A PLETHORA of health information is available on the Internet. Consumers (general readers as well as healthcare professionals) frequently search for facts, opinions, and scientific studies on disease states and wellness. Knowing if the retrieved information is reliable can be challenging. In order to advise patients accurately, nurses must first learn how to determine the credibility of a health information website and become familiar with high-quality resources. This article provides guidance for assessing Internet health information with quick-look tips to determine a website's validity.
Surfing the web
Seeking health information is as popular as playing games or downloading music online.1 In 2011, 80% of adults used the Internet as a resource for healthcare decision making.2 Let's take a look at one frequently accessed site: WebMD.
A popular website, WebMD is among the first to appear when a search for health information is entered into a search bar. Its parent company, WebMD Health Corporation, also includes Medscape, MedicineNet, eMedicineHealth, and RxList.
Upon accessing the WebMD home page, the user sees approximately 10 colorful pictures directing the user to news articles and articles on health conditions. Among the pictures are advertisements, which are identified with the word advertisement in tiny, pale-colored font that can be easily overlooked. This makes distinguishing advertisements from health information difficult.
Like most web pages, WebMD has an About Us section located at the bottom of the home page. Called “About WebMD,” it identifies the medical editors. However, the only way to truly check their credibility is to validate each editor's information individually.
WebMD is a commercial website (.com) with several sponsors; however, the sponsors' content isn't clearly distinguished from WebMD's own content. Furthermore, the content provided by the sponsors isn't reviewed by the WebMD editors for accuracy—a fact that's provided only after several clicks in the About WebMD section.
The possibility of bias on any commercial website can manifest in many different forms and may be subtle. On health information websites owned by drug companies, for example, the consumer may be directed to the drug company's product as the treatment of choice for a given condition even if this drug isn't the treatment of choice per clinical practice guidelines. Similarly, treatment recommendations for brand name drugs instead of generic versions can direct a consumer to a specific drug company—an example of indirect bias.
Hospital-based websites can also be biased—for example, when someone searching for a recommendation for a bone scan is referred to that hospital with a convenient click.
An emblem found on many health websites is the Health On the Net Foundation (HON) code seal. HON was developed by a Swiss nongovernment organization to monitor and improve the quality of health information on the Internet. Website authors/organizations that apply for the HON code seal must meet a set of criteria that include a disclosure of the authors' qualifications, citation of the sources of published information, potential conflicts of interest, and identity of the funding source. The websites must also clearly distinguish advertising from editorial content.3
The HON code seal implies a standard for trustworthy health information and can be seen on various websites. However, the HON designation doesn't necessarily ensure that a website's content is of high scientific quality, and the organization doesn't guarantee the accuracy of information.3-5 Although the HON organization periodically reviews sites that display the HON code seal, they rely on users to report noncompliance. Nurses shouldn't automatically assume that health information they retrieve from websites displaying the HON seal is credible or based on high-quality evidence. Unfortunately, there's no way to determine if a website displaying the HON code is credible. Use a tool such as the REAL mnemonic to help evaluate a site's credibility. (See Finding REAL websites.)
Check the domain
One way to find credible health information websites is to check the Internet domain or uniform resource locators (URLs).6 Searching directly on government agency or university sites is a good approach. Government sites (.gov) are the least likely to be biased by outside influences because Federal policy prohibits nongovernmental advertising on government websites.7 The reliability of university websites (.edu) is likely to be directly related to the quality of the academic institution, which can be difficult to evaluate considering the many institution accrediting agencies. Check information sources, or look for the author's contact information; the availability of contact information is a good sign that authors are willing to answer questions from readers. If the authors are accessible, they can provide such information as their authority to address the subject matter of the website.
Organizational sites (.org) were formerly available only to nonprofit organizations or noncommercial entities; however, today anyone can purchase and register for .org or .net domains. .Net domains were originally reserved for organizations involved in networking technologies. Nowadays, the .net domain is available for people who want a specific domain that's already taken under the .com or .org domain extensions. Be cautious when consulting .org or .net websites because many of them represent the interest of the organization or personal opinions and may contain overt or subtle bias.
Commercial websites can be very valuable for certain purposes, as long as the viewer is aware of potential bias or conflicts of interest. For instance, PatientsLikeMe.com is a data-sharing community of patients, physicians, and organizations. Patients can connect with thousands of others with the same condition, share their daily struggles, and learn about research and treatment options. Reports on disease states are retrieved by researchers and this data can be used to improve patient outcomes. Additionally, patient and industry interests are aligned through data-sharing partnerships working toward improvement in service, products, and patient care. Health information websites with a .com domain shouldn't be totally excluded, but viewers should conduct a detailed evaluation of every .com site.
What a reliable website looks like
Credible sites such as the National Institutes of Health (nih.gov) typically display clear text without commercial advertisements. Reliable healthcare websites are usually easy to navigate and often outline an area for general readers and a separate section for professionals. The literature sources are trustworthy with links provided to support sourced evidence and connect to other credible sites. All the links from reliable, well-maintained websites work well, and are relevant and appropriate.
Credibility is based on the fact that the sites aren't sponsored and have concrete references. Look for a notation that the site was updated recently. Occasionally the updated date may be older than the recently posted articles; however, current postings on the site indicate that it's being maintained well.
Websites that are valid and credible clearly detail the purpose of the site in the About Us section. Claimed experts are affiliated with legitimate organizations and their credentials and contact information are provided, making it easy to validate authors' expertise.
Evaluating a website is a complex task and can be difficult for nonexperts.8 Advise patients to search for websites that offer consumer health information without advertisements to alleviate some of the issues with website reliability. Reliable websites are best accessed via the nih.gov or cdc.gov search boxes rather than using large search engines. Lay users may be drawn to the visual aspect of a website rather than content; tell them to avoid sites with promotional tones and to obtain information only from sites that are clearly noncommercial and are likely to be nonbiased.8 Searchers must be savvy concerning a website's currency and look for a last modified date; although there's no established standard of time for updating, if changes are needed they're usually made every 2 to 3 months.9
Questionnaires are available to guide users to reliable health information on the Internet, but no criteria have been established for evaluating the quality of a website based on scores achieved on the questionnaires.5 Reliable sources that don't have questionnaire scores include: How to Evaluate Health Information on the Internet: Questions and Answers, Evaluating Online Sources of Health Information, and Evaluating Health Information (all found via the nih.gov search box).
Cracking the credibility code
Credible sites such as nih.gov provide many reliable forward links for health information. For instance, by typing diabetes into the search box, links are available to MedlinePlus, which is the NIH website for patients, as well as Pubmed Health, a health information site from the National Library of Medicine. The diabetes search also links to The National Diabetes Information Clearinghouse and numerous NIH sites relevant for patient and nursing research.
An excellent nursing research site is the Robert Wood Johnson Foundation website (rwjf.org) that works to build a culture of health in America. Healthcare research article summaries that include the purpose of the article, key findings, and the conclusions can be retrieved by typing your area of interest into the “find RWJF research” box. Finally, the CDC (cdc.gov) has a wealth of valuable health information available for professionals as well as patients, with forward links to numerous reliable sources. Rather than searching for health information using a standard search engine, go directly to the nih.gov or cdc.gov website. A query typed into either site's search box will yield thousands of trustworthy health information sites, all with .gov URLs.
Practice safe searching
Approach each site with careful analysis and a healthy dose of skepticism. Limit your search to the government site MedlinePlus and other sites that you've evaluated for credibility using the REAL evaluation tool. A firm grasp of the evaluation process and assessment vigilance is warranted both by the healthcare professional and the layperson who seek reliable health information. Remember: Anyone can publish anything on the Internet.
Finding REAL websites
* Read the url. Use .gov or .edu websites; avoid using personal/commercial sites unless you've previously performed an in-depth evaluation by checking the expertise of the authors and comparing the content for accuracy with sites known to be valid, such as .gov sites.
* Examine the content. Are the facts similar to facts found on other sites? Is the site well maintained with working forward links? Is the site up to date?
* Assess the author and the publisher. Is the author's name and contact information provided? Is information about the author provided? Is the author an expert on the topic?
* Look at the links. When you assess the URLs of the forward links, look for a variety of forward links to universities or government sites. Do you detect possible bias on the forward links?
Resource: November A. Web literacy for educators. 2008. https://hcsearcheval.wikispaces.com/Alan+November's+REAL.
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