Northumbria Research Link
Citation: Sillence, Elizabeth, Briggs, Pamela, Fishwick, Lesley and Harris, Peter (2006) A
framework for understanding trust factors in web-based health advice. International
Journal of Human-Computer Studies, 64 (8). pp. 697-713. ISSN 1071-5819
Published by: Elsevier
URL: http://dx.doi.org/10.1016/j.ijhcs.2006.02.007
<http://dx.doi.org/10.1016/j.ijhcs.2006.02.007>
This version was downloaded from Northumbria Research Link:
http://nrl.northumbria.ac.uk/id/eprint/3829/
Northumbria University has developed Northumbria Research Link (NRL) to enable users
to access the University’s research output. Copyright © and moral rights for items on
NRL are retained by the individual author(s) and/or other copyright owners. Single copies
of full items can be reproduced, displayed or performed, and given to third parties in any
format or medium for personal research or study, educational, or not-for-pro?t purposes
without prior permission or charge, provided the authors, title and full bibliographic
details are given, as well as a hyperlink and/or URL to the original metadata page. The
content must not be changed in any way. Full items must not be sold commercially in any
format or medium without formal permission of the copyright holder. The full policy is
available online: http://nrl.northumbria.ac.uk/policies.html
This document may di@er from the ?nal, published version of the research and has been
made available online in accordance with publisher policies. To read and/or cite from the
published version of the research, please visit the publisher’s website (a subscription
may be required.)
A framework for understanding trust factors in web based health
advice
Elizabeth Sillence
a
, Pam Briggs,
a
Peter Harris
b
& Lesley Fishwick
a
a
PACT Lab, School of Psychology and Sports Science, Northumbria University,
Newcastle upon Tyne, NE1 8ST, UK
b
Centre for Research in Social Attitudes, Psychology Department, Sheffield
University, Sheffield, S10 2TP, UK
Author for correspondence
Elizabeth Sillence
PACT Lab, School of Psychology and Sports Science, Northumbria University,
Newcastle upon Tyne, NE1 8ST, UK
Telephone + 44 191 243 7246
Fax + 44 191 227 3190
Email Elizabeth.sillence@unn.ac.uk
Abstract
Trust is a key factor in consumer decisions about website engagement. Consumers will engage with
sites they deem trustworthy and turn away from those they mistrust. In this paper we present a
framework for understanding trust factors in web based health advice. The framework is derived from a
staged model of trust and allows predictions to be made concerning user engagement with different
health websites. The framework is then validated via a series of qualitative, longitudinal studies. In
each study genuine consumers searched online for information and advice concerning their specific
health issue. They engaged in free searching and were directed towards sites previously reviewed using
the framework. Thematic analysis of the group discussions provided support for the framework and for
the staged model of trust wherein design appeal predicted rejection (mistrust) and credibility of
information and personalisation of content predicted selection (trust) of advice sites. The results are
discussed in terms of the merits of the framework, its limitations and directions for future work.
Keywords: Trust, credibility, health, social identity, internet, computer mediated communication,
framework
1. Introduction
The rapid growth of the Internet has brought with it renewed interest in the notion of
trust. Within the field of e-commerce especially people began to realise that trust is
vital to making online purchases (Cheskin, 1999). The realisation that design can
affect the trust of a user has had implications for user interface design, web sites and
interactivity in general (Nielson, 1999). This has led in turn to increased discussion in
fields such as Human Computer Interaction (HCI), Computer Supported Cooperative
Work (CSCW), agent systems and ambient intelligence about how to encourage,
maintain, and increase trust between people and machines and between users
themselves (e.g., Cheskin, 1999 ; Schneiderman, 2000 ; Olson & Olson, 2000a ;
Wang & Emurian, 2005; Corritore, Kracher & Wiedenbeck, 2003; Riegelsberger,
Sasse & McCarthy, 2005; Derbas, Kayssi, Artail & Chehab, 2004; and Marsh, Briggs
& Wagealla, 2004).
One area of Internet use in which trust is key is that of online advice. Online advice
takes many different forms from static advice pages and personalised calculators to
interactive chats with domain experts. In recent years health advice has gained
increasing prominence. The availability of sites, the speed of access to information
and advice and the anonymity it affords makes the Internet an attractive proposition
for gathering advice on health. However the expanding volume of sites coupled with
fears over the quality of information has led to questions being raised about how
people make trust decisions with regard to online health sites. This paper presents a
framework for understanding trust factors in online health advice. The concept of trust
is explored and a staged model of trust is presented. The paper begins however with a
brief overview of the Internet and health advice.
2. Using the Internet for health advice
It has been reported that 80% of adult Internet users have gone online for general
health information (Fox & Fallows, 2003). People search online for health
information and advice for a number of reasons. Some people want to be better
informed, better prepared when meeting the doctor, or are searching for support,
alternative answers or reassurance (Rozmovits and Ziebland, 2004). Time constraints
in the consulting room have also led to an increase in online searching. The average
length of an appointment with a family practitioner in the UK is currently about eight
minutes. In this short period of time both the doctor and the patient often find it
difficult to explain and discuss all their issues. Patients often think doctors do not give
them enough information to make sensible choices about how they want to be treated
(Carvel, 2005) and they often find it difficult to recall the specifics of their
discussions with the doctor after the consultation (Kalet, Roberts & Fletcher, 1994).
The appeal of the Internet is particularly strong for those people who wish advice on
important but sensitive matters (Klein & Wilson, 2002) and many people searching
online for health advice believe that it will enable them to better deal with their health
and will convey health benefits (Mead, Varnam, Rogers & Roland, 2003). However
less than half of the medical information available online has been reviewed by
doctors (Pew, 2000) and few sites provide sufficient information to support patient
decision-making with many also heavily jargon-laden and difficult to read (Smart &
Burling, 2001).
Assessing the qualityof information online is a daunting task not least because the
range of health topics and the number of different websites is so enormous. It is not
only the health topics that vary widely but also the nature of the websites themselves.
There are variations in authorship, scope and features. In a recent review, Petit-Zeman
(2004), examined some of the health resources currently available online. She noted
that sites ranged from those designed and supported by a series of individual patients
through to internationally renowned charity sites. Large-scale survey data has
indicated that people seek health advice across a range of different websites (Sillence
& Briggs, in press). Table 1 indicates the range of health advice websites available to
consumers.
<table 1 about here>
The websites described in table 1 are by no means exhaustive but provide an
indication of the type of information and advice available on different sites. The
nature of health websites varies depending on the provider and the health issues itself.
There is also considerable overlap between the types of sites in terms of content.
Within these sites the types of information and advice varies. Some sales sites for
example contain a lot of patient information, news and commentary in addition to
their commercial aspect. Some pharmaceutical sponsored sites also contain interactive
elements such as discussion boards as well as implicitly or explicitly selling their
brand.
2.1 Assessing the quality of online health information
The large variation in health websites has provided ample opportunity for health
website evaluations to take place. These evaluations predominantly assess the quality
of the online health information from a purely medical perspective and have included
topics as diverse as depression, sildenafil citrate (viagra) and the menopause (Griffiths
& Christensen, 2000; Eysenbach, 1999; Reed & Anderson, 2002). In a large scale
meta-review of health website evaluations, Eysenbach, Powell, Kuss & Sa (2002)
noted that the most frequently used quality criteria included accuracy, completeness
and readability. Accuracy referred to the degree of concordance of the information
provided with the best evidence or with generally accepted medical practice.
Completeness was generally calculated as the proportion of a priori-defined elements
covered by the website. Readability formulas were also used to establish the reading
level of a document. In their review, the authors noted that 70% of the studies
concluded that quality is a problem on the Internet.
Several other indicators of quality have been suggested. These include seals of
approval or trustmarks such as the Health On the Net foundation (HON) code and the
use of privacy policies. Seals of approval have been suggested as a strategy to help
consumers in identifying high quality information. Most seals act as proxy indicators
of quality by requiring websites to, for example, disclose any commercial interests
they might have. The codes, however, do not offer any direct assessment of content.
Unfortunately the presence of such codes and awards appears to have no significant
effect on the credibility or retention of health information on a web page (Shon,
Marshall & Musen, 2000). Furthermore, consumer expectations of such health seals
are often incongruent with practice (Burkell, 2004). Other researchers have been
interested in empowering health consumers to judge the quality of the information
they find on the Internet for themselves. Sue Childs (2004) and colleagues developed
two sets of guidelines to help both consumers and information providers. Their Judge
project (www.judgehealth.org.uk) provides guidelines for support groups on how to
produce good quality information and guidelines for consumers on how to judge the
quality of a website. These guidelines are particularly helpful for consumers because
they recognise the importance of alternative sources of advice, for example, support
groups, which may differ from traditional medical opinion and advice.
Kathleen Murray (2001) at the University of Alaska also proposes a set of five criteria
for analysing the quality of a health website. In addition to the criteria identified by
Eysenbach et al (2002) in their review, Murray highlights the importance of the
privacy policy of the website. She suggests that users should note whether or not the
site has a policy and if so what it says about the company’s use of personal data.
Murray’s inclusion of privacy policies as a criteria for assessing health website quality
highlights a key difference between medical assessments of website quality and what
we know about how genuine consumers search for, appraise and use health advice.
Eysenbach & Kohler (2002) noted that despite participants identifying, prior to a
search task, the importance of privacy policies in their assessment of health websites
during the study itself not a single participant actually noted whether or not the sites
they used even contained a privacy policy. The quality indicators suggested by
medical evaluations of sites do not appear to map directly onto trust indicators used
by genuine health consumers. Even within the quality assessment literature itself
discrepancies exist. Reed & Anderson (2002), for example in their assessment of the
quality of menopause information available online recommend pharmaceutical sites in
terms of providing the most accurate information. Accuracy is of course a key marker
of quality. The Judge Project (Childs, 2004) however warns consumers away from
pharmaceutical sites because of their potential for biased information.
So despite this body of research concerning the quality of online health advice very
little is known about how genuine health consumers actually seek advice. We know,
however that ordinary consumers search for and appraise information in a different
way to medical experts or health informatics professionals. They are more likely to be
influenced by the attractiveness of the design (Standford, Tauber, Fogg & Marable,
2002) and they will begin their search for advice from a general information portal
(Briggs, Burford, De Angeli & Lynch, 2002) – which means that they gain access to
information indiscriminately.
The trust cues that health consumers use are likely to overlap to a certain extent with
the quality markers many medical evaluations suggest. However there will be
differences. Some of the likely candidates for trust cues are simply missing from or
underplayed in the quality evaluation literature. This is partly due to the nature of the
sites considered in such reviews. Personal websites often containing little or no
medical input are often excluded from evaluation studies. Likewise those containing
more interactive features such as message boards are often disregarded. Another
reason that consumers’ trust indicators are likely to differ from the quality assessment
literature is that quality evaluations do not take into account the differing needs of the
consumers’ or the stage at which they are engaged with the site. Different trust cues
are likely to be important at different stages of engagement with health websites. The
issue of trust is explored in the next section.
