Searching Online for Information About Vaccination: Assessing the Influence of User-Specific Cognitive Factors Using Eye-Tracking

In Germany, the Internet is gaining increasing importance for laypeople as a source of health information, including information about vaccination. While previous research has focused on the characteristics of online information about vaccination, this study investigated the influence of relevant user-specific cognitive factors on users' search behavior for online information about vaccination. Additionally, it examined how searching online for information about vaccination influences users' attitudes toward vaccination. We conducted an experimental study with 56 undergraduate students from a German university that consisted of a survey and eye-tracking while browsing the Internet, followed by a content analysis of the eye-tracking data. The results show that the users exposed themselves to balanced and diverse online information about vaccination. However, none of the examined cognitive factors (attitude toward vaccination, attitude salience, prior knowledge about vaccination, need for cognition, and cognitive involvement) influenced the amount of time users spent searching the Internet for information about vaccination. Our study was not able to document any effects of attitude-consistent selective exposure to online information about vaccination. In addition, we found no effect on attitude change after having searched the Internet for vaccine-related information. Thus, users' search behavior regarding vaccination seems to be relatively stable.

Understanding the Chinese Hui Ethnic Minority's Information Seeking on Cardiovascular Diseases: A Focus Group Study

The Chinese Hui ethnic minority group is an Islamic minority. The Hui people comprise the third largest minority population in China and are widely distributed throughout the country. Previous research shows that the Hui had a higher prevalence of cardiovascular risk factors (CVRFs) than most other ethnic groups. Therefore, the availability of health information relating to these factors is especially important for the Hui minority’s preventive healthcare. They do, however, experience difficulties in obtaining health-related information. The current research aims to identify the needs of the Hui people on where and how they obtain cardiovascular disease (CVD) related information from the media and other sources. Six focus groups were conducted in Shenyang City. The results revealed that the participants relied on different sources to get advice about CVDs, of which the internet and television were the most prominent ones. The participants expressed a desire for credible and professional information from different sources and asked for mediated health communication programs specifically targeted at the Hui. In addition, the participants felt ignored by the Chinese mainstream media at large, which created barriers for them to get health information.

Embedding caregiver support in community-based services for older adults: A multi-site randomized trial to test the Adult Day Service Plus Program (ADS Plus)

There are over five million people in the United States living with dementia. Most live at home and are cared for by family. These family caregivers often assume care responsibilities without education about the disease, skills training, or support, and in turn become at risk for depression, burden, and adverse health outcomes when compared to non-dementia caregivers. Despite over 200 caregiver interventions with proven benefits, many caregivers lack access to these programs. One approach to enhance access is to embed evidence-based caregiver support programs in existing community-based services for people with dementia such as adult day services (ADS). Here we describe the protocol for an embedded pragmatic trial designed to augment standard ADS known as ADS Plus. ADS Plus provides family caregivers with support via education, referrals, and problem-solving techniques over 12 months, and is delivered on-site by existing ADS staff. Embedding a program in ADS requires an understanding of outcomes and implementation processes in that specific context. Thus, we deploy a hybrid design involving a cluster randomized two-group trial to evaluate treatment effects on caregiver wellbeing, ADS utilization, as well as nursing home placement. We describe implementation practices in 30 to 50 geographically and racially/ethnically diverse participating sites. Clinical trial registration #: NCT02927821.

User Experiences of an Electronic Personal Health Record for Diabetes

BACKGROUND

My Diabetes My Way (MDMW) is an electronic personal health record (ePHR) that provides access to educational resources and clinical data to people with diabetes in Scotland. This questionnaire study aims to assess user experience, barriers to access, and inform future development.

METHODS

All active MDMW users (n = 3797) were invited to complete an online questionnaire in May 2015, surveying usage patterns and system utility. A "utility score" was calculated, based on responses to Likert-scale questions and used as the dependent variable within regression analysis, with demographic features as independent predictors. Free-text responses were analyzed thematically and presented using descriptive statistics.

RESULTS

A total of 1095/3797 (27.5%) active users completed the survey. Of them, 690/1095 (63%) were male. There was representation of all age and socioeconomic groups. Respondents were positive regarding the system utility, which met expectations. The majority of respondents believed that online access to diabetes information has the potential to improve diabetes self-care within the population. The most valued features were personal clinical data associated visualizations. Th main problems cited were data accuracy and system access (ie, log-in procedure). Perceived usefulness of the system was inversely associated with duration of diabetes, which was the only significant predictor of utility score.

CONCLUSIONS

This study has demonstrated that MDMW users find the system useful in supporting diabetes self-management. The system was found to have greatest utility among those most recently diagnosed with diabetes. This study has informed further development of the service, including enhancing data visualization and the need to improve access to the system.

A Systematic Assessment of Google Search Queries and Readability of Online Gynecologic Oncology Patient Education Materials

The Internet is a major source of health information for gynecologic cancer patients. In this study, we systematically explore common Google search terms related to gynecologic cancer and calculate readability of top resulting websites. We used Google AdWords Keyword Planner to generate a list of commonly searched keywords related to gynecologic oncology, which were sorted into five groups (cervical cancer, ovarian cancer, uterine cancer, vulvar cancer, vaginal cancer) using five patient education websites from sgo.org . Each keyword was Google searched to create a list of top websites. The Python programming language (version 3.5.1) was used to describe frequencies of keywords, top-level domains (TLDs), domains, and readability of top websites using four validated formulae. Of the estimated 1,846,950 monthly searches resulting in 62,227 websites, the most common was cancer.org . The most common TLD was *.com. Most websites were above the eighth-grade reading level recommended by the American Medical Association (AMA) and the National Institute of Health (NIH). The SMOG Index was the most reliable formula. The mean grade level readability for all sites using SMOG was 9.4 ± 2.3, with 23.9% of sites falling at or below the eighth-grade reading level. The first ten results for each Google keyword were easiest to read with results beyond the first page of Google being consistently more difficult. Keywords related to gynecologic malignancies are Google-searched frequently. Most websites are difficult to read without a high school education. This knowledge may help gynecologic oncology providers adequately meet the needs of their patients.

Psychometric properties of the Hungarian version of the eHealth Literacy Scale

BACKGROUND

We adapted the eHealth Literacy Scale (eHEALS) for Hungary and tested its psychometric properties on a large representative online sample of the general population.

METHODS

The Hungarian version of eHEALS was developed using forward-backward translation. For the valuation study, 1000 respondents were recruited in early 2019 from a large online panel by a survey company. We tested internal consistency, test-retest reliability and construct and criterion validity using classical test theory, as well as item characteristics using an item-response theory (IRT) graded response model (GRM).

RESULTS

55% of respondents were female, and 22.1% were ≥ 65 years old. Mean eHEALS score was 29.2 (SD: 5.18). Internal consistency was good (Cronbach's α = 0.90), and test-retest reliability was moderate (intraclass correlation r = 0.64). We identified a single-factor structure by exploratory factor analysis, explaining 85% of test variance. Essential criteria for GRM analysis were met. Items 3 and 4 (search of health resources) were the least difficult, followed by items 5 and 8 (utilisation of health information), and then items 1 and 2 (awareness of health resources). Items 6 and 7 (appraisal of health resources) were most difficult. The measurement properties of eHEALS were not affected by gender, age, education or income levels. Female gender, older age, intensity of health information seeking, formal health education and visit at the electronic health-record website were associated with higher eHEALS scores, as well as best and worst self-perceived health states, BMI < 25 and participation at health screenings over the past year.

CONCLUSIONS

The Hungarian eHEALS is a useful and valid tool for measuring subjective eHealth literacy.

Physical activity in persons with diabetes: its relationship with media use for health information, socioeconomic status and age

Although low socio-economic status (SES) persons with diabetes show low levels of physical activity (PA), there is limited knowledge regarding which media is effective in improving their PA. This study aimed to determine the appropriate media for providing PA-related information to persons with diabetes in low SES compared with those in high SES. The data of 770 persons with diabetes in low or high SES were extracted from Multimedia Audience Research Systems 2013, a nationwide cross-sectional study. The relationships among media use for health information (i.e. magazine, television and Internet use), PA, and high and low SES were examined using regression analysis. Additional analysis was conducted to examine whether the above relationships differ by age, which influences the use of media. The relationships of media use for health information with PA levels varied by SES; while television use was associated with increased PA levels, Internet use was associated with decreased PA levels in older, low SES persons with diabetes. The findings indicated that television can be a useful resource to provide PA-related information to low SES persons with diabetes and suggest the significance of choosing appropriate media to provide PA-related information for them.

The reCAPTCHA of medical education

This article focuses on what Luis von Ahn called the "twofer," that is, a single solution that elegantly addresses two problems on a large scale. We describe two of von Ahn's creations: reCAPTCHA, which validates a human web presence while also digitizing hard-to-read words, and Duolingo, which teaches new languages while translating the web. We then consider how this approach can be applied to medical education. Embedding Wikipedia-editing into educational settings is one such solution that could both improve the quality of health information available to the public while enhancing the learning of future health professionals.

Effects of presentation formats on consumers' performance and perceptions in the use of personal health records among older and young adults

OBJECTIVE

To examine the effects of presentation formats on consumers' performance and perceptions in the use of personal health records (PHRs) and to compare the effects between older and young adults.

METHODS

A two-factor, mixed design experiment was conducted, where 36 older and 36 young participants were presented with hypothetical PHRs. The PHRs were randomly presented by six presentation formats: three tables and three line graphs, varying by visual cues. Participants' performance and perceptions in the use of PHRs were measured.

RESULTS

Presentation formats affected participants' performance and perceptions. Visual cue-enhanced line graphs and tables yielded less time and fewer errors, were considered easier and more useful in information comprehension, and resulted in higher confidence in correct comprehension of PHRs (all p's < 0.01), compared with their basic counterparts. There were age-related differences in task performance (all p's < 0.05), while young and older adults had similar perceptions for the six formats. Line graph with colored background was most preferred by both groups.

CONCLUSION

Visual cue-enhanced presentation formats appear effective in facilitating comprehension and eliciting favorable perceptions of PHRs for both young and older adults.

PRACTICE IMPLICATIONS

Consumer-facing displays of PHRs could use visual cue-enhanced presentation formats to facilitate comprehension.

Health information work and the enactment of care in couples and families affected by Multiple Sclerosis

Given the considerable emphasis placed on informed choice, the management of health information has become an increasingly important part of living with chronic illness. This paper explores the intra-familial dynamics of managing health information in the context of chronic illness. Drawing on 77 interviews with people affected by Multiple Sclerosis in the UK (patients, partners, family members and close friends), we show how families develop their own idiosyncratic information practices, including the careful, at times strategic, seeking, sharing and withholding of information. We describe how one individual, most commonly either the patient or their partner, often takes primary responsibility for managing growing quantities of health information. Doing this is a complex task, yet its dynamics within the family unit remain invisible and unacknowledged. In this paper we: (a) stress the importance of understanding information management in chronic illness as a collective process across all those affected, patients as well as carers; (b) conceptualise the process of managing health information in this context as 'health information work'; and (c) analyse it as part of the wider care practices families engage in and as a form of care in its own right.

Consumer Health Information Technology in the Prevention of Substance Abuse: Scoping Review

BACKGROUND

Addiction is one of the most rapidly growing epidemics that currently plagues nations around the world. In the United States, it has cost the government more than US $700 billion a year in terms of health care and other associated costs and is also associated with serious social, physical, and mental consequences. Increasing efforts have been made to tackle this issue at different levels, from primary prevention to rehabilitation across the globe. With the use of digital technology rapidly increasing, an effort to leverage the consumer health information technologies (CHITs) to combat the rising substance abuse epidemic has been underway. CHITs are identified as patient-focused technological platforms aimed to improve patient engagement in health care and aid them in navigating the complex health care system.

OBJECTIVE

This review aimed to provide a holistic and overarching view of the breadth of research on primary prevention of substance abuse using CHIT conducted over nearly past five decades. It also aimed to map out the changing landscape of CHIT over this period.

METHODS

We conducted a scoping review using the Arksey and O'Malley's modified methodological framework. We searched 4 electronic databases (PubMed, Cochrane, Scopus, and EMBASE). Papers were included if the studies addressed the use of CHIT for primary prevention of substance abuse and were published in English between 1809 and 2018. Studies that did not focus solely on primary prevention or assessed additional comorbid conditions were eliminated.

RESULTS

Forty-two papers that met our inclusion criteria were included in the review. These studies were published between 1970 and 2018 and were not restricted by geography, age, race, or sex. The review mapped studies using the most commonly used CHIT platforms for substance abuse prevention from mass media in the 1970s to mobile and social media in 2018. Moreover, 191 studies that were exclusively focused on alcohol prevention were excluded and will be addressed in a separate paper. The studies included had diverse research designs although the majority were randomized controlled trials (RCT) or review papers. Many of the RCTs used interventions based on different behavioral theories such as family interactions, social cognitive theories, and harm-minimization framework.

CONCLUSIONS

This review found CHIT platforms to be efficacious and cost-effective in the real-world settings. We also observed a gradual shift in the types and use of CHIT platforms over the past few decades and mapped out their progression. In addition, the review detected a shift in consumer preferences and behaviors from face-to-face interactions to technology-based platforms. However, the studies included in this review only focused on the aspect of primary prevention. Future reviews could assess the effectiveness of platforms for secondary prevention and for prevention of substance abuse among comorbid populations.

Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis

Over a third of adults go online to diagnose their health condition. Direct-to-consumer (DTC), interactive, diagnostic apps with information personalization capabilities beyond those of static search engines are rapidly proliferating. While these apps promise faster, more convenient and more accurate information to improve diagnosis, little is known about the state of the evidence on their performance or the methods used to evaluate them. We conducted a scoping review of the peer-reviewed and gray literature for the period January 1, 2014–June 30, 2017. We found that the largest category of evaluations involved symptom checkers that applied algorithms to user-answered questions, followed by sensor-driven apps that applied algorithms to smartphone photos, with a handful of evaluations examining crowdsourcing. The most common clinical areas evaluated were dermatology and general diagnostic and triage advice for a range of conditions. Evaluations were highly variable in methodology and conclusions, with about half describing app characteristics and half examining actual performance. Apps were found to vary widely in functionality, accuracy, safety and effectiveness, although the usefulness of this evidence was limited by a frequent failure to provide results by named individual app. Overall, the current evidence base on DTC, interactive diagnostic apps is sparse in scope, uneven in the information provided and inconclusive with respect to safety and effectiveness, with no studies of clinical risks and benefits involving real-world consumer use. Given that DTC diagnostic apps are rapidly evolving, rigorous and standardized evaluations are essential to inform decisions by clinicians, patients, policymakers and other stakeholders.

[Use of new technologies by adolescents in the search for health information]

OBJECTIVE

To describe Internet sources used by adolescents to consult health information and their sociodemographic characteristics, as well as to identify the variables that influence the choice of Internet site.

DESIGN

Cross-sectional descriptive study. Survey adapted from the questionnaire validated by Rideout.

PARTICIPANTS AND LOCATION

Adolescents aged 12-18 from 4schools in rural municipalities.

RESULTS

The study included a total of 405 adolescents, of whom 51.6% were female, age 14.9 ± 1.2 years. Most of them (87.25%) live with both parents, and 93.6% have computers at home, with 45.2% in their rooms, and a mean of 2.1 computers/home. The large majority (85.2%) have Internet at home, with 76.3% in their room. A total of 53.8% sought health information 0.71 ± 0.91 h/week, seeking mainly information on: cancer (89.9%), addictions (67.7%), STIs and HIV (49.6%), pregnancies/contraception (21, 5%), mental illness (40%), heart disease and diabetes mellitus (53.6%), and eating disorders (39.3%). Google was chosen by 63.2%, and only 11.9% chose medical websites. Information was shared on social networks by 12.8% (70.3% Facebook). The information found led to a change of behaviour in 70.7%. Just over half (56.05%) preferred to use the Internet for: speed, 34.8%, privacy, 15.8%, reliability, 13.6%, and more information, 17.6%.

CONCLUSIONS

Adolescents seek information mainly through Google, with no knowledge of systems that accredit content quality, but consider it useful and reliable, changing their behaviour patterns according to the information found. All this carries a risk in this age group with very sensitive characteristics. Therefore, we believe that we should continue along the line of designing other alternative communication channels adapted to their current reality.

Using Google to Trend Patient Interest in Botulinum Toxin and Hyaluronic Acid Fillers

Introduction: Google Search is an important tool for patients researching skin care treatments and finding dermatologists. Data from individual patient’s searches are aggregated by Google and yield powerful data sets that can be used to trend population behaviors. This study investigates the correlations between the volume of Google searches and the number of procedures performed annually for both botulinum toxin type A and hyaluronic acid tissue fillers. Methods: The volume of queries performed between 2005–2016 including [botox] or [hyaluronic acid + Juvederm + Perlane + Restylane + Prevelle] were analyzed in relation to the annual number of procedures using botulinum toxin type A and hyaluronic acid based soft tissue fillers, respectively. Results: The number of procedures performed using botulinum toxin and hyaluronic acid correlated significantly with the relative search volume for related search terms in both the same year (P< .001) and year prior (P< .001). Conclusions: Our findings highlight the importance of Google search data as a resource for understanding patient motivations and behavior. Dermatologists may use this resource as a tool to better address patient concerns and forecast local demand for specific procedures.

Effects of Food-Additive-Information on Consumers' Willingness to Accept Food with Additives

This study tested whether information on positive food additives and negative food additives had an effect on consumers' risk perception and their willingness to accept (WTA) food with additives. Consumers' WTA was examined via a random nth-price auction of exchanging freshly squeezed orange juice without additives for orange juice with additives. Results show that consumers' WTA differs with the order in which information was provided. Consumers are generally more sensitive to negative than positive information on additives. Female, middle-educated consumers are more susceptible to additive information and their WTA is more likely to change, while postgraduate-educated consumers are less sensitive to additive information. Consumers with higher food-safety satisfaction have lower WTA than those who are not satisfied with food safety. However, their satisfaction is easily affected by the negative-information intervention. Interestingly, consumers with relatively good knowledge of additives had higher WTA than those with no such knowledge. This study provides insight on how to establish effective food-safety-risk communication. Government and non-government agencies need to timely and accurately eliminate food-safety scares through the daily communication and disclosure of food-safety information, as well as prevent the misguidance of negative food safety-risk information.

Analysis of the Patient Information Quality and Readability on Esophagogastroduodenoscopy (EGD) on the Internet

Objective

Patients are increasingly using the Internet to inform themselves of health-related topics and procedures, including EGD. We analyzed the quality of information and readability of websites after a search on 3 different search engines.

Methods

We used an assessment tool for website quality analysis that we developed in addition to using validated instruments for website quality, Global Quality Score (GQS) and Health on Net (HON) certification. The readability was assessed using Flesch-Kincaid Reading Ease (FRE) and Flesch-Kincaid Grade level (FKG). 30 results of each search terms 'EGD' and 'Upper Endoscopy' from Google and 15 each from Bing and Yahoo were analyzed. A total of 45 websites were included from 100 URLs after removing duplicates, video links, and journal articles.

Results

Only 3 websites were found to have good quality and comprehensive and authentic information. These websites were https://www.healthline.com, https://www.uptodate.com, and https://www.emedicine.medscape.com. There were additional 13 sites with moderate quality of information. The mean Flesch-Kincaid Reading Ease (FRE) score was 46.92 (range 81.6-6.5). The mean Flesch-Kincaid Grade level (FKG) was 11th grade, with a range of 6th grade to 12th grade and above making them difficult to read.

Conclusions

Our study shows that there are quite a few websites with moderate quality content. We recommend 3 comprehensive and authentic websites out of 45 URLs analyzed for information on Internet for EGD. In addition, the readability of the websites was consistently at a higher level than recommended by AMA at 11th grade level. In addition, we identified 3 websites with moderate quality content written at 8th grade and below readability level. We feel that gastroenterologists can help their patients better understand this procedure by directing them to these comprehensive websites.

When the Hospital Is No Longer an Option: A Multiple Case Study of Defining Moments for Women Choosing Home Birth in High-Risk Pregnancies in The Netherlands

Some women in a high-risk pregnancy go against medical advice and choose to birth at home with a "holistic" midwife. In this exploratory multiple case study, grounded theory and triangulation were employed to examine 10 cases. The women, their partners, and (regular and holistic) health care professionals were interviewed in an attempt to determine whether there was a pattern to their experiences. Two propositions emerged. The dominant one was a trajectory of trauma, self-education, concern about paternalism, and conflict leading to a negative choice for holistic care. The rival proposition was a path of trust and positive choice for holistic care without conflict. We discuss these two propositions and make suggestions for professionals for building a trusting relationship using continuity of care, true shared decision making, and an alternative risk discourse to achieve the goal of making women perceive the hospital as safe again.

Food Rating Scale in Food Services: From Development to Assessment of a Strategy for Consumer Healthier Choices

This study aimed to create an easy tool to identify healthier choices for meal assembly in food services (self-service restaurants) and to allow consumers to compose their plates to make healthier choices. It is an interventional study, and the first step was setting healthy food parameters to design a rating scale. The first evaluation criterion was based on energy density (ED) and sodium content (SC) using “traffic light” color in the dishes’ nameplates; the second criterion was based on food groups; the third criterion was based on ingredients of the meals. After using the classification, we assessed the rating scale in a food service and we evaluated the strategy with its consumers. To evaluate the effect of the nutritional intervention, we developed a multiple-choice-questionnaire with eight questions to measure the impact on consumer food choices quantitatively. The dish nameplate allows identification of healthier choices regarding SC and/or ED by colors; ingredients that compose the dish; the food group and the serving size, helping the identification of the amount of food to compose the meal. Banners helped consumers to understand the information. After four weeks, all the consumers (n = 1000) received questionnaires regarding their comprehension of the classification. The questionnaire presented an ICC of 0.71. Most of the preparations (61%) were inadequate based on ED and/or SC at the studied food service. A total of 556 consumers returned questionnaires, and 86.3% of them observed the rating scale as a nutritional strategy. Almost 55% (n = 261) of consumers reported changes in food choice after reading the dishes nameplates. The items with greater impact on consumer change in eating behavior were the use of colors as an indicator of nutritional quality, portion size information and ingredients list. Almost 25% of the consumers that changed their eating behavior noticed more than three items presented on the nameplate.

The Dirt on Clean Eating: A Cross Sectional Analysis of Dietary Intake, Restrained Eating and Opinions about Clean Eating among Women

Clean eating is understood in broad terms to be an approach to eating which promotes the exclusion of processed foods. Social media and websites which promote clean eating are becoming increasingly popular as sources of nutrition information. Currently, there is a lack of knowledge regarding women's opinions about clean eating sites and their influence on eating behaviour. The aim of the present study was to investigate differences in dietary intake, dietary restraint and opinions about clean eating between women who had, and women who had never adhered to dietary advice from clean eating sites. Using a cross-sectional survey design, women (n = 762) ranging in age from 17⁻55 completed a self-report questionnaire on eating behaviour and beliefs about clean eating. Findings showed that 25.5% of the sample adhered to dietary advice from a clean eating site sometimes, often or very often. A significantly higher proportion of women who had adhered to dietary advice from clean eating sites met dietary guidelines for the consumption of fruit, meats and alternatives compared to women who had seldom or never adhered. Adherers also had significantly higher levels of restrained eating and were more positive about clean eating in general in comparison to those who seldom or never adhered. Results provide new information about exposure to clean eating sites and how they may influence women's eating practices. These preliminary findings suggest additional studies are required to better understand the influence of clean eating sites, particularly with regard to whether the information on such sites are from reputable sources and to what degree their recommendations may be problematic for individuals with eating concerns.

Impact of public release of performance data on the behaviour of healthcare consumers and providers

BACKGROUND

It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers.

OBJECTIVES

To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis.

MAIN RESULTS

We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects.

AUTHORS' CONCLUSIONS

The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Does Information Pattern Affect Risk Perception of Food Safety? A National Survey in China

Examining the variances in the assessments of risk, as perceived by residents, facilitates the development of appropriate risk information communication strategies. This paper aims to identify the effects of information source patterns on perceived food safety risks based on demographic factors. A national survey was conducted to examine, by means of multiple regression analysis, the relationship between the public's perceived risks, demographic factors and information access. The study finds that residents' preferences for information sources have been empirically proven to significantly affect their perceptions of food safety. We also find that more educated young urban dwellers, as well as those without cohabitation experience, tend to perceive a higher level of risk with respect to food safety. In contrast to our expectations, gender, family income and family size are not significantly correlated with the perception of food safety risk. The findings help to explain residents' attitudes toward food safety administration and reactions to food hazards in the Chinese context. It is recommended that the governing authorities strengthen their communication capacities using modern communication media and make full use of traditional and face-to-face communications with respect to regulations.

The Impact of Education on Health Outcomes and Behaviors in a Middle-Income, Low-Education Country

Although the impact of education on health is important for public policy everywhere, the overwhelming majority of research identifying the health returns to education has focused on developed countries. We use data from multiple waves of nationally-representative Health and Tobacco Surveys in Turkey, and exploit an education reform that increased the mandatory years of schooling from 5 to 8 years in 1997. Using exposure to the reform as an instrument for completing at least eight years of schooling, we examine the impact of education on health indicators and smoking among young adults. We find that extending schooling on this margin impacts men and women differently. Our results indicate that while a one-year of extra schooling increases the likelihood of being obese among males by 9.9 percentage points, the same increase in schooling improves the probability of women being in the healthy weight range by 15.5 percentage points. Consistent with this result, an extra year of education increases women's propensity to self-evaluate their health as excellent by 4.3 percentage points. Additional analyses reveal that education makes men (but not women) more likely to spend time on computers, using the internet, and to spend time on social media, suggesting that differential time allocation between men and women, triggered by enhanced education, may be a mechanism behind the differential results between the sexes. Education has no impact on smoking for men or women regardless of the measure of smoking.

A Multi-faceted Approach to Promote Comprehension of Online Health Information Among Older Adults

Purpose of the Study

Older adults' self-care often depends on understanding and utilizing health information. Inadequate health literacy among older adults poses a barrier to self-care because it hampers comprehension of this information, particularly when the information is not well-designed. Our goal was to improve comprehension of online health information among older adults with hypertension who varied in health literacy abilities.

Design and Methods

We identified passages about hypertension self-care from credible websites (typical passages). We used a multi-faceted approach to redesign these passages, revising their content, language, organization and format (revised passages). Older participants read both versions of the passages at their own pace. After each passage, they summarized the passage and then answered questions about the passage.

Results

Participants better remembered the revised than the typical passages, summarizing the passages more accurately and uptaking information more efficiently (less reading time needed per unit of information remembered). The benefits for reading efficiency were greater for older adults with more health knowledge, suggesting knowledge facilitated comprehension of information in the revised passages.

Implications

A systematic, multi-faceted approach to designing health documents can promote online learning among older adults with diverse health literacy abilities.