L Kogan, R Schoenfeld-Tacher, A Simon, A Viera
L Kogan, R Schoenfeld-Tacher, A Simon, A Viera. The Internet and Pet Health Information: Perceptions and Behaviors of Pet Owners and Veterinarians. The Internet Journal of Veterinary Medicine. 2009 Volume 8 Number 1.
Introduction: The current study assesses the online search behavior of pet owners for pet health information and the perception of clients’ internet use by their veterinarians.Materials and methods: A random sample of veterinary clinics was selected from two metropolitan US areas. Results and Conclusions: The majority of clients reported using the internet for pet health information with positive results. Veterinarians expressed concern over clients’ ability to understand medical information and the potential negative impact of misleading information. Recommendations pertaining to the growing presence of the internet and its impact to the field of veterinary medicine are offered.
Over 260,000 million (over 76%) North Americans have access to the internet, representing a 140% growth rate from 2000-20091. The internet is the most widely used source for health information; 59% of adults report accessing health information online compared to 55% who visit their health care provider and 29% who talk to relatives, friends or coworkers2. Other media sources (e.g., magazines, radio and television) rank far below these three major sources. Not only are growing numbers of people searching online for health information, but most do so frequently; 23% of online consumers report accessing health information at least weekly, 40% 2-3 times a month or monthly, leaving 36% who search less frequently 2.
It is not surprising that this surge of internet use for health information has led to the rapid expansion of a whole new area of research. There are now at least 20 journals devoted to the topic of health informatics3. Many of these journals are international, reflecting the global growth in consumers of internet health information. For example, a study investigating internet usage for health information in seven countries including Denmark, Germany, Greece, Latvia, Norway, Poland, and Portugal found that all participating countries reported an increase in health related internet usage from 2005 – 2007, with an average growth of 9.9% and the highest growth rate in Germany (12.2 %)4. Recent UK health policy changes reflect the growing usage of the internet for health information and include recommendations to health care providers related to the importance of embracing the internet and helping to ensure that people are protected from misinformation5,6. Similar research from Sweden resulted in suggestions that the internet be used as a resource to offer overall better health care7.
With the plethora of papers, conferences and attention focused on the use of the internet in providing human healthcare information, the dearth of information related to consumers’ use of the internet for veterinary health information is startling. Given the fact that most pet owners think of their pets as family members, and are just as vested in their pets’ health and well being as other family members or themselves, it is reasonable to assume that many pet owners are using the internet to help educate and guide them in making informed decisions about the health of their pets8. To illustrate, a recent Google search using the words [pet health information] on April 2010 resulted in 29,400,000 hits.
In fact, recent research has shown that over 80% of consumers seeking health information online start with a search engine, with only a minority who report going straight to a particular site9. Most online consumers report positive experiences using search engines. A Pew Internet study found that 92% of people who use search engines are confident about their search abilities, 87% feel they are successful in their searches most of the time, and 94% feel sought after information was easy to find9. The most common health topics researched on the internet include symptoms, treatment, and disease/conditions2. Most people who use the internet for health information report feeling positive about their experience10.
The limited studies that have been done in the area of online pet health information and the behavior of online consumers have found results similar to those in human medicine. A study by Hofmeister et al.11 found veterinary clients rank the internet as the 3rd most likely source of information about pet health - behind general practitioners and veterinary specialists, but ahead of family/friends and other media sources. Ninety-five percent of pet owners in this study reported they had consulted general practitioners in the last year, 81% consulted specialists and 70% consulted the internet11. A recent poll of veterinarians found that 67% report that their clients frequently bring internet information to their visit12.
Validity and reliability of health websites
Although there are an abundance of health related websites available, the quality of these sites and the information offered differs greatly. Despite the fact that many online consumers report being aware of the potential for poor or inaccurate information on the internet, many feel they are good judges of website quality14. Yet, many online consumers acknowledge they do not investigate websites and are not able later to recall the source from which they gained information14.
Unfortunately, misleading and inaccurate websites have been found to be more common than credible sites15. Higher quality, accurate websites typically include such features as: date of last update, reviewed by a doctor, current references, and a nonprofit top level domain16. Yet, only a minority of online consumers (25%) report they “always” or “most of the time” check the source and date of the health information they find online (S 2006).17 Furthermore, many people lack health literacy, the ability to understand the health information they need to make appropriate health decisions18.
Studies that have investigated websites related to specific veterinary topics have raised concerns about the accuracy, trustworthiness and usability of available information. Research pertaining to veterinary anesthesiology information online found that many sites were unreliable or inaccurate11 and similar findings have been reported in other studies19,20. For example, Taggart, et al’s study on canine cranial cruciate ligament (CCL) disease websites found that the most accurate websites were written at levels exceeding the recommended reading level for media information (7th-8th grade reading level) and that websites with lower reading levels were less accurate. They surmised that high quality information about CCL disease appears to not be accessible to a large segment of the population21. Similarly, research on canine osteoarthritis websites resulted in the conclusion that many sites are “at best incomplete and at worst questionable” and that most pet owners likely obtain incomplete, incorrect, or misleading information (p 1274)19. A common recommendation from these studies has been an increase in accurate online veterinary health information presented at lower reading levels, since much of the information presented at a reading level that impedes many owners from being able to understand the material8,21,22.
Organizations have been created to help people navigate through the vast number of health-related websites and make educated decisions about the information presented. For example, HON (Health on the Net Foundation) is a non-profit, non-governmental organization, accredited by the Economic and Social Council of the United Nations that promotes reliable online health information23. Given that most people find online health information through search engines, however, there is still cause for concern related to the reliability and accuracy of the internet information to which most consumers are exposed.
It is for these very reasons that many health care providers feel the health information online creates unique challenges for both human and animal health care and can negatively impact the relationship between client and health care provider.
Changing dynamics of health care and the internet
Today, more and more people are assuming active roles in health care, and fully participating in health care decisions about themselves and family members24. While the health care profession in the past was viewed as more paternalistic, the trend is quickly becoming more consumer-driven with changing expectations of clients/patients. Increasingly, they expect to play a more active role in the decision making process and their own health. It has been suggested that these changes have been stimulated by the dramatic increase of information available to the public and resultant decrease in the medical knowledge gap that has impacted the traditional imbalance of power between health professionals and the public25.
Access to health information can change the role of the patient/client to a more active one and make a medical consultation more collaborative in nature. The ability to bring information found on the internet to their doctor can increase clients’ confidence in their ability to manage an illness and make them more willing to ask questions. It can also lead to greater sense of responsibility, accountability, and self efficacy26. One study reported that 83% of people who discussed internet information with their doctor felt more in control and 78% reported feeling more confident13.
Clearly, the internet is transforming human and animal health and the relationships that people have with their health care providers. The internet offers incredible promise as a tool for health communication and education27 yet, this is only part of the picture. It also poses many hazards, offering information that is often inaccurate, misleading and potentially harmful.
In addition to online consumers using the internet to research health information, the internet is increasingly being used as a tool by health care providers to improve their services. A 2008 study found that 69% of veterinary practices have web sites, 22% use email to make appointments with clients, 18% send newsletters on pet care, and 16% use email to communicate with their clients12.
Our study was designed to assess the online behaviors, perceptions and desires of pet owners in addition to the views of these topics by veterinarians. This paper offers an overview of these topics; due to space constraints, differences based on client demographics will be addressed in a future paper.
Materials and Methods
A random sample of veterinarians and clients from two metropolitan US areas (and surrounding cities) were surveyed for this study. The clinics were chosen by selecting every 5th clinic in the phone book from each city. Each clinic that agreed to participate in the study was asked to distribute 100 surveys to their clients until all surveys were disbursed. Each participating clinic was given a total of 100 surveys, 50 of client survey Form A and 50 of client survey Form B. The client survey was divided into two parts to glean the most information from clients without creating a survey too long and thereby diminishing return rates. The client surveys Form A and Form B were alternated in the pile of surveys given to each clinic and instructions were to give the next available form to each client interested in completing the survey. All clients who frequented the clinic were asked to participate; no criteria for inclusion in the study were created except the willingness to complete the survey. The surveys could be returned via self addressed stamped envelopes so that clients could take them with them, or they could be left in sealed envelopes at the clinic. Surveys left at the clinic were returned in bulk after all surveys had been distributed. Each clinic was also asked to distribute the veterinarian survey to all their veterinarians. The number of veterinarian surveys sent to each clinic was determined by the number of veterinarians at that clinic. This study was approved by the Research Integrity & Compliance Review Office at Colorado State University and the Institutional Review Board at the University of Tennessee Knoxville.
Thirty-one clinics from Knoxville Tennessee agreed to participate and were sent a total of 3100 client surveys (100 to each clinic; 50 of Client Survey A and 50 of Client Survey B). We received 643 surveys (20.7%) from 28 clinics, 328 of Survey A and 315 of Survey B. There were no differences in demographics between Survey A and Survey B. Three clinics that originally indicated they would participate withdrew from the study. Additionally, 78 veterinarian surveys were sent and 44 (56.4%) were returned from 28 clinics.
Forty-three clinics from Denver Colorado and adjacent areas agreed to participate. A total of 4600 surveys were sent to these clinics (3 clinics indicated they would take an additional 100 client surveys due to their size). The remainder of clinics received 100 surveys; 50 of Client Survey A and 50 of Client Survey B. A total of 1040 client surveys from 40 clinics (22.61%) were returned, 535 of Survey A and 505 of Survey B. There were no differences in demographics between Survey A and Survey B. An additional 135 veterinarian surveys were sent and 75 (55.6%) from 25 clinics were returned.
Due to the number of analyses, p value for statistically significant differences was placed at p<.01. A total of 119 veterinarian surveys, 820 Client Survey A, and 802 Client Survey B were analyzed [Table 1].
Clients’ Internet Use
Perceptions of clients’ use of the internet
The majority of veterinarians reported feeling that their clients have frequent access to the internet. Most veterinarians (n=78, 66.1%) felt that over 80% of their clients have regular access to the internet Only 7 (5.8%) reported that under 60% of their clients had regular access.
Clients’ report of internet use
Veterinarians’ perceptions of their clients’ access to the internet matches what clients reported. The majority of clients reported daily use (707, 81.9%) and only 66 (7.7%) report using the internet less than once a month [Table 2].
Internet use for Pet Health Information
Veterinarians’ perceptions of clients’ internet use for pet health information
Veterinarians were asked what percentage of their clients they estimate use the internet for pet health information, and 53 (45.3%) reported that between 41-60% of their clients used the internet for this purpose, while 42 (35.9%) reported that even a higher percentage of their clients (61-80%) used the internet for pet health information.
Clients’ reported use of internet for pet health information
Veterinarians’ perceptions matched clients’ reports of internet usage for pet health information. Although most clients reported using the internet for pet health information at least once in a while, 27.3% of clients reported they do not use the internet for this purpose. The self-reported number of non-consumers coincides with the perception of veterinarians who reported that while the majority of their clients use the internet to obtain pet health information, they felt a substantial number of clients do not. Most clients reported using the internet for pet health information at least occasionally (625; 72.7%). The most frequent response was ‘less than once a month’ (319, 37.1%), but 97 clients (11.3%) reported using the internet for health resources at least once a week [Table 3].
How Clients Find Information on the Internet
Clients were asked to indicate how they find pet health information on the internet, either by using a search engine or going directly to a specific website. Most clients reported they frequently used a search engine, with fewer reports of visiting a specific website [Table 4].
Kind of Information Clients are Seeking Online
Clients were asked to identify the pet health topics they have searched for online. The most common responses were “specific disease or medical problem” endorsed by 51.3% of respondents, followed by “diet, nutrition, vitamins, nutritional supplements” endorsed by 38.9%. Additional topics mentioned by clients included information about specific breeds (n=10) and poisons (n=5) [Table 5].
Why clients use the internet for pet health information
When clients were asked to identify why they research pet health information online, the most common responses were curiosity (47.4%) and the desire for clarification of information given by their veterinarian (33.6%). Very few clients reported they did not agree with (1.3%) or did not believe information provided by their veterinarians (0.7%) [Table 6].
Veterinarian-Client Conversations about Internet Information
Although veterinarians reported feeling that a relatively high percentage of their clients use the internet for pet health information, they reported a much lower percentage of their clients who talk about information they find online. Most veterinarians reported that only half of their clients talk to them about what they found on the internet. Furthermore, close to a quarter of veterinarians (28, 23.7%) reported that 20% or less of their clients talked to them about their internet findings.
These numbers are similar to those reported by clients. Nearly a quarter of clients (135, 22.2%) report never discussing pet health information with their veterinarian, while 328 (53.9%) report ‘sometimes’ discussing internet information with their vets [Table 7].
Veterinarians’ receptivity to internet information
When clients were asked about their veterinarians’ receptivity in discussing information they found on the internet, 351 (78.5% of those who said they talk to their vet about internet material) reported their veterinarians were receptive. Only 10 (2.2%) indicated their veterinarians were unreceptive [Table 8].
Clients’ emotional responses to online information
Questions pertaining to clients’ emotional responses to information found online included such areas as relief, assurance, and frightened (see table 10). For example, most respondents reported feeling relieved by the information they found online, either ‘sometimes’ (58.2%) or ‘often’ (24.4%) and reassured they could make appropriate health care decisions for their pets ‘sometimes’ (37.3%) or ‘often’ (38.5%). They felt confident in raising concerns with their veterinarians ‘sometimes’ (44.7%) or ‘often’ (23.6%). Less frequently, clients reported feeling frustrated by a lack of information online, or their ability to find the information they were looking for (‘infrequently’ 31.0%, ‘sometimes’ 35.7%) or frightened by the information (‘never, 46.6%, ‘infrequently’ 31.6%) [Table 9].
Ease of accessing online information
In general, clients reported finding pet health information on the internet was relatively easy, 403 (67.1%) reported ‘very easy’ or ‘easy’, while only 35 (5.8%) reported ‘hard’ or ‘very hard’. Clients who reported they do not use the internet for pet health information (n=114) were asked to indicate their reasons. The most common reason was ‘I would rather talk to my veterinarian’. Less common responses included no access to the internet or no interest in searching on the internet.
Understandability of Internet Information
Veterinarians expressed concern over their clients’ ability to understand the pet health information they find online. Over half of the surveyed veterinarians reported feeling that 40% or fewer clients understand what they read on the internet. Only 10% of veterinarians reported feeling that most clients understand information they find online. When clients were asked how easy the information on the internet was to understand, most (432, 72.0%) reported ‘very easy’ or ‘easy’. Only 13 (2.2%) reported the information was difficult to understand [Table 10].
Similarly, when clients were asked if they were confused by information they found online, most reported either “never” (115 (20.3%) or “infrequently” (175, 30.9%). Only 41 (7.3%) reported feeling confused “often” or “almost always”. When clients were asked how often they feel overwhelmed with the amount of information they find online, very few reported “often” or “almost every time” (64 (11.6%). Many clients, however, reported “sometimes” (205, 35.9%) feeling overwhelmed with the amount of information they find online.
Accuracy/Trustworthiness of Information
Veterinarians were asked how much trust they feel their clients place in the information they find on the internet. Veterinarians report feeling that most of their clients trust what they read online. To assess the accuracy and trustworthiness from the clients’ perspective, clients were asked how often they check websites to determine the source of information. Most clients reported ‘almost always’ (219, 37.4%) or ‘most of the time (164, 28.0%). Similarly, most clients reported they check to see when information was last updated or reviewed by a medical professional [Table 11].
When clients were asked how they check the accuracy of pet health information they find online, most reported they discuss with their veterinarian (468, 57.1%), followed by comparing information from other websites (332, 40.5%), discussing with friends/family (224, 27.3%), and comparing with non-internet sources (107, 13.0%).
There are several things that can influence the perception of a website’s accuracy. Clients were asked to indicate how important several of these aspects are in influencing their determination of a website’s accuracy. Clients reported the most important aspects as: reliable source/author and his/her credentials (490, 85.7%), understandability of information (465, 81.3%), endorsement by a government agency or professional organization (448, 77.8%) and site is updated frequently (443, 77.4%) [Table 12].
Internet trustworthiness compared to other information sources
When asked to compare the trustworthiness of information from different sources, clients reported the most trustworthy sources as ‘veterinarian’ and ‘other pet owners with similar problems’. Least trustworthy sources included TV, radio and blogs/discussion groups [Table 13].
Impact on Pet Health Care
When veterinarians were asked about the impact of the internet on the health of pets, 65 (55.6%) reported feeling the internet has had a positive effect, 25 (21.4%) reported no impact and 27 (23.1%) reported a negative impact. Additionally, clients were asked to report the impact of searching for pet health care online on their decisions about their pet’s treatment, illness or general health maintenance. Most clients reported that reading pet health information online led them to ask their veterinarians new questions (‘strongly agree’ or ‘agree’: 408, 73.3%) but did not lead to getting a second opinion (‘neutral’ or ‘disagree’ 400, 72.9%). Furthermore, most clients felt the information on line helped them communicate better with their veterinarian (‘strongly agree’ or ‘agree’ 367, 65.6%), understand their pets’ health issues better (‘strongly agree’ or ‘agree’ 460, 82.6%), and make better choices about their pets’ health (‘strongly agree’ or ‘agree’ 396, 70.3%) [Table 14].
Clients were asked how often they used the internet to order medications for their pets. Most reported they have never ordered prescription drugs (464, 79.2%) or non-prescription drugs (401, 68.8%) online for their pets [Table 15].
Impact of the internet on the veterinary/client relationship and animal health
Veterinarians were asked how they felt the internet has impacted the amount of time they spend with clients. Most (73, 61.3%) reported it has not changed the amount of time they spend with clients, but a substantial number (46, 38.6%) reported it has increased the amount of time they spend with clients. None felt the internet had decreased the amount of time they spend with clients. When veterinarians were asked how they felt the internet has impacted the veterinary/client relationship, the opinions were mixed with 53 (45.3%) reporting a positive impact, 38 (32.5%) reporting a negative impact, and 16 (22.2%) reporting no impact.
Leveraging the Internet for Veterinarian-Client Communication
Given the potential of the internet as a tool for veterinarians to communicate with their clients, veterinarians were asked questions related to how their clinic uses the internet as a tool for client communication.
Veterinarians were asked if they suggest specific websites to their clients. Nearly 30% of veterinarians report they make specific website suggestions at least several times a week. Yet, a greater number (n=55, 47%) reported rarely or never suggesting specific websites. These numbers matched client reports when asked how frequently their veterinarians recommended internet websites. Most clients reported never (39.2%) or don’t recall (40.2%) [Table 16].
Of the veterinarians who reported they suggest specific websites, 60% tell clients the name of the website, 35% give their clients a written copy of the website name or address, and 6.7% show their clients the website while at the clinic. Most veterinarians who make website referrals feel their clients follow up on these recommendations; 85 (78.7%) reported feeling likely or very likely that their clients would follow up on their suggestion. This sentiment is agreed on by clients. When clients were asked how likely they would be to visit a website recommended by their veterinarian, most indicated very likely or likely. This percentage changed very little based on how the website information was presented [Table 17].
Clients were asked to report how frequently they would use internet related services provided by some veterinary clinics. Many clients reported they would very likely or likely use email to ask their veterinarian short questions (468, 80.8%) or more extensive contact with their veterinarian (458, 79.3%). Many also reported they would use advice on how to search the internet for pet health information (very likely or likely, 425, 74.2%) or make appointments online (very likely or likely 364, 63.0%). A substantial number also reported they would use a daily online log to help track their pet’s diet and exercise habits (very likely or likely 190, 32.9%) [Table 18].
The results of this study help define the ways in which pet owners use the internet for pet health information and how this interfaces with their veterinary experiences.
Clients’ use of the internet for pet health information
Veterinarians correctly assume that most of their clients have access to the internet and most use the internet to search for animal health topics; nearly 75% of clients report using the internet at least occasionally to search for pet health information. This figure is slightly higher than estimates of internet use for human health information, which has been estimated to be around 60% of the US population2. Most of our respondents indicated they primarily use search engines to find what they are looking for with only a minority going directly to specific websites. Similar search behaviors have been identified in human health, with over 80% of online health information consumers reporting they search primarily through a search engine 9.
Topics and reasons clients search online
Clients reported searching most frequently for specific diseases or medical problems, followed by nutritional topics, behavioral issues, and medical treatments (34.3%)11. also found medical conditions were the most common topics searched for by veterinary clients. Clients in our study reported they search online for pet health information primarily because they are curious, want clarification of information given by their veterinarian, or to help them decide if they should schedule an appointment. Only 2% of clients reported they accessed the internet either because they did not agree with or believe their veterinarian.
Discussion of internet information with veterinarians
Although a large number of clients search for pet health information online, many do not talk to their veterinarians about the information they find. Most veterinarians report that less than half of their clients talk to them about online information, and client reports support this premise. Nearly a quarter of clients report never talking to their veterinarians about online information and only 24% report talking to their veterinarians most of the time. The clients who do talk to their veterinarians about online information, however, report positive reactions from their veterinarian.
These figures are similar to those found in human medicine. Hay found that only 20% of patients discuss information they find online with their doctor28. Reasons given by patients for not broaching the subject include: not wanting to challenge the doctor (12%), thought of the information as background only (11%), or found the information online confusing or untrustworthy (9%)28. Yet patients who discussed the internet information with their doctor reported higher satisfaction with their doctor’s appointment when compared to those who did not. In fact, most patients report a positive impact on their relationship with their doctor when they discuss internet material13. As Murray noted, most patients who bring information to their doctor do so to obtain their opinion, not in an attempt to dictate specific tests or medications. Furthermore, when they did request something based on what they had read, and were refused, there was no indication that this negatively impacted the patient- doctor relationship13.
Emotional consequences for online consumers
Most clients reported positive emotions as a consequence to their online searches, feeling relieved, reassured and more confident in raising issues of concern with their veterinarian. Much less frequently, they reported feeling frustrated, confused, overwhelmed or frightened by their online searches. In fact, most clients reported finding information easily and understanding most of what they read. Hofmeister et al. found similar results, where 78% of respondents reporting feeling comfortable using the internet as source of veterinary information, 61% were satisfied with what they found online, and 80% felt the information helped improve their understanding11.
These results do not reflect the concern voiced by veterinarians however, in their clients’ abilities to understand online health information. Only 10% of veterinarians reported feeling that most of their clients understand online information. Veterinarians from a 2008 study also identified this concern; in which 61% reported feeling that online veterinary information confuses their clients12. It is likely that veterinarians are more accurate than clients in determining the amount of information that is accurately processed and understood. It is also possible that this discrepancy may be partly explained by the type of sites each group is envisioning. Perhaps veterinarians are referring to more professional, medical sites whereas clients may be referring to sites targeting the lay population. The fact that many people lack the health literacy needed to understand basic health information18, however, creates an environment ripe for confusion and misinterpretation.
Given that misleading and inaccurate websites are common15, the fact that most consumers do not fully investigate the credibility of websites14 only compounds the problem. Although over half of the clients reported they check a website’s source at least most of the time and when it was last updated, a large number of clients reported they seldom did either of these behaviors. These figures are similar to human health research that has found that most online consumers are not careful to screen out unreliable or inaccurate websites. It is not surprising that many veterinarians expressed concern that many of their clients place misguided trust in online resources. Written comments by veterinarians focused most often on this problem area. For example, one veterinarian explained that “There is so much misinformation on the internet and people will search for the article that confirms their belief, even when studies show no substance to the article’s claim.” Another veterinarian explains “ The degree to which clients have been willing to trust anything they read on the internet has been a bit demoralizing. Frequently even long term relationship clients will second guess my recommendation based on internet information…” These sentiments are shared by physicians. Although nearly all doctors use the internet29, many have negative views on the use of the internet for their patients30. This is likely because many doctors feel that it is difficult for patients to interpret medical information they find online31.
Although clients access the internet frequently, they rank it 4th in trustworthiness. Veterinarians are by far the most trusted source for pet health information with nearly all clients reporting that their veterinarian is trustworthy, compared to significantly lower levels of trust placed in pet owners with similar problems, family and friends and the internet. Similar patterns are seen in the relationship people have with their physicians, with 77% reporting that their physician is their most trusted resource, followed by specialists (55%) and nurses at 37%. The internet was listed as most trusted source by only 8%2.
Another recent study found that the public’s trust in physicians as their preferred source of health information has remained high and actually increased from 2002-2008, while trust in the internet during the same time has decreased slightly. Although patients are looking online first in many cases for specific disease information, this does not appear to be due to mistrust in doctors. In contrast, it appears likely that trust in doctors is increasing as patients rely more on them to interpret confusing information they find online32.
Perhaps partially due to the fact that veterinarians remain the most trusted source for pet health information, the majority of veterinarians reported feeling the internet has either positively impacted the health of pets or had no impact. These sentiments are echoed by clients, who report that online information helped them communicate better with their veterinarians, understand their pets’ health issues better, and make better choices related to their pets’ health. These numbers are similar to those in the 2008 veterinary medicine study in which approximately 40% of veterinarians reported feeling that online health information improved care of animals and helped them communicate better with their clients12. These factors all speak to the fact that more educated, informed clients can positively impact compliance.
Compliance and informed consent necessitates knowledgeable, educated clients. The use of the internet as an adjunct to information provided in the veterinary visit may help serve this purpose. Brevitz found that many clients use the internet to gain information in addition to, or to clarify, information they received from their veterinarian22. Other clients look online prior to their initial appointment. Hay found that most rheumatology patients gathered online information before seeing their doctor28. Other studies have also found that patients search online for supplemental information, often then wanting to get their doctors’ opinion on it, rather than to request specific treatment or medication13,30,31.
In fact,Trustin33 found that satisfaction with the care did not impact how much patients accessed the internet for health information, but instead to what extent they relied on this information. Satisfied patients reported using the information as a supplemental source of information33.
Although informed clients can result in less time spent in appointments, the need to explain inaccurate or misleading online information can result in more time needed with clients. Although nearly 40% of veterinarians reported feeling the internet has increased the time they spend with clients, over 60% reported it has not altered their appointment times. Studies in human medicine have also uncovered mixed results; while some have found the need to spend more time with clients13, others report needing less time with these clients34. One study at Johns Hopkins Medical Center found that when clients visited their own website, they required less time in the office to process information or make medical decisions35.
Credible, reliable information on the internet may offer the benefit of helping create more knowledgeable, and therefore more compliant, clients without the need for additional office time. Yet, part of this benefit rests heavily on the type and source of information gleaned from online sources. This might explain the mixed views expressed by veterinarians on how they feel the internet has impacted the client relationship. Although nearly half report it has had a positive impact, a substantial number report the opposite; that the internet has had a negative impact.
Advantages of health information online
The internet, when used appropriately, can be a useful tool to helping patients and clients be better informed, leading to better health outcomes and appropriate use of health services36. The information online can augment the information provided by a doctor and a more informed client may be able to play a more active role in their animal’s health care and have better communication with their health care provider (Wald, Dube and Anthony 2007)34. In this way, it has been suggested that a more informed client could make more efficient use of clinical time.
Given that AAHA has reported that lack of compliance may be partly due to the large amount of information given to clients in a limited amount of time, and the fact that these conversations often take place among many other distractions, the value of accurate information online should not be overlooked8,37. Additionally, some clients may not be able to accurately hear information presented during a veterinary visit. This may be due to shock or denial, but regardless, the ability to access information later, in the comfort of their own home, might help clients better understand and therefore, comply. Studies have found that having more informed clients leads to better compliance38.
Additionally, it has been suggested that information from the internet, when consistent with a doctor’s diagnosis or recommendation, may play a role in ‘priming’ patients, a way to improve behavioral responses to suggestions made by a doctor subsequent to information they read online36. As opposed to fears that people will substitute the internet for contact with a health care provider, Lee25 found that internet usage actually increased the frequency of health professional contact. This study found online consumers were more likely to seek health information from health professionals and treatment. They found that although online information increased some patients’ health knowledge, many of these patients still felt the need to seek professional help in order to understand what they read. Therefore, they feel the internet can complement professional care, rather than usurp it25.
Leveraging the Internet for Veterinarian-Client Communication
Given veterinarians’ concerns over the quality of information online and their clients’ abilities to discriminate among websites, it is noteworthy that only a small number of veterinarians recommend specific websites, even though most veterinarians who made recommendations report feeling their clients would follow up on these recommendations. Clients validate this perception, with nearly all clients reporting they would follow up on internet recommendations made by their veterinarian. In addition to website referrals, many clients would like additional online services, including the ability to make appointments online, ask short questions that do not necessitate an office visit, and learn more about how to effectively use the internet to search for pet health information.
Despite these client preferences, most veterinary clinics offer limited online services. While over half of veterinary clinics have a website, most are relatively basic and less than 20% of clinics offer online appointment scheduling (2008) 12. Studies in human medicine have also found that patients would like more online services, yet the medical community, due to concerns about confidentiality, reimbursement and workload, has been slow to offer online communication39. One study found that 59% of emergency department patients would like to receive medical related web site referrals with their discharge information38. Another study found that 77% of patients would like to be able to communicate with their physician online to ask questions, 71% would like to set up appointments, 71% refill prescriptions, 70% receive medical test results and 37% of patients said they would be willing to pay for these services40. Other sources report that 40-83% of people want internet based communication with their health care providers41. It would appear that preference for online communication is higher for patients than for health care providers42.
The fact that clients desire information on how to be better online consumers from their veterinarians supports the growing consensus that this area will become an increasingly important component for health care professionals. As recommended by Hofmeister et al.11 and others, veterinarians should be prepared to discuss online information clients bring to appointments, creating an opportunity to educate 26,43,44. In fact, veterinarians are urged to actually encourage their clients to talk about the information they find online.
This advice, however, does not acknowledge that many health care providers struggle with clients who come laden with internet information. Having conversations about material found online can be challenging for many doctors. One study found that 44% of doctors report difficulty discussing internet material and 9% reported feeling threatened30. It has been suggested that many may feel that their clients will be unwilling to accept treatment that differs from what they read online, that they may make inaccurate self diagnoses or that clients are challenging their authority45.
Yet, the manner in which this impacts the doctor/client relationship appears to greatly depend on how the health care provider reacts to the client’s questions and concerns. Internet information can be used to strengthen the relationship and empower the client but if seen as a challenge, can alienate the client and strain the relationship. Given the fact that the number of clients who come with internet material can only be expected to increase, it is paramount that veterinarians take a leadership position in shaping these experiences and making them positive for everyone involved.
It has been suggested that it is important to validate patient’s efforts in searching for information. Although professionals may disagree with the material presented, validating clients’ concerns and demonstrating that they take the information seriously can mitigate any negative impacts of disagreeing with information provided45. Suggestions in human medicine34 for dealing with clients who come with internet health information include: trying to view this information as possibly contributing to the partnership with the client, communicating respect for these clients as being proactive in their quest for information about their pet, acknowledging what they have read and the resultant feelings they may be experiencing, and taking the time to explain erroneous information or things that differ from diagnosis or treatment offered in office. Additionally, it might be useful to acknowledge the anxiety or fear that can arise from reading ‘worst case scenarios’ as a shift is made towards the most likely scenario.
Paving the path
In essence, veterinarians will be tasked with becoming increasingly internet friendly and may find that making internet prescriptions for specific websites helps to increase the benefits of health information online and minimize the potential drawbacks34.
It has been suggested that we should offer training and guidance to clients on how best to use the internet and help them analyze the material online effectively and critically26. Given this mandate, it has been suggested that health professionals receive training on such things as health informatics, the intersection of information technology and health care46. Although extensive training in the area is likely not practical to include within veterinary curriculum, it appears important to train veterinarians how to assess websites for accuracy and reliability so they can pass this knowledge on to their clients. As stated in a recent Veterinary Economics, “It’s up to us to help guide owners to the information that is beneficial to all involved – and especially the pet.” 47.
When helping clients learn how to determine reliable web sites, recommendations include asking clients to think about who is responsible for the site. It is important to point out differences if it is a veterinarian or a pharmaceutical company and how the source of funding can affect what material is presented. Additionally, the purpose of a website can help users identify the objectivity and trustworthiness of the site. Discussing with clients how information is documented and reviewed on websites can be another way to help them discriminate medical facts from clinical journals and reputable sources from opinions and advice. Lastly, clients should be made aware of the importance of current information and the fact that the date of updates should be clearly presented47.
Limitations of current study
There are some limitations to this study that suggest generalizing these results should be done with caution. Two metropolitan areas and surrounding towns were surveyed, and this population may not represent all pet owners in the United States. Although differences in responses based on client demographics were beyond the scope of this paper, it should be noted that our sample was approximately 75% female, and highly educated (approximately 58% had a four year degree).
Additionally, the survey was distributed by veterinary clinics, so our sample consisted of pet owners invested enough in their pets’ health to seek out services. It is possible that pet owners who do not seek out veterinary care may differ in their online pet health search behaviors. Additionally, this was a voluntary survey, and can thereby produce biases results since respondents who feel strongly about a subject are more likely to respond.
It is clear that the use of the internet for health information, and pet health information in particular will continue to expand rapidly. It is suggested that the field of veterinary medicine take a proactive role and help ensure clients obtain credible information, thereby positively impacting the client-veterinarian relationship and ultimately, the health of animals.