Interventions to Assist Health Consumers to Find Reliable Online Health Information: A Comprehensive Review
Emmerton LM (2014) Interventions to Assist Health Consumers to Find Reliable Online Health Information: A Comprehensive
Review. PLoS ONE 9(4): e94186. doi:10.1371/journal.pone.0094186
Interventions to Assist Health Consumers to Find Reliable Online Health Information: A Comprehensive Review
Kenneth Lee 0
Kreshnik Hoti 0
Jeffery D. Hughes 0
Lynne M. Emmerton 0
Laxmaiah Manchikanti, University of Louisville, United States of America
0 School of Pharmacy, Curtin University , Perth, Western Australia , Australia
Background: Health information on the Internet is ubiquitous, and its use by health consumers prevalent. Finding and understanding relevant online health information, and determining content reliability, pose real challenges for many health consumers. Purpose: To identify the types of interventions that have been implemented to assist health consumers to find reliable online health information, and where possible, describe and compare the types of outcomes studied. Data Sources: PubMed, PsycINFO, CINAHL Plus and Cochrane Library databases; WorldCat and Scirus 'gray literature' search engines; and manual review of reference lists of selected publications. Study Selection: Publications were selected by firstly screening title, abstract, and then full text. Data Extraction: Seven publications met the inclusion criteria, and were summarized in a data extraction form. The form incorporated the PICOS (Population Intervention Comparators Outcomes and Study Design) Model. Two eligible gray literature papers were also reported. Data Synthesis: Relevant data from included studies were tabulated to enable descriptive comparison. A brief critique of each study was included in the tables. This review was unable to follow systematic review methods due to the paucity of research and humanistic interventions reported. Limitations: While extensive, the gray literature search may have had limited reach in some countries. The paucity of research on this topic limits conclusions that may be drawn. Conclusions: The few eligible studies predominantly adopted a didactic approach to assisting health consumers, whereby consumers were either taught how to find credible websites, or how to use the Internet. Common types of outcomes studied include knowledge and skills pertaining to Internet use and searching for reliable health information. These outcomes were predominantly self-assessed by participants. There is potential for further research to explore other avenues for assisting health consumers to find reliable online health information, and to assess outcomes via objective measures.
There is a growing body of evidence that health consumers
increasingly rely on the Internet for health information . This
increase is largely due to 1) the immense abundance of online
information [9,10], decision aids  and Web 2.0 health
applications [10,12,13], 2) the increasing prevalence of chronic
disease in society , and 3) the pervasiveness and accessibility of
Information Technology in our daily lives .
While the role of health professionals in advising and assisting
health consumers with decision making is undisputed [1,16,17], it
is unrealistic, in terms of the health professionals time and ability,
to control out-of-consultation behavior of consumers, and to
expect consumers to rely entirely on written and verbal
information provided by their regular practitioner(s). Indeed,
health consumers empowered by information-seeking online may
be more engaged in the management of their health conditions,
and form more productive relationships with their healthcare
In order to effectively engage in self-management, health
consumers must be able to effectively find, understand and utilize
relevant health information . At the same time, health
consumers must also be able to discern reliable from less-reliable
information. Collectively, these abilities and skills constitute the
definition of an individuals health literacy . The literature
suggests that many health consumers have low levels of health
literacy  which hinders their ability to effectively find,
understand and use reliable health information to assist them
manage their health conditions. As use of the Internet requires
technological knowledge and skills , finding health information
online potentially becomes an even greater burden on consumers
with poor computer literacy as well as low levels of health literacy.
Rationale and Objectives
Given the prevalence of chronic diseases in society and the
important role self-management plays in chronic disease
management, there appears to be a need for initiatives to assist health
consumers to develop their capacity to find reliable health
information on the Internet, thereby potentially contributing to
improved levels of health literacy. Our comprehensive review
follows a systematic review by Car et al.  that examined the
effects of online health literacy training interventions on health
outcomes. We intended to focus on the gambit of interventions
(face-to-face, online or via other means) implemented by
researchers to assist adult health consumers to autonomously find
reliable online information about chronic health conditions, and
where possible, their outcome measures. This includes, but is not
limited to, training interventions.
As the focus of our review is on identifying and descriptively
comparing humanistic interventions, as opposed to evaluating
formal clinical trials, assessment of the quality of each study (as
would be performed in a systematic review) was not formally
conducted. Nevertheless, we adopted a systematic approach to the
identification and selection of relevant studies, and applied
methodological  and reporting  standards for the conduct
of systematic reviews where practical.
The method was guided by the Methodological Standards for
the Conduct of Cochrane Intervention Reviews , where
relevant, recognizing the humanistic nature of the interventions of
The eligibility criteria for published studies were developed via
consultation between all authors of this review, and were:
1. Participants: at least 18 years of age
2. Intervention: any approach where the intention, primary or
other, was to assist health consumers in autonomously finding
existing reliable online information related to chronic health
3. Language: publications in English.
Publications were included if the study, or a portion of the
study, met all of the above criteria. Studies that met criteria 2 and
3, but included some participants less than 18 years of age, were
considered relevant. Studies were excluded if the primary
intervention involved the development of new online health
information material, such as producing easy-to-understand
material for the purpose of assisting people with low health
literacy. Studies were also excluded where assistance was provided
to help participants use a particular existing online health website.
While the reporting of outcomes for studies is a critical component
to evaluating quality, and is desirable, studies that did not report
outcomes were not excluded from this review as the primary
objective of this review was to identify the types of interventions
that have been implemented.
Four health-related databases and two popular search engines
for gray literature were utilized for this review. While the term
gray literature is poorly defined in literature, we defined it as
studies published in a format other than academic journals.
Reference lists of selected publications were also searched, and
authors were contacted where clarification or more information
was needed for data analysis.
The databases used were PubMed, PsycINFO, CINAHL Plus
and Cochrane Library. Gray literature was searched via WorldCat
and Scirus. No limits were applied to dates, although it was
expected that most research in this field would be recent due to the
relative recency of the Internet and Information Technologies.
The last search was conducted on 11 February 2013.
Search terms and search strings were agreed upon by all authors
of this review, and further refined by the first author, KL, after
pilot searching various permutations of search terms in PubMed
and CINAHL Plus. To optimize efficiency and minimize the
volume of irrelevant publications returned, a single search string
was used for all databases and gray literature search engines. A
second search, using MeSH terms, was conducted on the four
databases. This is because MeSH terms are manually assigned
after a study has been published; thus, a search using MeSH terms
could potentially produced different results. Manual searching of
reference lists from selected publications were subsequently
conducted to ensure a more comprehensive search.
The following search terms were used to search all databases
and gray literature search engines: consumer*; patient*; find*;
search*; navigat*; seek*; access*; retriev*; locat*; identify*; health
literacy; informat*; internet; online; web*.
An example of a search string that was used for this review is:
((consumer* or patient*)) AND ((find* OR search* OR navigat*
OR seek* OR access* OR retriev* OR locat* OR identif*)) AND
health literacy AND informat* AND ((internet or online or
Study Selection, Data Collection Process and Data Items
After retrieval of publications from the aforementioned
databases and search engines, duplicate publications were removed.
A stepwise approach of selecting relevant publications firstly via
title, then abstract, then full text was used, adapting relevant
sections of the PRISMA flow diagram for reporting of systematic
reviews . In this approach, titles of publications were firstly
screened for relevance to the review, with relevant publications
retained. Where relevance was unclear from examination of title
alone, the abstract was then scanned and irrelevant publications
were subsequently removed. Publications in which both title and
abstract were examined, and relevance to the review was still
unclear, were retained for full-text review. Reference lists of
selected publications were manually searched for further relevant
Eligibility of publications was further ascertained by full-text
review. Authors were contacted for supplementary information
A data extraction form was developed to assist data collection
and subsequent analysis. This form was developed and piloted by
KL, and reviewed by LE. All elements of the PICOS model 
were incorporated into the form. As few relevant papers were
anticipated, trial of the form was not considered necessary,
although refinements were incorporated during data extraction.
KL extracted data from the included studies, and LE, confirmed
the extracted data. Consensus was reached on all points via
discussion between KL and LE.
As this review primarily focuses on identifying types of
interventions with a view to also identifying types of outcomes
where possible, as opposed to examining the effects of these
interventions on outcomes, risk of bias in individual studies and
across studies was not assessed. It was anticipated that little
methodological comparison would be viable.
The literature search identified 707 publications after duplicates
were removed (Figure 1). Of these, 680 publications were excluded
through the screening process (via their titles and abstracts).
Common reasons for exclusion were that the publications reported
train-the-trainer interventions with no follow-up of the trainers
subsequently coaching health consumers, interventions to help
consumers find information on a particular website, studies about
the various implications of poor health literacy, and exploratory
studies of health information-seeking behaviors.
A total of 27 publications were reviewed in full to assess their
eligibility for this review. To further assist in assessing eligibility of
publications, 14 authors were contacted for supplementary
information, with four replies. Overall, seven journal publications
and two gray literature reports were deemed eligible for synthesis
and analysis. Due to missing data in the gray literature reports,
they are described in a separate section from the published studies.
Of the seven published studies , two [29,32] were
randomized controlled trials, and the remaining five [30,31,33
35] were uncontrolled, single-group trials (Table 1). The number
of participants for one study  was unknown, while the number
of participants for the remaining six studies ranged from 60 to 448.
A convenience sampling method was used in all studies. Of the six
studies conducted in the United States [29,3135], three
[31,33,34] were located in regional or rural parts of the United
States. The remaining study  was conducted in metropolitan
The interventions for three [30,31,34] of the seven studies were
administered in a single session. The total duration of studies with
multiple-session interventions ranged from three weeks to nine
Regarding instruments used to measure outcomes, three studies
[30,32,35] used adapted instruments and one study  utilized
standard instruments for measuring biochemical and biometric
markers of health outcomes in people with diabetes. In terms of
the participant outcomes measured, one study  indirectly
measured health outcomes, while the remaining six studies
measured one or more humanistic indicators of health information
knowledge, skills and behavior, for which, measurements are not
directly comparable. Demographic data for participants were
reported in varying degrees for six studies [2932,34,35].
Common demographic variables were age [29,32,34,35], gender
[29,30,32], annual income [29,30,32,35], and level or years of
Design of Interventions
Interactive workshops. Interactive workshops featured as
the main intervention in five [3032,34,35] of the seven published
studies. The style of the interactive workshop for one study 
was unclear, however, four studies [30,32,34,35] used a
combination of a didactic approach to teaching and hands-on activities
that involved participants searching for health information online.
In most of the studies, participants were issued a copy of the
presentation slides, as well as lists of credible health websites.
Further, discussion amongst participants was encouraged during
the workshops in three studies [30,32,35]. In particular,
collaborative learning was emphasized in one  of the studies.
Although the intervention for this study included a didactic
component, the workshop trainer encouraged interaction between
participants. In another study , a website hosted the online
version of the in-person interactive workshop. This online version
used the same content as the in-person workshop.
Common workshop topics included how to judge reliability of
health information and credibility of health websites, and
awareness of credible websites. Two studies [34,35] used content
from The Trainers Toolkit from the NIHSeniorHealth website
(http://nihseniorhealth.gov/toolkit/toolkit.html) as the
foundation of their workshops. Participants in one study  were
provided information on their medical condition, in addition to
being educated on how to find credible health information online.
Health literacy curriculum and community outreach. In
one study , a health literacy curriculum was designed and
trialed in two middle schools, two high schools and one adult
education program, delivered by teachers and librarians. The
curriculum was designed as five one-hour lessons with activities,
although teachers and librarians were allowed to deliver each
lesson at their own pace. As a result, the duration of the
intervention ranged from three weeks to three months. In the final
lesson, participating students shared what they had learnt with
seniors in their community. In this way, seniors were taught by
participating students how to find health information online.
The curriculum established that health information is
commonly organized via disease type and population, and participants
practiced search techniques. Students were also given a checklist
adapted from the QUICK website (http://www.asparis.net/
evaluating the credibility and reliability of online health information.
Online portal with support via videoconferencing. One
study  took an arguably more holistic approach, in the
development of an online portal to house three modules:
selfmanagement, health education, and social networking. The
selfmanagement module provided a space for each participant to
access their individualized care plans. These plans were reviewed
during the bi-weekly videoconferencing with a telehealth nurse,
and were amended, if needed, by the participants physician.
During these videoconferences, participants were also encouraged
to raise questions with the telehealth nurse. The health education
module consisted of age and culturally-appropriate educational
videos and links to various health-related websites. The social
networking module provided a space for participants in the study
to interact with one another, and participants were encouraged to
share preferred educational resources.
All seven published studies demonstrated either
positivesignificant, or positive-but-non-significant outcomes in at least
some of the measured outcomes (Table 1). No study reported any
worsening of outcomes from baseline/pre-intervention. Of the
measured outcomes, many were self-reported. Two of the
published studies [29,31] included some form of objective measure
one study  used biometric and biochemical markers, another
study  used an objective test of knowledge. One study 
conducted a follow-up assessment up to nine months
Knowledge and skills. The breadth of knowledge and
skilloriented outcomes included participants knowledge of their
medical condition , awareness of what is evidence-based
health information [30,33], knowledge of credible online health
resources , ability to find reliable online health information
, ability to find relevant online health information [34,35],
ability to evaluate reliability of online health information [32,33],
and general computer/Internet knowledge and skills . The
majority of the knowledge outcomes were based on self-perceived
measures of knowledge, with the exception of two studies [29,31].
Carter et al.  applied a brief test of diabetes knowledge as part
of a survey pre- and post-intervention, whereas Gross et al. 
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Four seniors who
training at a
center in Revere,
Group training Style: A series of group training sessions with the
sessions (and option of one-to-one training if needed. Content:
website to assist Participants were taught general computer skills
navigation of relevant to using the Internet, and specific skills for
reliable health using the ARCH website (http://www2.massgeneral.
Other: Focus groups were Strengths: Participant
conducted to evaluate the responses were
outcomes of the ARCH reported verbatim.
training. Participants Weaknesses: No
reported that the ARCH demographic data
training was sufficient to collected; arguably
facilitate use of the ARCH small sample size for
website. They also felt that focus groups no
ARCH was easy to use to indication of whether
find basic health saturation of themes
information relevant to was achieved;
their own needs. qualitative data
presented as blocks of
individual focus group
participants, instead of
themes explored by
were reported to be more
aware of the existence of
online health information,
and have better knowledge
about how to find credible
health resources. How this
outcome was evaluated is
unclear. Other: The
participants to credible
Participants did not need
to learn how to conduct
searches to find these
credible health resources.
How these outcomes
were evaluated is unclear.
piloted prior to rollout,
and re-evaluated and
needs analysis for
training based on
survey completed by
an arguably small
sample size (n = 57); no
sample size of
survey mentioned in
report, but no clear link
to findings in the
measured knowledge of credible online health resources via a
pretest and post-test questionnaire based on items covered in the
interactive workshop. Two studies tested their participants skills:
one  tested participants ability to evaluate reliability of online
health information by instructing participants to rate two
preselected websites on five dimensions of website quality, as specified
by a previous study conducted by Kim et al. ; while the other
 investigated participants ability to find relevant online health
information by instructing participants to find answers to two
questions on a pre-selected health condition.
Attitude and behavior. In one study , the key attitude
and behavior-oriented outcome were participants change in the
way they search for health information, and in another study ,
information-seeking self-efficacy. In both of these studies, attitudes
and behaviors were assessed based on self-perceived measures.
Health outcomes. One study  indirectly assessed health
outcomes in patients with diabetes via measurement of
biochemical and biometric markers for both treatment and control groups
pre- and post-intervention: mean weight, mean blood pressure,
and mean hemoglobin A1c.
Gray Literature Reports
The interventions, outcomes and brief critique of relevant
aspects of the two gray literature reports are summarized in
Table 2. Both reports relate to projects aimed to facilitate access to
reliable health information for various communities in the United
States. The Access to Resources for Community Health (ARCH) project
[Schneider E. ARCH Evaluation Focus Groups. Boston (USA):
Massachusetts General Hospital; 2009] focuses on providing
access to online health information, whereas the Medline in the
Mountains project [Carlson G. NN/LM Quarterly Report.
Colorado (USA): Poudre Valley Health System; 2003] focuses
on providing access to print and electronic health information
resources and services.
The use of group training sessions was common to both
projects. The ARCH training focused on teaching general
computer and Internet skills, and how to use their projects
website to find reliable health information. The Medline in the
Mountains training focused on teaching skills to evaluate reliability
of health information, and how to use health information
databases; their website appeared to supplement the training, as
it hosted materials on how to evaluate reliability of health
information, and listed various health information databases.
While both projects were conducted in the United States, the
ARCH project was conducted in a metropolitan city, while the
Medline in the Mountains initiative addressed various geographically
isolated and rural communities. The ARCH project utilized focus
groups to evaluate their outcomes, while a pre-/post-intervention
survey was utilized in the Medline in the Mountains study, albeit with
limited data reported.
The seven published studies  included in this review
presented a number of substantive design limitations, including
small samples and the use of descriptive analysis. Outcomes were
predominantly assessed via self-reported pre-post measures, which
arguably have greater potential for bias . The majority of
these studies did not describe any validation process for the
instruments used. Further, only two studies [29,32] were
randomized-controlled studies. Despite this, four [30,31,33,35]
of the five remaining studies assessed either participants attitudes
or outcomes based on pre- and post-intervention measures; this
facilitates a more meaningful way to compare the impact of the
intervention. Nevertheless, only two [30,35] of these four studies
went beyond the use of descriptive statistics to assess statistical
significance of their findings. Thus, the design characteristics,
analysis, and perceived overall quality of these studies highlight
areas to be addressed in future research. Furthermore, the nature
of the studies did not lend themselves to being evaluated
Our review of the intervention type identified that five [30
32,34,35] studies used workshops with varying levels of
interactivity. Although a didactic approach to helping participants
search for online health information was not the sole approach to
teaching participants, it was a prominent approach that featured
in all of the included studies. Didacticism is a prominent, yet
arguably outdated, philosophy in education . Despite vast
literature suggesting that student-centered pedagogical approaches
may be more effective than didactic education in formal education
settings [40-42], such approaches do not appear prominent in the
education of health consumers, as based on our findings, and it is
unclear whether people with limited health literacy respond better
to, or prefer, didactic approaches to learning. The concept of
patient-centered care - whereby patients have active roles in
healthcare, and healthcare is based on the individual patient - is
flourishing [43-44]. It appears that a didactic approach to
developing health consumers online information-seeking skills
may only partially address the issue, given factors such as the
recognized importance health consumers play in day-to-day
management of their health, and an era of fast-developing
technologies and information abundance. Thus, there appears to
be potential to apply various student-centered pedagogical
approaches to educating health consumers. Further, it can be
argued that a potential contributing factor to the positive results
demonstrated by the five workshop-based studies is due to
engagement  between the workshop trainer and the
participants. Thus, reproducibility of results could be problematic.
It is also important to note that, of the included studies, only one
study  explicitly indicated the use of a particular learning
framework collaborative learning. There is therefore potential
for future studies to examine different learning frameworks in the
online health literacy space.
All of the seven studies measured varying facets of knowledge,
skills or both domains; in a majority, knowledge and skill domains
were assessed via measures that were self-reported by participants.
While it is important to gain insight into participants perceptions
of the impact of the intervention, the use of objective tests would
arguably improve objectivity and minimize potential for bias.
Despite the apparent lack of objective tests in many of the included
studies, it is important to note that there were no reported
worsening of outcomes from baseline/pre-intervention in any of
the included studies. This suggests that, while the effectiveness of
didactic approaches are yet to be compared with other
approaches, current identified interventions do not appear to have negative
or detrimental outcomes.
In the two included gray literature reports, a didactic approach
to helping participants search for reliable online health
information was prominent - similar to the findings from the seven
included published studies. The intervention for the first of these
studies aimed to general computer and Internet skills, with a view
to optimize participants use of a particular website developed
specifically for the project. The second study focused on improving
skills to evaluate reliability of health information and use of health
information databases. These interventions also bear similarity to
some of the included published studies. In terms of evaluation of
outcomes, no objective measures were used.
Few studies were deemed eligible for inclusion. It is possible that
the use of additional search strings may yield more relevant
studies. While the search strings were reviewed by all authors of
this review (discipline experts), and advice had been sought from a
medical librarian prior to the review, participation in the searches
by a medical librarian may have provided a different perspective.
While extensive, the gray literature search may have had limited
reach in some countries. The finding of few relevant published
studies on this topic highlights the potential for further research.
Furthermore, their varied application of scientific methods limited
our ability to compare them systematically.
Despite the increasing pervasiveness of, and reliance on, the
Internet in the area of health information, we found few reports of
interventions to assist health consumers to find reliable health
information online. The identified studies measured varying facets
of knowledge and/or skills, and commonly reported a didactic
approach to training their participants. Outcomes studied were
predominantly assessed via self-report by participants, and while
arguably subjective, were largely positive and there was no report
of worsening of outcomes. As such, there is considerable scope for
further research to enhance consumer health literacy in the
context of sourcing online information. With the pervasion of
mobile technologies and popularity of social media, future
research could focus on these developments. Specific interventions
could focus on transparent labeling of trustworthy websites or
conversely, blacklists of websites deemed biased or otherwise
Additionally, as only one identified study explicitly indicated the
use of a particular learning framework, there is also potential for
further research to explore the use of various learning frameworks
in the online health literacy space.
Conceived and designed the experiments: KL KH JDH LME. Performed
the experiments: KL. Analyzed the data: KL LME. Wrote the paper: KL
KH JDH LME.
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