Excerpt of the 8th HON's Survey of Health and Medical Internet Users

For the past six years, the Health On the Net Foundation has been tracking opinions of Internet users of health information through eight online surveys. The similitude of the surveys each year gives an interesting touch to the potential for understanding trends over the years.

A total of 2621 respondents voluntarily completed the survey questionnaire between May and June 2002. Mainly from North America (United States 38%, Canada 4%, Mexico 1.5%) and Europe (29%), worldwide citizens responded (South America 7%, Asia 6%, Oceania 3%, Middle East 2%, Africa 1.4%) (Table 3). This current paper aims at presenting some observations based on the results. We invite readers to consult the online charts also available for further details [1] http://www.hon.ch/Survey/Spring2002/res.html .

Most Important Issues facing the Internet

Both groups of respondents, patients and health professionals, agreed that 'Accuracy of Information' is the most important issue facing the medical Internet. The next item of concern for patients was 'Trustworthiness' and for professionals, 'Finding information/Navigation' and 'Availability of information'.

TABLE 1 MOST CRITICAL ISSUES FACING THE MEDICAL INTERNET

In your opinion, what is the most critical issue facing the Internet and especially the medical Internet?
	Total Sample, n=2621	Patients, n=1318	Professionals, n=1294
Accuracy of information	26.33 %	27.92 %	24.88 %
Trustworthiness	11.45 %	13.20 %	9.74 %
Finding information/Navigation	10.99 %	10.77 %	11.21 %
Availability of information	8.85 %	6.75 %	11.05 %
"Junk" web sites	5.84 %	6.68 %	5.02 %
Unsolicited Commercial Email (Spam)	5.38 %	5.61 %	5.18 %
Paying for online services or information	5.11 %	2.96 %	7.34 %
Pornography	3.97 %	4.55 %	3.4 %
Privacy	3.85 %	4.48 %	3.25 %
Equal access for all	3.59 %	3.72 %	3.4 %
Cost	2.21 %	1.75 %	2.7 %
Commercialisation/Advertising	1.95 %	1.9 %	2.01 %
Speed/Bandwidth	1.95 %	1.29 %	2.63 %
Government regulation	1.34 %	1.75 %	0.93 %
Security of electronic commerce	1.34 %	1.37 %	1.31 %
Access for disabled or physically impaired	1.14 %	1.37 %	0.93 %
Intellectual property/Copyright	1.14 %	0.76 %	1.55 %
Censorship	0.46 %	0.46 %	0.46 %
Legality of services offered in my country	0.42 %	0.38 %	0.46 %
No response	2.71 %	2.35 %	2.55 %

Source: 8th HON Survey, Health On the Net Foundation, May-June 2002. NB: this year, respondents were only allowed to select only one answer among the choices.

Certification: a Potential Solution?

Divergent opinions exist about the need for accreditation of health web sites and adoption by Internet users. Actions for regulating or rating the health web have been criticized on several occasions [2] [3] [4]. Although limited by sample size (<25 respondents) and the brief amount of time spent on each web site, a study performed in Germany revealed that none of the participants clicked to verify the seal carried by some of the sites [4]. This later may reveal a lack of awareness about the seal or verification system. More information on the Internet user's opinion and behaviours in respect to the use of health web sites posting seals of accreditation is needed. The following results revealed that respondents showed a positive attitude for the certified sites. About 66% of persons who answered the patient section only (n=1318) think that certification and/or accreditation of medical web sites may help resolve the issues listed above while 71% of professionals (n=1294) expressed a similar opinion. Among all respondents, 59% favor certified web sites, while the rest stated that they did not favor them (25.3%) or did not answer the question (15.6%).

59% of respondents favor certified web sites

The most familiar accreditations or trust mark systems were the HONcode and the Good Housekeeping Seal of Approval, selected by 50.3% and 27.5% of respondents (n=2621) respectively. The third most familiar mark was Trust-e (13.4%). About 6% of respondents were familiar with the Internet Health Care coalition. The least familiar to respondents were the URAC accreditation and the NetScoring mark (<5%). However, 29.3% were not familiar with any of the proposed marks, revealing a need for public education. Part of the difference observed in familiarity level may be an artefact of the recruitment process.

Impact on the Patient-Physician Relationship

Survey respondents demonstrated a high degree of Internet use in their health care dealings. As many as 62% of patient-type respondents have discussed the results of their Internet searches with their care providers (n=1318) which is a larger proportion than previously reported (38% USA; 33% German; 17% Japanese respondents) [5], and 37% have used online consultation services offered by web sites (76% of them occasionally, 24% frequently).

Positive Aspects
Among those who discussed their results of Internet searches with their care providers, 38.3% said ensuing discussions with their care provider was helpful because it improved communication, 71.5% agreed that it made them more knowledgeable. More than half of patient-respondents (52.5%) agreed that discussion about their Internet searches contributed to a more constructive consultation. As the other player in the patient-physician relationship, health professionals had a receptive and positive attitude toward this behaviour. Almost 70% of health care professionals reported having patients discussing information they had found online. Half of health professionals with an opinion agreed that the consultation was more constructive when patients discussed information they have found on the Net with them. According to 47% of health professionals, this behaviour was helpful because patients become a better "partner".

52% of patients who discussed the results of Internet searches
with their care providers found the consultation more constructive.

Medical professionals have embraced the Internet, with nearly half (48.9%, n=1294) engaging in email correspondence with their patients. Among those who gave precision about the frequency of this behaviour, 20% reported emailing frequently and 80% occasionally (n=537). About one third of medical professionals reported recommending online discussion lists to their patients while 62.75% make web site recommendations.

Negative Aspects
Of the 899 health professionals (69.4%) who reported patients coming to them with information found on the Internet, 11.1% did not find it helpful. Almost one in five health professionals (18.4%) agreed that there is a "risk of patient self-treatment". However, only 3.67% medical professionals complained of a loss of physician control, and only 2.78% feel such communication is a waste of time. More research is needed in order to better understand the negative facets that e-health behaviour of patients may convey as reported by some professionals.

Patients' and Professionals' Preferences of Search Engines

Little information is known about the potential differences in Internet utilization among patients and health professionals. Forty-six percent (46%) of patients (n= 1256) preferred to use general search tools compared to 28% who preferred medical search tools. However, contrasting preferences are observed among health professionals (n= 1282) where 57% preferred using medical search tools compared to 28% who preferred general search tools. However, caution is needed to analyse these figures, which may hide a lower awareness of medical search engines within the general public but not necessarily a definite preference.

FIG.1 PREFERENCE OF PATIENTS AND PROFESSIONALS FOR DIFFERENT TYPES OF SEARCH ENGINES

Sources: 8th HON Survey, Health On the Net Foundation, May-June 2002.

Trends Over the Years
Since similar surveys have been conducted by HON over the last 6 years, we can observe some trends among the groups of respondents. Observing the different groups of volunteers who are e-health consumers, we observed consistent results over the different yearly samples in the integration of technology in their health care behaviours, and a slight increase in usage of email by patients with their regular physician.

TABLE 2 TRENDS OF THE INTEGRATION OF TECHNOLOGY IN HEALTH CARE BEHAVIOURS

	2002*	2001**	1999§
Seek out information on medical professionals sites	77%, (n=1206)	77% (n=1594)
Discussed their Internet finding with their physician	62% (n=1216)	64% (n=1635)	69% (n=2137)
Search drug information	81% (n=1249)	82% (n=1574)	79% (n=3195)
Buy drugs online	13% (n=1244)	14% (n=1613)	15% (n=3115)
Use the Internet for 2nd opinion	49% (n=1252)	43% (n=1649)	41% (n=2010)
Email their own physician	23% (n=1253)	14% (n=1509)	21% (n=2103)

Sources: * 8th HON Survey, Health On the Net Foundation, May-June 2002. ** 7th HON Survey, Evolution of the Internet use for health purposes, Health On the Net Foundation, Feb-March 2001. § - 1st HON Survey, Health On the Net Foundation, Oct-Nov 1999.

The comparison of the respondents' profiles over the years is also an interesting aspect representative of Internet penetration worldwide. European citizens may present e-health behaviours in various proportions (data not presented here subject to publication approval). Cultural variation was also observed when evaluating the ratio of patients or professionals responding to the surveys in USA or Europe.

Barriers and Preferences when using the Web

Three out of four non-medical-professional individuals (patients or others) reported seeking medical sites or sections dedicated to medical professionals (n=1318). Among people who gave a reason, the main one was a preference for access to more complex information (selected by 80% of respondents), or because they complain that the information usually accessed is too basic (45%) (n=896).

This access to more complex information may raise concerns or fears from some researchers or health professionals, worried that patients could misunderstand or become lost in the torrent of medical information. However, it can be reassuring that patients are taking active autonomous actions; first by performing alternative searches to clarify information (86%) and to a lesser extent, by asking their doctor (32%) if they do not understand the information read online (n=853).

Profile of Respondents

TABLE 3 PROFILE OF RESPONDENTS OVER TIME

	2002*	2001**	1999§
Geographical Location - North America - USA, Canada, Mexico - Europe - Oceania - South America - Asia - Africa	(n=2586) 44% 38%,4%,2% 29% 3% 7% 6% 1.4%	(n=2951) 54%,5%,1% 26% 4%	(n=3276) 59% 35% 1% 0%
Type of Respondent - Patients - Professionals	(n=2621) 50% 49%	(n=2883) 57% 43%	(n=2893) 49% 51%
Gender - Female - Male	(n=2586) 48.2% 49.9%	(n=2953) 48.5% 51.5%	(n=3092) 50.7% 49.2%
Age <19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60 yrs and over	(n=2586) <1% 12% 19% 29% 24% 13%	(n=2945) <1% 9% 20% 31% 25% 14%	(n=3099) <1% 13% 23% 21% 7% 2%

Method

HON surveys use non-probabilistic sampling and cannot ensure that participants are representative of the entire medical and health information-user community on the Internet. However, HON is one of the most important medical information portals on the Web today, and benefits from one of the highest link factors of all healthcare Web sites.

HON surveys have been posted on the HON Web site. A link from HON's home page led users directly to the questionnaire. HON's news list members were invited by email to fill the survey. Announcements and links to the 8th HON survey was also posted on 100 collaborative Web sites[6] to help reaching participants and potentially increase generalizability with a larger diversity of respondents.

About Health On the Net Foundation

The Health On the Net (HON) Foundation (http://www.hon.ch/) has been actively working to improve Internet access to quality health information and encourage ethical behaviour by health web sites since 1996. HON is mainly recognised and known worldwide for its HONcode accreditation of health web sites. As a pioneer observer of the medical Internet HON, established in Geneva, Switzerland, has recently been accorded Non-Governmental Organization (NGO) status by the United Nations, becoming the first online health accreditation agency with this status.

Acknowledgements

We would like to thank all respondents, and the web sites who collaborated by announcing the survey. Without this collaborative effort of the Internet community, our understanding of the health information users would be very limited.

Non-peer-reviewed article.

Citation Information:
Boyer C., Provost M., Baujard V. Highlights of the 8th HON Survey of Health and Medical Internet Users. Health On the Net Foundation, 2002. URL: http://www.hon.ch/Survey/8th_HON_results.html

References

[1] The Health On the Net. Spring 2002 Survey Responses, URL: http://www.hon.ch/Survey/Spring2002/res.html
[2] 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;324:569-73. URL: http://bmj.com/cgi/content/full/324/7337/569
[3] Purcell GP, Wilson P, Delamothe, The Quality of Health Information on the Internet., As for any other medium it varies widely; regulation is not the answer. BMJ 2002;324:557-8.URL: http://bmj.com/cgi/content/full/324/7337/557 .
[4] Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-dept interviews. BMJ 2002;324:573-7. URL: http://bmj.com/cgi/content/full/324/7337/573 .
[5] Taylor H, Leitman R. 4-Country Survey Finds Most Cyberchondriacs Believe Online Health Care Information Is Trusworthy, Easy to Find and Understand. HarrisInteractive News 2002; June 11: 2pp. URL:http://www.harrisinteractive.com/news/printerfriend.asp?NewsID=464 .
[6] The Health On the Net Foundation. Evolution of Internet Use for Health Purposes, Spring 2002. Financial and Promotional Support for the Survey, URL http://www.hon.ch/Survey/Spring2002/support.html