How do patients evaluate and make use of online health information?

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Abstract

Increasing numbers of people are turning to the Internet for health advice despite reports that sites vary in terms of their quality. How do they decide whether or not to trust the advice they find online? A staged model of trust development is proposed and tested here in a longitudinal study in which fifteen women faced with decisions concerning the menopause and hormone replacement therapy (HRT) were observed while searching the Internet for information and advice over four consecutive weeks and then kept diaries over a six-month follow-up period. The women were all resident in the North-East of England and were recruited through advertisements in the local media. The study provided general support for a three-stage model of trust in which participants firstly engaged in rapid heuristic processing of information, efficiently sifting and rejecting general sales sites and portals but sometimes rejecting high-quality content because of poor design. Well-designed sites were then effectively interrogated for credible and personalized content before being designated trustworthy. The women appeared to act much like ‘scientists’ using web material to generate and test hypotheses and theories about HRT, although their capacity to deal with certain forms of risk information was limited. They subsequently reported integrating online advice with offline advice from friends, family and physicians in order to be fully confident in their final decisions. Women felt that the Internet influenced their decision-making and improved communications with physicians. Personalized stories from like-minded others improved trust perceptions. Despite the use of the Internet the physician was still seen as the primary source of information and advice.

Introduction

The Internet is an important source for health information and advice. Many of those who have access to the Internet use it for health care purposes, although usage estimates vary. It has been claimed that 80% of adults in the US and 66% of adults in Europe seek online health advice (Pew Research, 2003; Taylor & Leitman, 2002), although one of the most rigorous telephone-based surveys—conducted on 4764 US adults—put the figure at 40%, with about a third of these reporting that the Internet genuinely affected a health-care decision (Baker, Wagner, Singer, & Bundorf, 2003). Surveys of young people suggest that the Internet is a particularly appealing source of information and advice for them, especially when they want information about sensitive or stigmatized illnesses (Berger, Wagner, & Baker, 2005; Klein & Wilson, 2003).

Many people searching online for health advice trust the information and advice they find (Mead, Varnam, Rogers, & Roland, 2003). However this trust may be misplaced: in a systematic meta-analysis of health website evaluations, 70% of studies concluded that quality is a problem on the Internet (Eysenbach, Powell, Kuss, & Sa, 2002).

In the face of such variable quality, how do health consumers decide whether or not to trust the information and advice they find online? Relatively little is known about this, although we do know that ordinary health consumers are likely to adopt different trust criteria from experts, for example being more readily influenced by the attractiveness of the design, (Stanford, Tauber, Fogg, & Marable, 2002). Eysenbach and Köhler (2002) noted that non-expert consumers failed to read disclosure statements or check ownership of the website, despite suggesting these beforehand as important quality markers. Their study made use of an artificial search task, however, and the authors themselves conceded that different trust factors might be influential in a more realistic setting.

The literature regarding trust in an e-commerce setting provides a useful starting point for exploring the ways in which people evaluate the trustworthiness of health information and advice online (see Grabner-Krauter & Kaluscha, 2003 for a recent review). Based on this literature we can assume that various factors are likely to govern the extent to which people feel they can trust health advice online, although there is some disagreement over their relative importance in fostering trust in an e-commerce context. For example, some researchers argue that consumer trust (or a related construct, credibility) is primarily driven by an attractive and professional design (Fogg et al., 2002; Stanford et al., 2002) or by the presence or absence of visual anchors or prominent features such as a photograph or trust seal (Riegelsberger, Sasse, & McCarthy, 2003). Others argue that trust reflects the perceived competence, integrity, predictability and/or benevolence of the site (Bhattacherjee, 2002; McKnight & Chervany, 2001). A few authors also highlight the importance of personalization in the formation of trust judgments (Briggs, de Angeli, & Simpson, 2004) or the notion of good relationship management (Egger, 2000).

One way of reconciling such potentially contradictory findings is to adopt a staged model of trust in which users engage in a fast preliminary assessment of a site before moving on to a more in-depth evaluation of the information available in a selected few sites, and finally developing a long-term trusting relationship with one or more particular sites. Such a model (Fig. 1) was proposed by Briggs, Burford, de Angeli, and Lynch (2002).

According to this model, most users engage initially in a rapid screening of the large numbers of sites accessed using general search engines and do so using relatively superficial aspects of a website. Subsequently, they are presumed to spend longer exploring a handful of sites in greater depth using more considered judgments of content. The first stage is thus an heuristic or affect-based stage in which an initial trust impression is formed based upon more salient or easily processed information; the second stage is an analytic stage in which a decision is made to engage more systematically with the material. Such a strategy is consistent with dual-process models, such as those developed in the persuasion literature (Chaiken, 1980; Petty & Cacioppo, 1986).

It might be assumed that patients with genuine health concerns would be highly involved in the task and would therefore primarily engage in systematic processing of web content. However, most of those who seek health advice online begin their search via a general information portal, gaining indiscriminate access to large numbers of sites of variable quality (Briggs et al., 2002). Indeed, online health consumers often have to navigate their way through a large number of poor-quality sites in order to reach high-quality advice, and are initially open to many influences (Morahan-Martin, 2004). Given the size of this initial task, even the most highly motivated health consumer may rely upon heuristic strategies at the beginning of the search process, when they are initially formulating what McKnight and Chervany (2001) describe as an intention to trust (rather than actually engaging in a trusting activity).

Ultimately, however, health consumers need to engage in trusting activities and these activities may be informed by material and advice obtained online. This longer-term trusting relationship has been largely neglected in the online trust literature, although a putative long-term relationship was originally proposed in the Cheskin/Sapient report (1999) and also appears in Egger (2000), where the author describes a stage of trust maintenance in which the consumer develops an informal, habit-like relationship with the vendor. The extent to which such a long-term relationship plays an important role in the e-health context is less certain, although some studies have demonstrated high levels of engagement and participation among patients with HIV or AIDS (Reeves, 2001) cancer (Ziebland et al., 2004) and in adolescents (Gray, Klein, Noyce, Sesselberg, & Cantrill, 2004).

In the current study, we seek evidence for a staged model of trust development in a group of genuine health consumers: menopausal women who were keen to assess the costs and benefits of taking hormone replacement therapy (HRT). Traditionally, women have had access to information about HRT through their physician, the media and their family and friends (Griffiths, 1999). Recently a number of specialized websites have appeared dedicated to women's health issues and to the menopause in particular and increasingly, as with other health issues, menopausal women are turning to the Internet for information and advice (Pandey, Hart, & Tiwary, 2003).

When faced with the task of finding out more about HRT, how do women search the Internet and how do they determine which sites to trust, both in terms of the initial selection process and longer-term engagement with specific sites? The trust model proposed above suggests that women are initially influenced by fairly superficial or readily accessible properties of sites, but subsequently evaluate content more systematically, making judgments concerning the expertize of the authors and the credibility of the material. The potential for subsequent engagement with particular websites over time and the development of a trust relationship is something that relatively little is known about.

In order to explore these issues, a group of menopausal women were observed while searching the Internet for information and advice on HRT over four separate sessions taking place over a month. They were subsequently asked to keep diaries for a six-month period and were then interviewed about the way Internet advice had influenced both their decision-making and communication with their physician.

Section snippets

Participants

Fifteen women at various stages of the menopause participated in the study (41–60 years, mean 49). The women were all resident in the North East of England, with differing levels of educational attainment (eight women were high-school educated, five were educated to degree level and two to post-graduate level). Eight of the women worked in business or administration (with the remainder describing themselves as either housewives or retired). The women were recruited through advertisements in the

Results

The results for each phase of the study are described below, along with the forms of data analysis undertaken. In phase 1 the data-logs were analyzed to provide a timeline of rejected sites. The rejected sites were also classified by content. All discussions and verbal protocols from phase 1 were recorded on audiotape and then transcribed. The transcripts were scrutinized for extracts describing trust and mistrust and were then coded by one member of the research team under several anticipated

Discussion

The results of this study are generally supportive of the staged model of trust in that, as predicted, genuine consumers drew upon different trust factors at different stages of engagement with a particular site. This is particularly clear in stages one and two, although the longer-term trusting relationship underpinning stage three is less clearly in evidence, in part because of the limited evidence generated by the diaries in phase 2.

When presented with the opportunity to search freely,

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