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Persian language health websites on Ebola disease: less credible than you think?

Persian language health websites on Ebola disease: less credible than you think? Background: Ebola virus disease is an emergency situation in the area of international public health for which currently, there is no standard treatment. Thus, there is an essential need for awareness of individuals about the Ebola disease and consequently its prevention. Internet and health websites are considered a source of health information about certain diseases. Therefore, in this study, the credibility of Persian-language websites on Ebola is assessed. Materials and methods: The term “Ebola” was searched using the Yahoo, Google, and Bing search engines. The first 30 websites resulting from each search engine were studied. Persian language was a prerequisite for inclusion. Duplicate and inaccessible websites were excluded and 62 websites were retained for evaluation. These websites were manually assessed by the researchers. The research tool was HONcode official toolbar as well as the checklist set by the researchers based on the HONcode of Conduct tool. The data were analyzed using SPSS 18.0 software. Results: None of the retrieved websites was officially approved by the HONcode of Conduct. Moreover, the manual evaluation showed that none of them had fully considered the eight criteria of HONcode. The results showed that most of the retrieved websites (62%) were commercial. The justifiability criterion had been considered in 89% of the studied websites, but the authority criterion had been considered by only 16% of the websites. Conclusion and recommendations: Regarding the poor reliability of Persian websites on the Ebola disease, and considering that Persian language people prefer to read the information in their native language, it is recommended that the authorized health organizations introduce reliable health websites in the Persian language. This will help them to take part in active healthcare decision-making and disease prevention. Moreover, it is necessary to educate people especially Persian language ones about the website evaluation tools, which can be used to assess the credibility of health websites before consuming the information on those websites. Keywords: Ebola, Health portals, Patient education, Health websites, Website evaluation, Health information 1 Introduction of the disease, how it is developed, and its prevention The Ebola virus disease is an emergency situation in the methods is critical. area of international public health [1]. This disease The Internet has become one of the main and the emerged in West Africa in late December 2013 and led most popular sources of health information in recent to a massive outbreak in places such as Guinea, Liberia, years [4, 5]. Most people throughout the world refer to Sierra Leone, and Nigeria [2]. Ebola is a serious and the Internet and health websites to obtain information often fatal illness in humans [3] for which currently, about certain diseases, treatments, diets, fitness, and there is no standard treatment [2] and no vaccine has other medical issues [5, 6]. Health information is one of been produced to prevent it. Given that prevention is the three highly functional and favorite subjects of users always better than cure, the need for people’s awareness on the Internet [6]. Accordingly, 4.5% of all Internet searches worldwide are related to health topics [7]. This * Correspondence: Saeideh.valizadeh@gmail.com media provides easy and increasing access to health Department of Medical Library and Information Sciences, School of Allied information for the general public. Users of these infor- Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, mation often refer to the information available on the Iran Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 2 of 7 Internet before meeting with health professionals or In this regard, the necessity to assess the websites in after receiving medical advice [7, 8]. But how much can the Persian language is of great importance due to their we trust the information contained on such websites? direct impact on the health of Persian-language society This issue is more important in medicine, where the members. Therefore, considering the Ebola virus as one quality of information affects human life. of the most important health challenges in the world, in The quality of retrieved information is a matter of this study, the Persian-language websites which have concern due to the lack of control over the content of published information in the field of Ebola are evaluated information published on the Internet. Various re- using the HONcode tool. searches conducted on the quality of health websites in various topics showed that, in most cases, the quality of 2 Materials and methods health-related websites is poor and needs further atten- Search engines are the first and the most important tools tion [9–15]. No authority is directly responsible for man- and the resource of information for users of the Internet aging Internet resources. Therefore, dissemination of [27]. They play an important role in obtaining health in- information on the web is easy and inexpensive, or even formation by non-specialists [28]. According to the Alexa free, and any person with any level of expertise can pub- website statistics, Google, Yahoo, and Bing are three of the lish his/her health information resources on the web most widely used search engines in the world [29, 30]. with any degree of credibility. So, a wide variety of infor- Thus, for this study, the term “Ebola” (In Persian language mation of varying quality and by authors of varying and with the Persian alphabet) was searched using these degrees of reliability is made available. As noted by Silberg three most used search engines [31]. The Chrome browser and colleagues, “It is a medium in which everyone with a was used in this search. Given that 90% of search engine computer can serve simultaneously as author, editor, and users review and study one or some of the obtained results publisher” [16]. Therefore, recognizing the credibility of in the first three pages of search results [32, 33], the first health websites is of the utmost importance. 30 websites resulting from the search in the three selected Some measures should be taken to review the websites search engines, with a total of 90 web pages, were studied. and ensure the quality of retrieved health information via After excluding 28 websites including duplicate, inaccess- the Internet. In this regard, various tools have been cre- ible, and non-Persian websites, 62 websites were retained ated by different organizations to evaluate the quality of for evaluation. The flow chart that describes how the data health websites in order to help users and website foun- were collected and processed is shown in Fig. 1. ders. Among these tools are the HONcode of Conduct, In the first step, the retrieved websites were divided Silberg criteria, Discern, Hi-Ethics, and AMA guidelines. into four categories: university, governmental, commer- HONcode of Conduct is one of the tools that was created cial, and organizational. Then, they were manually in 1995 and have been frequently used to evaluate the assessed by MA and RH. The validity of the data was quality of health information websites [10–15, 17–22]. It assessed by SV. The search and data collection was con- guides lay users as well as health professionals to validate ducted using a direct observation method on February 9, medical resources on the Internet [23]. 2017. The research tool was the checklist set by the re- Persian is the second language in the Middle East, searchers based on the HONcode of Conduct tool. This and about 110 million people speak the language in the tool consists of eight criteria and these are authority, world. ThelanguageisanIndo-European language, complementarity, privacy, attribution, justifiability, trans- spoken and written primarily in Iran, Afghanistan, and parency, financial disclosure, and advertising policy a part of Tajikistan. A significant proportion of Persian (Table 1). The data were analyzed using SPSS 18.0 speakers live in other countries, including Iraq, the software. UAE, and Bahrain. In Persian-speaking countries like other countries, the internet is one of the tools which 3 Results are used to obtain health information. The importance The data collection and frequency of the unique web- of the phenomenon of the Persian web as an independ- sites retrieved by Bing, Yahoo, and Google are shown in ent and effective media in the communication of Per- Fig. 1. Of the 90 webpages retrieved by 3 used search en- sian speakers is undeniable. Limited English proficiency gines, 62 websites were retained for evaluation. In terms affects effective health communication [24]. Further- of uniqueness, the Google search engine had the highest more, language provides the experiential context for frequency among the search engines. understanding health information [25] because patients As shown in Fig. 2, most of the retrieved websites with limited English proficiency have restricted ability (62%) were commercial and only 4% of the retrieved to read or understand English materials [26]. Certainly, websites were provided by universities. reading the health educational materials in vernacular Overall, none of the retrieved websites was officially language is more understandable. approved by the HONcode of Conduct. Moreover, the Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 3 of 7 Fig 1. Data collection process manual evaluation showed that none of them had fully (20%) by the websites retrieved by Google search engine. considered all eight criteria of HONcode (Table 2). In The websites retrieved by the Bing search engine had general, the justifiability criterion had been considered the highest frequency in considering the attribution, jus- in 89% of the studied websites, but only 16% of the web- tifiability, complementarity, and financial disclosure cri- sites have identified the name and expertise of the teria. The advertising policy, transparency, and privacy author. The authority criterion was highly considered criteria had been less considered by the websites Table 1 HONcode principles* HONcode principles Description 1. Authoritative Indicate the qualifications of the authors 2. Complementarity Information should support, not replace, the doctor-patient relationship 3. Privacy Respect the privacy and confidentiality of site users 4. Attribution Cite the source[s] and dates of published medical information 5. Justifiability Site must back up claims relating to benefits and performance 6. Transparency Accessible presentation, accurate email contact 7. Financial disclosure Identify funding sources 8. Advertising policy Clearly distinguish advertising from editorial content *The table information is adopted from the HON website [23] Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 4 of 7 foundation, while the study on English language websites on Ebola showed that seven websites were approved offi- cially [34]. It is not out of the mind that this lack of credibility exists in Ebola-related websites in other lan- guages, and that the websites do not have good credibil- ity, although there is a need for detailed studies in this regard. Therefore, users must act with full awareness when using the Persian-language websites as a source of health information regarding Ebola, and they must use the provided information alongside expert medical ad- Fig. 2. Distribution of websites by organization vice from relevant experts [11]. In the current study, overall, the justifiability criterion obtained the highest score (Table 2). These findings show retrieved by Yahoo (Table 2). In general, and considering that the majority of the websites related to Ebola diseases all the criteria, it was found that 51% of the criteria were try to present the correct information and the actual per- met by the assessed websites. formance of a particular treatment, drug, or medical device, Since every website has to comply with eight criteria in and their related consequences. However, still, there is lack terms of HON code criteria, so in general, for reviewed of honesty in expressing material or commercial use in 11% websites of Google (25 × 8 = 200), Yahoo (15 × 8 = 120), of websites. and Bing (22 × 8 = 176) criteria should ideally be met. The authority criterion obtained the lowest score While the results showed that of all the criteria, websites (Table 2). Only 16% of the websites had specified the retrieved from the Google search engine have met 96 name and expertise of authors. However, the compliance (48%), Yahoo 61 (51%), and Bing 96 (54%) of the criteria. with this criterion reflects the credibility and reliability of the information resource, because this principle proves 4 Discussion that health information provided on the intended website The manual evaluation of Persian language websites that has only been given by qualified professional re- showed that the Ebola-related websites were of poor sources and written by experts is more reliable [38]. credibility because none of those websites met all the The complementarity criterion has been considered in eight HONcode criteria (Table 2). The results of this most of the surveyed websites (79%). The compliance study were consistent with the research results of Ebola with this criterion shows that the surveyed websites try English-language websites [34]. Furthermore, the results to guide the people to visit a physician instead of making of the present study were consistent with the results of health decisions just based on online information [23]. similar studies conducted on the evaluation of non- Nevertheless, still, 21% of surveyed websites have not Persian language websites in other health topics. Their paid attention to this criterion that may lead to the mis- findings showed unreliability and poor quality of health use of information. websites [34–37]. The website must describe its privacy policy regard- None of the Persian language websites evaluated at the ing how it treats confidential or private information present study was officially approved by the HONcode such as email addresses and the content of emails Table 2 Total number and Percentage of websites which are in compliance with each criterion of HONcode Criteria Search Engines Total Yahoo Google Bing N =15 N =25 N =22 Authority 2 [13%] 5 [20%] 3 [14%] 10 [16%] Complementarity 12 [80%] 19 [76%] 18 [82%] 49 [79%] Privacy 10 [66%] 16 [64%] 13 [59%] 39 [63%] Attribution 6 [40%] 10 [40%] 14 [64%] 30 [48%] Justifiability 12 [80%] 21 [84%] 22 [100%] 55 [89%] Transparency 4 [27%] 5 [20%] 4 [18%] 13 [21%] Financial disclosure 6 [40%] 7 [28%] 9 [41%] 22 [35%] Advertising policy 9 [60%] 13[52%] 13 [59%] 35 [56%] Total 61/120 [51%] 96/200 [48%] 96/176 [54%] 253/496 [51%] Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 5 of 7 received from or sent to its visitors. However, just 63% and financial disclosure criteria, it seems that the web- of the surveyed websites have identified privacy policy. pages retrieved by Bing are in better condition than While privacy policy is one of the seven key usability Yahoo and Google. Regarding the advertising policy, design issues that are particularly important for creat- transparency, and privacy principles, the webpages re- ing effective websites [39]. trieved by Yahoo are in better condition. Meanwhile, the Transparency principle is considered in just 21% of status of websites retrieved from the Bing search engine the surveyed websites. This principle indicates that in was generally better than other search engines and case of requiring additional information, people must be Google was worse than the others, although the dif- able to connect with content editors and to communi- ference was negligible (Table 2). cate with webmasters. Regarding that 79% of the Ebola- Most of the retrieved websites in this study (Fig. 2) related websites have not considered this principle, it is were commercial [62%], similar to the results reported necessary to website owners to modify their websites to in other studies conducted to evaluate the health help individuals to get additional information. websites [17], though commercial websites have lower Attribution policy has been considered in just 48% of quality compared to other websites [22, 40–42]. The the surveyed websites. It is necessary to specify the pub- government and university websites generally are aimed lication date as well as the latest updating of the content. to educate people [43]. In this study, 10% of retrieved This principle, in fact, helps to ensure the credibility of websites were of governmental type. Furthermore, just the written medical content. Medical content must con- 4% of the retrieved websites were of the university type. tinually be updated, in the event of non-compliance with The university websites, which a person would tend to this principle, the date is not revealed. Regarding that trust more, showed no significant advantages in credibil- 52% of the Ebola-related websites had not identified the ity compared with other types of websites. While the source of information or the last update date, people university websites are expected to highly consider the should be aware of the unreliable or outdated informa- HONcode of conduct principles, but the present study tion. Therefore, it is recommended that the health web- findings revealed that they are not so, as the findings of sites and consequently health information retrieved by studies on other health topics [34, 44]. Thus, looking for general search engines be used with more caution. health information on Ebola, the individuals may The advertising should be clearly distinguished from encounter less credible websites which may include in- editorial contents, but advertisement policy was less con- formation that is more commercial than educational. sidered in the surveyed websites (56%) which was mostly Consequently, they may receive information that is retrieved by Google search engine. Failure to comply harmful to their health. Moreover, in this study, 24% of with this principle indicates that the individuals may not the retrieved websites were organizational type in which be able to distinguish the advertisement information patients can access to some records on health issues from the main content. Thus, their trust in marketing such as future appointments, history of past visits, and information may mislead them to unreliable information the patient laboratory results. This type of website also which threatens their health. did not show any significant advantages in reliability The health websites including all types of websites compared with other types of websites. Thus, individuals (organizational, commercial, governmental, etc.) must searching for Ebola-related information must use all include the declaration of the funding resources as well types of health websites with caution. as the declaration of all conflicts of interest. While in the In the current study, the 62 evaluated Persian web- present study, just 35% of the surveyed websites have de- sites are samples of the websites that Persian lan- clared financial disclosure. Failure to comply with this guage users will face when searching for information principle indicates that the website may recommend the about Ebola. Failure to comply with all HONcode various medical interventions that have a hidden mar- criteria in these websites shows that while searching keting aspect. Thus, encouraging the individuals to use on the Internet, Persian language users will encoun- medication or a therapeutic method, and the individual’s ter none credible websites and consequently low- trust in such information, may have irreparable conse- quality information that can affect their decision quences for them. about the prevention and treatment of Ebola. This According to the results obtained from each search highlights the importance of understanding the qual- engine, Google, Yahoo, and Bing, it was found that none ity of online health information by physicians and of the evaluated websites had considered all eight cri- how to guide patients to reliable sources and high- teria. In terms of considering the authority criteria, credible websites [45]. amongst the three selected search engines, the websites This study was faced with some limitations. The returned by Google were in better condition (Table 2). “Ebola” keyword was searched in April 2016. Therefore, Regarding the complementarity, attribution, justifiability, this study cannot completely and comprehensively Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 6 of 7 represent other searches at different times. On the other Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. hand, due to the dynamic characteristics of the web, the results of the search will vary at different times and in Received: 5 March 2019 Accepted: 21 September 2019 different places. New websites are constantly created, while some websites are disbanded. On the other hand, the present study was conducted only on Persian- References 1. Love CB, Arnesen SJ, Phillips SJ. Ebola outbreak response: the role of language websites. The results of this study may be dif- information resources and the National Library of Medicine. Disaster Med ferent from the results of studies conducted in other Public Health Prep. 2015;9(01):82–5. languages, although the previous research by the re- 2. Tseng C-P, Chan Y-J. Overview of Ebola virus disease in 2014. J Chinese Med Assoc. 2015;78(1):51–5. searcher on English-language websites was consistent 3. WHO | Ebola virus disease [Internet]. WHO. 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Persian language health websites on Ebola disease: less credible than you think?

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Abstract

Background: Ebola virus disease is an emergency situation in the area of international public health for which currently, there is no standard treatment. Thus, there is an essential need for awareness of individuals about the Ebola disease and consequently its prevention. Internet and health websites are considered a source of health information about certain diseases. Therefore, in this study, the credibility of Persian-language websites on Ebola is assessed. Materials and methods: The term “Ebola” was searched using the Yahoo, Google, and Bing search engines. The first 30 websites resulting from each search engine were studied. Persian language was a prerequisite for inclusion. Duplicate and inaccessible websites were excluded and 62 websites were retained for evaluation. These websites were manually assessed by the researchers. The research tool was HONcode official toolbar as well as the checklist set by the researchers based on the HONcode of Conduct tool. The data were analyzed using SPSS 18.0 software. Results: None of the retrieved websites was officially approved by the HONcode of Conduct. Moreover, the manual evaluation showed that none of them had fully considered the eight criteria of HONcode. The results showed that most of the retrieved websites (62%) were commercial. The justifiability criterion had been considered in 89% of the studied websites, but the authority criterion had been considered by only 16% of the websites. Conclusion and recommendations: Regarding the poor reliability of Persian websites on the Ebola disease, and considering that Persian language people prefer to read the information in their native language, it is recommended that the authorized health organizations introduce reliable health websites in the Persian language. This will help them to take part in active healthcare decision-making and disease prevention. Moreover, it is necessary to educate people especially Persian language ones about the website evaluation tools, which can be used to assess the credibility of health websites before consuming the information on those websites. Keywords: Ebola, Health portals, Patient education, Health websites, Website evaluation, Health information 1 Introduction of the disease, how it is developed, and its prevention The Ebola virus disease is an emergency situation in the methods is critical. area of international public health [1]. This disease The Internet has become one of the main and the emerged in West Africa in late December 2013 and led most popular sources of health information in recent to a massive outbreak in places such as Guinea, Liberia, years [4, 5]. Most people throughout the world refer to Sierra Leone, and Nigeria [2]. Ebola is a serious and the Internet and health websites to obtain information often fatal illness in humans [3] for which currently, about certain diseases, treatments, diets, fitness, and there is no standard treatment [2] and no vaccine has other medical issues [5, 6]. Health information is one of been produced to prevent it. Given that prevention is the three highly functional and favorite subjects of users always better than cure, the need for people’s awareness on the Internet [6]. Accordingly, 4.5% of all Internet searches worldwide are related to health topics [7]. This * Correspondence: Saeideh.valizadeh@gmail.com media provides easy and increasing access to health Department of Medical Library and Information Sciences, School of Allied information for the general public. Users of these infor- Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, mation often refer to the information available on the Iran Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 2 of 7 Internet before meeting with health professionals or In this regard, the necessity to assess the websites in after receiving medical advice [7, 8]. But how much can the Persian language is of great importance due to their we trust the information contained on such websites? direct impact on the health of Persian-language society This issue is more important in medicine, where the members. Therefore, considering the Ebola virus as one quality of information affects human life. of the most important health challenges in the world, in The quality of retrieved information is a matter of this study, the Persian-language websites which have concern due to the lack of control over the content of published information in the field of Ebola are evaluated information published on the Internet. Various re- using the HONcode tool. searches conducted on the quality of health websites in various topics showed that, in most cases, the quality of 2 Materials and methods health-related websites is poor and needs further atten- Search engines are the first and the most important tools tion [9–15]. No authority is directly responsible for man- and the resource of information for users of the Internet aging Internet resources. Therefore, dissemination of [27]. They play an important role in obtaining health in- information on the web is easy and inexpensive, or even formation by non-specialists [28]. According to the Alexa free, and any person with any level of expertise can pub- website statistics, Google, Yahoo, and Bing are three of the lish his/her health information resources on the web most widely used search engines in the world [29, 30]. with any degree of credibility. So, a wide variety of infor- Thus, for this study, the term “Ebola” (In Persian language mation of varying quality and by authors of varying and with the Persian alphabet) was searched using these degrees of reliability is made available. As noted by Silberg three most used search engines [31]. The Chrome browser and colleagues, “It is a medium in which everyone with a was used in this search. Given that 90% of search engine computer can serve simultaneously as author, editor, and users review and study one or some of the obtained results publisher” [16]. Therefore, recognizing the credibility of in the first three pages of search results [32, 33], the first health websites is of the utmost importance. 30 websites resulting from the search in the three selected Some measures should be taken to review the websites search engines, with a total of 90 web pages, were studied. and ensure the quality of retrieved health information via After excluding 28 websites including duplicate, inaccess- the Internet. In this regard, various tools have been cre- ible, and non-Persian websites, 62 websites were retained ated by different organizations to evaluate the quality of for evaluation. The flow chart that describes how the data health websites in order to help users and website foun- were collected and processed is shown in Fig. 1. ders. Among these tools are the HONcode of Conduct, In the first step, the retrieved websites were divided Silberg criteria, Discern, Hi-Ethics, and AMA guidelines. into four categories: university, governmental, commer- HONcode of Conduct is one of the tools that was created cial, and organizational. Then, they were manually in 1995 and have been frequently used to evaluate the assessed by MA and RH. The validity of the data was quality of health information websites [10–15, 17–22]. It assessed by SV. The search and data collection was con- guides lay users as well as health professionals to validate ducted using a direct observation method on February 9, medical resources on the Internet [23]. 2017. The research tool was the checklist set by the re- Persian is the second language in the Middle East, searchers based on the HONcode of Conduct tool. This and about 110 million people speak the language in the tool consists of eight criteria and these are authority, world. ThelanguageisanIndo-European language, complementarity, privacy, attribution, justifiability, trans- spoken and written primarily in Iran, Afghanistan, and parency, financial disclosure, and advertising policy a part of Tajikistan. A significant proportion of Persian (Table 1). The data were analyzed using SPSS 18.0 speakers live in other countries, including Iraq, the software. UAE, and Bahrain. In Persian-speaking countries like other countries, the internet is one of the tools which 3 Results are used to obtain health information. The importance The data collection and frequency of the unique web- of the phenomenon of the Persian web as an independ- sites retrieved by Bing, Yahoo, and Google are shown in ent and effective media in the communication of Per- Fig. 1. Of the 90 webpages retrieved by 3 used search en- sian speakers is undeniable. Limited English proficiency gines, 62 websites were retained for evaluation. In terms affects effective health communication [24]. Further- of uniqueness, the Google search engine had the highest more, language provides the experiential context for frequency among the search engines. understanding health information [25] because patients As shown in Fig. 2, most of the retrieved websites with limited English proficiency have restricted ability (62%) were commercial and only 4% of the retrieved to read or understand English materials [26]. Certainly, websites were provided by universities. reading the health educational materials in vernacular Overall, none of the retrieved websites was officially language is more understandable. approved by the HONcode of Conduct. Moreover, the Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 3 of 7 Fig 1. Data collection process manual evaluation showed that none of them had fully (20%) by the websites retrieved by Google search engine. considered all eight criteria of HONcode (Table 2). In The websites retrieved by the Bing search engine had general, the justifiability criterion had been considered the highest frequency in considering the attribution, jus- in 89% of the studied websites, but only 16% of the web- tifiability, complementarity, and financial disclosure cri- sites have identified the name and expertise of the teria. The advertising policy, transparency, and privacy author. The authority criterion was highly considered criteria had been less considered by the websites Table 1 HONcode principles* HONcode principles Description 1. Authoritative Indicate the qualifications of the authors 2. Complementarity Information should support, not replace, the doctor-patient relationship 3. Privacy Respect the privacy and confidentiality of site users 4. Attribution Cite the source[s] and dates of published medical information 5. Justifiability Site must back up claims relating to benefits and performance 6. Transparency Accessible presentation, accurate email contact 7. Financial disclosure Identify funding sources 8. Advertising policy Clearly distinguish advertising from editorial content *The table information is adopted from the HON website [23] Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 4 of 7 foundation, while the study on English language websites on Ebola showed that seven websites were approved offi- cially [34]. It is not out of the mind that this lack of credibility exists in Ebola-related websites in other lan- guages, and that the websites do not have good credibil- ity, although there is a need for detailed studies in this regard. Therefore, users must act with full awareness when using the Persian-language websites as a source of health information regarding Ebola, and they must use the provided information alongside expert medical ad- Fig. 2. Distribution of websites by organization vice from relevant experts [11]. In the current study, overall, the justifiability criterion obtained the highest score (Table 2). These findings show retrieved by Yahoo (Table 2). In general, and considering that the majority of the websites related to Ebola diseases all the criteria, it was found that 51% of the criteria were try to present the correct information and the actual per- met by the assessed websites. formance of a particular treatment, drug, or medical device, Since every website has to comply with eight criteria in and their related consequences. However, still, there is lack terms of HON code criteria, so in general, for reviewed of honesty in expressing material or commercial use in 11% websites of Google (25 × 8 = 200), Yahoo (15 × 8 = 120), of websites. and Bing (22 × 8 = 176) criteria should ideally be met. The authority criterion obtained the lowest score While the results showed that of all the criteria, websites (Table 2). Only 16% of the websites had specified the retrieved from the Google search engine have met 96 name and expertise of authors. However, the compliance (48%), Yahoo 61 (51%), and Bing 96 (54%) of the criteria. with this criterion reflects the credibility and reliability of the information resource, because this principle proves 4 Discussion that health information provided on the intended website The manual evaluation of Persian language websites that has only been given by qualified professional re- showed that the Ebola-related websites were of poor sources and written by experts is more reliable [38]. credibility because none of those websites met all the The complementarity criterion has been considered in eight HONcode criteria (Table 2). The results of this most of the surveyed websites (79%). The compliance study were consistent with the research results of Ebola with this criterion shows that the surveyed websites try English-language websites [34]. Furthermore, the results to guide the people to visit a physician instead of making of the present study were consistent with the results of health decisions just based on online information [23]. similar studies conducted on the evaluation of non- Nevertheless, still, 21% of surveyed websites have not Persian language websites in other health topics. Their paid attention to this criterion that may lead to the mis- findings showed unreliability and poor quality of health use of information. websites [34–37]. The website must describe its privacy policy regard- None of the Persian language websites evaluated at the ing how it treats confidential or private information present study was officially approved by the HONcode such as email addresses and the content of emails Table 2 Total number and Percentage of websites which are in compliance with each criterion of HONcode Criteria Search Engines Total Yahoo Google Bing N =15 N =25 N =22 Authority 2 [13%] 5 [20%] 3 [14%] 10 [16%] Complementarity 12 [80%] 19 [76%] 18 [82%] 49 [79%] Privacy 10 [66%] 16 [64%] 13 [59%] 39 [63%] Attribution 6 [40%] 10 [40%] 14 [64%] 30 [48%] Justifiability 12 [80%] 21 [84%] 22 [100%] 55 [89%] Transparency 4 [27%] 5 [20%] 4 [18%] 13 [21%] Financial disclosure 6 [40%] 7 [28%] 9 [41%] 22 [35%] Advertising policy 9 [60%] 13[52%] 13 [59%] 35 [56%] Total 61/120 [51%] 96/200 [48%] 96/176 [54%] 253/496 [51%] Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 5 of 7 received from or sent to its visitors. However, just 63% and financial disclosure criteria, it seems that the web- of the surveyed websites have identified privacy policy. pages retrieved by Bing are in better condition than While privacy policy is one of the seven key usability Yahoo and Google. Regarding the advertising policy, design issues that are particularly important for creat- transparency, and privacy principles, the webpages re- ing effective websites [39]. trieved by Yahoo are in better condition. Meanwhile, the Transparency principle is considered in just 21% of status of websites retrieved from the Bing search engine the surveyed websites. This principle indicates that in was generally better than other search engines and case of requiring additional information, people must be Google was worse than the others, although the dif- able to connect with content editors and to communi- ference was negligible (Table 2). cate with webmasters. Regarding that 79% of the Ebola- Most of the retrieved websites in this study (Fig. 2) related websites have not considered this principle, it is were commercial [62%], similar to the results reported necessary to website owners to modify their websites to in other studies conducted to evaluate the health help individuals to get additional information. websites [17], though commercial websites have lower Attribution policy has been considered in just 48% of quality compared to other websites [22, 40–42]. The the surveyed websites. It is necessary to specify the pub- government and university websites generally are aimed lication date as well as the latest updating of the content. to educate people [43]. In this study, 10% of retrieved This principle, in fact, helps to ensure the credibility of websites were of governmental type. Furthermore, just the written medical content. Medical content must con- 4% of the retrieved websites were of the university type. tinually be updated, in the event of non-compliance with The university websites, which a person would tend to this principle, the date is not revealed. Regarding that trust more, showed no significant advantages in credibil- 52% of the Ebola-related websites had not identified the ity compared with other types of websites. While the source of information or the last update date, people university websites are expected to highly consider the should be aware of the unreliable or outdated informa- HONcode of conduct principles, but the present study tion. Therefore, it is recommended that the health web- findings revealed that they are not so, as the findings of sites and consequently health information retrieved by studies on other health topics [34, 44]. Thus, looking for general search engines be used with more caution. health information on Ebola, the individuals may The advertising should be clearly distinguished from encounter less credible websites which may include in- editorial contents, but advertisement policy was less con- formation that is more commercial than educational. sidered in the surveyed websites (56%) which was mostly Consequently, they may receive information that is retrieved by Google search engine. Failure to comply harmful to their health. Moreover, in this study, 24% of with this principle indicates that the individuals may not the retrieved websites were organizational type in which be able to distinguish the advertisement information patients can access to some records on health issues from the main content. Thus, their trust in marketing such as future appointments, history of past visits, and information may mislead them to unreliable information the patient laboratory results. This type of website also which threatens their health. did not show any significant advantages in reliability The health websites including all types of websites compared with other types of websites. Thus, individuals (organizational, commercial, governmental, etc.) must searching for Ebola-related information must use all include the declaration of the funding resources as well types of health websites with caution. as the declaration of all conflicts of interest. While in the In the current study, the 62 evaluated Persian web- present study, just 35% of the surveyed websites have de- sites are samples of the websites that Persian lan- clared financial disclosure. Failure to comply with this guage users will face when searching for information principle indicates that the website may recommend the about Ebola. Failure to comply with all HONcode various medical interventions that have a hidden mar- criteria in these websites shows that while searching keting aspect. Thus, encouraging the individuals to use on the Internet, Persian language users will encoun- medication or a therapeutic method, and the individual’s ter none credible websites and consequently low- trust in such information, may have irreparable conse- quality information that can affect their decision quences for them. about the prevention and treatment of Ebola. This According to the results obtained from each search highlights the importance of understanding the qual- engine, Google, Yahoo, and Bing, it was found that none ity of online health information by physicians and of the evaluated websites had considered all eight cri- how to guide patients to reliable sources and high- teria. In terms of considering the authority criteria, credible websites [45]. amongst the three selected search engines, the websites This study was faced with some limitations. The returned by Google were in better condition (Table 2). “Ebola” keyword was searched in April 2016. Therefore, Regarding the complementarity, attribution, justifiability, this study cannot completely and comprehensively Ansari et al. Journal of the Egyptian Public Health Association (2020) 95:2 Page 6 of 7 represent other searches at different times. 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