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BackgroundThe Internet is increasingly used as a medium for the delivery of interventions designed to promote health behavior change. However, reviews of these interventions to date have not systematically identified intervention characteristics and linked these to effectiveness. Objectives The present review sought to capitalize on recently published coding frames for assessing use of theory and behavior change techniques to investigate which characteristics of Internet-based interventions best promote health behavior change. In addition, we wanted to develop a novel coding scheme for assessing mode of delivery in Internet-based interventions and also to link different modes to effect sizes. MethodsWe conducted a computerized search of the databases indexed by ISI Web of Knowledge (including BIOSIS Previews and Medline) between 2000 and 2008. Studies were included if (1) the primary components of the intervention were delivered via the Internet, (2) participants were randomly assigned to conditions, and (3) a measure of behavior related to health was taken after the intervention. Results We found 85 studies that satisfied the inclusion criteria, providing a total sample size of 43,236 participants. On average, interventions had a statistically small but significant effect on health-related behavior (d+ = 0.16, 95% CI 0.09 to 0.23). More extensive use of theory was associated with increases in effect size (P = .049), and, in particular, interventions based on the theory of planned behavior tended to have substantial effects on behavior (d+ = 0.36, 95% CI 0.15 to 0.56). Interventions that incorporated more behavior change techniques also tended to have larger effects compared to interventions that incorporated fewer techniques (P < .001). Finally, the effectiveness of Internet-based interventions was enhanced by the use of additional methods of communicating with participants, especially the use of short message service (SMS), or text, messages. ConclusionsThe review provides a framework for the development of a science of Internet-based interventions, and our findings provide a rationale for investing in more intensive theory-based interventions that incorporate multiple behavior change techniques and modes of delivery.

BACKGROUND: The use of Internet-based questionnaires for collection of data to evaluate patient education and other interventions has increased in recent years. Many self-report instruments have been validated using paper-and-pencil versions, but we cannot assume that the psychometric properties of an Internet-based version will be identical. OBJECTIVES: To look at similarities and differences between the Internet versions and the paper-and-pencil versions of 16 existing self-report instruments useful in evaluation of patient interventions. METHODS: Participants were recruited via the Internet and volunteered to participate (N=397), after which they were randomly assigned to fill out questionnaires online or via mailed paper-and-pencil versions. The self-report instruments measured were overall health, health distress, practice mental stress management, Health Assessment Questionnaire (HAQ) disability, illness intrusiveness, activity limitations, visual numeric for pain, visual numeric for shortness of breath, visual numeric for fatigue, self-efficacy for managing disease, aerobic exercise, stretching and strengthening exercise, visits to MD, hospitalizations, hospital days, and emergency room visits. Means, ranges, and confidence intervals are given for each instrument within each type of questionnaire. The results from the two questionnaires were compared using both parametric and non-parametric tests. Reliability tests were given for multi-item instruments. A separate sample (N=30) filled out identical questionnaires over the Internet within a few days and correlations were used to assess test-retest reliability. RESULTS: Out of 16 instruments, none showed significant differences when the appropriate tests were used. Construct reliability was similar within each type of questionnaire, and Internet test-retest reliability was high. Internet questionnaires required less follow-up to achieve a slightly (non-significant) higher completion rate compared to mailed questionnaires. CONCLUSIONS: Among a convenience sample recruited via the Internet, results from those randomly assigned to Internet participation were at least as good as, if not better than, among those assigned mailed questionnaires, with less recruitment effort required. The instruments administered via the Internet appear to be reliable, and to be answered similarly to the way they are answered when they are administered via traditional mailed paper questionnaires. [J Med Internet Res 2004;6(3):e29]

An error in the CHERRIES statement has been corrected (J Med Internet Res 2004;6[3]:e34). In the original paper, in table 1, denominator and numerator were flipped in the recommendations on how response rates (view rate, participation rate, and completion rate) should be calculated. The view rate should be the ratio of unique survey visitors divided by unique site visitors. The participation rate should be the ratio of those who agreed to participate divided by unique first survey page visitors. The completion rate is the ratio of the number of people who finished the survey divided by those who agreed to participate. The corrections have been made in the table in both columns. [J Med Internet Res 2012;14(1):e8]

BACKGROUND: Concerns over health information on the Internet have generated efforts to enhance credibility markers; yet how users actually assess the credibility of online health information is largely unknown. OBJECTIVE: This study set out to (1) establish a parsimonious and valid questionnaire instrument to measure credibility of Internet health information by drawing on various previous measures of source, news, and other credibility scales; and (2) to identify the effects of Web-site domains and advertising on credibility perceptions. METHODS: Respondents (N = 156) examined one of 12 Web-site mock-ups and completed credibility scales in a 3 x 2 x 2 between-subjects experimental design. Factor analysis and validity checks were used for item reduction, and analysis of variance was employed for hypothesis testing of Web-site features' effects. RESULTS: In an attempt to construct a credibility instrument, three dimensions of credibility (safety, trustworthiness, and dynamism) were retained, reflecting traditional credibility sub-themes, but composed of items from disparate sources. When testing the effect of the presence or absence of advertising on a Web site on credibility, we found that this depends on the site's domain, with a trend for advertisements having deleterious effects on the credibility of sites with .org domain, but positive effects on sites with .com or .edu domains. CONCLUSIONS: Health-information Web-site providers should select domains purposefully when they can, especially if they must accept on-site advertising. Credibility perceptions may not be invariant or stable, but rather are sensitive to topic and context. Future research may employ these findings in order to compare other forms of health-information delivery to optimal Web-site features. [J Med Internet Res 2004;6(3):e24]

BACKGROUND: Many users search the Internet for answers to health questions. Complementary and alternative medicine (CAM) is a particularly common search topic. Because many CAM therapies do not require a clinician's prescription, false or misleading CAM information may be more dangerous than information about traditional therapies. Many quality criteria have been suggested to filter out potentially harmful online health information. However, assessing the accuracy of CAM information is uniquely challenging since CAM is generally not supported by conventional literature. OBJECTIVE: The purpose of this study is to determine whether domain-independent technical quality criteria can identify potentially harmful online CAM content. METHODS: We analyzed 150 Web sites retrieved from a search for the three most popular herbs: ginseng, ginkgo and St. John's wort and their purported uses on the ten most commonly used search engines. The presence of technical quality criteria as well as potentially harmful statements (commissions) and vital information that should have been mentioned (omissions) was recorded. RESULTS: Thirty-eight sites (25%) contained statements that could lead to direct physical harm if acted upon. One hundred forty five sites (97%) had omitted information. We found no relationship between technical quality criteria and potentially harmful information. CONCLUSIONS: Current technical quality criteria do not identify potentially harmful CAM information online. Consumers should be warned to use other means of validation or to trust only known sites. Quality criteria that consider the uniqueness of CAM must be developed and validated. [J Med Internet Res 2004;6(2):e21]

BACKGROUND: The use of medical experts in rating the content of health-related sites on the Internet has flourished in recent years. In this research, it has been common practice to use a single medical expert to rate the content of the Web sites. In many cases, the expert has rated the Internet health information as poor, and even potentially dangerous. However, one problem with this approach is that there is no guarantee that other medical experts will rate the sites in a similar manner. OBJECTIVES: The aim was to assess the reliability of medical experts' judgments of threads in an Internet newsgroup related to a common disease. A secondary aim was to show the limitations of commonly-used statistics for measuring reliability (eg, kappa). METHOD: The participants in this study were 5 medical doctors, who worked in a specialist unit dedicated to the treatment of the disease. They each rated the information contained in newsgroup threads using a 6-point scale designed by the experts themselves. Their ratings were analyzed for reliability using a number of statistics: Cohen's kappa, gamma, Kendall's W, and Cronbach's alpha. RESULTS: Reliability was absent for ratings of questions, and low for ratings of responses. The various measures of reliability used gave conflicting results. No measure produced high reliability. CONCLUSIONS: The medical experts showed a low agreement when rating the postings from the newsgroup. Hence, it is important to test inter-rater reliability in research assessing the accuracy and quality of health-related information on the Internet. A discussion of the different measures of agreement that could be used reveals that the choice of statistic can be problematic. It is therefore important to consider the assumptions underlying a measure of reliability before using it. Often, more than one measure will be needed for "triangulation" purposes. [J Med Internet Res 2002;4(1):e2]

BACKGROUND: The massive growth of health information on the Internet; the global nature of the Internet; the seismic shift taking place in the relationships of various actors in this arena, and the absence of real protection from harm for citizens who use the Internet for health purposes are seen to be real problems. One response to many of these problems has been the burgeoning output of codes of conduct by numerous organizations trying to address quality of health information. OBJECTIVES: Review the major self-regulatory initiatives in the English-speaking world to develop quality and ethical standards for health information on the Internet. Compare and analyze the approaches taken by the different initiatives. Clarify the issues around the development and enforcement of standards. METHODS: Quality initiatives selected meet one or more of the following criteria: Self-regulatory. A reasonable constituency. Diversity (eg, of philosophy, approach and process)-to achieve balance and wide representation, and to illustrate and compare different approaches. Historic value. A wider reach than a national audience, except when its reach is a significant sector of the Internet health information industry. The initiatives were compared in 3 ways: (1) Analysis and comparison of: key concepts, mechanism, or approach. Analysis of: the obligations that a provider has to meet to comply with the given initiative, the intended beneficiaries of that initiative, and the burdens imposed on different actors. These burdens are described in terms of their effect on the long-term sustainability and maintenance of the initiative by its developers. Analysis of the enforcement mechanisms. (2) Analysis and comparison by type of sponsoring organization, the reach of the initiative, and the sources of funding of the initiative or the sponsoring organization. (3) How the various initiatives fall under 1 of 3 key mechanisms and comparison of the advantages and disadvantages of these key mechanisms. RESULTS: The issues that affect the initiatives and future work on the quality of health information on the Internet are identified and analyzed. These issues are: (a) Three key mechanisms used in the quality initiatives (b) Sustainability issues that affect the initiatives: Burdens placed on health information providers, citizens and others. Currency and maintenance issues of the initiatives. Funding. Cost. Acceptance. Market conditions. User indifference or ambivalence. (c) Enforcement issues surrounding the initiatives (d) Adequacy of approach, scope, reach, and enforcement provisions of the various quality initiatives (e) Gaps that need to be addressed to achieve good quality of health information on the internet CONCLUSIONS: Ten conclusions are presented. A framework of action to be undertaken by the World Health Organization in the field of quality of health information on the Internet is recommended. [J Med Internet Res 2001;3(4):e28]

Background Patients in the United States commonly use the Internet to acquire health information. While a significant amount of health-related information is available on the Internet, the accuracy of this information is highly variable. Objectives The objective of the study was to determine how effectively students can assess the accuracy of Internet-based material when gathering information on a controversial medical topic using simple keyword searches. Methods A group of 34 students from the science magnet high school in Houston, Texas searched for the terms “vaccine safety” and “vaccine danger” using Google and then answered questions regarding the accuracy of the health information on the returned sites. The students were also asked to describe the lessons they learned in the exercise and to answer questions regarding the strength of evidence for seven statements regarding vaccinations. Because of the surprising revelation that the majority of students left the exercise with inaccurate information concerning the safety and efficacy of vaccines, these same students participated in a follow-up study in which a fact-based vaccine video was shown, after which the assessment of student knowledge was repeated. Results Of the 34 participants, 20 (59%) thought that the Internet sites were accurate on the whole, even though over half of the links (22 out of 40, 55%) that the students viewed were, in fact, inaccurate on the whole. A high percentage of the students left the first exercise with significant misconceptions about vaccines; 18 of the 34 participants (53%) reported inaccurate statements about vaccines in the lessons they learned. Of the 41 verifiable facts about vaccines that were reported by participants in their lessons-learned statement, 24 of those facts (59%) were incorrect. Following presentation of the film, the majority of students left the exercise with correct information about vaccines, based on their lessons-learned statement. In this case, 29 of the 31 participants (94%) reported accurate information about vaccines. Of the 49 verifiable facts about vaccines that were reported by participants, only 2 (4%) were incorrect. Students had higher correct scores in the “strength of evidence” exercise following exposure to the video as well. Conclusions Allowing students to use the Internet to gain information about medical topics should be approached with care since students may take away predominantly incorrect information. It is important to follow up conflicting information with a solid, unambiguous message that communicates those lessons that the instructor deems most important. This final message should be fact based but may need to contain an anecdotal component to counter the strong emotional message that is often delivered by inaccurate Internet sites.

BACKGROUND: The Internet is a viable channel to deliver evidence-based smoking cessation treatment that has the potential to make a large population impact on reducing smoking prevalence. There is high demand for smoking cessation information and support on the Internet. Approximately 7% (10.2 million) of adult American Internet users have searched for information on quitting smoking. Little is known about these individuals, their smoking status, what type of cessation services they are seeking on the Internet, or how frequently these searches for cessation information are conducted. OBJECTIVE: The primary goal of this study was to characterize individuals who search for smoking cessation information on the Internet to determine appropriate triage and treatment strategies. The secondary goal was to estimate the incidence of searches for cessation information using publicly available search engine data. METHODS: We recruited individuals who clicked on a link to a leading smoking cessation website (QuitNet) from within the results of a search engine query. Individuals were “intercepted” before seeing the QuitNet home page and were invited to participate in the study. Those accepting the invitation were routed to an online survey about demographics, smoking characteristics, preferences for specific cessation services, and Internet search patterns. To determine the generalizability of our sample, national datasets on search engine usage patterns, market share, and keyword rankings were examined. These datasets were then used to estimate the number of queries for smoking cessation information each year. RESULTS: During the 10-day study period, 2265 individuals were recruited and 29% (N = 655) responded. Of these, 59% were female and overall tended to be younger than the previously characterized general Internet population. Most (76%) respondents were current smokers; 17% had quit within the last 7 days, and 7% had quit more than 7 days ago. Slightly more than half of active smokers (53%) indicated that they were planning to quit in the next 30 days. Smokers were more likely to seek information on how to quit and on medications; former smokers were more interested in how to cope with withdrawal. All participants rated withdrawal information and individually tailored information as being more useful, while displaying little interest in telephone counseling, expert support, or peer support. Publicly available data from large search engines suggest that 4 million Americans search for resources on smoking cessation each year. CONCLUSIONS: This study adds to the limited data available on individuals who search for smoking cessation information on the Internet, supports the prior estimates of the size of the population, and indicates that these individuals are in appropriate stages for both active cessation interventions and aggressive relapse prevention efforts. Continued development and evaluation of online interventions is warranted, and organizations seeking to promote cessation should carefully evaluate the Internet as a possible modality for treatment and as a gateway to other traditional programs. [J Med Internet Res 2006;8(3):e17]

BACKGROUND: Globally, half of all new HIV infections occur among young people. Despite this incidence, there is a profound lack of resources for HIV-positive youth. OBJECTIVE: To investigate Internet access, use and acceptability as a means for health promotion and health service delivery among HIV-positive youth. METHODS: A community-based participatory approach was used to conduct a mixed methods research study. Thirty-five qualitative in-depth semi-structured interviews were conducted with youth (ages 12-24) living with HIV in Ontario. Also, brief structured demographic surveys were administered at the time of the interview. A stakeholder group of youth living with HIV, professionals and researchers collaboratively analyzed the data for emerging themes. RESULTS: Five main themes were identified with respect to the youth's use of and interest in the Internet as a health promotion strategy. These include: (1) high rates of Internet use and access; (2) issues around public and private terminals; (3) their use of the Internet primarily for communication and entertainment; (4) the rarity of health information seeking behavior in this group; and (5) wanting "one-stop shopping" from an e-health site. HIV-positive youth were enthusiastic about the possibility of content that was developed specifically to target them and their needs. Also, they were keen about the possibilities for increased social support that youth-specific online chat rooms and message boards might provide. CONCLUSION: Given high rates of use, access and interest, the Internet provides an important way to reach young people living with HIV using health services and health promotion programs. The onus is on e-Health developers to understand the particular needs of HIV-positive youth and create relevant content. [J Med Internet Res 2004;6(3):e32]

BACKGROUND: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality information rather than evaluating actual accuracy and comprehensiveness. OBJECTIVE: This research sought to develop a new performance-measurement tool for evaluating the quality of Internet health information, test the validity and reliability of the tool, and assess the variability in diabetes Web site quality. METHODS: An objective, systematic tool was developed to evaluate Internet diabetes information based on a quality-of-care measurement framework. The principal investigator developed an abstraction tool and trained an external reviewer on its use. The tool included 7 structural measures and 34 performance measures created by using evidence-based practice guidelines and experts' judgments of accuracy and comprehensiveness. RESULTS: Substantial variation existed in all categories, with overall scores following a normal distribution and ranging from 15% to 95% (mean was 50% and median was 51%). Lin's concordance correlation coefficient to assess agreement between raters produced a rho of 0.761 (Pearson's r of 0.769), suggesting moderate to high agreement. The average agreement between raters for the performance measures was 0.80. CONCLUSIONS: Diabetes Web site quality varies widely. Alpha testing of this new tool suggests that it could become a reliable and valid method for evaluating the quality of Internet health sites. Such an instrument could help lay people distinguish between beneficial and misleading information. [J Med Internet Res 2003;5(4):e30]

BACKGROUND: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality of information, rather than evaluating information accuracy and comprehensiveness. OBJECTIVE: This research sought to build a conceptual framework that could lay the groundwork for a robust performance-measurement system for evaluating the quality of Internet health information. METHODS: Application of the quality-of-care measurement paradigm to developing a conceptual framework for defining and evaluating the quality of diabetes consumer-information Web sites. RESULTS: Performance measures related to accuracy and comprehensiveness of information can be added to structural criteria to provide a more-robust approach to Web site evaluation. CONCLUSIONS: The development and implementation of a reliable and valid method for evaluating the quality of Internet health sites could provide lay people with a tool to identify useful content more easily and distinguish between beneficial and misleading information. [J Med Internet Res 2003;5(4):e29]

BACKGROUND: The Internet is an invaluable tool for researchers and certainly also a source of inspiration. However, never before has it been so easy to plagiarise the work of others by clipping together (copy & paste) an apparently original paper or review paper from paragraphs on several websites. Moreover, the threshold of stealing ideas, whether lifting paragraphs or perhaps even whole articles from the Internet, seems to be much lower than copying sections from books or articles. In this article, we shall use the term "cyberplagarism" to describe the case where someone, intentionally or inadvertently, is taking information, phrases, or thoughts from the World Wide Web (WWW) and using it in a scholarly article without attributing the origin. OBJECTIVE: To illustrate a case of cyberplagiarism and to discuss potential methods using the Internet to detect scientific misconduct. This report was also written to stimulate debate and thought among journal editors about the use of state of the art technology to fight cyberplagiarism. METHODS: A case of a recent incident of cyberplagiarism, which occurred in the Journal of the Royal College of Surgeons of Edinburgh (JRCSEd), is reported. A systematic search of the Internet for informatics tools that help to identify plagiarism and duplicate publication was conducted. RESULTS: This is the first in-depth report of an incident where significant portions of a web article were lifted into a scholarly article without attribution. In detecting and demonstrating this incident, a tool at www.plagiarism.org, has proven to be particularly useful. The plagiarism report generated by this tool stated that more than one third (36%) of the JRCSEd article consisted of phrases that were directly copied from multiple websites, without giving attribution to this fact. CONCLUSIONS: Cyberplagiarism may be a widespread and increasing problem. Plagiarism could be easily detected by journal editors and peer-reviewers if informatics tools would be applied. There is a striking gap between what is technically possible and what is in widespread use. As a consequence of the case described in this report, JMIR has taken the lead in applying information technology to prevent and fight plagiarism by routinely checking new submissions for evidence of cyberplagiarism. [J Med Internet Res 2000;2(1):e4]

INTRODUCTION: Health information on the Internet undergoes no quality control at the stage of production, thus its quality is highly variable, making it difficult for consumers to weed out the helpful from the harmful. In 1997, a uniform, machine readable vocabulary based on the WWW-Consortiums PICS-Standard (Platform for Internet Content Selection) was proposed and has become known as "medPICS". The advantage of this system is that it allows authors and third parties to label medical information on the Web using metadata which is standardized (PICS/RDF/XML), can be transmitted in a secure way, can be assigned by third parties and is machine-readable allowing the user being able to filter the information he wants. This presentation introduces a forthcoming European project dubbed Med-CERTAIN (MedPICS Certification and Rating of Trustful and Assessed Health Information on the Net), proposed by a consortium of partners from several European countries who are involved in the medical, Internet cataloguing and Web standardisation communities in co-operation with the W3C metadata interest group. The aim of this EU project is to provide a system which will allow European citizens to place greater trust in networked information in the domain of health information. METHODS: Med-CERTAIN establishes a fully functional demonstrator for a self- and third-party rating system enabling patients and consumers to filter harmful health information and to positively identify and select high quality information. A standard rating vocabulary and Internet standards such as PICS/RDF/XML will be used to assign evaluative and descriptive meta-information to health information on the web. A trusted community of medically qualified volunteers will rate Internet information as they surf using advanced rating techniques such as Netscape's "Whats related" feature, bookmarklets (=Javascript-Code stored as Bookmarks), bookmark-uploads and JAVA tools. RESULTS: The rating project will be starting in the year 2000. We are presently building up a database of several hundred medical volunteers who will rate the web and solicit institutional partners for this collaborative rating approach. DISCUSSION: The project will demonstrate how PICS-based content rating and filtering technologies can automate and exploit value-adding resource description services. The proposed technology strategy combines a pragmatic use of simple existing technologies for data acquisition with a future-oriented standards policy intended to lead rather than follow the evolution of definitions for information-mediation services. []

Introduction Common telemedicine consultations can be divided in two classes: real-time telemedicine consultations and asynchronous telemedicine consultations. The advantage of real-time consultations is obvious - this is a natural discussion between physicians, which may be realised on the basis of desktop videoconferences. But the problems are also obvious: the necessity of additional hardware and the elevated demands for channel bandwidth. Because of the latter, the use of asynchronous telemedicine consultations is more preferable in most cases. Methods We can consider asynchronous telemedicine consultations as a special form of a discussion forum, very familiar tool for users' collaboration in global networks. Currently, there exist many software products that facilitate the discussion forums using Web-technology and Internet standards. After a period of research and analysis, we have taken the decision to use as our development basis the Lotus Notes/Domino server. The following characteristics of Lotus Notes can explain our decision: Ready-to-run discussion forum model Mechanisms for access control, Build-in integration with Web-technology, Visual tools for database design. Results The first version of Web-server for telemedicine consultation "Telemedicine concilium" using Lotus Notes/Domino technology is already in use. The main form, describing clinical case description documents, has the two main parts: description of patient vital status/systems and section of multimedia upload files (attached files with clinical investigation data). The clinical cases database is currently containing about 30 clinical cases. Approximately 40 physicians not only from Moscow, but also from other regions of Russia and from other countries of ex-USSR were registered as users of server. Discussion The current operation of the Lotus Notes server has proven the efficiency and attraction of the proposed technology. However, some problems have been detected: the Web-interaction mode is not available for all users, while some of them prefer to use e-mail for information exchange. Also, the form for the clinical case descriptions must be differentiated for different clinical cases or diverse category of patients (adults, children).