Evaluating World Wide Web-based foot care information

Diabetic Foot, The, Spring, 2006 by Mairghread Ellis, Brian Ellis

Introduction

The NHS is encouraging individuals to be increasingly proactive in their healthcare, promoting the Internet as a source of patient information (Department of Health and NHS Executive, 1998). As the Internet is increasingly used by patients, it is important to ensure that individuals source relevant and good-quality information, which is easily accessible through UK-focused consumer health websites. This article describes a study undertaken to assess the quality of Internet-based information on foot care available to people with diabetes in the UK.

KEY WORDS

* Internet

* Information appraisal

* Self-management

* Patient education

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Given the possible outcomes of peripheral ischaemia and neuropathy associated with diabetes, the care of individuals with the condition is one of the most important areas of podiatric practice. These outcomes, combined with high foot pressures, self-treatment or both, can lead to morbidity and mortality, with foot ulceration the most common manifestation of diabetic neuropathy, and diabetes being the second commonest cause of lower limb amputation (Department of Health [DoH], 2001). Guidelines for diabetes care have cited health education as essential to prevent and minimise foot pathology, and foot care education is promoted as an important part of managing diabetic foot disease (Scottish Intercollegiate Guidelines Network [SIGN], 2001). For podiatrists, as for other health professionals, health education constitutes a large part of practice with regard to the high-risk patient, such as those with diabetes (Cooper et al, 2003).

Traditionally, within the medical model of health care, the health professional holds the role of educator, and health education has been delivered on a face-to-face basis, usually verbally or with printed material. Historically, the health professional has been the giver of this necessary information and the patient has merely been the vessel to receive it (Muir Gray, 2002). In the 20th Century, the clinician held the resources, and the patient simply had to be patient (Coulter, 2002). It is now recognised that the 21st Century patient needs and desires knowledge about his or her condition and its management, and increasingly uses his or her own resources (e.g. the Internet) to access this (Muir Gray, 2002).

The Internet is a key influence in the changing balance of power and knowledge between the medical professions and the public (Powell and Clarke, 2002). This move towards patient empowerment and involvement in decision-making has meant that many individuals wish to access information at their own convenience; the Internet facilitates this (Rhodes, 2000). The access of Internet information is totally within the control of the individual.

Many doubts remain, however, about quality. The Internet is widely unregulated, and anyone who wishes to can publish information online. While online appraisal tools are available, many lay searchers may not understand the need for this, and may accept information at face value (Rhodes, 2000; Powell and Clarke, 2002). They may be unaware of possible information bias, or misleading authorship (Kiley, 2000; Cline and Hayes, 2001).

While Hejlesen et al's study (2001) on using the Internet for patient-centred diabetes care reported that patients often find it hard to judge quality of information, UK research of Internet use for health information by patients from one general practice found that consumers are indeed aware of potential difficulties with interpreting information (Rose et al, 2002). Where they might falter is in knowing what criteria to use to judge health information. Criteria discussed by Silberg et al (1997) remain relevant today, and include authorship (who wrote the content?), copyright (who owns it, and what is its date?), ownership of the website and currency (is the content current, and when was it last updated?). These criteria form the basis of quality 'kite marks' for health websites, such as the 'HON code' (Health On the Net Code of Conduct) of the Health On the Net Foundation (http://www.hon.ch [accessed 23.02.2006]; Figure 1). Evaluated subject catalogues such as Organising Medical Networked Information (OMNI; http://www.omni.ac.uk [accessed 23.02.2006]), and information quality sites such as Judge: web sites for health (http://www.judgehealth.org.uk [accessed 23.02.2006]) also adhere to these criteria.

Silberg et al's (1997) maxim 'caveant lector et viewor--let the reader and viewer beware' is as sensible a caution today as it ever was, and should be remembered by all who seek health information on the Internet.

We undertook a small study, funded by Queen Margaret University College, Edinburgh, with the specific objective of evaluating the diabetes foot care advice of UK-focused consumer health websites against a 'gold standard': Taking care of your feet (Diabetes UK, 2000). The information in this leaflet was condensed and itemised to give a possible maximum score of 23, and the content of web pages was compared against this.