of websites displaying the HONcode (Health on the Net quality seal) was 215 (36%), of which 72 are under revision process.

The variability found in the seal being displayed by the website was high, only 53% (range 23%-96%) of the websites certified display the quality seal. 60% of the sites display more than one quality seals. In some cases 6 quality seals were found in the website.

The criteria used by each initiative is based on the quality Principles established by the Health on the Net Foundation and the European Commission. Some also include an evaluation of aspects related with the design, the accessibility, the existence of a sitemap, the differentiation of content for the general public and medical professionals, the use of references to evidence based medicine and practice guidelines and the use of plain language. All of the initiative are free of charge for the website.

Conclusions:
It has been noticed that most of the initiatives that guide the health internet users, by certifying health websites with a quality seal do not remain active for a long period of time.

The existence of multiples quality seals in one website does not indicate a higher quality of the website, regarding the principles of the different initiatives evaluated.

Users, and mostly patients, are not aware of all the quality initiatives existing, and they are not aware of the importance of looking for quality seals when doing there information search. A proposal to develop a platform, sponsored by each country government, with the collaboration of public institutions, professional associations, scientific societies and user associations, unifying the experience of each quality initiative should be taken into account, in order to improve the awareness of users and patients and avoid the confusion that comes from the existence of multiple quality seals. This awareness would keep the poor quality and fake medical information from the user-patient, and would avoid the consequences of misleading medical information. The European Union is studying the development of a joint action among its members to establish a quality seal for health websites. Initiatives such as MedCIRCLE have this objective.

Keywords:
Internet, quality, information, health, ethic code, certification.

Conflict of interests:
The authors have not received any external funding for this study. They are consulters with the Health on the Net Foundation.

Bibliography:
[1] Ávila JF, Portillo BE, Pajares JM. Calidad en la información biomédica existente en Internet. Aten Primaria 2001; 28 (10): 674 - 679.
[2] Eysenbach G, Powell J, Kuss O, Sa ER. Empirical studies assessing the quality of health information for consumers on the World Wide. A systematic review. JAMA. 2002; 287:2691-2700.
[3] Fox S, Fallows D. Internet Health Resources: Health searches and email have become more commonplace, but there is room for improvement in searches and overall Internet access. Pew Internet & American Life Project. 2003. Available in: http://www.pewinternet.org/reports/
[4] Gagliardi, A, Jadad, A. Examination of instruments used to rate quality of health information on the internet: chronicle of a voyage with an unclear destination. BMJ 2002; 324: 569-573.
[5] Mayer MA. Acreditar webs de contenido sanitario: ¿una necesidad imposible? Med Clin (Barc) 2001; 116: 496 - 497.
[6] Purcell GP, Wilson P, Delamothe T. The quality of health information on the internet. BMJ 2002; 324: 557-558
[7] Smith R. Almost no evidence exists that the internet harms health. BMJ 2001; 323: 651.