This paper is in the following e-collection/theme issue:

Consumer & Patient Education and Shared-Decision Making (679)

Published on in Vol 14, No 1 (2012): Jan-Feb

Comparing the Use of an Online Expert Health Network against Common Information Sources to Answer Health Questions

Comparing the Use of an Online Expert Health Network against Common Information Sources to Answer Health Questions

Comparing the Use of an Online Expert Health Network against Common Information Sources to Answer Health Questions

Authors of this article:

Martijn DF Rhebergen1 ;   Annet F Lenderink2 ;   Frank JH van Dijk1 ;   Carel TJ Hulshof1, 3
Article Authors Cited by (16) Tweetations (8) Metrics

    Original Paper

    1Academic Medical Center Amsterdam, Coronel Institute of Occupational Health, University of Amsterdam, Amsterdam, Netherlands

    2Academic Medical Center Amsterdam, Dutch Center for Occupational Diseases, University of Amsterdam, Amsterdam, Netherlands

    3Netherlands Society of Occupational Medicine (NVAB), Centre of Excellence, Utrecht, Netherlands

    Corresponding Author:

    Martijn DF Rhebergen, MSc

    Academic Medical Center Amsterdam

    Coronel Institute of Occupational Health

    University of Amsterdam

    Meibergdreef 9

    P.O. Box: 22700

    Amsterdam, 1100 DE

    Netherlands

    Phone: 31 20566 ext 2831

    Fax:31 20 697 7161

    Email: m.d.rhebergen@amc.uva.nl


    Background: Many workers have questions about occupational safety and health (OSH). It is unknown whether workers are able to find correct, evidence-based answers to OSH questions when they use common information sources, such as websites, or whether they would benefit from using an easily accessible, free-of-charge online network of OSH experts providing advice.

    Objective: To assess the rate of correct, evidence-based answers to OSH questions in a group of workers who used an online network of OSH experts (intervention group) compared with a group of workers who used common information sources (control group).

    Methods: In a quasi-experimental study, workers in the intervention and control groups were randomly offered 2 questions from a pool of 16 standardized OSH questions. Both questions were sent by mail to all participants, who had 3 weeks to answer them. The intervention group was instructed to use only the online network ArboAntwoord, a network of about 80 OSH experts, to solve the questions. The control group was instructed that they could use all information sources available to them. To assess answer correctness as the main study outcome, 16 standardized correct model answers were constructed with the help of reviewers who performed literature searches. Subsequently, the answers provided by all participants in the intervention (n = 94 answers) and control groups (n = 124 answers) were blinded and compared with the correct model answers on the degree of correctness.

    Results: Of the 94 answers given by participants in the intervention group, 58 were correct (62%), compared with 24 of the 124 answers (19%) in the control group, who mainly used informational websites found via Google. The difference between the 2 groups was significant (rate difference = 43%, 95% confidence interval [CI] 30%–54%). Additional analysis showed that the rate of correct main conclusions of the answers was 85 of 94 answers (90%) in the intervention group and 75 of 124 answers (61%) in the control group (rate difference = 29%, 95% CI 19%–40%). Remarkably, we could not identify differences between workers who provided correct answers and workers who did not on how they experienced the credibility, completeness, and applicability of the information found (P > .05).

    Conclusions: Workers are often unable to find correct answers to OSH questions when using common information sources, generally informational websites. Because workers frequently misjudge the quality of the information they find, other strategies are required to assist workers in finding correct answers. Expert advice provided through an online expert network can be effective for this purpose. As many people experience difficulties in finding correct answers to their health questions, expert networks may be an attractive new source of information for health fields in general.

    J Med Internet Res 2012;14(1):e9

    doi:10.2196/jmir.1886

    Keywords

    Information services; online expert network; medical informatics; information-seeking behavior; occupational health; evidence-based practice; question and answer 


    Many workers seek information to answer occupational safety and health (OSH) questions [1-4]. For this purpose, workers commonly use a variety of sources, such as asking advice from OSH experts within their company or social network, or exploring informational websites [5-7]. Ideally, the information available from these common information sources is of high quality [6,7], as low-quality information may lead to incorrect answers and wrong decisions regarding the prevention or management of OSH at work [8]. It is unknown whether workers can find correct, evidence-based answers [9,10].

    In general, one might ask whether it is possible for workers to find correct answers to their OSH questions. Finding information and answering health-related questions require specific skills or literacy [11,12]. The World Health Organization defines health literacy as “the cognitive and social skills which determine the motivation and the ability of an individual to gain access to, understand and use information in ways that promote and maintain good health” [13]. The Internet, the source that workers use most frequently, often provides excessive amounts of information that is not always easy to understand or of high quality [14-17]. The solution might be to consult OSH experts who are trained in finding evidence-based answers to clinical questions [18,19]. However, the consultation of experts by workers might be hampered by restricted access and high costs [20]. An attractive solution might be a selection of the best of both options by offering workers easily accessible, free-of-charge online advice from OSH experts [21-23].

    Question-and-answer expert network tools could be useful for providing such online expert advice, as these tools are designed for communication, and knowledge dissemination, storage, and retrieval [22,23]. These tools have the potential to build a network of experts on a particular topic (and many subtopics) and make them accessible to questioners. We tested the hypothesis that workers who used this online network of OSH experts would find correct answers to OSH questions more often than workers who used commonly available information sources. The aim of this study was to answer the following question: is there a difference in the rate of correct answers to questions about OSH between workers who use expert advice through an online expert network and workers who use common information sources?


    Study Design

    In a quasi-experimental study, we compared the rate of correct answers formulated by a group of workers who used an online expert network with that of a group of workers who used common information sources.

    Online Network on OSH: ArboAntwoord

    ArboAntwoord is an experimental, free-of-charge facility for workers with OSH questions [23,24]. The network was launched by means of a small-scale campaign in October 1, 2008. The home page of ArboAntwoord comprises several main categories of leading OSH topics (Figure 1). After registration, a worker can pose his or her question directly in the designated text field on the home page, or he or she can use the button “ask your question” that is presented in all subcategories. Both possibilities lead to a webpage in which the question must be given a title and the questioner must prohibit or authorize the publication of the question (Figure 2). After formulating his or her question, the worker needs to select one or more experts in that subcategory (Figure 3). Every expert is indexed to the subcategory that corresponds to his or her expertise. Appreciation scores expressed by earlier questioners and mean reaction time to previously answered questions are provided to facilitate questioners’ choosing an expert. Questioners may choose more than one expert. To notify the selected expert about his or her asked question, the page provides a “send question to the expert” button. With this button the selected expert will receive an email notification with a direct hyperlink to the question. Here the expert is also provided a main text field where he or she can also add an attachment when wanted (Figure 4). An expert can notify the questioner about his or her answer by using a “send answer to the questioner” button. All stored questions and answers are published and can be searched by other users when authorized by the questioner and the moderator. When required, experts can react to published questions and answers. Eligible questions and answers are stored and made accessible to other questioners in a searchable database after moderation and after informed consent by the questioner (Figure 5).

    A steady network of about 80 experts participate in the network. All experts are invited and/or accepted to participate if they meet all of the following criteria: (1) working in a university, or a commercial OSH expert center or OSH organization operating on a national level, (2) having (inter)national expertise on a specific OSH topic, (3) having at least 5 years of experience on this topic, and (4) participating in at least one knowledge-dissemination activity such as authorship of scientific articles or participation in an expert committee. The professions of the experts vary: occupational physicians, hygienists, safety workers, health scientists, psychologists, neuropsychologists, and experts in OSH law and regulations. All ArboAntwoord experts participate on personal title and on voluntarily basis. Discussion among experts is not common, although about a third of the questions are answered by more than one expert.

    ‎
    Figure 1. Screenshot of the ArboAntwoord home page, where a questioner can select a question category and use a search function to find stored questions and answers.
    View this figure
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    Figure 2. Screenshot of the webpage in a subcategory, where workers actually pose their question, give the question a title, and authorize publication.
    View this figure
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    Figure 3. Screenshot of the webpage in a subcategory, where a questioner can select one or more experts. The webpage also includes the experts’ mean reaction time and appreciation and a button to send the question.
    View this figure
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    Figure 4. Screenshot of the webpage in a subcategory, where an expert can provide his or her answer, with or without an attachment. The page includes a button to send the question.
    View this figure
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    Figure 5. Screenshot of the webpage in a subcategory that provides workers with a hyperlink to view stored and recently asked questions and answers in that subcategory.
    View this figure

    Intervention Group

    The intervention group was instructed to use the online network ArboAntwoord for solving 2 OSH questions that were provided by the researchers. As we did not have the opportunity to observe and log their use of the online network directly, we incorporated the 2 OSH questions into paper logs. These logs were mailed to the participants. A log included a question, a field to provide an answer, and several secondary outcome-related questions. A short additional questionnaire for information on background characteristics such as gender, age, educational level, work role, company size, and company sector was sent with the logs. We mentioned that ArboAntwoord was an experimental, free-of-charge online network of experts answering workers’ OSH questions, and we explained that they had to register on the website. Participants were instructed to pose a question in the (subcategory) they thought was the most convenient. The participants were requested to provide a clear and complete answer. Lastly, participants were asked to return the completed logs to the researchers in the return envelop provided. They could also deliver the logs with the start of the course, explained below. Participants had a maximum of 3 weeks to fill in the logs. As an incentive, the participants were promised a memory stick with useful OSH information.

    Control Group

    The control group can be interpreted as a care-as-usual group, using the information-seeking strategies and sources of workers with OSH questions in daily practice. Similar to the intervention group, the control group was sent 2 OSH questions that were incorporated into paper logs. These logs included a question, a space to provide the answer, and several secondary outcome-related questions. The logs of the controls instructed them that “You may use all (types of) information sources available to you to solve the questions.” Additionally, we asked them where they looked for information. For this question we provided 4 answer categories: (1) Internet using Google, (2) written sources (ie, magazines and books), (3) experts or specialists, and (4) other sources of information. In addition to this question, controls were requested to note the source that provided the most relevant information. Lastly, we asked the question “How much time in minutes did you spent seeking the information?” The participants were requested to provide a clear and complete answer. They were asked to fill in the logs and return these to the researchers. In total, participants got about 3 weeks to finish the logs. As an incentive the participants were promised a memory stick with useful OSH information.

    Participants

    Because we needed a motivated group of workers for this study, we decided to recruit workers who were enrolled to take part in a course for OSH supervisor (in Dutch: preventiemedewerker). An OSH supervisor is a common worker who is responsible for recognizing and suggesting basic solutions for OSH risks in a company. In general, short courses lasting 1–2 days on basic OSH issues are provided to educate and train new supervisors. Although workers enrolled in these courses probably have a higher than average interest in OSH, we know from training reports that more than 80% of the workers start without any substantial knowledge of OSH. Therefore, before the start of a course, we consider enrolled workers to be OSH interested, but not OSH educated. We approached all enlisted course participants from 2 training organizations during 2010 (N = 192). There were no important differences in the content of the course programs. Workers enrolled in the OSH supervisor courses prior to July 2010 were allocated to a control group (courses 1–16; n = 105). All workers enrolled in a course starting in August 2010 or later that year were assigned to an intervention group (courses 17–29; n = 87).

    Data Collection

    Both groups were offered 2 questions from a pool of 16 standardized OSH questions. As the difficulty and the topic of the question may affect the likelihood of finding a correct answer, we included these aspects in the construction of the question pool. For question difficulty, we distinguished simple information or knowledge questions and complex interpretation or advice questions. A simple question was defined as an OSH question that could be answered directly by one specific piece of information or advice. A complex question was defined as a question that could only be answered by interpreting and combining several pieces of information, often accounting for contextual aspects. We formulated 8 simple and 8 complex questions. We further distinguished 2 questions topics. Of the 16 questions, 5 considered OSH laws and regulations (eg, Are safety shoes obligatory for workers in an army storage depot?). The remaining 11 questions were about actual OSH issues, such as causes and risks factors for work-related health and safety (eg, Is radiation a risk for pregnant magnetic resonance imaging workers?), diagnosis (eg, What are the diagnostic criteria for designating posttraumatic stress disorder as an occupational disease?), interventions in occupational safety or health (eg, What is an effective intervention for occupational dermatitis?), or social mapping (eg, Where can I find the best expert on chronic low back pain rehabilitation?).

    To increase the ecological validity (the extent to which research emulates the real world) of the 16 OSH questions to be selected, we randomly selected 12 questions with answers from the ArboAntwoord database [25]. Additionally, 4 simple questions were formulated by the researchers based on information provided in the OSH supervisor course handbooks, and these questions were added to the pool. For the random selection of the 12 ArboAntwoord questions, all 319 questions in the ArboAntwoord database were first stratified by 2 researchers independently (MR and AF) in 4 categories based on difficulty (simple or complex) and topic (OSH law and regulations, or OSH content). Subsequently, 2 simple OSH law and regulation questions, 3 complex OSH law and regulation questions, 6 simple OSH content questions, and 5 complex OSH content questions were used in this study. An example of a difficult OSH content question is “Are the glass fibers or dust released after the crushing, cutting or fragmentation of (car) windows in the open air hazardous to my health? What can be done to prevent hazards?” We observed that the structure of 8 questions included 2 components—that is, these questions were actually composed of 2 questions. This corresponds to our experience with questions from practice, where workers often seem to have a concern about an OSH risk and wonder about a possible solution. The 16 questions are included in Multimedia Appendix 1.

    We randomly assigned 2 questions to each participant and sent them out about 3 weeks before the start of their OSH supervisor course, ensuring that all participants received 1 easy and 1 complex question (to ensure they would not be discouraged by getting 2 complex questions). Based on the level of question difficulty, an automatically created randomization list was used with 56 possible combinations (8 simple × 8 – 1 complex questions) for both the intervention and control groups. Because we anticipated about 200 course participants and a response rate of 50%, we expected that every question would be answered about 6 times in the control group and 6 times in the intervention group. Although participants in the intervention group posed a question directly to an ArboAntwoord expert, the system moderator (MR) always provided questioners with the original answers to 12 randomly selected OSH questions to prevent unnecessary use of expert time and to avert possible learning effects resulting from answering the same question more than once. For the 4 self-formulated OSH questions we used the first answer provided by an expert in our experiment.

    Primary Outcome and Scoring Procedure

    To define the main study outcome parameter answer correctness we used the experiences and approaches of evidence-based practice [9,10]. Evidence-based practice is a strategy for clinical decision making that involves the integration of the patients’ needs and context, the expertise of professionals, and the best available research evidence. In this study, we define a correct answer as “an answer that accounts for the context of the question(er) and corresponds with conclusions or recommendations of the best available evidence”. Two steps were needed to assess whether provided answers were correct.

    First, 16 standardized correct model answers were constructed with the help of 2 reviewers with expertise on the question topics. A total of 10 reviewers were internal experts who also participated in the ArboAntwoord network, and 13 external reviewers were recruited for the review process. Internal experts could not review their own answers. All reviewers were provided with a draft model answer formulated by the research team. The reviewers were requested to report whether the draft model answer was in complete, partial, or no agreement with the conclusions or recommendations from the best available evidence. Similarly to the evidence-based practice method, reviewers were asked to consider 4 levels of evidence by means of an evidence literature search looking for evidence-based guidelines, reviews, or scientific research articles, or using their own professional expertise, in that order. If evidence from the highest level was not available, we requested the expert to move on to the next best level of available evidence. Because these levels of evidence do not apply to OSH law and regulation questions, reviewers of draft answers on this topic were requested to first regard laws and regulations, policy, jurisdictions, or standards, followed by their own professional expertise. All additional evidence and comments provided by both reviewers were included in the final versions of the standardized correct model answers.

    Second, we developed a scoring system defining correctness for all 16 standardized model answers separately based on the essential aspects required for a correct answer (see Multimedia Appendix 1). The scoring system consisted of an answer correctness score between 0 and 4. The essential aspects were directly dependent on the nature of the particular OSH question. For example, questions sometimes asked for confirmation or proof, for conditions under which an OSH situation holds, for a specific location, for possible risks or solutions, or for a combination of these. To verify whether a participant finally reached the correct answer conclusion to the main question, we included this as one of the essential aspects in all 16 model answers. This aspect can be considered as the correctness of an answer’s main conclusion (yes, no, or possibly). The question about the health hazards of glass fibers and dust discussed earlier in the Methods was scored as follows. The main conclusion, “Yes, this could possibly be hazardous to health,” was given 1 point. Another point was provided when the answer mentioned something like “Depending on glass (particle) type and exposure.” Two more points were awarded when a security measure were given. As in health care in general, there is sometimes some variation or interpretation for what constitutes a correct, evidence-based answer. This especially holds true for the questions related to OSH content. For all questions some room was created to account for this variation and interpretation issue (Multimedia Appendix 1). Based on the scoring system, all participants’ answers were scored and compared with the model answers by 2 raters. The first rater was a medical student unrelated to this study. The second rater, MR, checked the answer scores of the first rater. Both raters were blinded to the group (intervention or control) to which the answers belonged.

    Secondary Outcomes

    We assessed 2 secondary outcomes: (1) the experienced quality of the information source used: whether the source was usable or easy to use, and how easy it was to learn to use, and (2) the experienced quality of the information obtained: whether the information was complete, applicable, and reliable, and how satisfied the participant was with the information. All response categories to these questions were based on 7-point Likert scales (ranging from completely disagree to completely agree).

    Data Analysis

    We described most outcomes by means of descriptive analysis. Analyses were performed with SPSS version 17.0 (IBM Corporation, Somers, NY, USA). To establish any group differences in background characteristics that required adjustment in further analysis, we first applied the chi-square test for dichotomous or nominal variables, and the Yates and Cochrane test for ordinal variables (P < .05).

    The correctness of the participants’ answers was analyzed in 2 ways. First, we verified whether the answers given were sufficiently correct by dichotomizing the 4-point answer scores (0–2 points = insufficiently evidence based; 3–4 = sufficiently evidence based). We considered using the ordinal data, but we observed that the distribution was skewed. Thus, dichotomization seemed the best option without giving away a lot of information. Second, we looked at the correct main conclusions of the answers. Possible group differences between the intervention and control groups regarding the prevalence of correct answers and of correct main conclusions were analyzed with the chi-square test (P < .05). Because we found no differences between the groups in terms of question difficulty, question topic, or background characteristics (P > .05), we used binary logistic regression analysis only to establish possible interaction effects of these factors on the main outcome(s) (P < .05). We stratified the effect of group type on the number of correct answers by question difficulty, question topic, question structure, and background characteristics. We used the chi-square test for dichotomous and nominal variables, and the Yates and Cochrane test for the ordinal background characteristics (P < .05). To describe the strength of associations, we used rate differences. In this study, rate difference is probably the most appropriate measure because it describes the absolute change in the rate of, for example, correct answers attributable to the intervention.

    Potential differences between the groups regarding the 2 secondary outcomes (the experienced quality of the information source used and the information it provided) were analyzed with the Wilcoxon rank sum test (P < .05). Because we observed moderate to high Spearman correlations (r = .45–.65) and good internal consistency (Cronbach alpha = .74) between the 4 items on the experienced quality of the source used, these 4 items were processed into a single-item factor by calculating mean scores. We observed no high correlations between the 4 items on information quality (r < .40).

    In the control group we also applied the Wilcoxon rank sum test to determine the effect of information-seeking time and experienced information quality or quality of the information source used on providing correct answers.


    Group Characteristics

    Overall, 47 of the 87 (54%) workers assigned to the intervention group agreed to participate in the study compared with 62 of the 105 (59%) in the control group. This resulted in 94 answers in the intervention and 124 answers in the control group. In total 110 of the 124 (89%) questions in the control group were answered with information obtained online, 9 (7%) with information from written sources (ie, magazines, books), and 5 (4%) with advice from experts or specialists. Because removing questions that were answered with written information or expert advice did not change any of the outcomes, these questions were preserved in further analysis. The median information-seeking time in the control group was 10 minutes per question (interquartile range: 5–20 minutes), and this time in minutes was not comparable with the time in days the intervention group had to wait for their answer of the ArboAntwoord experts. We did not observe any significant group differences in background characteristics (P > .05) (Table 1). Young participants between the age of 15 and 24 years were not represented in either group.

    Table 1. Background characteristics of the intervention group (n = 47) and the control group (n = 62)
    Characteristic Intervention group
    (online network
    ArboAntwoord)     		Control group
    (common
    information sources)
    n % n %
    Gender
    Female 28 60 33 53
    Male 19 40 29 47
    Age group (years)
    15–24 0 0 0 0
    25–34 17 36 14 23
    35–44 12 25 22 35
    45–54 13 28 20 32
    ≥55 5 11 6 10
    Educational level
    Low 11 23 13 21
    Intermediate 17 36 21 34
    High 19 40 28 45
    Role
    Worker 32 68 42 68
    Employer/manager 8 17 13 21
    OSHa (semi)professional 7 15 7 11
    Company size
    Small 19 40 27 44
    Medium 16 34 18 29
    Large 12 26 17 27
    Company sector
    Agriculture and fishery 2 4 3 5
    Industry 13 28 12 19
    Construction industry 4 10 6 10
    Trade 8 17 11 17
    Transport and communication 1 2 3 5
    Financial services 1 2 1 2
    Business services 8 17 7 11
    Public policy or civil service 3 6 3 5
    Education 1 2 3 5
    Health care 3 6 7 11
    Culture and other services 3 6 6 10
    Self-rated Internet and computer experience
    Relatively inexperienced 8 17 16 26
    Relatively experienced 39 83 46 74

    a Occupational safety and health.

    We observed no statistical group differences in the distribution of simple or complex questions (χ21 = 0; P = .9) and OSH legislation or OSH content questions (χ21 = 0; P = .9). Nevertheless, we observed a discrepancy in the distribution of the answers to 2 of the OSH questions. Question 7 was answered once in the intervention group and 4 times in the control group, and question 13 was not answered at all in the intervention group and was answered 8 times in the control group. Because removing these 2 questions did not change any of the outcomes, both were preserved in further analysis. All other questions were answered between 4 and 10 times in both groups.

    Answer Correctness

    In total, 58 of the 94 (62%) answers of the intervention group were rated correct, compared with 24 of the 124 (19%) answers for the control group. A significant difference with a rate difference of 43% was observed (95% CI 30%–54%) (Table 2). The use of the online expert network ArboAntwoord had a positive effect on providing correct answers, and the effect was identical for answers to simple or complex questions, for answers to questions related to OSH law and regulations or OSH content, and for answers to single or double questions (Table 2). Stratification by background characteristics consistently showed similar differences in the distribution of evidence-based answers in favor of the intervention group, with rate differences ranging from 33% to 66% (Table 2). Only Internet use significantly interacted with the effect of intervention on answer correctness: using the online network ArboAntwoord for providing correct answers was found to be even more beneficial for relatively inexperienced Internet and computer users (Wald χ21 = 3.9; P = .048).

    In the intervention group, answers to questions about OSH law and regulations were significantly more often correct than questions about OSH content (χ21 = 7.9; P = .01). This same trend was observed in the control group (χ21 = 3.2; P = .07). Furthermore, within the control group we found that correct answers were significantly less often provided by men than by women (χ21 = 5.7; P = .02), with a similar trend for gender in the intervention group (χ21 = 3.7; P = .06). Spending more time seeking information did not affect the likelihood of finding a correct answer (Z = –0.18, P = .9).

    Finally, we analyzed a subgroup on the one essential aspect that was similar for all answers: the correctness of the main conclusion (yes, no, or possibly). In total, 85 of the 94 (90%) main conclusions in the intervention group were correct compared with 75 of the 124 (61%) conclusions for the control group. A significant difference with a rate difference of 29% was found (95% CI 19%–40%) (Table 3). This positive effect in favor of the intervention was identical for answers to simple and complex questions, for answers to questions related to OSH law and regulations and OSH content, and for answers to single and double questions.

    Table 2. Rates of correct answers in the intervention group (n = 94 answers) compared with the control group (n = 124 answers) stratified by question difficulty, question topic, question structure, and background characteristics
    Intervention group
    (online network
    ArboAntwoord)     		Control group
    (common
    information sources)     		Intervention vs
    control group
    n/N % n/N % RD%a 95% CIb
    Total (all questions) 58/94 62 24/124 19 43 30–54
    Question difficulty
    Simple 25/47 53 12/63 19 34 16–50
    Complex 33/47 70 12/61 20 50 33–65
    Question topic
    OSHc law and regulations 24/29 83 11/38 29 54 31–71
    OSH content 34/65 52 13/86 15 37 22–51
    Question structure
    Single 18/31 58 10/50 20 38 17–57
    Double 40/63 63 14/74 19 44 29–58
    Gender
    Female 39/56 70 18/66 27 43 25–57
    Male 19/38 50 6/58 10 40 22–56
    Age group (years)
    15–24 NAd NA NA
    25–34 22/34 65 6/28 21 44 19–63
    35–44 15/24 63 10/44 23 40 15–60
    45–54 16/26 62 6/40 15 47 23–66
    ≥55 5/10 50 2/12 17 33 –7 to 66
    Educational level
    Low 14/22 64 4/26 15 49 21–69
    Intermediate 22/34 65 9/42 21 44 21–61
    High 22/38 58 11/56 20 38 19–56
    Role
    Worker 40/64 63 20/84 24 39 23–53
    Employer/manager 7/16 44 1/26 4 40 16–64
    OSH (semi)professional 11/14 79 3/14 21 58 20–80
    Company size
    Small 22/38 58 9/54 17 41 22–58
    Medium 16/32 50 5/36 14 36 14–55
    Large 20/24 83 10/34 29 54 29–72
    Self-rated Internet and computer experience
    Inexperienced 12/16 75 3/32 9 66 38–8
    Experienced 46/78 59 21/92 23 36 22–49

    a Rate difference.

    b Confidence interval.

    c Occupational safety and health.

    d Not applicable.

    Table 3. Rates of correct main conclusions of answers in the intervention group (n = 94 answers) compared with the control group (n = 124 answers) stratified by question difficulty topic and structure
    Intervention group
    (online network
    ArboAntwoord)     		Control group
    (common
    information sources)     		Intervention vs
    control group
    n/N % n/N % RD%a 95% CIb
    Total (all questions) 85/94 90 75/124 61 29 19–40
    Question difficulty
    Simple 41/47 87 40/63 64 23 7–38
    Complex 44/47 94 35/61 57 37 21–50
    Question topic
    OSHa law and regulations 28/29 97 26/38 68 29 11–45
    OSH content 57/65 88 49/86 57 31 17–43
    Question structure
    Single 31/31 100 31/50 62 38 26–52
    Double 54/63 86 44/74 60 26 11–40

    a Rate difference.

    b Confidence interval.

    c Occupational safety and health.

    Experienced Quality of the Information (Sources) Used

    On average, the online network ArboAntwoord was rated of higher quality than common information sources, with mean scores of 5.8 (interquartile range: 5.5–6.3) and 5.2 (interquartile range: 4.4–6.0), respectively (Z = –3.5, P < .001). Participants in the intervention group experienced the completeness of the received information to be significantly higher (Z = –2.6, P = .01) and were significantly more satisfied with the received information (Z = –2.3, P = .03) than participants in the control group (Table 4). Notably, judging the quality of the information seemed to be difficult for the participants. Within both the intervention and the control group, we did not find a significant difference in the experienced information quality scores between workers who provided correct answers and those who did not (within the intervention group: information completeness Z = –0.9, P = .4, applicability Z = –1.0, P = .3, and credibility Z = –1.5, P = .1; within the control group: information completeness Z = –0.8, P = .4, applicability Z = –1.3, P = .2, and credibility Z = –0.6, P = .5). This finding corresponds to the comparably high applicability and credibility scores found for both ArboAntwoord and the common information sources.

    Table 4. Comparison between the intervention group (n = 94 answers) and the control group (n = 124 answers) regarding experienced information completeness, applicability, credibility, and satisfaction with the information
    Experienced
    information
    quality     		Intervention group
    (online network
    ArboAntwoord)     		Control group
    (common
    information sources)     		Intervention vs
    control group
    Z    		 Intervention vs
    control group
    P value
    Mean IQRa Mean IQR
    Completeness 5.4 5.0–6.0 4.7 3.0–6.0 –2.6 .01
    Applicability 5.5 5.0–6.0 5.3 5.0–6.0 –1.2 .2
    Credibility 5.4 4.0–6.0 5.4 5.0–6.0 –0.05 .9
    Satisfaction 5.6 6.0–6.0 5.0 4.8–6.0 –2.3 .03

    a Interquartile range.


    Principal Results

    Our findings show that the rate of correct answers to OSH questions provided by workers who used expert advice obtained from an online network was significantly higher than the rate of correct answers provided by workers who used common information sources. When workers used their common information sources (in 90% of the cases, these were informational websites found through Google), only 19% of the answers were correct. The rate of correct answers was 62% for workers using the online expert network ArboAntwoord, which is significantly higher. This difference was found for answers to simple and complex questions, for answers to questions about OSH law and regulations and about OSH content, and for answers to single and double questions. Answer correctness rates in both groups increased to 90% and 61% when we analyzed only the correctness of the main conclusion of the answers. Overall, workers who used ArboAntwoord were more satisfied with information that they received, and they experienced the information as more complete than workers who used common information sources. Nevertheless, the perceived information quality scores were relatively high in both groups. Remarkably, within both the experimental and control groups, workers who provided incorrect answers believed the information that they used to be as credible, complete, and applicable as did workers who provided correct answers. Workers appear to be unable to judge the quality of the information they find.

    Comparison with Prior Work

    To our knowledge, this is one of the first studies evaluating whether and how workers can find correct evidence-based answers to OSH questions. So far, most studies on answering OSH questions focus on OSH professionals and their use of evidence-based practice strategies [6,7,18,19,26]. Our findings clearly demonstrate that workers provide correct answers more often with the support of expert advice than with common information sources. Because we checked that all information necessary to answer the 16 questions correctly was available on the Web, our findings might be partly explained by the fact that workers have limited search skills and seem unable to judge important qualities of the information they find. Consequently, workers who wrongly judge the credibility, completeness, and applicability of information as high are likely to provide an incorrect answer. This especially holds true for participants in the control group, who often used online information found with Google. In several studies, non-health professionals have been found to use too few search terms and to select only one of the first few results displayed by a search engine [27-29]. Moreover, the quality of information found with these search engines has been shown to vary [14,16,30-32]. Consequently, using search engines such as Google does not always result in finding correct evidence-based answers. Thiele et al [33] demonstrated that medical students, resident physicians, and attending physicians provided only about 65% correct answers to 8 anesthesia and critical care-based clinical questions using Google. Similarly, Kingsley et al [34] found that only 25% of first-year dental students provided correct answers to several fundamental biomedical questions when using Google. In a study by Tang and Ng [17], several samples of diagnostic cases were selected from the New England Journal of Medicine that were subsequently googled for a diagnosis. The searches revealed a correct diagnosis in only 58% of the cases. Moreover, Kortum et al [35] showed that nonprofessionals (high school students) often provide incorrect answers to health questions when using the Internet. Consistently with our results, they concluded that difficulties in distinguishing trustworthy from untrustworthy medical information resulted in these incorrect answers. In sum, similar to the concept of health literacy [13], OSH literacy corresponding to “the cognitive and social skills which determine the motivation and the ability of an individual to gain access to, understand and use information in ways that promote and maintain good occupational safety and health” seems to influence workers’ ability to find correct answers to OSH questions. It would be worthwhile to further explore OSH literacy and its role in finding correct answers effectively.

    The higher rate of correct answers in the intervention group was probably further amplified by the high proficiency of the experts associated with ArboAntwoord. They are leading national experts on specific OSH topics and are familiar with finding, selecting, appraising, and applying evidence-based information. Nevertheless, even these experts did not always provide a correct answer, which is in accordance with the findings of Schaafsma et al [36], who stated that caution is required when relying blindly on expert advice. Again, it is possible that participants sometimes did not understand or interpret the information of the experts correctly. Another possible explanation is that experts were hindered by a lack of time in answering questions thoroughly and performing evidence searches when needed [26]. Moreover, the experts in ArboAntwoord participated voluntarily and were not paid. In commercial, nonhealth-related networks, (perceived) answer quality was shown to increase when users were paid to provide answers [37]. Possibly, to further increase answer correctness, experts could be given small incentives and more thorough instruction in how to answer questions correctly.

    Subgroup analysis resulted in additional interesting findings. Within the intervention and control groups, we observed that the rate of correct main conclusions was much higher than the rate of correct answers in general. It is possible that workers are often able to provide a sort of “logical” conclusion based on deduction, observation of current practices, common sense about moral responsibility, or even implicit knowledge. Additionally, the a priori chance to provide a correct conclusion is 33% (yes, no, or possibly), which may also partly explain why, in both groups, the rate of correct conclusions was higher than the rate of correct answers in general.

    In both the intervention and control groups, the rate of correct answers to questions about OSH law and regulations was higher than that of answers to questions about OSH content. Apparently, OSH content questions are more difficult to answer than questions about OSH legislation for both questioners and experts. Possibly, the (poor) formulation of the OSH content questions might have made them more difficult to answer. Finally, in both the control and intervention groups, we found a trend that women seemed to outperform men. It is possible that men feel less obligated, motivated, or aroused to find correct answers to the questions, or they may have less efficient learning styles (including information-seeking strategies) that affect the effort of seeking information [38,39].

    Two expected effects could not be established in our analyses. We expected that for complex questions the rate of correct answers would be significantly lower than for simple questions, especially in the control group. We presumed that expert advice would be particularly necessary for the complex questions. Our findings did not corroborate these expectations. Our hypothesis may have been incorrect, or it is possible that our simple questions were not actually very simple, or our complex questions were not actually very complex. Finally, we expected that information-seeking time would influence the rate of correct answers in the control group: that spending more time seeking information would have a positive influence on this rate. However, this difference could not be established. Again, because workers often seem to misjudge information quality, they believe that spending more time on information seeking is unnecessary. Another explanation might be that self-reporting of the time spent seeking information is subject to social desirability bias. Estimating the time required might therefore be less reliable than actually observing and timing the information-seeking process.

    Strengths and Limitations

    This study has several apparent strengths. The use of specific OSH questions from practice increases the ecological validity of our study. The stratified assignment of questions, the blinding of raters regarding the group to which the answers belonged, and the quasi-experimental design improved the quality of the study. Our study also has methodological limitations. The selection of workers who were planning to take part in an OSH supervisor course limits the generalizability to all workers. In addition, workers younger than 25 years were not represented in either group. As we believe that our sample may have been more motivated because of their proven OSH interest, the low rate of correct answers in the control group may be an overestimation.

    Furthermore, although selecting OSH questions from ArboAntwoord may have increased the ecological validity, it also introduced a limitation. Participants probably did not personally relate to these specific OSH questions, and this might have caused participants to be less motivated to find an answer. This effect could be more apparent in the control group, who had to find an answer to these questions on their own. An alternative study design, letting participants bring in their own OSH question, may increase workers’ understanding and commitment with the question, and as a consequence the efforts spent answering it. A disadvantage of this design is the potentially poor comparability of the outcomes between the two groups. The selection and composition of the questions might constitute another limitation. Our distinction between simple and complex questions can be questioned, as this was based on our personal estimation of whether an answer needed the combination and interpretation of information (complex). In retrospect, almost all our questions may be regarded as fairly complex, which might have caused the rate of correct answers to be lower than in daily practice. Furthermore, in view of classic evidence-based practice methods, at least several of the selected OSH questions seem poorly formulated. The accurate formulation of a clinical question is often mentioned as one of the most important skills required for evidence-based practice [9,10]. Several of our questions comprise more than one issue, do not address a specific target group, do not define a clear outcome, or do not take into account important contextual factors. Consequently, a poorly formulated question is more difficult to answer correctly, especially for participants in the control group, who had to interpret the question themselves. Moreover, this might also have influenced what we defined as a correct model answer, especially because for several questions the highest available level of evidence was the experts’ (reviewers’) opinion. In these cases, expert reviewers other than those involved in this study might have had a different opinion on what constitutes a correct evidence-based answer. In this line, the design and use of our model answers require consideration. For example, in this study we decided to dichotomize our ordinal data because of a skewed distribution. This may have caused some loss of information. Future studies may consider using continuous correctness scores. Lastly, our way of data collection may constitute a limitation. Participants had to answer the questions and complete the paper logs at home or at work. It might have been better to let participants search for information in the lab, where we could have videotaped them and assessed computer log files. However, the advantage of a field test is that it represents the real-life situation better than a laboratory experiment and that it is possible to study search strategies other than online ones.

    Conclusions and Implications

    Workers are often unable to find correct evidence-based answers to OSH questions when using common information sources, generally informational websites. The limited experience of workers with finding high-quality information seems to play an important role in finding correct answers; workers seem to be unable to judge the credibility, completeness, and applicability of the OSH information they find. Future research should explore workers’ OSH information-seeking skills, their appraisal of information quality, and their ability to apply the obtained information to solve their question.

    In addition to common information sources, other strategies and sources are required to assist workers in answering their OSH questions and to overcome difficulties in finding high-quality information. Expert advice provided through an online expert network (ArboAntwoord) can increase the rate of correct answers substantially, especially when focusing on the correct main conclusions. This purpose might also be facilitated by educational strategies such as short custom-made evidence-based practice courses for workers and managers or their representatives, or decision-support tools, or by providing accreditation to high-quality information. Future research could further establish the effectiveness of these new strategies.

    Lastly, the identified difficulties with finding, appraising, and applying health-related information is not unique to workers. It is also relevant to other non-health professionals seeking health information, such as people in the general population or patients. Our findings on the potential value of online expert networks and expert facilities in general seem also applicable to other groups of people seeking answers to their health questions, albeit dependent on the quality of the knowledge infrastructures built around specific health topics (eg, asthma, cancer, or schizophrenia). Future research may focus on the impact of similar expert facilities in other health-related fields.

    Acknowledgments

    We thank the Foundation Institute GAK (Hilversum, The Netherlands) for funding this study. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors’ work on this article was independent of the funder.

    Conflicts of Interest

    None declared.

    ‎

    Multimedia Appendix 1

    The 16 occupational safety and health (OSH) questions and their standardized correct model answers.

    PDF File (Adobe PDF File), 94KB
    1. Canadian Centre for Occupational Health and Safety. 2008. Report of the Council: April 1, 2007 to March 31, 2008   URL: http://www.ccohs.ca/ccohs/reports/annualReport0708.pdf [accessed 2011-06-21] [WebCite Cache]
    2. Hoekstra P, van der Laan N. Inventarisatie naar informatiebehoeften over arbeidsomstandigheden [Inventory of Informational Needs in Occupational Health and Safety]. Report C6403. Amsterdam: TNS-NIPO; 2008.
    3. Lang KH, Deilmann M, Nover H. Institut ASER e.V., Bergischen Universität Wuppertal, Germany. 2007. Zusammenfassung und Fortschreibung der Ergebnisse zum Pilotprojekt REACH-Net [Summary and Follow-up of the Results of the Pilot Project REACH-Net]. Forschungsbericht Nr 17   URL: http://www.institut-aser.de/pdf_files/literatur/REACH-Net-Zusammenfassung-Fortschreibung.pdf [accessed 2011-06-21] [WebCite Cache]
    4. Scott Porter Research and Marketing. NHS Health Scotland. 2004 May. Safe and Healthy Working: The Occupational Health Service for Small and Medium Enterprises (SMEs)   URL: http://www.healthscotland.com/uploads/documents/RE04920032004Final.pdf [accessed 2011-06-21] [WebCite Cache]
    5. Dryson E. Occupational health needs in small industry in New Zealand: preferred sources of information. Occup Med (Lond) 1993 Nov;43(4):176-179. [Medline]
    6. Hugenholtz NI, Schreinemakers JF, A-Tjak MA, van Dijk FJ. Knowledge infrastructure needed for occupational health. Ind Health 2007 Jan;45(1):13-18 [FREE Full text] [Medline]
    7. van Dijk FJ, Verbeek JH, Hoving JL, Hulshof CT. A knowledge infrastructure for occupational safety and health. J Occup Environ Med 2010 Dec;52(12):1262-1268. [CrossRef] [Medline]
    8. Shepperd S, Charnock D, Gann B. Helping patients access high quality health information. BMJ 1999 Sep 18;319(7212):764-766 [FREE Full text] [Medline]
    9. Offringa M, Assendelft WJJ. Inleiding in evidence-based medicine: klinisch handelen gebaseerd op bewijsmateriaal. 2nd edition. Houten: Bohn Stafleu Van Loghum; 2003.
    10. Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Elsevier/Churchill Livingstone; 2005.
    11. Anton B, Nelson R. Literacy, consumer informatics, and health care outcomes: Interrelations and implications. Stud Health Technol Inform 2006;122:49-53. [Medline]
    12. Schardt C. Health information literacy meets evidence-based practice. J Med Libr Assoc 2011 Jan;99(1):1-2. [CrossRef] [Medline]
    13. World Health Organization. 1998. Health Promotion Glossary   URL: http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf [accessed 2011-06-21] [WebCite Cache]
    14. Eysenbach G, Powell J, Kuss O, Sa ER. Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review. JAMA 2002;287(20):2691-2700 [FREE Full text] [Medline]
    15. Haigh CA. Wikipedia as an evidence source for nursing and healthcare students. Nurse Educ Today 2011 Feb;31(2):135-139. [CrossRef] [Medline]
    16. Leithner A, Maurer-Ertl W, Glehr M, Friesenbichler J, Leithner K, Windhager R. Wikipedia and osteosarcoma: a trustworthy patients' information? J Am Med Inform Assoc 2010;17(4):373-374 [FREE Full text] [CrossRef] [Medline]
    17. Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ 2006 Dec 2;333(7579):1143-1145 [FREE Full text] [CrossRef] [Medline]
    18. Hugenholtz NI, Schaafsma FG, Nieuwenhuijsen K, van Dijk FJ. Effect of an EBM course in combination with case method learning sessions: an RCT on professional performance, job satisfaction, and self-efficacy of occupational physicians. Int Arch Occup Environ Health 2008 Oct;82(1):107-115. [CrossRef] [Medline]
    19. Schaafsma F, Hugenholtz N, de Boer A, Smits P, Hulshof C, van Dijk F. Enhancing evidence-based advice of occupational health physicians. Scand J Work Environ Health 2007 Oct;33(5):368-378 [FREE Full text] [Medline]
    20. Burg MA, Zebrack B, Walsh K, Maramaldi P, Lim JW, Smolinski KM, et al. Barriers to accessing quality health care for cancer patients: a survey of members of the association of oncology social work. Soc Work Health Care 2010;49(1):38-52. [CrossRef] [Medline]
    21. Himmel W, Meyer J, Kochen MM, Michelmann HW. Information needs and visitors' experience of an Internet expert forum on infertility. J Med Internet Res 2005;7(2):e20 [FREE Full text] [CrossRef] [Medline]
    22. Iske P, Boersma W. Connected brains: question and answer systems for knowledge sharing: concepts, implementation and return on investement. J Knowl Manag 2005;9(1):126-145. [CrossRef]
    23. Rhebergen MD, Hulshof CT, Lenderink AF, van Dijk FJ. An online network tool for quality information to answer questions about occupational safety and health: usability and applicability. BMC Med Inform Decis Mak 2010;10:63 [FREE Full text] [CrossRef] [Medline]
    24. Coronel Institute, Dutch Center for Occupational Diseases, Academic Medical Center Amsterdam. 2011. ArboAntwoord   URL: https://www.arboantwoord.com/default.aspx [accessed 2011-06-21] [WebCite Cache]
    25. Thomas JR, Nelson JK. Research Methods in Physical Activity. Champaign, IL: Human Kinetics; 1996.
    26. Hugenholtz NI, Nieuwenhuijsen K, Sluiter JK, van Dijk FJ. Do knowledge infrastructure facilities support evidence-based practice in occupational health? An exploratory study across countries among occupational physicians enrolled on Evidence-Based Medicine courses. BMC Health Serv Res 2009;9:18 [FREE Full text] [CrossRef] [Medline]
    27. Eysenbach G, Köhler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 2002 Mar 9;324(7337):573-577 [FREE Full text] [Medline]
    28. Hansen DL, Derry HA, Resnick PJ, Richardson CR. Adolescents searching for health information on the Internet: an observational study. J Med Internet Res 2003 Oct 17;5(4):e25 [FREE Full text] [CrossRef] [Medline]
    29. Peterson G, Aslani P, Williams KA. How do consumers search for and appraise information on medicines on the Internet? A qualitative study using focus groups. J Med Internet Res 2003 Dec 19;5(4):e33 [FREE Full text] [CrossRef] [Medline]
    30. Ilic D, Bessell TL, Silagy CA, Green S. Specialized medical search-engines are no better than general search-engines in sourcing consumer information about androgen deficiency. Hum Reprod 2003 Mar;18(3):557-561 [FREE Full text] [Medline]
    31. Minzer-Conzetti K, Garzon MC, Haggstrom AN, Horii KA, Mancini AJ, Morel KD, et al. Information about infantile hemangiomas on the Internet: how accurate is it? J Am Acad Dermatol 2007 Dec;57(6):998-1004. [CrossRef] [Medline]
    32. Whelan AM, Jurgens TM, Bowles SK, Doyle H. Efficacy of natural health products in treating osteoporosis: what is the quality of internet patient advice? Ann Pharmacother 2009 May;43(5):899-907. [CrossRef] [Medline]
    33. Thiele RH, Poiro NC, Scalzo DC, Nemergut EC. Speed, accuracy, and confidence in Google, Ovid, PubMed, and UpToDate: results of a randomised trial. Postgrad Med J 2010 Aug;86(1018):459-465. [CrossRef] [Medline]
    34. Kingsley K, Galbraith GM, Herring M, Stowers E, Stewart T, Kingsley KV. Why not just Google it? An assessment of information literacy skills in a biomedical science curriculum. BMC Med Educ 2011;11:17 [FREE Full text] [CrossRef] [Medline]
    35. Kortum P, Edwards C, Richards-Kortum R. The impact of inaccurate Internet health information in a secondary school learning environment. J Med Internet Res 2008;10(2):e17 [FREE Full text] [CrossRef] [Medline]
    36. Schaafsma F, Verbeek J, Hulshof C, van Dijk F. Caution required when relying on a colleague's advice; a comparison between professional advice and evidence from the literature. BMC Health Serv Res 2005;5:59 [FREE Full text] [CrossRef] [Medline]
    37. Harper FM, Raban D, Rafaeli S, Konstan JA. Predictors of answer quality in online Q&A sites. In: Proceedings of the twenty-sixth annual SIGCHI conference on Human factors in computing systems. 2008 Presented at: 26th SIGCHI Annual Conference on Human Factors in Computing Systems (CHI); 2008; Florence, Italy. [CrossRef]
    38. de Saintonge DM, Dunn DM. Gender and achievement in clinical medical students: a path analysis. Med Educ 2001 Nov;35(11):1024-1033. [Medline]
    39. Smits PB, Verbeek JH, Nauta MC, Ten Cate TJ, Metz JC, van Dijk FJ. Factors predictive of successful learning in postgraduate medical education. Med Educ 2004 Jul;38(7):758-766. [CrossRef] [Medline]

    ‎
    CI: confidence interval
    OSH: occupational safety and health

    Edited by G Eysenbach; submitted 12.07.11; peer-reviewed by P Kortum; comments to author 28.09.11; revised version received 10.10.11; accepted 28.10.11; published 02.02.12

    Copyright

    ©Martijn DF Rhebergen, Annet F Lenderink, Frank JH van Dijk, Carel TJ Hulshof. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.02.2012.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.