Quality of health information on the internet indian medical students perspective

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Quality of health information on the internet indian medical students perspective

  1. 1. Quality of health information available on internet & its use bystudents of Panjab University Chandigarh, IndiaDr Birpreet, Dr Amarjeet Singh, Dr Manoj KumarBhojia Dental College and Hospital,Budh, Distt. Solan, Himachal Pradesh, IndiaE mail: docbirpreet@gmail.comAbstract21st century is the era of information technology. Internet is becoming a popular source ofinformation on various subjects even in developing countries. A cross sectional exploratorystudy was done among 200 randomly chosen students during January 2010 to April 2010 toascertain the extent & pattern of internet based health information use by students ofPanjab University, Chandigarh ,to determine the factors affecting such use of internet .Health related sites and advertisements on internet were also studied to evaluate thequality of internet based health information and to determine the impact of such use ofinternet based health information on health behavior of students. A scoring system wasdeveloped to evaluate the quality of internet based health information for ten selectedproducts.Majority of the students first checked and then retrieved health information from internetbefore using it. Most of them reported no adverse effects from the advice given online.Majority of them found health information available online useful. Skin / beauty/hairrelated searches were more frequent. Quality of information on various health productswas not found to be satisfactory. Key words- E health, information technology, internet 1
  2. 2. Introduction21st century is the era of information technology. In the globalised world, computers areomnipotent and omnipresent. Our daily lives are becoming more and more dependent oncomputer based applications. Internet is becoming a popular source of information on varioussubjects including health. Worldwide, about 4.5% of all Internet searches are for health-relatedinformation (Fox 2005).Before the information era, knowledge of medicine belonged only to thephysician. The patients role was only to passively comply with physician’s advice. However, theInternet has opened up the doors of information like never before. There are innumerable sitesready to give detailed information about various diseases.In this context, E Health has emerged as a relatively recent term which encompasses a range ofservices that are at the cutting edge of medicine/healthcare and information technology(Wikipedia).E-health improves the efficiency of health care delivery by:•Improving health status by supporting healthy life styles,• Improving health related decisions and enhancing health care quality;•Empowering people to take greater control of their health by supporting better informed healthdecisions and self care;•Enhancing clinical care and public health services by facilitating information retrieval by healthprofessionals.•Providing greater speed and efficiency in transmitting feedbacks to the participants.• Internet based information can be hyperlinked to more in depth information andinteractive programmes that can help the individual get started immediately on health 2
  3. 3. intervention. This may be supplemented with daily news feeds on health topics of interest,moderated chat rooms and live video feeds from experts on health and behavioral change topics.•Video and internet conferencing allows for contact between patient and doctor from greatdistances.(http://www.telehealth.com.)However, despite these changes in the health information scenario, very few studies are availableto reflect the extent to which Indian people use internet for this purpose. Against this backgroundstudy was planned with following objectives:• To ascertain the extent & pattern of internet based health information use by students ofPanjab University, Chandigarh.• To determine the factors affecting such use of internet.• To evaluate the quality of internet based health information.• To determine the impact of such use of internet based health information on healthbehavior of students.Material and methodsThis cross sectional exploratory study was done among 200 randomly chosen students from 20different departments of Panjab University (including graduates, post graduates, M.phil students,PhDs) during January 2010 to April 2010. Health related sites and advertisements on internetwere also studied. The students who were willing to participate in the survey were explained thepurpose of study and questionnaires were handed over to them for completion.The questionnaire comprised of 7 sections viz. : Section A – Socio demographic details andfamily background, Section B – Personal details, Section C – General computer use, Section D -Frequency of use of internet ,Section E – Use of internet for seeking health information , Section 3
  4. 4. F – Impact of health information sought from internet ,Section G–Problems faced while usinginternet.For interview of students, a pre tested, pilot tested interview schedule was used. A list of healthtopics was first developed, viz. – beauty tips, hair problems, weight loss, height gain, skin relatedproblems, diet, sexual behavior, illness, sleep, memory enhancers and other such issues. Aproforma was developed for assessment of quality of health information available online. It hadquestions on following aspects of online health information: Why was the site created? Who isresponsible for funding? Who is responsible for the information? Is the subject coveragecomplete and in-depth? Is the information up-to-date? How easy is the site to use; Warningsigns; whether there is complete product information; whether the personal information remainsconfidential?For evaluation of health related websites / advertisements, first a list of different health relatedtopics was made and requisite information was sought on the internet. Thereafter, a scoringsystem was developed for evaluation. Every question had sub questions, each of which wasgiven a score of 1 in case of a positive response. Reverse scoring was done in case of negativelyworded items. After marking the responses total score was calculated. Three score ranges werecomputed, viz. 0-15 scores indicated poor quality, 16-31 fair quality, and 31-60 scores indicatedgood quality information. For each health topic, a search was made on internet using Google.Out of all items that appeared on the first page, every alternate item was clicked to get thedetails. Apart from this, for every health related item selected, every alternate advertisement thatappeared on screen was selected. Three such advertisements were selected for each healthproblem/issue. Duplicate and irrelevant items were deleted. The details were saved in a folder in 4
  5. 5. the computer created for this project. Using the scoring system developed for this study theseadvertisements were assessed for quality and credibility.Percentage/mean and Chi square test were used for analysis. Informed consent was taken.Confidentiality of the data was ensured.ResultsOut of 200 students questioned, majority were females (152; 76%) and 112 (56%) were of theage group 21-30 years. Majority of the respondents were Hindus (135; 68%).Half of the studentswas post graduates (99; 50%) and rest were graduates (94; 47%). Majority of the studentsreceived monthly pocket money ranging from Rs 1000-5000(126; 63%).Most of the students(155; 93%) had separate bank account. Out of 200 students interviewed, families of 189; (95%)students owned a computer and majority (130; 65%) had one PC at home. Some of them hadacquired a computer during last 5 yrs (85; 42.5%) while some of them owned a computer for last5 – 10 yrs (81; 40.5%). Most of them used computer for watching movies (164; 82%) & listeningto music (172; 86%).Some students used computers for typing (100; 50%), playing games (106;53%) or analysis of data (87; 43.5%). Most commonly used accessory device was a pen drive(186; 93%), followed by CD (186; 84%), speaker (165; 82.5%) and webcam (105; 52.5%). Most(186; 93%) students had access to internet. Majority of them accessed internet through home(125; 67%) or department (107; 58%) followed by cyber cafe (91; 49%). Both Google andYahoo were the commonly used search engines (125; 62%).Most of the students perceived their health as OK (176; 88%).Majority made efforts to stayhealthy (118; 59%) that included exercise, yoga, jogging etc. Most of the students sought healthinformation from internet for themselves (100; 57%) or their relatives (41; 24%) or friends (25;14%). 5
  6. 6. Majority of the students first checked and then retrieved health information from internet beforeusing it (101; 54%). Only (45; 24%) students consulted internet before going to doctor. Most ofthem (116; 87%) reported no adverse effects from the advice given online. Majority of them (99;53%) found health information available online useful. Most of the students (123; 95%) hadnever mailed a health query or subscribed to a news letter. Nobody had ever participated in anyonline discussion forum or attended any health programme online or ever used e mail to contacta health professional.Students faced many problems while using internet for seeking health information like slowinternet connection (113;30%) followed by sponsored sites (53;14%), useless information(50;13%), paid sites (43;12%), lack of information seeking skills (39;11%), unfamiliar medicalterms (31;8%), difficult key words (24;6%), difficulty in comprehension (11;3%) .Most of thestudents (151; 86%) told that they intended to use internet in future also.None of the products had a score in the range of 31-50, seven items scored in the range 16-30and 23 items scored in the range of 0 -15.In all advertisements there was no up to date information and no assurance of confidentiality.Only hair products had scores more than 15 for all three advertisements while for beauty related,skin, height, sleep and weight related advertisements none of the three scored more than 15.DiscussionIn modern society, the doctor patient relationship has changed drastically. There has been atangible shift towards internal locus of control among the patients. Doctor’s opinions and actionsare increasingly being challenged by patients. Until recently, the thought that a patient wouldparticipate so fully in treatment process was unheard of in India. 6
  7. 7. Among the literate sections of society, doctors often have to confront now empowered andenlightened patients who intend to take larger responsibility of their treatment. They refer to allthe resources at their disposal -- from opinion of people to the printed word. They use suchknowledge to help make decisions about the treatment to be imparted to them.Now a days , people tend to gather information about their diseases and the prescription .Theyuse resources that range from observation, recording symptoms and family histories,participating in medical tests, discussions with providers and other patients, using the internetand libraries for researching relevant diseases, conditions and treatments. In fact, now peoplehave become smart healthcare consumers.In the present study also, it was found that many students (24%) consulted internet before goingto a doctor. This represents the above mentioned change in patient’s behaviour. Most of themchecked the health related information retrieved from internet before using it. This shows theirconcern for quality of the information available online.In today’s society, much attention of the health care industry has been devoted to the potentialuse of the mass media to modify attitudes, shape behaviour, and generally persuade audiences touse their products. With their broad reach and reliance on visual and audible communication,internet-based resources appear to belong in the category of mass communication. However, theinteractive capabilities of these resources suggest that they also share important characteristicswith interpersonal communication and may therefore share its capacity for effecting persuasion.In many countries, evidence is available that people use internet to access health information. Forinstance, 86% of adult internet users utilized the Internet to do research on a specific disease orhealth care (Harris Interactive, 2001). Most of these individuals used the Internet for healthrelated purposes at least once a month. Half of them told that access to information on the 7
  8. 8. Internet improved the way they took care of themselves (Pew Internet and American LifeProject, 2000).The present study revealed that majority of the students (65%) never used internet for seekinghealth information. Only a few students (14%) regularly sought health information online. Inanother study conducted in 2004 by Castren et al, 12% of Finnish undergraduate students hadused the web-based health advice service provided by the Finnish Student Health Service.Escoffery et al reported that 74% of the students reported having ever received healthinformation online, and more than 40% reported that they frequently searched the Internet forinformation. Baker et al found that approximately 40% of respondents used the Internet to lookfor advice or information about health or health care in 2001.Most of the students in our study considered themselves as healthy. They appeared to be quitehealth conscious as they looked for health information from different sources including internet.Most common reason to use internet by students was to find answers to their health queries. Themost common queries were hair problems skin troubles, diet related problems and beauty tips.This reflects the desire among the students to look good. They also looked for home remedies onthe internet. This indicates their hesitation to see a doctor directly for consultation. Rather, theyinclined to do something on their own for their health problem. A few students also used internetto know more about tests prescribed by doctors. This reveals lack of adequate interactionbetween doctor and patient. This also hints at the inquisitiveness of the patients.Similarly, Castren et al (2004) found that the internet was a method suitable for sensitive,stigmatized, or disquieting health issues. It represented an anonymous way of asking questionson delicate themes. 8
  9. 9. Many of our respondents reported that the material they gathered from internet directly affectedtheir decisions about getting care and treatment for their illnesses. It has also been reported thatconsumers are also using internet-gathered material to enhance their face-to-face interactionswith health care providers. The most important effect of the Internet may be its influence on howpatients approach their health care providers. Those who seek information online report that itinfluences how they manage their overall health and how they comply with prescribed treatments(Harris Interactive, 2001).The present study revealed that the number of students willing to use internet in future is quitehigh (86%).This implies the need for regulation of internet based information to make sure thatquality information reaches the seekers and they get the maximum benefit out of that .As statedby Landor, ‘Products are made in factories but brands are created in our minds’. Market forcesand advertisements seriously influence our thought process. Today, our life and thinking iscontinuously invaded by product information bombarded through advertisements in every spherepossible (SMS, phone, TV, internet, newspapers, magazines, hoardings, pamphlets and wallpaintings).We can protect ourselves now from sun, rains and wind but not from advertisements.Our subconscious mind is influenced by endless repetition of advertisements in media.Keeping in mind the above issues related to e- health and in an effort to promote better quality ofhealthcare resources on the internet, the Internet Healthcare Coalition (IHC), a group oforganizations that include for-profit and not for profit members introduced an international codeof ethics for health care sites and services on the internet. (Journal of Medical Internet Research-health code of ethics by Helga Ripen, MD, PhD, 2000)However, many malpractices in internet advertisement have been reported and these can bepotentially harmful. In the present study, majority of the students found health related 9
  10. 10. information online. However, 13% of them reported that they experienced adverse effects onfollowing the advice available online.In the present study it was found that majority of internet advertisements scored poorly as far astheir quality was concerned. Majority of advertisements were not following the laid downguidelines and were liable to strict legal action. There are various statutes impacting advertisinglike -The Drugs and Magic Remedies (Objectionable Advertisements) Act (DMRA) This statuteprohibits advertisements of drugs for certain purposes and of treatment of certain diseases anddisorders. It also prohibits misleading advertisements relating to drugs and advertisements ofmagical remedies for the treatment of certain diseases and disorders. In similar way, ConsumerProtection Act promotes and protects the rights of the consumer, including protection againstunfair trade practices. Information Technology Act, 2000 (IT Act) prohibits the publication andtransmission in electronic form of material which is misleading.Internet has been a boon to consumers who want research information on various health topics atthe tip of their fingers. However, simultaneously, the ease of Web publishing has also given anunregulated forum to unreliable sources to post their ware on the net. Therefore, the quality ofsuch information is open to question. Careful scrutiny and a healthy dose of skepticism isnecessary to separate chaff from grain and determine what applies to you and what may need asecond opinion.ConclusionMajority of the students (65%) never used internet for seeking health information. Most of thosewho did so (73%) found health information available on internet useful.Most common health problems for which information was sought were- beauty tips, hairproblems and skin care related queries. Quality of health information available on internet was 10
  11. 11. found to be poor. Common deficiency in all advertisements was lack of up to date informationand lack of assurance of maintaining confidentiality of information. All the advertisementsviolated the Online Advertising Act and Drugs and Magical Remedies Act.LimitationsThe present study was conducted in Chandigarh which is a modern and relatively rich city with ahigh literacy rate. The chosen sample from Panjab University was computer literate students whobelonged to middle, upper middle and high socioeconomic class. So, results should beinterpreted accordingly. Evaluation of limited number of health advertisements was done. Smallsample size was taken due to time constraints. The "topics of health information" werepurposively selected. Responses to the questions on each topic were treated as a dichotomousvariable measured in a Yes/No format. It did not provide information about the degree ofconsumer use of the different health topics. Further exploration of the depth of use was not done.RecommendationsQuality and content of all internet advertisements should be properly and scientifically screenedbefore these are released for public exposure. A code of ethics needs to be evolved and violatorsand defaulters of this code should be punished. People should be educated about the dangers ofself diagnosis and self medication based on online health information. For this there is a need fora regulatory body or expert committee to enforce ethics in advertising on internetReferencesAkerkar SM, Bichile LS .Doctor patient relationship: Changing dynamics in the informationage. E-medicine 2004; 50(2):120-122 11
  12. 12. Baker L, Wagner TH, Singer S and Bundorf MK. Use of the Internet and e-mail for health careinformation: results from a national survey. Journal of American Medical Association 2003;Vol. 289.Castrén J , HuttunenT and Kunttu K . Users and non-users of web-based health advice serviceamong Finnish university students – chronic conditions and self-reported health status (a cross-sectional study). BMC Medical informatics and Decision Making 2008; 8: 8.Culver, J D, Gerr, R, & Frumkin, H . Medical information on the Internet: A study of anelectronic bulletin board. Journal of General Internal Medicine 1997 ; 12(8): 466-70Diaz JA, Griffith RA, Ng JJ, Reinert SE, Friedmann PD, Moulton AW Patients use of theInternet for medical information. Journal of General Internal medicine 2002 ; 17:180-5.Donald, A, Lindenberg B & Humphreys L. Medicine and health on the Internet: The good, thebad, and the ugly. Journal of American Medical Association 1998 ; 280 : 1303-1306.Dudley, T E, Falvo, D. R., Podell, R. N., & Renner, J.The informed patient poses a differentchallenge. Patient Care 1996; 30 : 128-138.Dutta-Bergman MJ . Health Attitudes, Health Cognitions, and Health Behaviors among InternetHealth Information Seekers: Population-Based Survey. J Med Internet Res. 2004 Apr–Jun; 6(2):e15.Eastin MS.Credibility Assessments of Online Health Information: The Effects of SourceExpertise and Knowledge of Content. Journal of Computer-Mediated Communication (JCMC)2001; 6(4)Escoffery C, Miner KR, Adame DD, Butler S, McCormick L, Mendell E. Internet use for healthinformation among college students. Journal of American College Health 2005;53(4):183-8. 12
  13. 13. Flanigan, A, & Metzger, M. Perceptions of Internet information credibility. Journalism & MassCommunication Quarterly 2000; 77: 515-540.Gaziano,C., & McGrath, K. Measuring the concept of credibility. Journalism Quarterly 1986 ;63:451-462.Gerber BS, Eiser AR. The Patient Physician Relationship in the Internet Age: Future Prospectsand the Research Agenda .J Med Internet Res 2001; 3(2):edition15Herman ES , Mcchesney RW . The Global Media: The New Missionaries Of CorporateCapitalism. Delhi: Madhyam Books ; 1998.106 -126http://www.ehealthinstitute.org/index.aspxhttp://www.pewinternet.org/Reports/2002/Vital-Decisions-A-Pew-Internet-Health-Reporthttp://www.quackwatch.com/01QuackeryRelatedTopics/quackweb.htmlIndu V, Archana S , Neha A, Ankita G . E-Health and Ethics . Saarthi conference on medicalethics ;17-18 Jan 2010 ; ChandigarhJacabson P . Empowering the physician patient relationship, effect of internet. Canadian Journalof Library and Information Practice and Research 2007; vol.2Kotler P . Marketing Management : Pearson Education Inc ; 2004Morahan-Martin JM . How internet users find, evaluate, and use online health information: across-cultural review. Cyberpsychology and Behaviour 2004 Oct;7(5):497-510Parameswaran MG . Understanding Consumer : Tata Mc Graw Hill Publishing Company ;Pellegrino ED. The commodification of medical and health Care: The Moral consequences of aparadigm shift from a professional to a market ethic. Journal of Medicine and Philosophy 1999;24 : 243 13
  14. 14. Singh R, Vij S . Socio-Economic and Ethical Implications of Advertising – A Perceptual StudyInternational Marketing Conference on Marketing & Society ; 2007 8-10 April ; IIMKTalwar K.K. An opportunity to be Knowledge city. Ht Live Chandigarh 2010 May 7Wagner TH . Baker LC , Bundorf MK and Singer S .Use of the Internet for Health Informationby the Chronically Ill . Preventing chronic diseases: public health research , practice and policyOctober 2004; 1(4)Wright, J. B. Quality connection on the Internet. Healthcare Executive 1998; 13: 44-45.Table 1 Frequency and pattern of use of internet by students (n= 186)Variables Number PercentageInternet used today 85 45Internet used once or twice per week 75 40Internet used thrice or more per week 114 61Preferred to use on weekends 130 69Time preferredDay 18 4Night 07 11Any time 161 85 14
  15. 15. Internet used forMail 136 73Academic purposes 129 69Chat 96 52Download movies/songs 68 36Health information 27 14Air/railway ticket 16 8Movie ticket 11 6Bills payment / e-Banking 6 3Table 2 Pattern of use of internet for health related informationVariables Number PercentageSources of health informationTV/newspapers/magazines 126 68 84 45Family member/friendDoctor 113 15Internet 84 11Internet used for 93 50Finding answers to queriesTo look for home remedy 44 24To know more about tests prescribed 25 13To retrieve related articles 24 13To know about treatment options 30 13Specific health problemsHair problems 80 43Skin query 78 42Diet related 77 41Beauty tips 66 35Weight loss 43 23Height gain 29 16 15
  16. 16. Illness related 27 15Sexual behaviour 21 11Table 3 Impact of health information sought from internetVariable Number PercentageWhat did you do with information retrievedUsed after verificationIgnored right away 101 54Ignored after verification 18 10Used without verification 3 2 11 6Ever consulted a doctor for health problem 81 44Internet consulted before going to doctor 45 24Online advice had adverse effect on health 18 10Information useful 99 53Ever mailed a health query 7 4Got response on mail 3 2Subscription of any health news letter 5 4Table 4 Score range of 10 kinds of health related products advertised on internetProduct Score range 0-15 16-30Beauty 8,8,12 16
  17. 17. Hair care 22,25,27Skin care 4,5,10Weight loss 2,5,8Height gain 4,5,10Diet related 8,15 23Sexual behavior 5,9 20Illness related 10,12 17Sleep 7,7,10Memory 6,7 16The three figures in each row represent scores for the three advertisements scrutinized for each product.Maximum possible score was 60 17
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