An automated HONcode detection system informs internet users of HONcode compliance

The purpose of this paper is to describe the needs and the process of establishing an online Arabic health encyclopedia to empower patients and health professionals with trustworthy information. A study was conducted by King Saud bin Abdulaziz University for Health Sciences in collaboration with Health on the Net (HON) Foundation to review the quality of Arabic health information on the internet. A review of health portals in other languages was performed. Meetings were conducted to investigate areas of collaboration with different stakeholders including: WHO, HON, the U.S. National Library of Medicine, and the NHS. The results of the assessment of Arabic health sites showed that a very small percentage (almost 4%) meets international standards. The study results call for immediate action to improve the trustworthiness of Arabic health information on the net. This will be achieved by establishing a reliable Arabic health encyclopedia and by encouraging health professionals from all Arab countries to contribute to its creation. It is important for the 300 million Arabic citizens around the world to be able to access valuable health information on the internet. More than 300 million Arab citizens around the world have missed the opportunity to use the internet to provide them with quality health information. Hence, to bridge this gap, a new project was launched to develop an online Arabic health encyclopedia. Moreover, this study proposes an Arabic health information foundation be established to govern and accredit the Arabic health websites, and to work in collaboration with HON, to regulate and promote the quality of health information on the internet in Arab countries.

Quality and readability of online information on dental treatment for snoring and obstructive sleep apnea

Adolescents increasingly rely on the Internet as a private resource for sexual health information. Despite growing interest in adults' use of online health resources in HCI, we lack a deeper understanding of adolescents' information-seeking processes and assessments of trustworthy online health information. We conducted a qualitative, observational study of late adolescents as they searched for sexual health and sexuality information and a think aloud protocol to concurrently capture user thoughts and perceptions of online content in situ. Our results reveal a four-phased process that late adolescent users employ for searching and evaluating sexual health information on the web, as well as several emergent themes regarding credible and trustworthy information.

To evaluate the quality and readability of online information about the treatment of burning mouth syndrome (BMS). An internet search using the phrase "burning mouth syndrome treatment" was carried out on the Google search engine (www.google.co.uk) on 8 June 2015, and the first 100 websites listed were examined. Data collection included DISCERN score, the Journal of the American Medical Association (JAMA) benchmarks for website analysis score, the presence of the Health on the Net (HON) Foundation seal, and the Flesch Reading Ease Score (FRES). Descriptive statistics were performed using Microsoft Office Excel. The search strategy initially yielded 635,000 links; following the application of the exclusion criteria, 53 sites remained for analysis. The overall DISCERN score varied between websites, with half of all websites achieving an overall score of 2 and none of these websites achieving the maximum score of 5. The mean score ± standard deviation (SD) was 2.4 ± 0.7. Only 10 (18.9%) of the websites achieved the four JAMA benchmarks while 3 (5.7%) of the websites did not achieve any of them. Only 9 (17%) displayed the HON seal. The FRES of the websites ranged from 32.4 to 82.2; the mean ± SD rating was 55.4 ± 10.7, which is considered to reflect fairly difficult reading. The information available online about BMS is of questionable quality and content. Perhaps engaging patients in determining what type and format of information they desire when searching online for health information could guide clinicians and researchers alike in providing reliable and readable information sources.

This study aimed to evaluate the quality, content, and readability of top‐listed websites on intravenous (IV) iron. We conducted online searches for the term “iron infusion” using Google, Bing, and Yahoo. The search term was determined based on Google Trends data for March 2025. Five gynecologists independently reviewed the websites using the DISCERN instrument, Journal of the American Medical Association (JAMA) benchmarks, and Abbott's Scale. Credibility and readability were further assessed using the Health on the Net (HON) Foundation Code of Conduct Certification, the Simple Measure of Gobbledygook (SMOG), the Flesch–Kincaid Grade Level (FKGL), and the Flesch–Kincaid Read Ease formula (FRES). A total of 25 websites were included. The mean DISCERN score was moderate (2.9 ± 0.9 out of 5), with only three websites (12%) providing excellent quality information. Seven (28%) websites were classified as having poor to very poor quality information. The mean JAMA score was low (2.1 ± 1.3 out of 4), and only three websites (12%) met all benchmarks. The overall content score on Abbott's scale was low (45.4 ± 16.1 out of 106). The average authorship score (2.1 ± 1.2 out of 3) and esthetics rating (5.4 ± 1.2 out of 10) were moderate. Notably, 21 (84%) websites were not certified by the HONcode. Readability levels were poor, as reflected by the FRES (38.1 ± 16.9 out of 100), the FKGL (equivalent grade, 12.4 ± 2.8), and the SMOG (equivalent grade, 12.7 ± 2.4). Although information on IV iron is widely available online, its overall quality and content are generally poor and not easily accessible to the public. This underscores the opportunity for knowledge translation efforts aimed at developing online resources that are both accurate and understandable.

Many patients use the Internet for health information. However, there are few guarantees to the reliability and accuracy of this information. This study examined the quality and content of the Internet Web pages for 10 common pediatric orthopaedic diagnoses. We identified 10 common diagnoses in pediatric orthopaedics: brachial plexus injury, cerebral palsy, clubfoot, developmental dysplasia of the hip, leg length discrepancy, osteochondroma, polydactyly, scoliosis, spina bifida, and syndactyly. We used 2 of the most popular search engines to identify the top 10 Web sites for each disease. We evaluated the Web sites utilizing both the quality-based Health On the Net (HON) Foundation criteria and our own content-based grading sheets. The custom grading sheets focused on essential information about disease summary, pathogenesis, diagnosis, treatment, and prognosis. Three orthopaedic surgeons graded 98 academic, commercial, nonprofit, and physicians' Web sites for 10 diseases. Academic Web sites scored the highest in content (mean, 60.8% ± 15.5%), whereas commercial Web sites scored the lowest (mean, 46.7% ± 22.2%). Among the diagnoses, osteochondroma Web sites had the highest content scores (mean, 75.8% ± 11.8%), whereas polydactyly Web sites had the lowest content scores (mean, 39.3% ± 15.7%). In contrast, Web sites about developmental dysplasia of the hip had the highest HON scores (65.0 ± 11.1), whereas those about brachial plexus birth palsy scored the lowest (42.6% ± 16.9%). Among the content subgroups, scores were generally higher for disease summary and diagnostics and lower for prognosis. The Internet Web sites reviewed demonstrated a wide range of content and information. We found that nonprofit and academic Web sites were the most reliable sources, whereas commercial and, surprisingly, physician-run Web sites were the least reliable. We advise physicians to talk to their patients about the information they get on the Internet and how it dictates their expectations. We hope this study, combined with further understanding of how our patients use this information, can help improve the Internet content. Physicians should know that their patients may be receiving misleading information from the Internet and be able to discuss this with their patients.

More and more people are using the Internet as a source of information on health and mental health issues. Assuring quality and preventing abuse of the medium for the provision of health and mental health information is an increasing concern. This can be particularly important for more at-risk populations, such as people with chronic diseases and mental health concerns. This chapter presents the current situation of the health and medical Internet usage and the actions that have been taken to improve the quality of medical and health information. The chapter will particularly describe the methodology used by Health On the Net Foundation (HON), an international organization that has been certifying medical websites since the beginning of the Internet era. HON’s goal is to guide healthcare consumers and providers on the Internet to sound and reliable medical information. By certifying sites that adhere to its eight ethical guidelines (the HON Code), HON seeks to contribute to better, more accessible healthcare. HON certification is free and thereby available to all, and not subject to conflict of interest concerns that can arise from client-provider relationships. The HON code provides a transparent, flexible, accessible, and reliable methodology that promotes and improves the quality of medical websites worldwide. The success of the HON Code attests to its growing importance and the suitability of its methodology. More than 7,500 websites have been certified in 34 languages from 118 countries; 450 of these websites are related to mental health. In 2007, the French National Health Authority mandated that all health websites in France be certified by HON.

Trust, authority and credibility in the digital environment have attracted the interest of many researchers in the recent years. Reliable and credible information are key factors for making numerous decisions in our everyday lives, from making political choices to choosing a healthy lifestyle. Various health-related narratives are present in the public sphere. Health advice and recommendations on vaccination, antibiotics, nutrition, exercise and numerous other topics are provided by different sources, scientific community, healthcare professionals, media, lay people, patients, social networks, etc. It was the infodemic associated with the coronavirus pandemic that again brought to the forefront the importance of reliable and credible health information and health information literacy in this complex digital environment. In such fragmented information ecosystem, characterized by the post-truth era, where misinformation and fake news spread by uninformed individuals or advocates of various conspiracy theories are considered equivalent to reliable scientific information, individuals have to choose whom to trust, based on their critical capacities and competencies, in order to make health decisions for themselves and their families. The young people of today, especially those born after the year 2000, represent the generation of digital natives, who grew up and spent their entire lives surrounded by digital technologies that have become an integral part of their lives. They think and process information differently than their predecessors. Most of them use the Internet as their primary source for accessing information, most often through smartphones, spend the vast majority of time online, increasingly use social networks for private and professional purposes, but at the same time have difficulty assessing the reliability of online information. The way they assess trust in digital information is different from the way they question information credibility in traditional media. Given that trust and credibility of information strongly influence the effect of information message itself, which, in extraordinary circumstances and public health crisis such as the coronavirus pandemic, is of vital importance for the lives of people, it is very important to understand how users decide whom to trust. Health information literacy is a multidimensional and dynamic concept that incorporates social, cognitive, economic, and personal skills to search, understand, and use health information in order to improve and maintain good health. The evaluation of online health information, i.e. its reliability and credibility, plays a significant role in the process of health behavior change. Research to date has not reached a consensus on unique framework for understanding the process of building user confidence in online health information. The focus of this doctoral dissertation are theoretical and analytical challenges of health information literacy as a multidimensional and dynamic concept, particularly in understanding the process of creating trust in online health information. By examining the attitudes and opinions of medical students about the evaluation of online health information we aimed to determine factors that influence the assessment of health information quality and credibility. The main research objective is to examine the element of information appraisal in the concept of health information literacy and to determine the processes of creating trust in health information in an online environment. The specific research objectives are as follows: 1. to identify factors and techniques for assessing the quality, reliability and credibility of online health information; 2. to determine the elements of cognitive heuristics for assessing the reliability of online health information; 3. to determine the impact of infodemic during a healthcare crisis on online health information trust issues; 4. to examine methods for assessing the quality and reliability of user-generated online health information; 5. to investigate medical students' attitudes and knowledge of the concepts and tools for assessing health information literacy. Our research aimed to determine common elements of information appraisal in the concept of health information literacy and related concepts dealing with online health information (health literacy, information literacy, media literacy, digital literacy, etc.). The research was performed using multiple methods conducted in three phases: 1. literature review and comparative analysis of selected tools and instruments for assessment of health information literacy and related concepts; 2. a survey questionnaire that examined the attitudes and opinions of medical students of the University of Zagreb School of Medicine regarding online health information appraisal, and 3. semi-structured interviews with a smaller subgroup of respondents in order to build on the findings from the survey questionnaire related to the determination of factors that influence trust in online health information, i.e. assessment of their quality and credibility. The results of our research demonstrated that medical students have the knowledge, skills and techniques necessary to assess the quality, reliability and credibility of online health information. Although medical students generally considered Internet to be a questionable source for health information, the majority reported that they always use online search engines as the first step when searching for health topics, regardless of their purpose (general interest, academic assignment, or personal or health problem among family and friends, etc.). Medical students consider the following analytical criteria when assessing the credibility of online health information: trustworthiness, completeness, objectivity and comprehensiveness of information, referencing other data sources and author disclosure. Apart from analytical criteria, medical students also use cognitive heuristics when assessing the reliability of online health information, especially user-generated content that is published and shared via social networks. Students also emphasized the importance of critical thinking, factual analysis, information verification on multiple sources, determination of source credentials as well as sharing information with family members, friends, colleagues, physicians and university professors who they consider as cognitive authorities in health communication. Research results indicate an overall positive relationship between perceived health information literacy of medical students, their ability to evaluate online health information and trust in the Internet as a source of health information. Students with high self-perceived level of e-health literacy more often use websites of government institutions and professional medical associations than other sources for online health information. Our research also revealed that the degree of trust that medical students have in online sources of information affects their behavior when searching and evaluating online health information. In healthcare crisis situations, medical students apply additional evaluation criteria for usergenerated health information on social media. In general, medical students expressed mistrust towards social networks, especially as a source of credible health information in the context of an infodemic. Although the majority of students use social networks only passively, they also believe that social networks present a platform that has the potential, if used appropriately, to convey reliable information and improve health information literacy. Students also stressed that, during infodemic, strategic crisis communication skills should be applied for proactive dissemination of credible, factual and scientific evidence in order to contribute to a faster and more efficient containment of the spread of misinformation and fake news on social media. The results of our research have shown that online health information should be comprehensive, accurate, evidence-based, objective and up-to-date in order to convey a quality health message. According to medical students, quality of information, source credibility, comprehensibility and readability, as well as verification of information in evidence-based sources are main predictors of trust in online health information. Understanding which health channels and sources are considered most reliable among different user groups can help health professionals reach at-risk patients in order to communicate health messages more successfully and implement interventions aimed at strengthening skills that are important for health information appraisal. By analyzing medical students` attitudes and opinions about credibility of online health information, we explored ways to promote critical thinking in the digital environment in order to empower individuals to make decisions in their everyday life based on verified and credible sources of information. Placing greater emphasis on lifelong learning about health, and formal and informal health information literacy education, enables greater autonomy and empowerment of individuals, and can be viewed as part of personal development towards an improved quality of life. Health information literacy increases individual and community resistance to harmful and misleading information and reduces the impact of the infodemic on human health. Improving health information literacy among population requires joint action and cooperation between stakeholders and policymakers (government authorities, media, scientific, educational and health institutions, healthcare professionals, scientists, researchers, librarians and others). Health information literacy is an important competence of every individual, but its implications for society are much broader. They include personal and social responsibility of individuals and taking ethical actions for the benefit of the community. A modern democratic society implies engaged citizens who autonomously reflect on political, ethical and social challenges in everyday life. Empowerment in health and social care, achieved by developing critical competencies, helps in distancing oneself from various social pressures, making independent informed decisions and taking responsibility for one's own health. Croatia, unlike most other European countries, still does not have an official strategy or action plan for developing and improving health information literacy among its population. Our research results point out the importance of including health information literacy in the national health policy and education strategy, with particular emphasis on developing critical thinking skills and competencies in evidence-based approach to online health information appraisal. The results of this research contribute to the conceptual linking of theoretical constructs on information appraisal and critical theories from information and communication sciences with constructs from the field of public health. The mentioned approach resulted in unifying the narratives of different domains, and synthesizing separate theoretical frameworks, namely health information and related literacies, which adds to the value of this research. The results of this research serve as a basis for defining skills for critical appraisal of online health information in order to increase the level of health information literacy and development of tools for evaluating the reliability of online health information. On the applicative level, this doctoral dissertation provides recommendations for communication of reliable online health information from the current infodemic perspective, in planning public health activities and interventions in the future.

Background Healthcare information is increasingly being sought on the Internet. Ischaemic heart disease (IHD) poses a significant health burden. Concern often arises for patients with IHD when undergoing dental treatment, leading to online searching for relevant healthcare information.Objective To evaluate the readability and quality of webpages regarding IHD and dental treatment.Materials and methods Three searches were performed on the Google search engine. The first hundred results of each search were collated and exclusion criteria applied. The remaining 66 webpages were categorised. Readability was assessed using the FRES and SMOG readability tools. Quality was assessed using the PEMAT questionnaire, the JAMA benchmarks and the Health On the Net (HON) seal.Results Most examined webpages were commercial. Readability of 90.1% of webpages was deemed fairly to very difficult. Understandability and actionability scores were generally below the comprehension level of the general population. Less than 50% of websites achieved the authorship, attribution and disclosure JAMA benchmarks. Only 12.1% of websites displayed the HON seal.Conclusions Online health information related to IHD and dental treatment is generally too difficult for the average individual to read, understand, or act upon, and may be of questionable quality. Given the low health literacy rates among the general population, future revisions of educational materials by non-commercial sources regarding IHD and dental treatment are warranted, in order to ensure online health information is understandable and of genuine benefit to patients and/or their carers.

providing health information to consumers [1,2]. Even cancer patients, who are not in the typical demographic group of Internet users, often name the Internet as the second most important source for cancer information after health professionals [3,4,5], and people are more satisfied with information they receive from the Web than from other media [6]. The aim of this chapter is to give an overview of best practices for developing and providing consumer health information on the Web and to provide a framework for best practices, quality criteria, and methods for quality assurance and evaluation. Developers and health information providers are faced with “everyday” practical questions such as how to ensure, monitor, and continuously improve the quality of the information they publish. End-users (consumers) are also interested in “quality criteria” and best practices, as they wish to have “markers” (attributes of a Web site or Web page or a health information provider) that can be used to predict the “quality” in order to select “trustworthy” health information.The issue of quality criteria is also important for third-party expert evaluators working for gateways or portals, or other intermediaries such as librarians or healthcare workers putting together lists of “recommended” health Web sites, because they need to specify and apply selection criteria for the sites they endorse. Similarly, organizations that are in the business of Web site certification need to have a checklist of quality criteria to justify their decisions to certify a Web site. Finally, policy makers are interested in the subject of what makes a good (or bad) health Web site, especially in the context of making regulatory and legislative policy decisions. There has been considerable debate and research on the variable quality of health Web sites [7] and how to best evaluate health information Web sites. One reason for the controversy is that “quality” is an elusive concept and implies subjectivity. Quality can be broadly defined as the “totality of characteristics of a product or service that satisfy stated or implied needs of the user” [8,9]. This definition stresses that “quality” is determined by the concordance (or gap) between individual user needs and the actual attributes of the service or product. Perceived quality (or satisfaction) is further confounded by the users’ prior expectations, which also vary individually. In other words, certain aspects of quality seem to be in the eye of the beholder, and can be measured only by the gap between user needs and attributes of the Web site or service [10]. This apparent subjectivity has led to a pessimistic view that quality of Web sites cannot be measured or evaluated, at least not by third parties [11]. The fact that we are talking about “health information” makes the issue even more problematic, as in medicine there are often “gray” areas with no clear black-or-white 4 Design and Evaluation of Consumer Health Information Web Sites

BackgroundResearch networks offer multidisciplinary expertise and promote information exchange between researchers across Europe. They are essential for the European Union’s (EU) health information system as providers of health information and data. The aim of this mapping exercise was to identify and analyze EU research networks in terms of health data collection methods, quality assessment, availability and accessibility procedures.MethodsA web-based search was performed to identify EU research networks that are not part of international organizations (e.g., WHO-Europe, OECD) and are involved in collection of data for health monitoring or health system performance assessment. General characteristics of the research networks (e.g., data sources, representativeness), quality assessment procedures, availability and accessibility of health data were collected through an ad hoc extraction form.ResultsFifty-seven research networks, representative at national, international or regional level, were identified. In these networks, data are mainly collected through administrative sources, health surveys and cohort studies. Over 70% of networks provide information on quality assessment of their data collection procedures. Most networks share macrodata through articles and reports, while microdata are available from ten networks. A request for data access is required by 14 networks, of which three apply a financial charge. Few networks share data with other research networks (8/49) or specify the metadata-reporting standards used for data description (9/49).ConclusionsImproving health information and availability of high quality data is a priority in Europe. Research networks could play a major role in tackling health data and information inequalities by enhancing quality, availability, and accessibility of health data and data sharing across European networks.

Health information is a frequent subject for online information seeking. Research on the phenomenon has to a certain extent included students. This review, based on an analysis of 61 articles, shows the current state of the art of research on students’ trust in online health information. The review covers methodological approaches and findings of previous previous empirical studies: research design; trustworthy health information sources; credibility assessment; and factors impacting on trust formation. The analysis of research designs reveals that the survey method was most frequent, but small qualitative studies were also occurring. More than half of the studies were administered in the USA, while only a smaller part concerned ‘non-Western’ countries. Female subjects were more frequent than male.The concept of trust was not always explicitly defined in the studies. The students' actual propensity to use internet was generally taken as an expression of trust. The antecedents of trust identified in the studies can be summarized as the perceived quality of the information, the perceived credibility of the source or source provider, the users’ general inclination to trust, the actual use of information, and the perceived intelligibility of the information. The findings show that Internet was among the main sources for health information, but parents or other family members, friends, schools, health professionals were also frequent sources of health information, and students were not immediately accepting online information as trustworthy. The students’ trust and credibility judgments were influenced by social and demographic, cultural, psychological, knowledge and skills-related, and source, system and content-related factors. Governmental and organizational websites were reported as the most trustful sources, although some issues regarding website features and presentation of content were reported as barriers. Easy access were of importance for using a particular resource, but there seemed to be a learning effect impacting on seeking behaviour and trust formation.

Complex and ineffective health communication is a critical source of health inequity and occurs despite repeated policy directives to provide health information that is easy to understand and applies health literacy principles. To evaluate the effectiveness of the Sydney Health Literacy Lab Health Literacy Editor, an easy-to-use online plain language tool that supports health information providers to apply health literacy guidelines to written health information. This randomized clinical trial, conducted online in Australia from May 2023 to February 2024, included a convenience sample of health information providers with no previous experience using the Health Literacy Editor. Analysts were blinded to study group. Participants were randomized 1:1 to the intervention or control group. Participants in the intervention group were provided access to the Health Literacy Editor and a 30-minute online training program prior to editing 3 prespecified health texts. The Health Literacy Editor gives objective, real-time feedback on words and sentences. Control participants revised the texts using their own standard health information development processes. The preregistered primary outcome was the text school grade reading score (using a validated instrument, the Simple Measure of Gobbledygook). Secondary outcomes were text complexity (percentage of text using complex language), use of passive voice (number of instances), and subjective expert ratings (5-point Likert scale corresponding to items on the Patient Education Materials Assessment Tool). A total of 211 participants were randomized, with 105 in the intervention group and 106 in the control group. Of 181 participants in the intention-to-treat analysis (mean [SD] age, 41.0 [11.6] years; 154 women [85.1%]), 86 were in the intervention group and 95 in the control group. Texts revised in the intervention group had significantly improved grade reading scores (mean difference [MD], 2.48 grades; 95% CI, 1.84-3.12 grades; P < .001; Cohen d, 0.99), lower text complexity scores (MD, 6.86; 95% CI, 4.99-8.74; P < .001; Cohen d, 0.95), and less use of passive voice (MD, 0.95 instances; 95% CI, 0.44-1.47 instances; P < .001; Cohen d, 0.53) compared with texts revised in the control group in intention-to-treat analyses. Experts rated texts in the intervention group more favorably for word choice and style than those in the control group (MD, 0.44; 95% CI, 0.25-0.63; P < .001; Cohen d, 0.63), with no loss of meaning or content. In this randomized clinical trial, the Health Literacy Editor helped users simplify health information and apply health literacy guidelines to written text. The findings suggest the tool has high potential to improve development of health information for people who have low health literacy. As an online tool, the Health Literacy Editor is also easy to access and implement at scale. ANZCTR Identifier: ACTRN12623000386639.

Resolving embarrassing medical conditions with online health information

ObjectivesThis study analyzed the current operation of the National Health Information Portal, which provides trustworthy evidence-based health information to the public, to propose directions for improvement in response to the evolving artificial intelligence (AI)-based search environment and increasing demand for personalized health information.MethodsTo examine Portal operation, we reviewed project reports, internal planning documents, content management system data, Google Analytics 4 statistics, and triennial quality assessment results produced by the Seoul National University R&DB Foundation, which has managed the project since 2018. Relevant policy documents and domestic and international best practices were also analyzed to identify directions for improvement.ResultsThe Portal operates to achieve its core values of “verified, easy-to-understand, and integrated information” through a standardized authoring and review system. It enhances reliability and accessibility by developing life cycle-based customized content, providing plain language explanations and summaries, and establishing an ontology- and metadata-based management framework. User engagement has been strengthened by improvements in user interfaces, newsletters, and interactive events.ConclusionsIn response to expanding AI-based search availability, the Portal has implemented a Generative Engine Optimization strategy and is exploring strategies to more effectively provide personalized health information in the future, including connectivity with national personal health record systems. The Portal will continue to strengthen its role as a leading public platform that improves health literacy and promotes healthy lifestyle practices in the population.