Communications of the ACM
Home/Magazine Archive/January 2004 (Vol. 47, No. 1)/Trust-Building Measures: a Review of Consumer Health.../Full Text
Communications of the ACM
Trust-Building Measures: a Review of Consumer Health Portals
A common reason consumers use the Internet is to search for health-related information. A survey found that 52 million Americans sought health information over the Internet at least once a month, and 40% of them indicated that online health information affected their health care decisions [1]. But consumers are also concerned about the quality and reliability of health-related information on the Web [2]. They wonder: Can they trust the information they receive from health portals, and can they trust health portals will protect sensitive health data they submit there?
Trust has been recognized as a critical factor in the development and growth of e-commerce [8]. The lack of consumer trust with respect to online privacy and security, for example, has prevented many consumers from engaging in online shopping [4]. Many consumers are not comfortable divulging personal and financial information to a virtual storefront. The degree of consumer trust required for using a health portal is higher than for online shopping sites. In many cases, consumers must reveal highly sensitive personal information, including medical conditions and health history, in order to receive useful information. In addition, consumers take risks by trusting online medical information, for the consequences of following erroneous medical advice can be costly, even life threatening. Unlike with name-brand products like computers or watches, the quality of medical information can be difficult to evaluate. If such information proves incorrect, furthermore, it might be too late to reverse the damages.
Recognizing the importance of consumer trust, health portals have adopted measures ranging from posting online privacy policies to participating in third-party seals programs. While such measures play an important role in a portal's effort to build trust [9], questions persist regarding exactly how these measures engender consumer trust, and to what degree. This article highlights research that begins to answer these questions by analyzing trust-building measures employed by 12 major health portals (see Table 1) and identifying the potential effects of these measures on consumer trust.
A health portal may have the following features: a catalog of health information, a search engine, a personalization system, and a network of communities. The health information catalog is a mechanism for organizing original and/or edited health and medical treatment information and providing links to other health-related Web sites where consumers might find answers to their questions. The search engine allows consumers to search for a medical topic within the portal or the entire Web. The personalization system allows consumers to customize the portal interface based on his or her preferences and allows the portal to individually target consumers. Finally, the community feature of a health portal lets consumers exchange information with other patients and share their experience about an illness or disease.
As shown in Table 1, all major health portals have a catalog of health-related information and a search engine, but fewer portals provide personalization and community features. Health portals also vary in terms of their sources of information, ownership/sponsorship, and offline brand. A close look at these portals reveals even more divergence in information quality and organization. Such diversity makes it difficult for consumers to know which portals are trustworthy. Without trust, they are less likely to engage in more-involved online health care activities, such as personalization and community exchange [10]. Since most portals derive revenue primarily from advertising, it is imperative they attract repeat traffic and inspire the deep engagement of consumers [7]. One way to gain consumer trust is by incorporating trust-building measures into the Web site.
Trust-building Measures
One perspective on trust building explores how factors such as ability, benevolence, and integrity, contribute to trust building [6]. Another perspective focuses on five trust-building processes: the calculative, predictive, intentionality, capability, and transference processes [3]. Figure 1 defines them. In attempting to gain consumer trust, health portals have employed various measures, including self-regulating policies, source disclosure, ownership disclosure, third-party seals, and branding. Here, we review these measures and examine how they affect the various trust factors and trust-building processes.
Self-regulating policies. Self-regulating policies are the rules and guiding principles a health portal follows in operating a site. Most health portals post their policies with respect to privacy, security, editorial, and advertising. Privacy and security policies tell consumers what information is being collected, how it may be used, and what security measures are in place to protect collected information. Editorial policy reveals the portal's practices and procedures on gathering, reviewing, and updating health information. Advertising policy addresses such issues as how site advertisements are identified, how editorial independence is guaranteed, and the nature of the business relationship between the portal and its sponsors.
By displaying these policies, health portals hope to clarify privacy and other sensitive issues, as well as to demonstrate their benevolence and integrity. Consumers may view the presence of such policies as good intention on the part of health portals, and thus, these policies can help consumers initiate the intentionality trust-building process. However, several factors may reduce the effectiveness of self-regulating policies as a trust-building measure. First, self-regulating policies are often posted as footnotes, so consumers may be unaware of their existence. Second, these policies are self-proclaimed. Without corroborating evidence, it is difficult for consumers to determine whether they are followed in practice. Finally, self-regulating policies are not standardized, and health portals offer policies with varying degrees of detail.
Source disclosure. The most important aspect of health portal trust involves the health information presented on the Web site. One way to reassure consumers about the quality of health information is through source identification. Health portals generally draw content from three types of sources: original research, edited health information, and Web links. Published original research usually includes author names and affiliations. Consumers can examine the reported research methodology and results to determine for themselves the quality of the study. Edited health information is often a synthesis of multiple studies or a review of the current state of medical knowledge. It is up to the health portal to disclose who was responsible for content creation. For example, at InteliHealth.com, articles labeled "Medical Contents Reviewed by the Faculty of Harvard Medical School" are created by InteliHealth staff and reviewed by Harvard faculty serving on the InteliHealth's editorial board.
Source disclosure may affect both capability and transference processes of trust building. By using high-quality and capable sources, a health portal can demonstrate it has the ability to gather, organize, and present quality health information and add value for consumers. If consumers trust most of the sources used by a health portal, they are likely to transfer that trust to the portal itself. But if consumers are suspicious of the quality of certain information sources presented by the health portal, they may doubt the portal's ability to find quality information sources. That distrust may spread to other unfamiliar sources.
Ownership disclosure. Many health portals are partially owned and sponsored by major pharmaceutical companies, HMOs, or other for-profit organizations. Such ties may cause consumers to question the editorial independence of the portal and perceive inherent biases in the kind of health information provided there. By disclosing ownership information up front, health portals hope to inform consumers about the nature of the relationship and prevent misconceptions.
Ownership disclosure may be considered by consumers as a gesture of benevolence and good intention. Thus, it may affect the intentionality process of trust building. Additionally, if the portal owners or partners have a reputation conducive to trust, their sponsorship may transfer creditability to the portal. For example, Dr. C. Everett Koop, former U.S. Surgeon General, used his name to start the portal DrKoop.com and quickly made it a major player in the online health care field.
Third-party seals. Another popular trust-building measure employed by health portals is the third-party seal. Third-party seal programs remedy some of the drawbacks associated with self-regulating policies. The Health on the Net (HON) Foundation Code of Conduct (www.con.ch), Truste (www.truste.org), URAC (www.urac.org), and Hi-Ethics (www.hiethics.com) are the four main health-related seal programs. They attempt to standardize the reliability of medical and health information available on the Web and protect the privacy of online consumers by publishing principles and guidelines for health Web sites to follow. Such programs license seals of approval to those meeting their requirements. For example, Truste awards a "trustmark" to Web sites that adhere to its privacy principles, and agree to comply with Truste's supervision and consumer resolution procedures. Thus, the display of a trustmark signifies a health portal conforms to the privacy standards and principles advocated by Truste. The HON Code seal, on the other hand, guarantees that a health portal observes basic ethical standards in the presentation of information and informs consumers about the source and purpose of the information being presented.
The use of third-party seals assists the transference process of trust building. If consumers understand and trust the seal programs, they are likely to trust the Web sites bearing the seals. Depending on the nature of the principles promoted by a seal program, the presence of a seal may help consumers trust the ability and integrity of the health portal. However, for the transference process to be effective, third-party seal programs must demonstrate their own ability and integrity among consumers first, which may require them to publicize the importance of their principles and the reliability of their seal-granting procedures.
Branding. Leveraging existing online or offline brands is an efficient way to build trust among consumers. Yahoo has utilized this measure through its Yahoo Health. Yahoo, arguably the best-known Web brand, has millions of online users potentially interested in health information. As part of Yahoo, Yahoo Health benefits from this name recognition. In addition, health information from Yahoo Health can be seamlessly incorporated into Yahoo user's individual portals using personalization technology.
An offline brand can also bring consumers to online outlets. The Mayo Foundation for Medical Education and Research (Mayo Clinic), for example, has long established itself as a leading provider of consumer health information. Consumers who have benefited from books and studies published by the Mayo Clinic readily trust health information presented by www.mayoclinic.com.
Branding helps consumers to trust health portals through the predictive and transference processes. Consumers may use past experience with an existing brand to predict the ability, benevolence, and integrity of the health portal with the same brand. The transference process may be invoked when consumers perceive an existing brand as trustworthy. The trust of that brand may be transferable to the health portal since it is a part of the brand. Overall, branding has the most significant effect on trust building.
Table 2 summarizes how trust-building measures employed by health portals can affect trust factors and trust-building processes. The table also demonstrates that health portals can use different trust-building measures to establish different trust factors. For example, health portals can use source disclosure to demonstrate their ability and employ self-regulating policies and ownership disclosure to show their benevolence. Similarly, health portals can employ different trust-building measures to initiate and/or facilitate various trust-building processes. Note that trust-building measures may play varying roles in a trust-building process and may affect different trust factors within each process.
Analysis of Trust-building Measures in Health Portals
To assess the use of trust-building measures at major health portals, we conducted a Web site analysis to determine whether and how trust-building measures are deployed at major health portals. For each health portal identified in Table 1, we searched the Web site for self-regulating policies, source and ownership information, and third-party seals. The result of that analysis is presented in Table 3. Next, we discuss the implications of the results.
Table 3 shows that most health portals post privacy and security policies on the front page, but a number of sites do not have clear editorial and advertising policies. Among those portals with posted self-regulating policies, the content and level of detail was variable. For example, some portals discuss in their privacy policy the kind of personal information being collected, how cookies are used, and how users can opt out of the data-collection process. Other portals have only a simple statement on privacy. Yet others include editorial philosophy as a part of the privacy policy.
Almost all health portals disclose their information sources and ownership information. However, the manner in which they are disclosed varies among major health portals. Some portals provide the author or other source information for each article presented. Others describe and classify their sources in the editorial policy, and then each article references the established classification. Third-party seals are employed by two-thirds of the portals. Among the seal programs adopted by health portals, HON code is the most popular, followed by TRUSTe.
Our analysis further shows that, except for HealthTouch.com, every major health portal employs multiple trust-building measures. However, the implementations of such measures differ widely among health portals. This finding may reflect variations in each portal's strengths, weaknesses, distinctiveness, and strategic positioning. For example, the National Institutes of Health, as a government organization and authority on medical issues with established trust among consumers, needs fewer trust-building measures on its Web site. By contrast, Intelihealth.com, owned by a major U.S. HMO, has one of the most elaborate editorial policies and participates in multiple third-party seal programs. Clearly, it is trying hard to demonstrate its independence and integrity. As for Yahoo Health, it benefits from Yahoo.com's strong brand name and consumer familiarity with Yahoo's editorial and advertising policies, so it does not have to spell out these policies again.
Consumer trust of health portals consists of four distinct aspects: information content, privacy, security, and technical functionality. It is evident from our Web site analysis that health portals may put more emphasis on one particular aspect of trust than another. For instance, one health portal may decide to build a site with the best medical information content, while another focuses on building the most user-friendly Web site with adequate information quality. Both approaches may improve the trustworthiness of the portal and accomplish its goals.
Conclusion
Based on a review of existing trust literature, we analyzed five trust-building measures deployed by health Web sites. Each measure was examined in terms of how it contributes to the building of a trustworthy health information portal. We found that each measure affects the trustworthiness of the portal in different ways.
This survey of major health portals demonstrates that trust-building measures are widely deployed. However, the number and type of measures used vary considerably among these portals. Several possible explanations exist for this phenomenon. First, health information portals have varying strengths and weaknesses and may employ only those measures that enhance strength. Second, portals may have varying views on the effectiveness of some of the measures. Portals may choose only those measures that have a significant effect on the trustworthiness of their Web sites. Third, not all trust-building measures are available or easy to implement. Further research may empirically evaluate the effectiveness of each measure.
References
1. Bendict, C. E-health: Act 2. Los Angeles Times (Dec. 11, 2000).
2. Chin, T. Patients put trust in Internet health information. American Medical News 45, 23 (2002), 2627
3. Doney, P.M., Cannon, J.P., and Mullen, M.R. Understanding the influence of national culture on the development of trust. Academy of Management Review 23, 3 (1998), 601620.
4. Hoffman, D.L., Novak, T.P., and Peralta, M. Building consumer trust online. Commun. ACM 42, 4 (Apr. 1999), 8085.
5. Lewicki, R.J. and Bunker, B.B. Trust in relationships: A model of trust development and decline. In Conflict, Cooperation, and Justice. Jossey-Bass, San Francisco, 1995.
6. Mayer, R.C., Davis, J.H., and Schoorman, F.D. An integrative model of organizational trust. Academy of Management Review 20, 3 (1995), 709734.
7. Parente, S.T. Beyond the hype: A taxonomy of e-Health business models. Health Affairs 19, 6 (2000), 89102
8. Quelch, J.A and Klein, L.R. The Internet and international marketing. Sloan Management Review 37, 6 (1996), 6075.
9. Schoder, D. and Yin, P. Building firm trust online. Commun. ACM 43, 2 (Feb. 2000), 7379.
10. Terrace, R., Singer, C., and Rosen, R. Jump-starting digital health. Jupiter Research Center, Mar., 2001
11. Worchel, P. Trust and distrust. In W.G. Austin and S. Worchel, Eds., The Social Psychology of Intergroup Relations. Wadsworth, Belmont, CA, 1986.
Tables
Table 1. A list of major health portals.
Table 2. Measures for trust building.
Table 3. Application of trust-building measures in major health portals.
©2004 ACM 0002-0782/04/0100 $5.00
Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. To copy otherwise, to republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee.
The Digital Library is published by the Association for Computing Machinery. Copyright © 2004 ACM, Inc.
No entries found