Safety and security on the Internet Challenges and advances in Member States
Based on the findings of the second global survey on eHealth
Global Observatory for eHealth series - Volume 4 ii © World Health Organization 2011 The mention of specific companies or of certain manufacturers’ products does not imply that they are they that imply not does products manufacturers’ certain of or companies specific of mention The The designationsemployed andthepresentation ofthe materialinthispublicationdonotimplythe All reasonable precautionshavebeen taken bythe World Health Organization toverify the information All rightsreserved. Publicationsofthe World Health Organization are availableonthe WHO website Geneva 27, Switzerland (tel.:+4122 7913264;fax:+4122 7914857;e-mail: [email protected] ). ( Safety and security on the Internet: challenges and advances in Member States: based on the findings of findings the on based States: Member in advances and challenges Internet: the on security and Safety WHO Library Cataloguing-in-Publication Data yet be fullagreement. with thereader. Innoevent shallthe World Health Organization beliablefordamages arisingfromitsuse. any kind,either expressed orimplied. The responsibility fortheinterpretation anduse ofthe materiallies contained inthispublication. However, the publishedmaterialisbeing distributed withoutwarrantyof are notmentioned. Errors andomissionsexcepted, the namesofproprietaryproductsare distinguished by endorsed orrecommendedbythe World Health Organization inpreference toothersofasimilarnature that status ofanycountry, territory, cityorarea orofitsauthorities, orconcerning thedelimitation ofits expression ofanyopinionwhatsoever onthepartof World Health Organization concerningthelegal distribution –should beaddressed to WHO Press throughthe WHO web site(http://www.who.int/about/ ISBN 9789241564397 Printed in Switzerland. Printed Requests forpermission toreproduce ortranslate WHO publications–whether forsale orfornoncommercial initial capitalletters. the secondglobalsurvey oneHealth.(Global Observatory foreHealth Series, v. 4) frontiers orboundaries. Dottedlines onmapsrepresent approximateborderlines forwhichtheremaynot licensing/copyright_form/en/index.html). www.who.int) orcanbepurchasedfrom WHO Press, World Health Organization, 20 Avenue Appia, 1211 1.Internet - utilization.2.Computer security. 3.Computers. 4.Access toinformation.5.Medical informatics. I.WHO Global Observatory foreHealth. (NLM classification: W26.5)
eHealth series -Volume 4 Global Observatory for second survey global eHealth on of the findings the on Based in MemberStates Challenges andadvances on theInternet Safety andsecurity
2011 iv
Photo credits:©Thinkstock,page55-©WHO eHealth: MishaKay, Jonathan Santos, andMarina Takane. The global survey and this report were prepared and managed by the WHO Global Observatory for Our appreciationgoesto Jillian Reichenbach Ott forthedesignandlayout,KaiLashley forediting. We aregratefulforthefinancialsupportandcollaborationof Rockefeller Foundation. publication wasinternallyreviewed byNajeeb Al Shorbaji and Joan Dzenowagis. reviewers including: ErinHolmes, Lana Ivanitskaya, Pauline Sweetman, and Michael Veronin. The work KevinSpecial totheauthorsofthis thanks and Karen Clauson Vieira, and theinternationalexpert in114countries experts 800eHealth over to worldwide whoassistedwiththedesign,implementation,andcompletionofsecondglobalsurvey. due are thanks Sincere offices. country and regional, eHealth expertsandthesupportofnumerouscolleagues at the World Health headquarters, Organization of network extensive Observatory’s the of input the without possible been have not would report This Acknowledgments 1 9 5 17 21 21 21 12 12 iv 10 14 19 16 16 16 15 23 22 22 24 24 25 25
.
.
. . .
Table ofTable contents
.
. .
......
. . . .
. .
Summary Availability of prescription-onlyAvailability oversight drugs of clinical and lack Medical questionnaires Internet pharmacy locations Counterfeit and substandard medications labelling and Packaging Methodology Safety cause for there is concern? online: of purchased medications Accuracy and reliability of online health information health online of reliability and Accuracy HealthOnline countries Information developing in Phishing scams Unsupervised and teens children to access Spam Viruses and malware Internet pharmacies Internet 1 Internet pharmacies . . 3 Online safety of children and adolescents children of Online safety 3 4 Digital and literacy online health quality information 1 . . . security Internet .2 2 1 1 1 1 Executive summaryExecutive Acknowledgments Introduction the literature of Review . 1. 2 2 3. Analysis discussion and of survey results 3 2 2 2 . . . . 1 4 Digital literacy and online health information quality health online literacy and 4 Digital 2 Internet security 2 Internet security adolescents safety and of3 Online children . Internet pharmacies Internet Summary children linkThe between online child and pornography Children and adolescents online supervision without children whenonline? risk at Are adolescents and Methodology Summary e-mails spam purchased from health of products Reliability andvalidity behaviour?consumer affect spam Does spit and spim, Pharmaceutical spam, andhealth-related Methodology Implications Regulation online of purchase abroad pharmaceuticals of from operations pharmacy Regulation Internet of Summary searches retrieve desired Internet healthDo information? search of engine results Quality seekers search do healthHow information? information for search of role enginesThe online:contentSearching easily health information for accessible? is quality Methodology
. .
.
.
.
.
.
.
.
29 40 28 28 28 28 35 35 36 36 39 39 34 47 34 30 43 32 32 33 33 31 31 31 31 3 81 61 83 78 78 53 77 77 47 67 82 82 80 80 49 84 86 86 85 58 50 50 56 55
. . .
. .
. .
on eHealth . . . .
......
Implications about Internet education safetyInformation and Response rate by World Bank income group Bank income World rate by Response References Limitations Data processing rate Response WHO rate by Response region Survey development Data Collector survey the launch Preparation to Survey Purpose Survey implementation Survey instrument Safety security and requirements Implications Implications 3 Online safety of children3 Online of and safety adolescents 2 Internet security2 Internet 4 Digital and literacy online healthquality information . . . 3 Appendix the 1. Methodology globalsecond survey of 3 3 Conclusions References . . 5 4
Executive summary 5 Executive summaryExecutive Internet security, in the form of spam, is another persistent challenge. Crime follows opportunity and theCrime challenge. in the form of spam, is another persistent Internet security, first spam actually appeared in 1978, shortly after the Internet itself had been opened Spam to the public. itself poses a risk for individuals and institutions, but its greater threat may be as a vehicle for fraud, viruses, malware, and spyware. Spam has also been used to target vulnerable populations suffering from poorly treated or socially stigmatized medical conditions. Overall, technology filters remain the most common organizational/ local the both at States Member by used are filters E-mail spam. combat to employed tool A combination of legislative (33%) and educational levels. and Internet service provider (67%) business (75%) although countries, spam by responding in attempting to reduce also remain staples (30%) responses at rates of 55% and 52% respectively. countries, in high-income to occur most likely are these Internet pharmacies demonstrated potential early on as a hub within a wider set of eHealth services, set of eHealth services, within a wider potential early on demonstrated as a hub Internet pharmacies its viability even and product quality, fraud, but has since in transparency, mired doubts regarding been as an ethical business model. Even now, over a decade after the first Internetof legality and policy this It is plague venture. telling that among the total responding countries to this pharmacies, questions whether to decide unable on this issue, uncommitted remain (66%) States most Member (114), survey Bank categorized World those among And while or allowed. prohibited should be pharmacies Internet to this have addressed issue, overall there is still and countries high-income are most likely upper-middle more prohibition (19%) than permission (7%) of Internet pharmacy operations. The Internet has moved beyond an educational and research tool that served as a social network for a few elite tool that served and research an educational The Internet has moved beyond to much theof scientists and has been transformed into a commerce and health care juggernaut accessible by complication and challenge. unencumbered this resource has not been of the accessibility planet. However, 6 Executive summary education wouldbebeneficial. to integrate digital literacy and awareness of onlinesafety issuesintorequisiteand schooling adult practices educational codifying or Formalizing changed. has access Internet of face the devices mobile have insulated youth indeveloping countriestodate, but with theexplosionofInternet accessibility via area; Internetpenetration emphasizing thislowerrates of initiative ratesshouldconsider low with health literacyare still hurdles tobe overcome in mostMember States. Developing countries andthose decade, presentenormouschallenges,asbasicand the next Internet safetyandliteracy Moving into are naturalfocifordirectinglegislativeandintervention efforts. safety,child Internet accessgranting centres and community libraries, schools, and teenagers children to Member legislation foronline and prioritization, or strengthening States contemplatingintroduction public health threat presented by the Internet may be to the safety of children and adolescents. For those currency,as spamcreateproblems billionsinany issues suchcosting While security themostpolarizing threats thatcanaccompany spam(e.g. viruses). – resources existing help avoidthemoreserious educational programmesto to for citizens diluted multiple– currently inways reallocating suggest findings Additionally, possible. alsobe when spam should for established andenforcement penalties, definitions, Stronger efforts. educational fragmented of consolidation as including well as volume Spamhaus) (e.g. this efforts non-profit-making in of findings support international the continued on based targeted be should spam of receipt and Distribution consulting basedontheir work inthese areas. merit also (FIP) Federation Pharmaceutical International the including institutions and Organizations be avaluable pointofcontactanddataforother countries wishingtomoveforwardinthisarena. can volume this in identified legislation existing with States Member medicines. essential of delivery to protect publichealthand,whenfeasible, createanalternative, butsecure distributionchannelfor To addressunresolved issues withInternet pharmacies, Member States shouldconsider regulation than one thirdofMember States. less by used were approval) of seals official intervention, government programmes, education (e.g. content providersandwebsiteowners. All the othermeasures toassure qualityinformationonline online health informationquality, themostcommonapproach(55%)wasvoluntarycompliance by of assurance care, health and Internet the with associated challenges daunting most the of one For locations childrenareknowntofrequent(e.g. librariesandschools)inmoredeveloped countries. a quarter(22%)than as less for growth legallyrequirein ofrespondingcountries theuse“safetytools” room much is there However, (93%). children protecting at efforts direct specifically also majority vast Member government-sponsoredof have sometype States that (47%), Internet safetythe initiativeon by a cybercafé,or Internet athome,in the to via connection is that Smartphone. Todate, those of communities withinappropriatecyberbullyingamongpeers, content,andonlinepredators – whether The Internetpresentsaworld of opportunitiesforchildrenandadolescents,but it alsothreatens Executive summary 7 The results of this survey indicate a need for action and progress across the eHealth spectrum. However, a need for indicate action and progress across The results of this However, survey the eHealth spectrum. institution-initiated along with citizen- and pharmacies with Internet illustrating successes case studies these could in the text of the report; provided online health information quality are methods of addressing Organization Health World Similarly, upon. foundation on which of a to build examples considered be conclusions to approaches in regarding navigate obstacles detailed the report as well as measures (WHO) in the discussion. to build on existing initiatives are included The capacity for digital literacy is intertwined with accessibility to quality and online of information. health is literacy The capacity with intertwined for digital accessibility in the coming prominent more even become of these issues will the importance that It is anticipated Solutions the quality for of managing health information of included use proposed medically years. utility, have tools those While HONcode). (e.g. approval of seals official as well as engines search focused stricter globally: implemented and developed being holistic approach more a seeking are stakeholders codes of ethics on health content, and regulations abiding and content and more guidelines provider One is taking these factors approach that into consideration is that of the proposed dot accountability. serve as TLD could an organizational indicator for quality A dot health domain (TLD). health top-level many to address resource global act as a hence it could then sources on the Internet; health information issues raised here. of the related eHealth
Introduction 9 (3). 1.1 3.2 5.6 13.5 10.4 24.2 42.0 ), there 2),
Source: Distribution (%)
3).
21.3 63.2 475.1 825.1 110.9 204.7 266.2 (millions) Internet users
Introduction 1 Asia Europe Region North America Latin America / Caribbean Africa Middle East Oceania / Australia few academics to permeating nearly all facets few academics to permeating of personal and professional life has as been described . While just 3 million people had access to the While just had access 3 million people (1). by technology alike experts and media revolutionary remarkable rate during the 1990s and 2000s. This transition of the Internet from a curiosity among a the 1990srate during and 2000s. remarkable Internet in 1990 (73% of which lived in the United States of America and 15% in western Europe; America of States United the Internet in 1990 of which in (73% lived are now nearly 2 billion people connected to the Internet worldwide (Table 1; are now nearly 2 billion people connected to the Internet worldwide (Table
The Internet, which began as a government-funded initiative, has spread throughout the world at a throughout the has spread initiative, which as a government-funded The Internet, began Table 1. Global Internet access 1. Table 10 Introduction The scopeofthe Internet haschanged drastically during this period as well. In itsinfancy, theInternetwas 2009 (the methodology ofwhichisexplained in Appendix 1). This report focuses onInternetpharmacies, IT fr elh te ol Hat Ognzto’ Goa Osraoy o eelh Ge conducted (GOe) eHealth for Observatory Global Organization’s Health World the health, for (ICT) 1 While the evolutionof theInternetawayfrombeingcontrolled,research-based atightly medium has vast commercial potential. Worldwide e-commerce sales are predicted to reach US$ 1. a prescription,aswell as dangerous counterfeit medications. Children andteenagers are groomed and and Northern Ireland alone) (5) and identities carryatremendous(e.g. cost £1.7billionannuallyinthe United Kingdom of Great Britain a series of case studies, before the remaining unanswered questions and future directions for Internet studies, beforeremainingunanswered andfuturefor case thequestionsdirections a seriesof in survey detailed more a by followed was 2005. This in practices eHealth State’s Member of survey a comes at a price. Misinformation on the Internet is rife. Phishing the Internetis on a price.Misinformation at comes and medicalpracticewasmuchlessdistinct. of the first Internet-based pharmacy, Internet-based first the of and occurredcentralized, mandatorygovernmentcontrols separate asadiscretesystemfrommedical Internet security,health and online and adolescents,digitalliteracy of children safety online averaging growthof19.4%ayear(4). Because of thelacksystematicresearch into theuse of informationand communication technologies For centuries, the brick-and-mortar approach to selling pharmaceuticals served as the template around template the as served pharmaceuticals selling to brick-and-mortarapproach the centuries, For Pharmacy’s Ages. Middle the during Europe in appear to began enterprises commercial as Pharmacies unless it directly served research or education goals. In its current incarnation, the Internet has developedInternet has the incarnation, current its In education goals. served researchor directly it unless information quality. Itbegins by providing an overview of these four topics,aswell as anevaluation of in the in United 120States. Morethan yearslater,mail-order this tradition wouldunderpin the formation risks to individuals and the public health if medical products were sold via online means in a mannerthat means in individuals via online to andthepublichealthifmedical were sold risks products pharmacies, onlinehealthinformation,andcross-borderregulationarediscussed. then analysed and discussed, highlighting key findings. These results are given a deeper context through the available literature. global of thesecondeHealthsurveysections The resultsofthecorresponding are produced great potentialformasscommunication,commerce and informationsharing,thisgrowth the world.However, inthelate 1870s, pharmacies began selling prescriptionmedications viamail order practice modern era has witnessed its development largely in western European countries withtheaid of strong, pharmacy launched in the United Kingdom medications. And byearly 2004, this number was estimated at more than 1000 lured bypredatorsintoabusivesituations. launch of these first Internet pharmacies, the World Health Organization (WHO) highlighted the possible limited to research, education and government uses; commercial use was barred until theearly 1990s 1. Internet pharmacies Phishing is the use of e-mail messages that falsely claim to be from an established, legitimate business or organization established,an legitimatebusiness ororganization thebe from Phishing isuseofe-mailto messages thatfalselyclaim but are designedtosteal youridentity. (6) . In countries such as the . Incountriessuch United Kingdomand the United States, thelinebetween pharmacy . Some Internet pharmacies sell potentially addictive substances without , in January 1999. A few months later, the first Internet first later,the months few 1999. A January in Soma.com, (7) . By the endastaggering . Byof1999,400 web sites were selling 1 scams using e-mailstealinformation scamsto (8). Shortly following the 963 billion by2013,963 Introduction 11 . Source: (13) . Currently Currently it is . (9) . Based on their (13) Operational approach . The (12). FIP and its member associations have developed a dialogue Provide medications as extension of established brick-and-mortar established brick-and-mortar Provide medications as extension of contingent upon patient possession of a valid medical pharmacy, prescription. selling prescription-only to pharmacies Advertise online access for a subscription fee paid drugs without a prescription in return online with a credit card. or male erectile dysfunction, obesity, Supply ‘lifestyle drugs’ (e.g. after being issued a pattern baldness) directly to the patient prescription through an ‘online consultation’. Offer mail-order delivery of drugs such as opioids, benzodiazepines and methylphenidate without a prescription in return for online credit card payment. )
2 http://www.fip.org/?page=menu_about. Legitimate Subscription Lifestyle No-prescription Pharmacy category 50 to 75 billion (10; 11). billion to 75 US$ 50 from the Fight Against the HIV-AIDS Pandemic, Good Pharmacy Practice guidelines, and involvement in the pharmacies, buying prescription medications online is truly a matter of caveat emptor. medications online is truly a matter prescription pharmacies, buying investigation, the authors grouped Internet pharmacies selling prescription medications into four distinct Internet pharmacies investigation, the authors grouped unknown how many pharmacies are doing business over the Internet, but estimates of the industry range of the industry estimates but over the Internet, doing business unknown are how many pharmacies using the search engines Google and AltaVista with the keywords “prescription drugs” AltaVista with the keywords Google and using the search engines Pharmaceutical Federation (FIP In 2005, a cross-sectional study was performed that examined 275 English-language web sites located web English-language 275 that examined a cross-sectional was performed study In 2005, International Medical Products Anti-Counterfeiting Taskforce (IMPACT) coalition. (IMPACT) Taskforce Anti-Counterfeiting Products International Medical could bypass legislative measures that had been introduced that introduced to had been measures could bypass assure consumer legislative safety with WHO, WHO, evidenced with in efforts such as WHO/FIP Joint the Declaration on theRole of the Pharmacist in categories (Table 2). categories (Table Globally, Globally, Member States’ national pharmacy organizations are connected by the International 2 These categories of Internet pharmacies speak to the fact that when compared with traditional pharmacies speak to the fact that when compared with traditional of Internet categories These Table 2. Models of Internet pharmacies Table 12 Introduction Table 3. Spam ratesbycountry Spam The term ‘spam’ describes unsolicited electronic messages sent in bulk Spam is very common. MessageLabs Intelligence recently reported a global ratio of spam in e-mail traffic With thegrowthofglobal e-commerce, an ever-increasing number of people are becoming more 1 spam, malwareandphishingscams. Selected examplesaredescribedhereafter. including agendas, their perpetuate to cybercriminals for means different of number a are crime. There criminal activity,cybercrime. or Cybercrime beganinside as ajobperpetratedfunctional with by those comfortable with makingonline. monetary transactions This hasnaturallyled to theexpansionofonline of 75.8%,of everyin one to corresponds e-mails which1.32received serve asavehicle formalwaredisseminationscams(see orphishing followingsections). Inthismanner, spam e-mail butisincreasinglybeingemployed viashortmessage service (SMS) ortext message, computer instant knowledge of businessesbut has transformedananonymous attackoftenbackedinto by organized in theworld,withaspamrateof82% (Table 3). is alsoincreasinglyused asatoolofthe aforementioned no-prescription or‘rogue’pharmacies. percentage points over the previous month, the Russian Federation became the most spammed country message (IM),andbytelephone. Spam e-mails oftendirect therecipient toanexternal web site,butitcanas .2 Internet security China, HongKong SAR Russian Federation The Netherlands United Kingdom United States Luxembourg Saudi Arabia South Africa Singapore Country Denmark Germany Australia Hungary Japan China Brazil (15). spam levelsAs 2.9 increasedby (14). Spam ismostfrequently seen as Spam rate(%) 82.2 81.6 80.1 81.0 76.4 79.8 74.8 74.0 73.9 75.9 75.4 75.2 72.3 75.5 77.5 75.1 Source: (15) . Introduction 13 (18). . (17) Spamhaus also Spamhaus works with cybercrimes units various law enforcement and 3 /. www.spamhaus.org they . send (16) they Despite this low response rate, spammers are still able to generate a profit, albeit not This profit mayUS bethe dollars due, millions in assumed of in part, tosome identitycircles. theft and a managed poorly from suffering those (e.g. groups consumer certain which in spam of use targeted more and open, to receive, likely more are obesity) like social element or conditions with a diseases medical spam e-mails purchase items from the “Indian Pharmacy” are appearing more frequently the “Indian Pharmacy” are appearing including Scotland Yard Computer Crime Unit (United Kingdom), Independent Authority of Posts and Authority of Posts Independent Unit (United Kingdom), Crime Computer Yard Scotland including is an international non-profit-making organization based in Geneva, Switzerland and London, United FBI, in the United States), and media (e.g. Virus Bulletin Award for the greatest contribution to combating combating to contribution greatest the for Award Bulletin Virus (e.g. media and States), United the in FBI, Kingdom and maintains numerous spam blocking databases as well as publishing the Register of Known the Register as publishing as well blocking databases spam maintains numerous and Kingdom Pharmaceutical spam, as a subset of spam, is very common. In fact, Internet security experts estimate that estimate security experts In fact, Internet is very common. of spam, as a subset spam, Pharmaceutical spam in the past 10 years). accolades in support of their efforts by both governmental agencies (e.g. Federal Bureau of Investigation, of Bureau Federal (e.g. agencies governmental both by efforts their of support in accolades conducted in 2008 calculated that spammers only receive one response for every 12.5 million e-mails 12.5 million for every one response only receive that spammers calculated in 2008 conducted . The most common in pharmaceutical brands featured of all spam is spam” (18). “Pharmaceutical over 65% or other sites similar web such as the “United Pharmacy,” spam is the “Canadian Pharmacy”; however, One of the most coordinated attempts to combat spam to date is the Spamhaus Project. Spamhaus Project. Spamhaus One is the of the most coordinated attempts to combat spam to date Spam Operations Operations Spam (ROKSO). Spam messages are an inefficient, but low-risk means for perpetuating cybercrime. A study of spamming spamming of study A cybercrime. perpetuating for means low-risk but inefficient, an are messages Spam Cyber-Forensics Cyber-Forensics & Training Alliance (United States). Notably, Spamhaus has received a number of 3 Telecommunications (Netherlands), Australia Communication and Media Authority, and the National and Authority, Media Communication and Australia (Netherlands), Telecommunications 14 Introduction Table 4.Malwareratesbycountry Viruses malware and 4 These malicious programs could be spyware, which monitors the user while he/she is browsing thebrowsing theuserwhilehe/she is monitors which couldbespyware, Thesemalicious programs Spyware canalsobeused tostealprivatedatalike passwords,medicalinsuranceinformation,orcredit one inevery 81.8e-mailscontainingmalware;additionalcountryinformationcanbefoundin Table 4. malwaresome formof(20)contained . levelshighest The malware ofweredetected in South Africa, with spyware andphishingcanaccelerate thatprocess,especially asmore patient dataisdigitallyhoused card andbankaccount numbers, resulting intheftandfraud. In2010 morethan100cybercriminalsand easy toconcealmaliciousprogramsinPDFfiles. electronic share to ways common most the of documents one and the majority of people are consider PDFs to be a trusted PDFs file type. However, it that is exceptionally fact the of advantage taking are choice fortargeted attacks, withtheir usage increasing 12.4% between 2009 and 2010 In a recent report,everyIn arecentMessageLabsin one Intelligencecalculated that e-mails 290.1worldwide Internet in order to display advertisements or redirect marketing revenues to the spyware’s creator. spyware’s the to revenues marketing redirect or advertisements display to order in Internet of malware include computer viruses, adware, dishonest spyware, scareware, Perhaps most notably, portable document format (PDF) file attachments are now the attack vector of vector attack the now are attachments file (PDF) format document portable notably, most Perhaps fraudulent or intent” “malicious software” with the “broadrangeof Malware thetermfor is helping combatmedicalidentity theft(23). in open-system electronic health recordsandpersonal health records. This development prompted to releaseareport in2009 that included aprovisionforthe role ofhealthinformationtechnology in States United the in Information Technology Health for (ONC) Coordinator National the of Office the ‘Zeus’ named money muleswerearrestedforstealing US$ 70millionfrombankaccounts usingthe crimeware toolkit Scareware isdeception softwarethatisusedtofrightenpeople intopurchasing andinstallingit. China, HongKong SAR (21). Similarly, complete medicalidentity theft isincreasing atalarmingrates(22) and The Netherlands United Kingdom United States South Africa Singapore Country Denmark Germany Australia Canada Japan China Malware ratio(pere-mail) 1 in828.9 1 in910.4 1 in328.8 1 in365.8 1 in457.0 1 in455.3 1 in139.0 1 in451.1 1 in393.1 1 in713.6 1 in1331 1 in81.8 4 Trojanhorses, andworms. (20)Cybercriminals. . Examples (19). Source: (20). Introduction 15 . Source: (20) 1 in 32.5 1 in 1117 1 in 96.3 1 in 1288 1 in 477.1 1 in 4466 1 in 817.4 1 in 167.9 1 in 780.5 1 in 853.4 1 in 536.9 1 in 545.2 Phishing ratio (per e-mail) . Consequently, a high a owners percentage of computer purchase cheaper Consequently, (24). China Japan Canada Australia Germany Denmark Country Singapore South Africa United States United United Kingdom The Netherlands China, Hong Kong SAR China, Hong Kong licences for operating systems (OS) and antivirus software are simply unaffordable. Vulnerability may the cybercriminals take the buyer’s money and credit card details without ever intending to fill the order. without ever and credit card details money the buyer’s the cybercriminals take these data. Just like a fisherman, the bait, cybercriminals knowing throw that Just while like out their e-mails like these data. biting. into will be tricked most will ignore their message, some private information, such as passwords, bank account numbers, medical insurance registry and medical numbers, numbers, private information, such as account passwords, bank machines vulnerable because they are nearly impossible to update, but also because they themselves, are, are nearly but also they impossible to update, because they because machines vulnerable in developing economies in developing be further exacerbated due to a culture of piracy and a general lack of network security. Based on the Based security. lack of network and a general of piracy to a culture due exacerbated further be Phishing scams . to a phishing scam (20) be linked could 216.7 e-mails point that 1 in every to the Phishing has progressed Rogue Internet pharmacies are often used as an online front for phishing scams. The web site provides Internet pharmacies are often as an used online front phishing for scams. Rogue Phishing scams involve e-mail messages that falsely claim to be from an established, legitimate business legitimate an established, from to be that falsely claim messages Phishing scams involve e-mail Internet users in developing countries are particularly susceptible to viruses and other malware because other malware and to viruses susceptible particularly countries are in developing users Internet a convincing ‘storefront’ that purports to sell a range of lifestyle drugs; after however, placing an order credit card details, via e-mail or direct the recipient to a web site where they are duped into providing duped are they site where web to a recipient the or direct e-mail via details, card credit or organization but are designed to steal your identity. These e-mails either ask the recipient to send their ask the recipient either These e-mails your identity. to steal designed are or organization but another likely source of viruses. source another likely combination of a basic Windows OS and antivirus program can cost the equivalent of a month’s salary Organisation for Economic Co-Operation and Development Task Force (OECD) on Spam findings, the South Africa was the most targeted country with phishing levels calculated at one in 32.5 e-mails (Table 5). (Table in 32.5 e-mails at one calculated Africa was the most targeted country with phishing levels South (and more often than versions (and more often than software and operating systems not, of that pirated) not their only leaves Table 5. Phishing rates by country Table 16 Introduction ”spend more time with media than theyexcept doinanyotheractivityforsleeping” Adults are increasingly spending their discretionary time theInternet, Adults arespendingtheirdiscretionaryonandchildrenadolescents increasingly As with all e-mail-mediated cybercrime, the most effective means of protection is awareness and caution, 5 (26) (28), andcyberbullying When it comes to finding and luring potential victims, the Internet provides numerous opportunities and opportunities numerous provides the Internet victims, potential luring and finding to comes it When victims, as well as the opportunity to create their own ‘communities’ to exchange ideas and reinforce and ideas exchange to ‘communities’ own their create to opportunity the as well as victims, 1 1 of the easy and often private access to children that the Internet offers, it has provided a new medium new a provided has it offers, Internet the that children to access private often and easy the of as therecipientislastlineofdefence. a broader meaning competency inandreconcilecomputerliteracy, healthinformationliteracy evaluate the newknowledge gleaned from digital environments (32). The abilityevaluateto critically Unsupervised accessUnsupervised to children teens and anonymous or create false identities. By disguising their true identity and motives, predators are able to build anonymous orcreate falseidentities. Bydisguisingtheirtrue identityandmotives,predatorsareable tobuild advantages forpredators. Chat rooms,role playinggames(e.g. World of Warcraft), virtualworlds(e.g. Second Prior to the 21st century, literacy was simply defined as a person’s ability to read and write; today, with today, write; and read to ability person’s a as defined simply was literacy century, 21st the to Prior Examples include students in New Zealand who were recipients of bullying by text and were significantly More recently, varyingformsofharassmenthavebecome a more prominent issueforchildrenandteens. Life), and social networking sites (e.g. Facebook), facilitate predators’ agendas by allowing participants to remain information retrieved online is an integral part of the concept of digital literacy.retrievedof information the concept integral partof an is online forward, Going the through which child exploitation,maltreatment, through whichandsexual and emotionalabusepropagate can their prurientdesires. the advance of modern technology and the advent of the Internet, the concept of literacy has takenhas of literacy and theadventofInternet,concept the advance ofmoderntechnology on related concept of eHealth literacy will also be of growing importance as individuals achievegrowing importanceasworkto be of will also of eHealth literacy related concept a digitalmedium, and in gathereddigitalsources, tasks understandanduseinformationfromavarietyof more likelyfeel tounsafeatschool long-term online relationships with theirtargeted victimspriortoanyattempt topromotephysical contact. . . 4 Digital literacy information health online and quality 3 Online safety3 Online of adolescents and children . Broadlyspeaking, the Internetgives child predators accessinstant to alarge group of potential “The harassment ofonepartybyanother, bymeans oftheInternet oranyelectronicdevice” (29). . In this new era, literacy encompasses a person’s ability to effectively perform effectively to ability person’s a encompasses literacy era, new this In (31). 5 beginninginmiddleschool(30). (27) , the link between online and offline stalking of teens in Canada in teens of stalking offline and online between link the , (33), andmedialiteracy (25). However, because (34). Introduction 17 (42). . Similarly, a study of university Similarly, (35). , 53% of American respondents stated that their American respondents (43), 53% of . However, many other patients use online health information to many otherpatients use 45). However, (40, literate until he/she has the ability to judge the reliability of online information (32; 34). Unfortunately, Unfortunately, 34). (32; of online information reliability the judge has the ability to until he/she literate last Internet search impacted their personal health care in some way or the way they last cared for someone Internet search their personal health care in impacted some way or the way they . This of critical lack signs to multiple of associated detect with danger pharmacies (36). rogue Internet the Internet. of health information found on is particularly worrying in the context thinking and analysis related decisions. In a 2010 survey by Fox and Purcell Purcell and Fox by survey 2010 a In decisions. related that respondents reported that information found on the Internet prompted them to that respondents that information found on reported the Internet prompted ask their physicians . This means that nearly 115 million Americans are gathering health information gathering Americans are This means that nearly 115 million . online (41) found they recent estimates suggest approximately 8 out of every 10 adults who have online access do so in the online access who have 10 adults 8 out of every approximately suggest recent estimates information seekers said they “always” checked the source and the publication date of the information the source and the publication date “always” checked said they information seekers be put on patients, however. A study conducted under the direction of the U.S. Department of Health Department U.S. the direction of the A study conducted under however. patients, put on be unconsidered acceptance of its content can mislead. Therefore, one cannot be considered digitally digitally cannot considered one be Therefore, of its content can mislead. acceptance unconsidered questions (62%) and some to even seek a second opinion (28%) (44). even and some to questions (62%) However, according to a survey conducted by the Pew Research Center, only of online 15% health Center, Research Pew conducted by the to a survey according However, students (n=1914) in the United States found that a quarter of all students were unable to use similar cues similar use to unable were students all of quarter a that found States United the in (n=1914) students subset of digital literacy skills actually suffered decline overassumptions about increasing of abilities digital natives and others time demonstrating potentially flawed critical evaluation of online information is generally lacking in A society. pair of studies conducted five determine treatment options. do so to self-diagnose, with the highest rates of this practice occurring in Russia, the United States, the United the in Russia, with the highest rates of this practice occurring do so to self-diagnose, else. Further, one third of e-Patients reported that what they found online A study conducted at an clinic outpatient in India similarly found specificallydecision whether or not to see a doctor. affected their and Human Services calculated that only 4% of the most frequently visited health web sites published the published sites health web visited that only of the most frequently 4% calculated Services and Human how the content was updated source of their content and just 2% revealed online without evaluating its quality. Not all of the blame for diminished quality control mechanisms can for diminished Not the blame all of its quality. online without evaluating United Kingdom, and Australia and Kingdom, United , as well as India, China, Russia, Brazil, and Mexico (40). Brazil, and China, Russia, as India, as well countries (39), European , 38) United States (37, years apart by the Open University in Israel detected that the “information and literature reproduction” and literature that the “information detected University in Israel Open by the years apart While the Internet provides practically unlimited potential for acquiring new knowledge, rash, new knowledge, for acquiring potential practically unlimited provides the Internet While Separately, it has been reported that one in every two searching it people for health information has that online one been reported in every Separately, Searching for health information online is among the most Internet activities; commonly performed These practices are worrying because patients use the information they find online maketo health- Accuracy and reliability online information health of Accuracy 18 Introduction 6 6 sites inFrance(48). (Haute Autorité de Santé, HAS), whichresultedinimprovementsweb with government agencies such as the French National Authority for Health covers 10millionweb pages(47).HONhasalsoentered intopartnerships andcountries 100 over by used been HONcodehas formation, initial its Since begins oneyearafterinitialcertification. and periodic is site the of monitoring on, point that From performance. the detailing site web HON’s on certificate byaHON a to back links which seal, HONcode andconducted is voluntary review committee. the eightprinciplesare Those sitessatisfyinggiven the process certification actual The financial transparency; justifiability; disclosure; andadvertising. attribution; confidentiality; complementarity; authority; are: to certain adheres site the that and providers principles and has undergone HON’s certification process. The eight principles governing patients the HONcode to signifies logo HONcode the of presence The publishers. web and professionals, health-care public, the benefit to created was HONcode The The followingyear, HONlaunchedoperations toimplement its Code of Conduct (HONcode). a meeting ofexperts ataconference in Geneva, Switzerland andisanongovernmental organization(NGO). the qualityofmedical andhealthinformation”thatcanbefoundonline (46).In1995,HONwasbornoutof becomes paramount. To this end, the Health On the Net Foundation (HON) aims to their “help to questions abouthealth, disease, andtreatment options,thequalityof informationthey locate online unify answers and find standardize or guidance seek to Internet the to gravitate increasingly public the of members As ofonlinehealthinformationdetermine trustworthiness Case study1 documentation ofhealthclaims,andadvertisingpolicies. content. Web 2.0 principlesinclude information onsitesregarding moderator status, privacypolicy, second web featuring a bidirectional,dynamicuser-generatedthe webandarecharacterizedby iteration of the of descriptors are media social or 2.0 2.0’.Web Web ‘HONcode nascent their for principles the HONcode, the Toolbar displays the seal in colour. Looking ahead, the Foundation also developed eight with compliant is being visited.Ifthesitestatus is the websitethat plug-in check for Internetbrowsers to a as acts HONcode Toolbar,which the as such Foundation the by formulated been have resources New http://www.hon.ch/HONcode/Pro/Visitor/visitor.html. standards setbytheEU(49). quality the implementing organization first the become and recognised been has HONcode the developed criteria in2002,EU quality the introduction of the to Thanks contributed, HON which to distinguished awardhasgivenlegitimacytoHONandvisibilityitsactions… Europe an award,the levelwith a multilingual at information health of Award foreHealth. This Union recognized Health Foundation’sOn Net the quality supporting the and services activities not well-known. was In web 2004,on the information European the CommissionEuropean and the In beginning,HON’sthe medical andhealth of quality the in improving andvision strategy . Foundation inSwitzerland helpscitizens —Celia Boyer, Executive Director, Health On theNetFoundation
Introduction 19 – the highest utilizers(40, 45) – the highest . Overall, 87% of the health-related web sites web comprised fewer of the health-related Overall, 87% (51). . This indicates thatThis indicates . or better (50) a reading ability at high school level required sites health web language than 100 pages and only 8% contained health education for the general public as their main content. as their main content. public and only contained health education for the general than 100 pages 8% these sites are only useful resources for people with a relatively strong grasp of the English language. with a relatively strong grasp for people resources only useful are sites these respectively. According to a study published in the Journal of the American Medical Association, all English- Medical American of the Journal in the published to a study According respectively. this possible demand, people in developing countries face two important disadvantages to accessing to accessing countries disadvantages face two important in developing people this demand, possible may have a greater reliance on health information they find online than people in developed nations been called into question: a study investigating the credibility of 255 health-related web sites found that health-related been called into question: a study the credibility of 255 investigating health information: much of the health content online is based in the United States and written in English; United health information: much of content the health online is in based the because of the higher costs associated with seeing a medical professional face to face (40, 45). Despite professional a medical of the higher costs associated with seeing because Online Health Information in developing countries developing in Information Health Online Further, an investigation of health-related web sites in Sri Lanka found that only 64% were controlled by a by controlled were 64% only that found Lanka Sri in sites web health-related of investigation an Further, Health Information Articles and Health Newsletter (mercola.com), Medline Plus, Drugs.com, Medscape, Drugs.com, Plus, Medline (mercola.com), Newsletter and Health Articles Information Health significant increases in Internet usage over the previous few years. over the previous significant increases in Internet usage It has been suggested that citizens in emerging economies like Brazil, China, India, Mexico, and Russia Mexico, and Russia China, India, Brazil, that It has citizens been suggested economies like in emerging of these health portals, after Americans, come from India, the United Kingdom, Australia, and China Australia, and Kingdom, United the India, Americans, come from portals, after health of these and the United States Patent and Trademark Office’s AIDS Patents Database Office’s Trademark States Patent and United and the and health information in developing nations is often inadequate and unreliable. nations is often inadequate and in developing and health information United States – including the U.S. National Institutes of Health, WebMD, PubMed, Medicinenet.com, Natural Medicinenet.com, PubMed, WebMD, Institutes of National Health, U.S. States – including the United With the exception of www.who.int, the remaining 20 most popular global health sites are based in the based are most popular global health sites remaining 20 the of www.who.int, With the exception Sri Lankan or a Sri Lankan organization or Sri Lankan a Another example comes from Thailand, where the reliability of available online health information has of available the reliability where Thailand, comes from Another example . ethical issues, while only 9% provide a disclaimer (52) 99% of these sites have legal and/or The authors concluded that the number of web sites available to Sri Lankans had not increased despite The authors concluded that of the number web sites to available
Review of the literature 21 ‘safety ‘safety 7
. However, there are there (8). However,
(53). Because of these potential threats Review of the of Review
literature 2 . Asterisk is a character used in wildcard searching. Asterisk is a character used 1 Internet pharmacies Internet 1 to safety, researchers have started to forecast and evaluate the safety, reliability, and accessibility of and accessibility reliability, the safety, to forecast and evaluate started researchers have to safety, not require a valid prescription for prescription-only prescription for prescription-only not a valid medications require including lower prices, greater convenience, and avoidance of embarrassment convenience, and greater including lower prices, in order to gain a better understanding of both the risks and benefits found online in the eHealth arena. risks and benefits of both the in order to gain a better understanding Medline, EMBASE, Cochrane Database of Systematic Reviews, and EBSCO databases, as well as as as well and EBSCO databases, Reviews, Systematic Cochrane Database of EMBASE, Medline, For consumers, there are many perceived benefits of purchasing prescription pharmaceuticals online, Internet pharmacies, as well as the impact on consumers and the industry of the prescription medications as well Internet pharmacies, Internet Internet medic*’, ‘online pharmacy safety’, ‘online counterfeit medic*’, ‘Internet counterfeit medic*’, sold via these portals (54) and ‘online medic* access’. and ‘online also real health risks associated with especially when Internet pharmacies, purchasing from sites that do Methodology Google Scholar, were searched for the periods January 1999 to March 2011 using search terms including including terms using search 2011 1999 to March January periods for the searched were Scholar, Google 7 A comprehensive review of the literature was conducted for each of the four main areas covered in this report main areas covered in this of the four for each was conducted literature of the review A comprehensive 2. ‘Internet ‘Internet pharmacy’, ‘online pharmacy’, ‘Internet pharmacy safety’, ‘safety online medic*’, 22 Review of the literature Availability of prescription-only drugs and lack and drugs of of clinical prescription-only Availability Safety of medications online: purchased is there cause for The literature search alsoincluded a limitedofreferences search retrieved from included articles butdid A number ofstudies have shownthatnearlyevery majorcategoryofprescriptiondrugisavailable Viagra® toconsumersbetween directly 14 April and28 April 1999. Of 4400 potentially eligible sites identify allsitesselling Viagra® search oftheInternetto online, researchersconductedasystematic Searches using terms such as “no prescription codeine” and “Vicodin” yielded prescription codeine”and“Vicodin”more300 as “nothanweb Searches usingtermssuch sites of medications called opioids over the Internet without a prescription of medicationscalledopioidsovertheInternetwithout were readilyavailable. without requiringaprescription; even thenewest andmostexpensive products(e.g. biologicalagents) treatments available of majority the selling pharmacies Internet find to expertise Internet significant of treatmentsforpsoriasis(62) . They discoveredwas afacileprocessforconsumers thatitwithout availability online the investigated researchers French 2009, In online withoutaprescription (58–65). as painkillers, but their use can also lead to dependence and serious side-effects such as respiratory colleagues and such Forman 2006, In side-effects depression. serious and dependence to lead also can use their but painkillers, as offering tosellopioidswithoutaprescription. offered butdidnotrequire aquestionnaire,and40%didnotofferanytypeofe doctor. Of these 86 sites,55% required the customertocomplete an onlinemedical questionnaire, 5% articles published in Englishand those obtainable in Englishtranslationwere considered for inclusion answer these questions. stringent legal framework forInternet pharmaciesworldwide? The discussion thatfollowsseeks to sites? And if so, is this evidence sufficient and compelling enough to warrant the development of a more Incidents highlighting the dangers of purchasing prescription medications online are widelyreported medications online in purchasing prescription the dangersof highlighting Incidents Even more worrisome, other groupsofresearchershave found itsurprisinglyeasyto purchase theclass Perhaps one of the easiest drugs to find online without a prescription is the drug sildenafil. While sildenafil However, do data exist to show there are significant risks posed to consumers by Internet pharmacy Internet by consumers to posed risks significant are there show to exist data do However, oversight concern? is used for treating pulmonary arterial hypertension (WHO treating pulmonaryarterialhypertension used for is Group I)(Revatio®),much betterknown is it in thisreview. Studies and/orlegal discussing policyimplicationsforherbal supplements, natural health returned by the search engines, 86 offered to send Viagra directly to the buyer without needing to see a see to needing without buyer send the to offered to 86 directly engines, Viagra search the by returned products or‘legalhighs’werenotincludedforreview. Listsofarticleswerededuplicated. Internet websites,greysearching authors extend to not contacting or literature, abstracts, conference them incountriessuchasHungary the media of developedabout Despitethosedangers, countries. concernsconsumersare still purchasing for itsusetotreat erectile (Viagra®). dysfunction Inoneoftheearliest studies thesaleof looking into for unpublished data. studies, Clinical feasibility studies, survey studies, meta-analyses, and review (55) , Italy(56) (60) , Germany conducted47 Internet searches fora range of opioids. (57) , andthe United States (36). (65) . are used Opioids medically valuation (58) . Review of the literature 23 used five . The ease with which The ease . (63) posed alternately as (63). (8, 58, 67) . . . (59) . The researchers were unable to determine whether the to unable determine were The researchers (61). conducted a content analysis of online medical pharmacy (66) found that 34% of Internet pharmacy sites offered to Viagra® sell to consumers in theUnited Kingdom to the authors, the results suggest that the Internet is “a relatively minor source for illicit purchases of to minor the authors, the results suggest that the Internet is “a relatively prescription medications by the end-users of these drugs” (68) national data sets from the United States (three of which to of prescription related the abuse stimulants United national data sets from the the process was still under-scrutinized. The study’s lead author was able to use the same prescriptions prescriptions same the use to able was author lead study’s The under-scrutinized. still was process the more than five times because many Internet pharmacies allow customers to fax their prescriptions to purchase, and later receive, the desired contraceptives. The investigators also noted that there was no also noted that there investigators The contraceptives. the desired receive, later and to purchase, for offers of additional products medical follow-up to these sales except percentage that asked women if they were pregnant or breastfeeding. Even more telling was the fact pregnant or breastfeeding. were women if they that asked percentage by a health- on diagnosis provided a medical the customer if the purchase was based that only 19% asked medical questionnaires offered by 59% of sites were required to be completed prior to purchase. offered by 59% of sites were required medical questionnaires included in this study queried why the lead author had a prescription from a doctor in Indiana when in Indiana when from a doctor had a prescription author lead why the included in this study queried individuals are able to purchase controlled able prescription are substances also suggests there is individuals without a valid into question. Orizio and colleagues into question. he lived in Washington, DC. Washington, DC. in he lived by online pharmacies exist more as a marketing ploy to convey a sense of security and assurance than to sense of security and a ploy to convey marketing as a exist more by onlinepharmacies questionnaires to examine their completeness. While nearly all questionnaires (97%) asked if the While nearly all questionnaires (97%) asked questionnaires to their completeness. examine Despite the relative ease of acquiring medications like opioids, Inciardi and colleagues (68) ease of Despite the relative acquiring medications like reported that even when ordering from Internet pharmacies requiring prescriptions, prescriptions, pharmacies requiring when ordering from Internet and Hess (59) reported that even Bate and opioid analgesics) to estimate who is using non-prescribed medications purchased online. According According online. medications purchased non-prescribed who is using and opioid analgesics) to estimate and do not contact the doctor who wrote the prescription. None of the Internet pharmacies (n=55) ample opportunity for prescription drug abuse as it may increase the risk of contraindications interactions treatment or by delaying or drug-drug side-effects and adverse reactions bynot accounting for potential accurately assess health status and actual need for the medication (66) assess health status accurately care professional. According to that questionnaires the authors, these results suggest provided medical According care professional. contraceptives or contraceptive patches a prescription. entering known without risk factors Despite for able were sites, the researchers targeted three by two of the on estrogen use the questionnairesprovided customer had any drug allergies, other types of allergies were only queried by 70%, which the same only by 70%, was were queried types of allergies other allergies, customer had any drug user” who woman tobacco was obese and a heavy and a woman”, a “35-year-old a “healthy 25-year-old control the sale of potentially dangerous medications, Memmel and colleagues control of potentially dangerous medications, Memmel the sale without any consultation form of medical Medical questionnairesMedical The unfettered availability of prescription medications online poses a significant danger to patients To the information on test whether Internet pharmacies actually use health questionnaires provided to To The validity and reliability of medical questionnaires hosted on Internet pharmacies sites has been called questionnaires sites has been hosted on of medical pharmacies Internet and reliability The validity The online sale of sildenafil has not changed muchin a A decade. morerecent study conducted in 2010 “35-year-old smoker on to and attempted purchase combination an antihypertensive medication”, oral smoker “35-year-old 24 Review of the literature This situation has improved situation butremainsunresolved.RecentThis 2009studies in and2010than less foundthat Three years earlier the Office of Compliance in the U.S. Food and Drug Drug Administration’s and for the Food Center in U.S. ofthe Compliance Office earlier years Three Additional tests discovered that more than half of the samples (55%) had different formulations compared Veronin and Nguyen (67) Counterfeit drugs may be contaminated, contain improper ingredients, incorrect ratios of the proper Counterfeittheproper drugs maybecontaminated,of containimproperingredients,ratios incorrect (dissolution and purity), callsintoquestionthebioavailability which and safety oftheseproducts. Safe Medicines (EAASM)stated intheirreport, The counterfeiting superhighway, that 62% ofmedications variability hasimplicationsforthesafetyandeffectiveness oftheonlineproducts. obscure theirphysicaladdressarecounterfeitinmorethan50% ofcases(71). and theirquality. Similarly, medicinesobtained fromillegalthat that Internet sites found that has WHO shipped the order from Shanghai (according tothepostmark), and labelled their tablets with thename of address in British Columbia, received the initialmoney transferforthemedication purchased in Panama, was the online pharmacy that described itself as an “off-shore company based in Cyprus,” listed a contact dollars; however foranypurchase made, they charged in Chinese orIndian currency. Evenmore convoluted pharmacies claimedbe online tobased in the Canada or United in their sites States andpostedpriceson samples failed to meet USP standards for dissolution,and two failed uniformity.for content All 19samples supplier purchased fromalocal products compared to from foreignsources online or treat serious healthconditionssuchasheartdiseaseordiabetes. The European Alliance for Access to In 2010, researchers purchased five popular drugs from various Internet pharmacies Internet various from drugs popular five purchased researchers 2010, In In 1999, Bloom and Iannacone Bloom In 1999, been straightforwardaboutrevealingalways Internet pharmacieshavenot wheretheyare located. Deceit about location raises concerns about an Internet pharmacy’s validity, its source of medications of source its validity, pharmacy’s Internet an about concerns raises location about Deceit Evaluation and Research commissioned a study to evaluate the quality of five drug products purchased products drug five of quality the evaluate to study a commissioned Research and Evaluation Counterfeit medications substandard and half ofInternetpharmacywebsitesdisclosetheirlocation,43%and48%respectively(70,61) had issues withhardness, weight, andcharacteristics. other physical According totheinvestigators,this nentoa Itre pamce ad oprd hm o h Uie Sae invtr rdc. Five product. innovator States United the to them compared and pharmacies Internet international ingredients, containnoactive ingredients,allofwhichcanbeverydangerousforpeople tryingtomanage the brandnamepharmaceuticalcompanythatsellsitand“USA” (59) provided information concerning their geographic location beyond what information was offered online. to the United States product,whichisaseriousqualityissue. received and tested, two failed United States Pharmacopeia (USP)monographsforqualityattributes purchased online are fake orsubstandard(e.g. expiredorimproperly storedduringdelivery)(72). Internet pharmacy locations pharmacy Internet investigated 19 generic medication tablets and capsules they purchased from (69) found that only five Internet pharmacies in a sample of 46 (11%) 46 of sample a in pharmacies Internet five only that found . (73). the 20Of samples (59) . Three of these . Review of the literature 25 . (78) found that packaging that (73) found (71). . In these areas, where the social stigma for a condition the social stigma where . In these areas, (76, 77) investigated the packaging of 41 drug products obtained from online from online obtained products drug (75) investigated the packaging of 41 like like erectile dysfunction is even more pronounced, Internet availability of drugs like sildenafil without , quality control studies regulatory controls well as the lack of drugs as legitimate (74) and enforcement treat conditions like malaria, tuberculosis, and HIV/AIDS malaria, tuberculosis, and treat conditions like them susceptible to the same model the same to susceptible them this, however, may only reflect a time-lag of the medium: as some medications targeted bypharmacies (e.g. Internet sildenafil) are being increasingly used in parts of Latin America(e.g. Brazil, Colombia, pharmacies generally outweigh the potential benefits for consumers. It must be noted the research products did not have labels at all. According to the authors, these substandard distribution processes processes substandard distribution to the authors, these According products did not have labels at all. present a challenge to patient comprehension and health literacy and may affect the patient’s pharmaceuticals are purchased over the Internet. Westenberger and colleagues Westenberger the Internet. over purchased are pharmaceuticals pharmacies from 12 different countries. Of these samples, seven were dispensed in paper envelopes to the prescription container may be the only of source instructions a patient has on how it should be The container taken. is also the only mechanism used to maintain a product’s strength, identity, quality involving a prescriber may further exacerbate public health concerns (i.e. erectile dysfunction has a health concerns erectile public (i.e. exacerbate may further involving a prescriber have been conducted predominantly in North America and Europe. A exception notable is by a report America and Europe. conducted have been in predominantly North Packaging and labelling Packaging Ecuador, Venezuela) as well as Africa and the Middle East (e.g. Egypt, Morocco, Nigeria, Pakistan) making Pakistan) Nigeria, Morocco, Egypt, East Africa and the Middle (e.g. as as well Venezuela) Ecuador, Based on this literature review, the the risks of purchasing prescription pharmaceuticals from Internet Based on this review, literature Despite its importance to consumers, packaging and labelling is often absent or deficient when More recently, Veronin More Veronin recently, strong association with coronary heart disease, which may go untreated if patient is self-medicating) strong association with coronary if patient is which heart disease, may go untreated self-medicating) anti-cancer medications, or “lifestyle drugs” while those in developing countries commonly to are used while those anti-cancer in medications, or “lifestyle drugs” developing contained in this review primarily focuses on North America and Europe; conclusions America conclusions and Europe; drawn from these primarily focuses on contained North in this review No research on this topic the situation in these areas. to describing limited be must therefore, data, was identified from developed or developing countries elsewhere in the world. A possible reason for adherence to their drug treatment regimen. adherence with an affixed label that was missing important information, as directionssuch for while 28 use, and purity. Child-resistant packaging also protects young children from accidental overdose or overdose poisoning. Child-resistant packaging also protects young children from accidental and purity. was a significant problem for practically all of the samples they purchased online during their study. Many study. their during online purchased they samples the of all practically for problem significant a was of the product, and usage had no information the proper on regarding of the drugs or minimal their labels some were written in foreign languages. WHO stating counterfeit medications found in developed countries are generally expensive hormones, expensive generally countries are in developed WHO counterfeit medications found stating While developing countries to for obvious targets are due both medications, counterfeit the high cost While developing of A drug’s packaging and labelling is an important safety feature. After purchasing a drug, the label affixed label the drug, a purchasing After feature. safety important an is labelling and packaging drug’s A Summary 26 Review of the literature At least one study has shown that consumers can reduce the risks associated with buying prescription At leastonestudyhasshownthatconsumers canreduce therisksassociatedwithbuyingprescription While scientific research into the effectiveness of these types of regulatory initiatives is scarce, Boyer scarce, is initiatives regulatory of types these of effectiveness the into research scientific While While data are not globally representative, there is sufficient evidence to back calls forstricter calls toback evidence sufficient is there representative, globally not are data While what needstobe done. Box2showsamodel toverify the veracityofInternet pharmaciesbeingused will helpdetermine the limitsofcurrent legislationinthisarea andprovideamore in-depth picture of com) intotheir processes have been found todeliver unverified pharmacywebsites(80). even and pharmacies; Internet find to engines search use predominantly still consumers as challenge a or “notrecommended” web sites (O outof86)failed,whereas 8.6%(3outof35)failed from“highlynot categories providedbythe NABP. Of the drugsanalysed, nonefromthe“approved”, “legally compliant”, a listofweb siteslikely tosellpotentiallyharmfulorillegal drugs. A programme withsimilaraimswas analgesics offeredforsale. and Wines as EAASM,founded2007,purchased theInternet,suchin counterfeit medicines,thoseon notably and fight to organizations of creation France); in Laboratory Anti-Counterfeit Central Sanofi-Aventis the of It canbe concludedfromthis literature review thatconsumers needprotectionfromthe dangers tested the quality of five popular drugs purchased from web sites listed in the various various the in listed sites web from purchased drugs popular five of quality the tested Bate andHess(59) National Association ofBoardsPharmacy(NABP)(59). The NABP, with the support of the FDA, maintains inauguration 2008 (i.e. laboratories anti-counterfeit of creation counterparts; European its and FDA, have been undertaken byinternationalbodies: guidance by the World Health Organization, the U.S. in Canada andthe United States. international policeenquiries. posed byInternet pharmacies. The resultsfromthe2009 eHealth survey presented laterinthis report those search engines thatpurportedly integrate qualityrequirements (such asthose byPharmacyChecker. recommended” and unidentifiable web sites. Nonetheless, just creating awareness of these tools remains opioid like medications prescription of availability the in decreases significant to lead may pharmacies of intensification the and (IMPACT);TaskforceAnti-Counterfeiting Products Medical International the medications onlinebyrelying onthe listsofrecommended sitescompiled bycredentialingagencies like the regulation of Internetpharmacies. Mahe As andcolleagues (62) have delineated, multiple initiatives launched bytheRoyal Pharmaceutical Society of Great Britain(RPSGP)withitsgreen crosslogo.In2010, (79) foundthatincreasedregulation of, andlawenforcementoperationsdirected at, Internet Review of the literature 27 (81). VIPPS Canada (86). Courtesy of the National Association of Boards of Pharmacy Courtesy of the National tested the quality of five popular drugs purchased from (83). Notable among In 2010, Bate and Hess (59) Bate and In 2010, (59). —Dr Carmen Catizone, Executive Director of the National Association of Boards of Pharmacy of the National Catizone, Executive Director Carmen —Dr VIPPS empowers the public to make informed decisions about pharmacy practice. It also Internet VIPPS empowers the to public make serves as a valuable tool to help distinguish safe Internet pharmacies from Internet sites and drug to public health (84). outlets that are dangerous and a threat /. http://www.nabp.net/about At least one study has indicated that consumers can the risks reduce associated with buying prescription medications online by relying on the lists sites of recommended compiled by credentialing agencies the NABP like It is recommended that those seeking Internet pharmacy services should consider beginning with a search Internet that those seeking It is recommended the status of an to verify anyone to allow resource NABP a site (85). has created VIPPS approved for a users of these Potential Internet pharmacy by its resource locator (http://vipps.nabp.net/). uniform (URL) of themselves medications by availing counterfeit of receiving the chance also reduce types of sites may VIPPS process Internet pharmacies that have undergone the web sites listed in the various categories provided by the NABP. Of the drugs analysed, none from the web sites listed in the by various categories provided the NABP. 8.6% (3 out whereas out of 86) failed, sites (0 web recommended” compliant” or “not “legally “approved”, of 35) failed from “highly not recommended” and unidentifiable web sites. issues some of the global solution a scalable to address VIPPS may represent after modelled A programme facing Internet pharmacies. The NABP comprises member boards from all 50 United States and eight Canadian provinces along with Canadian provinces along with States and eight United 50 boards from all The NABP comprises member in “developing, members Islands. Its mission is to assist its Virgin the and Guam, Rico, Puerto Zealand, New In health”. protecting the public of and enforcing for the purpose uniform standards implementing, response to concerns mounting public health NABP safety of pharmacies operating online, about the created the Verified Internet Pharmacy Practice Sites (VIPPS) programme in 1999 One model of verifying Internet pharmacies: case case pharmacies: Internet model of verifying 2. One Box Northfrom study America In order to obtain certification and display the VIPPS seal, Internetpharmacies must satisfy 19 authentication of prescription orders, and demonstration of a including assurance of patient safety, criteria sites on hyperlinked is logo the legitimacy, For consult. pharmacist-patient a establish to offer meaningful the The hyperlink will not using work on sites fraudulently home page. that display it to the programme pharmacy sites NABP Internet has reviewed, Of the 8034 logo. 8034 standards of practice; complyless than 4% with good as categorized “not were recommended” years following the initial application. three every reviews mandates Maintenance of this accreditation have pharmacies brick-and-mortar 12 000 over representing So far almost 30 pharmacy companies completed the verification process. followed thereafter as a partnership between NABP and Canada’s by supported lone consumer safety programme VIPPS is also the Authorities Regulatory (82). (NAPRA) National Association of Pharmacy States. United Administration in the Enforcement the FDA and the Drug criteria unsatisfied for those “not recommended” were 6812 which did a prescription and 5089 not require sites that did While only 260 Internet relationship. not a pre-existing require pharmacy to this sites be potentially appeared legitimate, does year. represent a 15% increase from the previous 8 8 28 Review of the literature ‘pharma* phishing’. 2 There are a handful of scientific studies investigating the relationship between consumer behaviour consumer between the relationship investigating studies scientific of handful a are There The literature search alsoincluded a limitedofreferences search retrieved from included articles butdid Scholar, were searched for theperiods January toMarch20111999 usingsearchtermsincluding‘spam While many people find these messages annoying and intrusive, they also pose a potential threat to threat potential a pose also they intrusive, and annoying messages these find people many While Unwanted, usuallycommercial,anumber messages comeinofforms.Internetusersareprobably can Methodology of irritation caused. of irritation Women generallyseemdisliketo men duethesexualnatureof spammorethanto amount the and intrusiveness advertisement’s the of perception their to correlated inversely was spam and spame-mail. Morimoto and Chang exclusively frommedicationandsexuallytargetedadvertisements generated was 39% (n=1390), spam of subset the of that found e-mail of composition the examining as spam also known articles published in English and those obtainable in English translation, were in obtainable translation,consideredforinclusion articles publishedandthoseinEnglish in English spamming throughsocialnetworkingsites(e.g. Twitter) arealsoontherise(88,89). messageor short service (SMS), unwanted IM or commercial informationare SMS containing sessions arenas. enter othercommunications messaging (IM) With theincreaseduseofinstantandtextmessaging commercial messageshaveontheirrecipients. deceptiveness increasedto69%inhealth-relatedspam. Medline, EMBASE, Database Cochrane of Systematic Reviews, databases, and EBSCOaswell as Google Receiving unsolicited e-mail messages that are sent inbulk without thepermissionofrecipient, Practices’ False claims in spam report spam in claims False Practices’ Pharmaceutical health-related spam,spit spim, and and Does affect spam consumer behaviour? Despite its prevalenceDespite its health-related studies onspamhave few originalsystematic andpotentialrisks, health, ‘spam medic*’, ‘spam e-mail’, ‘spam drug*’, ‘pharma* spam’, ‘pharma* e-mail’, ‘junk e-mail’, and been conducted. Researchers have only just begun to investigate the effects spam and other unsolicited other and spam effects the investigate Researchersto conducted. begun been just only have it was the sender’s name, the recipient’s name or information within the body of the message. This message. the of body the within information or name recipient’s the name, sender’s the was it this review. Listsofarticleswerededuplicated. Internet websites,greysearching authors extend to not contacting or literature, abstracts, conference now appearing. This issometimes known as“spim”or“spit”(spam over Internettelephony)(88),and most familiar with spam e-mails; however, withthegrowthofonlinetechnology, spammers have begun to those who engage with them. According to the U.S. Federal Trade Commission’s Division of Marketing of Federal TradeU.S.Division the Commission’s to Accordingthem. with engage who those for unpublished data. Clinical studies, feasibility studies, survey studies, meta-analyses and review .2 Internet security (14), isamajorproblem for people using Internetcommunications. One casestudy (90) found that the favourability of a recipient’s attitude toward attitude recipient’s a of favourability the that found (91) , 66% of alle-mailfalseinformation,whether , 66%spamcontained (87) . Review of the literature 29 Age may be a factor in the widely a be may Age received 4153 spam messages in 4153 spam messages received . As in their previous study, some of some study, As in their previous . (99) (92, 94–97). found that older adults are more likely to report found that older adults are more likely (92) . investigated 200 recipients’ responses to spam e-mails advertising sexual . Despite the negative feelings people have about spam, they do not appear to be to be do not appear they spam, about have people feelings the negative . Despite (98) the more valuable commodity. provided to the ostensible customer to indicate if the transaction was successful. While 13 sites did not While 13 to provided the ostensible customer to indicate if the transaction was successful. they purchased 13 prescription prescription drugs and 6 natural health products. During the ordering process, four 13 purchased they three separate e-mail accounts opened in Canada. Of these messages, 1334 (32%) were health-related. were (32%) 1334 Of these messages, Canada. in opened accounts e-mail separate three much of its contentmuch of its (92) the participants had weight issues while some did not. Similarly, the participants with weight problems the participants with weight Similarly, not. some did weight issues while the participants had received (87.7% vs. 73.3%, p=0.02), opened (41.5% vs. 17.8%, p<0.001), and bought products (18.5% vs. performance problems may not perceive spam advertisements as negative and intrusive since they are since as and intrusive spam advertisements negative they performance problems may not perceive performance products. Some of these participants had sexual performance problems while others did while problems performance sexual of these participants had Some products. performance (100% received problems performance with sexual that participants of the study showed The results not. purchasing a product from a spam e-mail than younger ones, although being affectedby socially a by sexual performance problems may be so driven to enhance their sexual performance that they will they that performance so to enhance their sexual may be driven problems performance by sexual have purchased products advertised through spam e-mails through spam products advertised purchased have Reliability and validity of health products purchased from Reliability and products health validity of purchased from Fogel and Shlivko actually process the order, all of them recorded the full set of personal information provided, arguably set of personal information provided, the full recorded of them all actually process the order, web sites stopped working after the credit card information was submitted; no further information was no further the credit card information was submitted; after working sites stopped web available for free or at very low cost. available for free or sufficiently motivated to take much personal action against it. According to a study conducted by Grimes Grimes by conducted a study to According it. against action personal much take to motivated sufficiently who received spam e-mails advertising weight-loss products (17) weight-loss advertising e-mails spam who received offering a product of interest (98) consider any product or potential solution, even if it comes from a less-than-reputable source; 2) e-mail is if it source; 2) e-mail consider any comes from a less-than-reputable product or potential solution, even to the due products from a pharmacy the same to purchasing preferred and may be media a very private 3) those with sexual performance; sexual like that often surrounds sensitive health issues embarrassment stigmatized condition may be a contributing factor as well. may be a contributing factor as stigmatized condition spam e-mails via spam e-mails. During November 2006, Gernburd and Jadad and Gernburd 2006, November During e-mails. via spam versus 73.5%, p=0.024), opened (66.7% versus 11.4%, p<0.001), and purchased more products (46.7% than participants without sexual performance problems. versus 5.4%, p<0.001) from spam e-mails varying range of purchases. Grimes and colleagues Grimes varying range of purchases. While the majority of people take no action to filter spam, anywhere between 4% and 66% of people (93), most e-mail users have not installed anti-spam filters despite the numerous filtering programs One study of note was conducted investigating the actual process of purchasing health-related products One study of note was conducted investigating the actual process of purchasing health-related 5.2%, p=0.003) from spam e-mails more often than those without weight problems. from spam e-mails more often than those without 5.2%, p=0.003) A similar study conducted in 2010 by those researchers focused on the behaviour of 200 young adults focusedon of 200 by those researchers the behaviour study conducted in 2010 A similar Throughout the last week of the study, the authors received 19 health-related spam e-mails from which spam e-mails the authors 19 health-related received Throughout the last of the study, week The authors speculated that the increased interest in spam e-mails was three-fold: 1) those affected 30 Review of the literature Summary 30 millionpiecesofspamadayafter (100).However, thislegislationislargely based onobservational work. 150 millionpieces ofspamadayontheircellphones before thepassage ofanti-spamlegislationandjust Some legislationandotheranti-spamming initiativesemployed byMember States haveshownpromise. Out of the 19 orders placed Out ofthe19byauthors,5prescriptiondrugs and 4 natural health productswere consumers andenhancingprogrammaticsupport,spam willbe nearly impossible toeradicate. and search forsolutionstohealthandlifestyleproblems,thenumberofe-mails, textmessages, and enforcement intherarecaseswhenconsumerstriedtoreportincidents spammers because half-lifeof theshort of theassociatedlinks(i.e. approximately 2 weeks). According to card informationappeared to be abused. fraud The onlythatwasdetectedstudybyonesite in this delivered, examined. of theseproductswasnot although thequality Surprisingly,of thecredit none Hope andgreedare powerful motivators, soasmorepeoplearoundtheworldbegintoaccess theInternet Internet pharmacies (see Section 2.1), it would stand toreasontherisks ofpurchasingmedicationsonline For example, in Japan, the 38 million customers using DoCoMo, Japan’s largest wireless company, received Even iftheproductspurchased were defective or harmful, could be very littleactiontaken againstthe For example: Because ofthelackpublishedstudies;thisliterature review raisesmore questionsthananswers. to matchthedemand (99). Therefore,without increased research intothemotivationsofspammers and mobile web solutions offering promises, legitimate or otherwise, will undoubtedly increase and customize the spammers could largelydisappear without atrace,it precluded real being any actiontaken bylaw the authors,bytime the productswere delivered the spammers had become “virtual ghosts”. Since through spamwouldbecongruent. was nevera productthat payment for took that delivered. However,with basedresearchconducted on • • • • • • Are consumers aware of the dangers of spam? Does this knowledge (or lack thereof) affect thereof) lack (or knowledge this Does spam? of dangers the of aware consumers Are Are products purchased through spam links safe and effective? Or are they counterfeit and counterfeit they are Or effective? and safe links spam through purchased products Are What typeofpeopleopen,read,andactuponspammessageswhy? What aretheincidenceandeffectsofvirusesmalwarecontainedinhealth-relatedspam? substandard? How muchofspam-linked contentisvalid,andwhichpartofaphishingscam? How does spam affect consumers’ attitudes toward the pharmaceutical industry and online and industry pharmaceutical the toward attitudes consumers’ affect spam does How health information? their behaviour? (99) . Review of the literature 31 (30, 106). (30, . Considering the level of their Considering the level (105). . More specifically, the Pew American Internet. the & More specifically, to Turkey (104) to Turkey . The single biggest risk in social circles The single biggest media (107). (108). (103) and Qatar 3 Online safety of children and adolescents of 3 Online safety . for unpublished data. Clinical studies, feasibility studies, survey studies, meta-analyses and review review and meta-analyses studies, survey studies, feasibility Clinical studies, data. for unpublished reported sending or posting nude or semi-nude pictures or videos of themselves online. Of these teens, online. pictures or videos of themselves sending or posting or semi-nude reported nude A survey conducted in 2008 by The National Campaign to Prevent Teen Teen Campaign to Prevent The National by conducted in 2008 A survey brain maturation (109). related putting themselves into compromising situations. Adolescents, in particular, are liable to adopt risky to adopt liable are Adolescents, in particular, into compromising situations. themselves putting this review. Lists of articles were deduplicated. this review. not extend to searching Internet web sites, grey conference abstracts, literature, or contacting not extend to authors searching grey Internet web sites, they are increasingly targeted for exploitation, sexual and emotional abuse, and maltreatment abuse, and emotional for exploitation, sexual increasingly are targeted they may be the individual’s complete “lack of control over where the information is going, how it” posted, and who is going to be able to access it will be to online risk and can also become easy targets for online predators. also become easy targets for online to online risk and can ranging from Argentina to Guatemala Guatemala Argentina to ranging from popular pastimes for children. This is due, in part, to the fact that over 90% of children and adolescents and of children 90% over to the fact that in part, is due, This for children. pastimes popular in developed countries have access to the Internet (101) countries have access in developed behaviour without considering consequences due to underlying neural and cognitive factors age- to underlying neural during without considering consequences behaviour due Children and adolescents online without supervision and adolescents Children useful forum for child predators. Since children have easy and often unsupervised access to the Internet, access often unsupervised easy and Since children have predators. for child forum useful Medline, EMBASE, Cochrane Database of Systematic Reviews, and EBSCO databases, as well as Google as as well and EBSCO databases, Systematic Reviews, of Cochrane Database EMBASE, Medline, By being able to disguise their identity, sexual predators have a great advantage of being able to target able of being advantage a great have predators sexual their identity, to disguise By able being Internet’, ‘adolescent activity Internet’, ‘teen* activity Internet’, and, ‘child* OR teen* predators’. ‘teen*Internet’, ‘adolescent activity Internet’, activity Internet’, and, ‘child* . robust use Rising or (102) years) use the Internet Project that Life found 93% 12–17 of youth (i.e. aged It is normal today for children and adolescents to base their extracurricular activities around the Internet. around the Internet. activities extracurricular their to base and adolescents today for children It is normal and Unplanned Pregnancy found that 22% of teenage girls and 18% of teenage boys (aged 13–19 years), 13–19 boys (aged of teenage 18% girls and of teenage Unplanned Pregnancy found that 22% and articles published in English in Englisharticles published and those considered for inclusion obtainable translation, in were child* safety, ‘online child* health’, ‘Internet child* safety’, ‘Internet child* access’, ‘child* activity and approach their young victims in many popular forums such as chat rooms and social media platforms such forums as chat rooms and social media and approach their young victims in many popular connectivity and a transient lack of supervision and controls in place, children and adolescents are subject are adolescents and controls children and in place, transient lack of supervision connectivity a and of the Internet by children and adolescents has also been noted in research in many other countries in research in many other countries noted been children and adolescents has also of the Internet by Methodology With access to video games, chat rooms, and social networking, being ‘plugged in’ is one of the most Scholar, were searched for the periods January 1999 to March 2011 using search terms including ‘online using search terms 1999 to March 2011 January the periods for searched were Scholar, (e.g. Facebook, Twitter) without Twitter) (e.g. them Facebook, ever knowing Children and adolescents are using their online access without restriction and can be unaware they are without restriction and can they be unaware Children and adolescents are using their online access As use of the Internet has greatly increased over the past twenty years, so has its role in becoming a in becoming so has its role the past twenty years, over increased has greatly the Internet of As use The literature search also included a limited search of references retrieved from included articles but did from included search retrieved a limited of references search also included The literature Are children and adolescents at risk when online? when at risk and adolescents children Are 2 32 Review of the literature ‘friends’ or ‘relationships’ forged online. Without cautionary guidelines for children who go online, there is is there online, go online. who forged children ‘relationships’ for guidelinesor cautionary ‘friends’ Without The link between children child and online pornography Summary At the least,Member At of sendingpersonal fostering awarenessoftherisks States shouldconsider 15% reported that they sentthese sexually suggestive images of themselves to someonetheyknew only , it is difficult to get a clear picture on the severity of this risk. There is also a lack of a consensus of a lack also is There risk. this of severity the on picture a clear get to difficult is it (116), (118) With little research being done concerning the numbers of children abused by child pornographers online abused child the numberschildrenby of little researchbeingdoneconcerning With With children With children andadolescentsaccessingthe Internetunsupervised for lengthyperiods of time every day Without knowingtheactualidentityofperceived friends and relationshipsforged online, childrencould With children and adolescents accessing andadolescents With children and the Internetunsupervised andengagingdiscussions in situations with predators;alsoleadbullyingorunwantedsexual situations itcantoadvancesbytheirpeers. A study or informationsharedlimited by childrenandadolescentsonlineisnottoplacingthem in compromising or restrictionsonthe sitesthey are accessing andthe amount ofpersonalinformationthey are providing to and adolescents using the Internetforlearning orimprovingskills,there isobviously aneed forregulation of sexual predators online or are aware of the consequences of sending sexually explicit photographs of sending sexuallyexplicitphotographs of the consequences are awareof sexualor of predatorsonline an increasedprobabilitythatthey willexperience exposuretosomesortofexploitationduringtheirusage. online, usually to be “fun or flirtatious” children revealed that13.6% ofchildrenwerethevictimcyberbullying which sexuallysuggestivephotosand/ormessagesaresentviamobilephone children andadolescentstargetedbyonlinechildpornographerssexualpredatorsisunknown. Based ontheevaluation ofthisliterature review concerningtheonline safetyofchildrenandadolescents, been messages sent ofasexual content be encouragingunwittingly sexual predators. Online predators willattempt to leverage relationships with information andphotosonline throughschoolcurriculaand/ormeetingsbetween parentsandteachers. in the United Kingdom found that more than a third ofthe2000 surveyed childrenhad secondary school these vulnerable manipulate populations inordertobehaviour (112) regarding an association between predilections to commit real-life offenses and collecting child collecting and offenses real-life commit issue this to may haveslowedresponses that pornography to predilections between association an regarding targeting bypaedophilesandchildpornographers theyunfortunate, butunsurprising, that a sexualnature,is pictures ofitsusceptibleto would behighly this age group can be characterized as at-risk when online. Although there are many benefits to children children to benefits many are there online. Although when at-risk as characterized be can group age this themselves via the World Wide Webvia themselves phones among all age groups, therebeen has consequentlyanincreasein“sexting”among teenagers in , further research needs to be conducted on how many childrenareactuallyaware , furtherbehow of thedangers researchneedstoconductedon (119). (110) (113). study generated Another from data behaviour WHO onin . Similarly,ubiquitous natureofmobile duetheincreasingly to (115). (117) . Hence, the extentandmagnitude Hence, of . . However, sexuallyexplicitphotos (114). (111) . Review of the literature 33 . (123) (128), This, to in turn, led the ) to guidelines from WHO ) to from guidelines (120, 121). (120, on web sites in English, French English, in sites web on , and sexual health (127) (126), and sexual (131–136). . These results have led to These results have led calls for improving or certifying the quality of . (138–143) , among others. More recently, with the rise of social media, health information health with the rise of social media, others. recently, , among More (130) , medications , medications (125) , malaria (124), malaria , Spanish Spanish , (129) /) to vetting DISCERN (http://www.discern.org.uk created ranging from checklists were like Tools 4 Digital literacy and online health information quality and online health information literacy 4 Digital . for unpublished data. Clinical studies, feasibility studies, survey studies, meta-analyses and review review and meta-analyses studies, survey studies, feasibility Clinical studies, data. for unpublished this review. Lists of articles were deduplicated. this review. not extend to searching Internet web sites, grey conference literature, abstracts, or contacting not extend to searching authors Internet web sites, grey the validity, accuracy, and completeness of online health information, with a large number of studies completeness of online of and health information, with number a large accuracy, the validity, is being shared via blogs, social networking sites, Twitter, and in particular Wikipedia; the quality of these Wikipedia; and in particular Twitter, via blogs, social networking sites, shared is being information is accurate and appropriate, offers enormous potential for informed decision-making and health health information online. However, ensuring there is accurate and complete health content available is ensuring there accurate health information online. However, quality that of information and its expressed were potential impact Evaluations of online health information quality have since been conducted for topics such as women’s Medline, EMBASE, Cochrane Database of Systematic Reviews, and EBSCO databases, as well as Google as as well and EBSCO databases, Systematic Reviews, of Cochrane Database EMBASE, Medline, Italian Internet health information’, ‘online OR Internet Internet health health information’, information ‘online quality’, ‘quality online information’, systems such as the HON Foundation (See Box 1) (http://www.hon.ch (122, to online of hundreds of instruments information being created measure health quality (122, development sources is now being examined as well articles published in English articles published and those in English obtainable translation, considered for inclusion were in suggesting significant deficiencies in quality for online patient-oriented information covering variety a of medical conditions . As a result, much emphasis has been placed on placed has been much emphasis As a result, . of patients in their own care (137) participation greater it. must be able to find and access online is not enough; information seekers Methodology Scholar, were searched for the periods January 1999 to March 2011 using search terms including ‘online OR using search terms including ‘online January 1999 to March 2011 were searched for the periods Scholar, After health information started to appear online, along with the promise it offered, concerns about the 123). The literature search also included a limited search of references retrieved from included articles but did from included search retrieved a limited of references search also included The literature The Internet is a quick, convenient and private means for obtaining medical information, and when such when such information, and for obtaining medical means The Internet is a quick, convenient and private 2 ‘digital literacy’, ‘Internet literacy’, ‘search engine*’, OR ‘online Internet health information accessibility’, OR Internet information’. online OR Internet information’, and ‘evaluate ‘assess online 34 Review of the literature The role of search engines Searching for health information content online: is quality Three categories of searchenginesare available to help health information seekers retrieve information 145, 146, 148, 149). This issue is particularly germane as new research has demonstrated up to onethird A wealth ofhealthinformationiscurrentlyavailable on theInternet, and as previous studies have shown, A web site’s ranking within search results is extremely important because sites listed on the first page first the on listed sites because important extremely is results search within ranking site’s web A 146). But do search engines retrieve146). Butdosearch thehighestqualityhealthinformation? And more importantly, does While generalimproved search engines havevastlyuser accessto onlinehealthinformation,thecriteria with a specific health-related question, nearly all Internet users (more than 95%) use a search engine (145, sites of online searches for prescription drugs were the subject of search-redirect attacks; in effect the high- the effect in attacks; search-redirect of subject the were drugs prescription for searches online of sites, general search enginesare the mostcommonstartingpointsforhealthinformation searches(102, engines are much more specific, as they only catalog online medical information. Such searches generally Finally, theresults(147). collate generalengines and then a selectgroupofsearch within search medical as engines such search Google, Yahoo!,were and Bingdesigned beuser-friendly to programsforsourcing are “significantly more likely to be accessed by health information seekers, with an exponential decline exponential an with seekers, information health by accessed be to likely more “significantly are web site,thesearchterminologyemployedbyuser, andanyuseofpaid placements Despite the fact there are search engines specifically designed to retrieve information from selected web easily accessible?easily used to identify and rank health-related web sites vary considerably among search engines, andthe amongsearch identifyand rankhealth-relatedconsiderably used tovary web sites information via the Internet.Meta-search via enginesweredevelopedinformation perform to simultaneoussearches the qualityofinformationpresented varies greatly. Butwithwellover100000 health-related web make educatedhealth-relateddecisions? the waypeoplesearchesandassessresultsprovide conduct them with informationthey canuse to ranking linkswerere-routedtoinfectedhostpharmacysites(150) . retrieve fewer, butmorerelevant, results. thereafter” (145,146,152).thereafter” returned by a search engine depends on its specific algorithm but may include variables such as the as such variables number of times a web site hasbeen accessed from the results page, of the the structureand content include may but algorithm specific its on depends engine search a by returned results the within ranking site’s web A users (151)apparent to not is ranking resultsoften method for . from the Internet:general search engines, meta-search engines, and medical search engines. General (144), it isimpossible forinformationseekers tosurf through them all. As a result, when confronted (151). Review of the literature 35 asserted (153) observed that observed examined the search strategies of 68 (146) examined (156, 157). (156, . According to a 2009 study conducted by Laurent and Vickers (160), Wikipedia Vickers and study conducted by Laurent to a 2009 According . observed similar techniques among adults. The general search strategy of The general adults. techniques among similar (145) observed (159) . (158) Wikipedia is the world’s largest reference web site and is the most successful million articles have been generated and edited in and edited English many of which alone by volunteers worldwide, million articles generated have been many of the top results are so-called sponsored links, meaning the web site owner has paid the search has paid site owner the web sponsored links, meaning so-called are many of the top results the quality of information retrieved by the search engines they utilized was very low. They also found that also found They was very low. utilized they by the search engines the quality of information retrieved that users need to be educated about how search that to and display their results and be trained users need be educated engines prioritize Another author cautions, however, information. reliable sites for health web to systematically evaluate remembered, from which web sites they had gathered information. Buhi and colleagues had gathered from which sites they web remembered, their participants was to try a number of initial search terms and briefly examine the contents of a page . to users (152) the quality of health information available to health-related questions to questions online. health-related Hansen and colleagues when answering health-related questions. the source of the information them and did not consider three per cent of participants clicked on links that appeared within the first nine results returned by the is often Wikipedia been raised over whether Wikipedia provides accurate information about health and medical topics. Two Two topics. health and medical information about accurate provides Wikipedia over whether raised been before iteratively refining their search. According to the authors, few According of the participants noted, and later before iteratively refining theirsearch. Quality of search engine results engine Quality search of Eysenbach & Köhler How do health information seekers search for information? for search seekers information health do How are on medical topics topics on medical are Wikipedia content are discussed below. studies assessing the quality of example of a ‘wiki’, a site collaboratively written by its users. Since it began in January 2001, more than 3.3 than more 2001, January in began it Since users. its by written collaboratively site a ‘wiki’, a of example tested. they keywords health-related for engines search of 71–85% in results ten first the within listed was engine for higher placement commercial web sites appeared much more frequently within the top 20 results returned by the search results returned frequently within much more the top 20 sites appeared commercial web sites. Based onengines thethan findingsnot-for-profit of two more recent studies, this may be because In a study evaluating online information about depression, Lissman and Boehnlein (155) depression, online information about In a study evaluating against too much consistent to paralysis and may be against too much analysis, which with the suggestion that could lead determining the accuracy and reliability of the web sites listed on these pages is important for evaluating sites listed on is important for evaluating pages of the web these and reliability the accuracy determining search engine. A qualitative assessment by the authors revealed that the teenagers used a trial-and-error used that the teenagers assessment by the authors revealed A qualitative search engine. than systematically rather evaluating searches, randomly scanning their pages approach for formulating adolescents and noted they were generally successful in finding correct and useful information to answer to information useful and correct finding in successful generally were they noted and adolescents a list from directly came (87%) accessed of sites the teenagers The majority question. a health-related of search engine results, of which 10% were from a search engine’s list of recommended links. Eighty- Since anyone, expert or layperson, is able to write and edit Wikipedia entries anonymously, concern has entries anonymously, Wikipedia Since anyone, expert or layperson, is to able write and edit Several studies have investigated the methods different groups of Internet users employ to find answers find to employ users Internet of groups different methods the investigated have studies Several After sponsored links, the next most common site to appear in the first page of health-related search results search health-related of page first the in appear to site common most next the links, sponsored After As the majority of health information never seekers get past the first few pages of search engine results, . “more is less” (154) 36 Review of the literature Summary This reviewThis users aremorelikelythat the websites suggests accessto are based health information for The first, published by Clauson and colleagues and by Clauson published first, The 300 search engineresults. Of these results, just 23% (70 sites) containedinformationrelevant tothetopic. At least two studies have shown that only a small percentage of sites retrieveda smallpercentagesites of only that healthkeywordonline studies haveshownby leasttwo At 5 minutes 42 seconds (medianminutes 42seconds 5 however,per question; 4 minutes 18seconds) techniques theirsearch were oftendeemedtobesuboptimal. first the evaluated and “treatment” and “diarrhea” as such keywords using searches similar conducted 395 (6.6%)contained actual of whichonlyknee-related information. McClungand colleagues searches contain theinformationbeingRosesearches contain sought. andcolleagues accessed byhealthinformation seekers, aswelleducatingcitizens. a result, researchershaverecommended a numberimprove of ways totheoverallofweb quality sites general their rankingwithin search engineresultsandusuallyaresitesdedicated on of lowerqualitythan In a largerIn a Australian study, 227 undergraduate answered ofhealth-related students aset questions Köhler However, other studies have shown that patients are easily able to find the information they are searching errors ofomissionthanthe MedscapeDrugReference. The studyalsofound thatthemedicationentries of druginformationon Wikipedia incomparisontoafree, online,traditionally-edited database, Medscape HealthInsite Drug Reference. Basedonthe results, Wikipedia hadanarrower scope, waslesscomplete,andhadmore Do Internet searches retrieve desired health information? before and after usinga search engine to retrieve online informationfrom PubMed, MedlinePlus, and keywordsfor knee-related search online. to information generated The searchnearly6000pages, be made inthe depthandreadabilityofindividualarticles. Bothstudiesconcludedthatwhile Wikipedia incorrect answers. This may be because a person’s prior belief (anchoring bias) may impact their search their impact may bias) (anchoring belief prior person’s a because be answers. may incorrect This in Wikipedia improved significantly over time (p=0.024) In the second study, Heilman and colleagues p<.001). However, they also discovered that searching the Internet increased users’ confidence in confidence users’ increased Internet the searching that discovered also they However, p<.001). 82.0%, post-search versus 61.2% (pre-search questions health-related answering in accuracy user’s the not savvy enoughtoevaluatenot the sourcesofinformationtheyuse toanswerhealth-related questions. As to health information (e.g. MedlinePlus). Further, it appears users are too rushed, unconcerned, or simply may beauseful pointofengagement,itshould notbe used asanauthoritative source ofhealthinformation. reported that Wikipedia’s many medical articles contain few factual errors but that improvements need to for online, for online, although their evaluation ofthesitesmaybe lacking. Basedand on theresultsofEysenbach for informationandtheirconfidenceintheanswersfound (145), Internetuserssuccessfullyhealth-related anaverage found theanswerstoinof questions (162). improved sources quality healthinformation found thatsearching The investigators (134), investigatedthescope, completeness, andaccuracy (163,164). (161) used 25 commonly-used (159) (141)
Review of the literature 37 (147) www. (165, 166). /; also see Box 3) or /). ; also see Box ; also see that 1) www.hon.ch/HONsearch/Patients/index.html http://www.chu-rouen.fr/cismefp ) and HONsearch ( for health-related information and practices on the Internet. In leveraging the .health TLD, WHO could TLD, the .health information and practices for health-related on the Internet. In leveraging functions of trusted resources like MedlinePlus (http://www.nlm.nih.gov/medlineplus MedlinePlus functions of trusted resources like promote consensus building and broad adoption of quality standards for health-related information promote consensus on and broad adoption of quality building standards for health-related to TLD could be used help protect information the Internet. In addition to the generation of a .health value, patients locate comprehensive and accurate online health information. patients locate comprehensive and accurate the first page of results suggests that patients are often being directed to health-related web sites on recommended sites (167–169). recommended idea of creating .health as an Internet top-level domain (TLD) was first advanced in2000. TLD A is the identified higher-quality web sites. Conversely, medical search engines did not provide higher quality in the ageing male or prostate cancer screening information about androgen deficiency in sourcing relevant health information. All three studies found that, as with other search engines, the All three studies found that, health information. in sourcing relevant highest hierarchical level of a web address and is structurally analogous to .com, .org, and .edu (ICANN, and is structurally analogous to .com, .org, and .edu address of a web highest hierarchical level how search engines prioritize and display their results and learn to systematically evaluate health web how search to systematically engines prioritize and display their results and learn evaluate healthfinder.gov unique and relevant (165, 166, 147). However, the studies diverged on whether the overall quality of web quality of web the overall on whether diverged studies the 166, However, 147). (165, and relevant unique use web sites recommended by their health-care providers when searching for health information, for health information, providers when searching health-care by their use web sites recommended quality as well as privacy and safety of Member States’ citizens. quality as well as privacy and safety of Member significantly to the protection of the public’s health through the global adoption of quality standards assessed the quality of osteoarthritis information retrieved through general, medical, and meta-search medical, through general, assessed the quality of osteoarthritis information retrieved search engines the medical quality of the results was poor, the overall concludedthat while engines and sites before making any decisions based on information they responsibility for helping the growing has role the Internet in patient care and take also to need accept find online. Health-care professionals sites retrieved by medical search engines was higher than general ones. Maloney and colleagues search by than ones. medical engines was higher Maloney general sites retrieved about educated more to become users need Therefore, grounds. than informative, rather commercial, search specificity of medical search with programsonly was about low, 10% of web sites retrieved being a handful of randomized controlled trials have shown that such advice does increase the use of a handful of randomized controlled trials have shown that such advice does the use of increase direct their patients to high-quality online health resources. Although less than 5% of patients currently than 5% of patients currently less Although resources. health online to high-quality patients their direct other sites officially hosted States and by local Member institutions Choices such (http:// as NHS Patient CISMeF-patient ( ) and www.nhs.uk only list information from trusted content providers as well as sites that perform similar aggregating aggregating similar sites that perform as well as content trusted providers only from list information One possible approach is to promote the use of medical search engines such as Healthfinder ( A strategic alternative to addressing these issues is the dot health (.health) proposal. The ambitious proposal. these issues is the dot health (.health) to addressing A strategic alternative A second suggestion that has been posed is to encourage more health-care providers to specifically 2000). Creation of the .health TLD under the auspices of an international organization would contribute of an international organization would the auspices under TLD Creation of the .health 2000). The variation among search engine listings and the prevalence of sponsored or recommended sites of sponsored on or recommended listings The variation among search engine and the prevalence Three of the studies identified include those that evaluatedefficiency the of medical search engines
Analysis and discussion of survey results 39
of discussion survey results Analysis and Analysis 3 Digital literacy and online health information quality Internet pharmacies Internet security Online safety of children and adolescents 1. Internet pharmacies 3. 2. 4. . responding countries were asked a series of four questions and invited to on elaborate their responses. responding countries asked were processing, response rate and survey limitations are included in Appendix 1. Appendix limitations are included in processing, response rate and survey trends and patterns will be discussed. into the following four areas: Responses to the questions in Section 6 of the second global survey on eHealth have been categorized been on eHealth have survey Section 6 of the second global questions to the in Responses Full details of the survey methods including survey instrument development, data collection and In order to ascertain the current legal status and regulation of Internet pharmacies in Member States, to In order ascertain status the current legal and regulation of Internet pharmacies in Member In this section, analyses and observations relating to each of these areas will be presented and the key and the key presented will be In this section, to each of these areas analyses and observations relating well as the online ordering of pharmaceuticals from other countries. These questions covered the general regulation of Internet pharmacy operations within their country These questions regulation as covered the general 3.1 40 Analysis and discussion of survey results As shown in Figure 2, when classified by prohibit classified countries when more 2, significantly Figure group, in income shown Bank As World With the significant increase in the number of Internet pharmacies over the past decade, concern over concern decade, past the over pharmacies Internet of number the in increase significant the With customers aboutpotentialside-effectsanddangerousdruginteractions. also agrowingnumber of rogue pharmacies medications withoutvalid dispensing prescription-only likecontrolled, are tightly web-based brands,thereis enterprises managedwell-knowncorporate by general trendappearstobefortheirprohibition(19%versus7%). same holds true were when respondingcountriesdividedtheir respective into regions. Infact, WHO nent hray prtos Fgr 1. oee, n hs cutis ht o ae euain, the regulations, have do that countries those in However, 1). (Figure operations pharmacy Internet Internet pharmacy operations than allow themineveryInternet pharmacyoperationsthan categoryexceptthelow-incomegroup. The National and local governments have traditionally regulated governments havetraditionally drugs and localthesaledispensingofprescription National Regulation of Internet pharmacy operations pharmacy Internet of Regulation be lagging. prohibiting legislation eitherallowingor have no (66%) responding countries of The majority by pharmacies.However,sale ofthesemedications, regulation the onlineappears whenitcomesto prescriptions, providingcounterfeitdrugs of questionablequality, andfailingtoproperlyinformtheir the safetyofprescriptionmedication dispensed online hasalsogrown. While some online pharmacies the European, Americas, and Western Pacific Regions were the only constituencies with countries that countries with constituencies only the were Regions Pacific Westernand Americas, European, the formally allowInternetpharmacyoperations(Figure3). Key findings (19% versus7%). legislation Existing prohibitsInternet pharmacy operationsmore often thanpermitting it countries. Developed were countries morelikelydevelopinghave establishedlegalthan to policies Internet pharmacyoperations. legislationeither allowingorprohibiting (66%)haveno The majorityofrespondingcountries
Analysis and discussion of survey results 41 Prohibits Allows Prohibits Allows Pacific Western Western Don't know Low income Asia South-East No legislation Americas Lower middle Legislation WHO regions Legislation Legislation Europe World Bank income groups World Prohibits Upper-middle Eastern Mediterranean Allows Africa High income 0% 0%
0% 10% 30% 50%
20% 40% 60% 10% 30% 50% 20% 40% 70% 10% 30% 50%
20%
80% 40% 60%
Percent of countries of Percent Percent of countries of Percent Percent of countries of Percent Figure 3. Legislation of Internet pharmacy operations, by WHO region Figure 3. Legislation of Internet pharmacy operations, by Figure 2. Legislation of Internet pharmacy operations, by World Bank income group Bank income World operations, by Figure 2. Legislation of Internet pharmacy Figure 1. Global legislation of Internet pharmacy operations, globally Internet pharmacy legislation of Global Figure 1. 42 Analysis and discussion of survey results As with Internet pharmacy legislation, the vast majority of responding countries (86%) do not regulate, (86%) donot responding countries of majority vast legislation, the Internet pharmacy with As Of the 7%ofresponding countries thatdoregulate, accredit, orcertifyInternet pharmacysites,the vast majority are located in the European Region (Figure 4) and all are high- or upper-middleincome or high- are all and 4) (Figure Region European the in located are majority vast Figure 5.Regulation, accreditation, andcertificationby World Bankincomegroup Figure 4.Regulation, accreditation, andcertificationby WHOregion accredit, orcertifyInternetpharmacysites. countries (Figure5). Respondents were also asked if their country regulates, accredits, or certifies Internet pharmacy sites. pharmacy Internet certifies or accredits, regulates, country their if asked also were Respondents Percent of countries Percent of countries 20% 10% 20% 15% 10% 25% 15% 0% 5% 0% 5% Africa High income Mediterranean Eastern Upper-middle World Bankincomegroup Europe WHO regions Regulation Regulation Americas Lower middle South-East Asia Low income Western Pacific Analysis and discussion of survey results 43 WHO region % prohibited % allows Pacific Western Western Asia South-East Americas Legislation WHO regions Europe Eastern Mediterranean Africa Globally, the online purchase of medications from other with countries is largely unregulated, Globally, the practice. permitting or prohibiting of responding countries having no legislation 75% some type of legislation. largest percentage of countries with has the The European Region or did not respond if there were countries Nearly 80% of responding do not have, do not know, of pharmaceuticals. breach of laws regulating online purchases consequences for 0%
10% 30% 50% 20% 40% 60%
Key findings Key countries of Percent non-domestically. Notably, Norway responded that it has legislation which prohibits Internet pharmacy which prohibits Internet that it has legislation Norway responded Notably, non-domestically. pharmaceuticals from abroad, categorized according to WHO region. The European Region was by far Region The European WHO region. to categorized according pharmaceuticals from abroad, to with nearly 53% of responding countries having some form of policy. have legislation, the most likely this task is echoed in the survey results, as 75% of responding countries have no legislation permitting or no legislation permitting of responding countries have as 75% results, this task is echoed in the survey from other countries. prohibiting the online purchase of medications Regulation of online purchase of pharmaceuticals from abroad from pharmaceuticals online Regulation of purchase of Figure 6 shows the proportion of responding countries with policies concerning the online purchase of It was the only region in which countries legally permit the online purchase of medications originating It was the only region in which countries permit legally operations based in its own country, but allows purchase from other countries. but allows purchase operations based in its own country, within the physical jurisdiction of a sovereign state is extremely difficult and such regulation becomes The difficulty of jurisdiction. more problematic when even the pharmacies originate outside of a nation’s Figure 6. Legislation of online purchase of pharmaceuticals from abroad, by Figure 6. Legislation of online purchase The Internet is truly a borderless medium. As such, regulating e-commerce like Internet pharmacies Internet like As such, e-commerce regulating The Internet is truly a borderless medium. 44 Analysis and discussion of survey results Countries with policies prohibiting the online ordering of pharmaceuticals from other countries were also Countries withpolicies prohibitingthe onlineorderingofpharmaceuticals fromother countrieswere also Only 20% of responding countries provided a specific consequence associated with ordering with associated consequence specific a provided countries responding of 20% Only Figure 8. Consequences forbreachoflaw Figure 7.Legislation ofonline purchase ofpharmaceuticals fromabroad,by World Bankincomegroup asked todescribe theconsequences forbreachofthe law. The particularpenalties included inthesurvey were: were forbreachingno consequences thelaw, 28% did not knowifthere were and consequences 31%did Figure 7 shows the percentage of countries reporting legislation that allows or prohibits online medication high-income countries being high-income countries more likelyin theupper-middle,those countries than tohaveapolicy such purchases from abroad based on World Bank income groups. The results reflect a common trend with trend common a reflect results The groups. income Bank Worldon based abroad from purchases not answer(Figure8). over theInternet. pharmaceuticals fromforeigncountries 20%the remainingcountries, Of saidthere lower-middle, andlow-incomebrackets. Percent of countries Percent of countries • • • • 20% 30% 25% 10% 35% 15% 0% 5% 40% 20% 50% 30% 10% 0% Consumer fineorprosecution Seizure ofgoods Other No consequences High income No of Goods Seizure Upper-middle prosecution World Bankincomegroup Consumer Legal consequences fine or Legislation Do NotKnow Lower middle Other Low income No Answer % allows % prohibited Analysis and discussion of survey results 45 legislation” (Azerbaijan, Iceland, India, Malaysia), gave seizure of goods as a consequence for breach of law. consequence of goods as a Iceland, India, Malaysia), gave seizure legislation” (Azerbaijan, purchased online from other countries, three later responded that the consequence for breach of law was of for breach consequence that the responded later three countries, from other online purchased no legislation, or even that the online government allows their foreign pharmaceuticals from purchase of or even no legislation, reasonable explanations for why so many responses to this series of questions seemed inconsistent on on inconsistent seemed why so many responses to this series of questions for explanations reasonable Germany. by as exemplified surface, the number of other countries (and thus entered a consequence for breach of law in question 6.17). It is It is 6.17). of law in question for breach a consequence entered other countries (and thus of number by responding Member States as “other”. It is important to note that some countries stating there was States as “other”. Member by responding quite possible that the legislative situation within countries is not straightforward, which would lead to to lead is not straightforward, which would countries within situation legislative that the quite possible For example, among the countries that responded there was legislation allowing Internet pharmacy sales seizure of goods and/or consumer fine or prosecution. In the same way, four countries which responded “no responded which countries four way, same the In prosecution. or fine consumer and/or goods of seizure countries, provided examples of consequences under “other”. countries, provided of pharmaceuticals (e.g. Germany responded “allows” for question 6.16), but only from a limited limited only from a for question 6.16), but “allows” responded Germany (e.g. of pharmaceuticals Table 6 summarizes the consequences for breach of law, including a description of any penalty described the consequences6 summarizes of law, for breach Table These seemingly contrary replies appeared to occur most often in countries which allow online ordering most often which allow online ordering in countries appeared to occur seemingly contrary replies These 46 Analysis and discussion of survey results Table 6. Summary oflegislationandconsequencesforbreachlaw —indicatesfieldnotcompleted byMember State. Singapore Pakistan Malta Denmark Cyprus Canada Bangladesh Austria Malaysia India Iceland Azerbaijan Turkey Zealand New Jordan Morocco Estonia Croatia Poland Norway Germany Finland Greece Country None None None None None None None None None None None None Prohibits Prohibits Prohibits Prohibits Prohibits Prohibits Allows Allows Allows Allows Allows Legislation Other Other Other Other Other Other Other Other Seizure ofgoods Seizure ofgoods Seizure ofgoods Seizure ofgoods Other Other prosecution Consumer fineor Seizure ofgoods Seizure ofgoods Seizure ofgoods Other Other Other prosecution Consumer fineor Seizure ofgoods Consequence — — products areforpersonaluse. No consequencesaslongtheorderedmedicinal — Seizure andprosecution — — are notfulfilled. If requirementsofDoc-Morris-Judgment (C-322/01) — — — — formally empoweredwithrelatedlegislations. initiatives exceptthroughpharmacies. This policyis Ministry ofhealthpolicyistoforbidanyselling Medicines areonlyallowedtobesoldinpharmacies. circumstances. goods, andalicenceisrequiredtoimportinsome general legislationcoveringtheimportationof presenting awrittenprescription;thereismore Some drugsareonlyavailabletoconsumersby — — — — only frombrick-and-mortar pharmacies(not online). a prescription.Prescriptiondrugscanbepurchased All ofaboverefersonlytodrugsavailablewithout goods andconsumerfineorprosecution. Consequences forbreachofthelawareseizure (only allowedfornon-prescriptiondrugs). the mailorderpharmacy),and Czech Republic (only ifacommunitypharmacyexistsinadditionto customers: the United Kingdom,theNetherlands are allowedtosendpharmaceuticals German order pharmaciesofthefollowingthreecountries Federal MinistryofHealth(BMG),currentlymail According tothecountrylistof German — — Description of“other” Analysis and discussion of survey results 47 Overall, technology filters are theresponding countries. most common method for combatingare abuse and mechanisms to report programmes, Government intervention, educational spam among in high-income countries. to occur much more likely Local filters at the organizational/business level are the primary way to prevent spamWHO regions. in all Key findings Key 2 Internet security security .2 Internet Implications legislation, treaties, and cooperative agreements between Member States, rogue rogue Internet pharmaciesStates, legislation, treaties, and cooperative Member agreements between the number one preventive action in the African (63%), Eastern Mediterranean (71%), and Americas (92%)Americas (71%), and African (63%), Eastern Mediterranean action in the preventive number one the more frequently used in high-income countries than in low-income countries. Unsurprisingly, developed developed Unsurprisingly, countries. in high-income countries than in low-income frequently used more mechanisms to report abuse also exist but on a much smaller scale. threatens to undermine this trust. In recent years spam has evolved from disruptive, malicious messages malicious disruptive, from has evolved this trust. In recent years spam threatens to undermine the creation of political and legal frameworks for the online sale of pharmaceuticals. online sale and legal frameworks for the the creation of political regulatory framework. The lack of legal statutes and inconsistent consequences for breach of law globally consequences for breach and inconsistent The lack of legal statutes framework. regulatory intervention (e.g. laws, regulations), educational programmes for consumers educational programmes and professionals, and laws, regulations), intervention (e.g. Regions and shared this ranking with ISP filters in the European (81%) and South-East Asia (88%) Regions. Asia (88%) South-East (81%) and European and shared this ranking with ISP filters in the Regions Figure 10 shows that government interventions (55%), education (52%), and reporting (55%) are much Figure 9 illustrates that technology filters at both the Internet service provider (ISP) level and (67%) the countries also report a higher use of technology to combat spam than developing ones. countries also report a higher use of technology to combat spam than developing organizational/business level (75%) are the most popular methods for combating spam. Government methods for combating spam. the most popular are (75%) organizational/business level asked to describe what actions were being taken to reduce spam. to reduce what actions were being taken to describe asked or irritating advertising into a global business linked to crime, fraud, and identity theft. business linked or irritating advertising into a global and within WHO regions reflects the need for greater development of governance mechanisms to facilitate to mechanisms governance of development greater for need the reflects regions WHO within and when Internet pharmacies located in foreign countries. This is because without suitable harmonizedThis is because without countries. foreign located in Internet pharmacies when restrictivethe least sites within jurisdictions having their web by operating stringent regulation can evade When divided into WHO regions When (Figure divided 11), into filters at the local (i.e. organizational/business) as level ranked As outlined in the GOe survey, preservation of trust online is an important element as eHealth matures. of trust online is an important element preservation GOe survey, in the As outlined As detailed in Section 2, many of the risks associated with online pharmaceutical purchases are compounded are purchases pharmaceutical with online risks associated many of the Section 2, in As detailed To establish how Member States are dealing with escalating Internet security issues, countries were security issues, with escalating Internet dealing are States establish how Member To The issue of unsolicited electronic messages sent in bulk, known as spam, is growing exponentially and known is growing sent in bulk, as spam, The issue of unsolicited electronic messages 3 48 Analysis and discussion of survey results The Working Group on Anti-Spam Technologyand NetworkManagement began 2004 in bringvarious to Canada has also undertaken a number of efforts and initiatives to help deal more effectively with spam. with effectively more deal help to initiatives and efforts of number a undertaken also has Canada Figure 10. Actions toreducespam, by World Bankincomegroup Figure 9. Actions toreducespam, globally self-regulation, spamcontrollegislation,andinternationalcooperationtocurbspam. industry measures, technology appropriate programme, education apublic of benefits the combines spam. posed by the threats was neededcombat orderto in Singapore developedhas a programme that deserve mention. Act) Spam and Wireless operators, andlargeenterpriseusers(170). The Anti-Spam for Plan Action introduced at also Canada was Despite the reliance on technological solutions, several solutions, Despite thereliancetechnological on a multi-pronged indicatedthat countries strategy Pornographyand Marketing) (174) industry groupsindustry togethertoencourage the broad adoption ofbestpracticesamongISPs,othernetwork . Parallel and temporally similar efforts were also were efforts similar temporally and following a force into Parallel in Governor order (173)Council . . In December 2010, Canada passed extensive anti-spam legislation (i.e. Fighting Internet Fighting (i.e. legislation anti-spam extensive 2010,passed December Canada In time (171)that . made with the introduction of the so-called of made theintroduction with CAN-SPAM (i.e. Act the Controlling Non-Solicitedof Assault
Percent of countries 100% Percent of countries 60% 40% 80% 20% 60% 40% 80% 20% 50% 30% 10% 70% 0% 0% Govt. Intervention Govt. Intervention Technology Technology (172) thatincludesformationofa Spam Reporting Centre, willcome which Technology -local Technology -local . Finally, the efforts of The Spamhaus project, detailed in Section 1, also Actions Actions Education Education Report Report income High middle Upper- middle Lower- income Low Analysis and discussion of survey results 49 Report Education Technology - local Technology Govt. Intervention . However, local spam filters have no effect effect no have filters spam local However, . Pacific Western Western (175) Asia South-East Americas of spam messages. Actions WHO regions Europe Eastern Mediterranean Africa 0%
20% 80% 40% 60%
100% Percent of countries of Percent Implications from using their countries as a base for sending spam to other countries. messages found in an individual’s inbox is genuine e-mail genuine is inbox individual’s an in found messages passively decided to leave the matter of safeguarding against spam to individual businesses, organizations, against spam to individual of safeguarding to the matter passively decided leave promotion and development of an international, multi-pronged approach to reducing spam is needed. multi-pronged approach to reducing of an international, promotion and development regulations in place to stem the tide of spam. To compound the issue, few developing nations other have developing few compound the issue, To of spam. tide the to stem in place regulations such as consumer protection laws, privacy or network security laws, or computer crime types of law, not States are only many Member As a result, spammers. to prosecute used that could be regulations spammers in preventing their citizens also exploiting but from spammers to keep in their ability restricted incoming e-mail messages and can incoming block ensuring that e-mail up to majority 98% of messages, the spam of the Based on the results of the survey it would appear that many Member States have either actively or that it would appear many Member Based on the results of the survey and This citizens. may be, in part, as most popular e-mail clients have built-in spam filters that pre-sort at all in combating the distribution Figure 11. Actions to reduce spam, by WHO region reduce spam, by Actions to Figure 11. Spam is a global problem; therefore, international cooperation is key. It is clear from these results that further Spam is a global international problem; therefore, cooperation is key. According to survey responses, only 34% of responding Member States have government laws or States have government of responding Member responses, only 34% to survey According 50 Analysis and discussion of survey results 3 47% of responding countries have government-sponsored web sites or official initiatives that provide that initiatives official or sites web government-sponsored have countries responding of 47% The developmentof theInternethascreatedmedium acommunication that existsapart from the Although there are many stakeholders responsible forthesafetyofchildrenandteenagers online, (67%) and Americas (67%) Regions (Figure14). When aggregated When by region,WHO 75%from the responding countries of South-East RegionAsia had Figure 12.Existenceofofficialwebsitesorinitiatives,globally prpit ifrain n euain bu Itre sft ad ieay Fgr 1) Floig a Following 12). (Figure literacy and common trend,thehighestpercentage(81%)wasfoundinhigh-incomecountries(Figure1 safety Internet about education and information appropriate results, survey the area. to According this in government’sefforts their on focus to asked were countries and adolescents relish the freedom that the Internet and online anonymity can bring, it also carries with also bring, it can anonymity relish thefreedomInternetandonline and adolescentsthat confines and structure of the ‘real world’, as well as away from the prying eyes of parents. While children it hiddendangers,like sexualpredatorsandthethreatofcyberbullying. these web sites and official initiatives, while inroads had also been made in countries of the European the of countries in made been also had inroads while initiatives, official and sites web these Information Internet education and safety about . 3 Online safety3 Online of adolescents and children Percent of countries Key findings 40% 20% 50% 30% 10% 0% directed atraisingawarenessofInternetsafetyspecificallyamongchildrenandteenagers. The Regions of South-East Asia, Europe, and the Americas had the highestratesofinitiatives had effortsaimedspecificallyatchildren. withgovernment-sponsoredNinety-three perofcountries cent educationprogrammes online Regions (67%). and European Americas the in made also were efforts substantial initiatives; education online Seventy-five per cent of governments responding from the South-East Asia Region sponsored official or sites web government-sponsored have initiatives educatingcitizensaboutInternetsafetyandliteracy. countries responding of half than Less Yes Web sitesorinitiatives No Do notknow No answer 3). Analysis and discussion of survey results 51 Pacific Western Western Low income Asia South-East Lower-middle Americas WHO regions Europe Web sites or initiatives Web Web sites or initiatives Web World Bank income groups World Upper-middle Eastern Mediterranean High income Africa 0% 0%
20% 70%
80% 40% 10% 30% 60% 50% 20% 80% 40% 60%
100% Percent of countries of Percent Percent of countries of Percent the existence of such initiatives in the Western Pacific (8%), Eastern Mediterranean (8%) Regions were low. low. were Regions (8%) Mediterranean Eastern (8%), Pacific Western the in initiatives such of existence the these are mostly high-income countries. Taken as a whole, 48% of high-income countries, of upper- 24% Taken these are mostly high-income countries. of low-income countries income countries, and 8% have of lower-middle 20% income countries, middle in implementing initiatives specifically directed at raising awareness among children and teenagers, while teenagers, and children among awareness raising at directed specifically initiatives implementing in initiatives explicitly designed to educate children and teenagers about online safety. initiatives explicitly designed to educate children and teenagers about online in their countries were then asked whether any of these efforts were aimed specifically at protecting Figure 16 shows responses to this question by World Bank income group. While the majority of countries of majority the While group. income Bank World by question this to responses shows 16 Figure Responding Responding countries indicating that there were government-sponsored web sites or official initiatives It is interesting to note the WHO regional lines (Figure 17) upon which age-targeted efforts were developed. developed. were efforts age-targeted which upon 17) (Figure lines regional WHO the note to interesting is It with official informative web sites and initiatives have ones specifically directed at children and teenagers, and at children directed specifically ones have initiatives and sites web informative official with children. The vast majority (93%) responded in the affirmative (Figure 15). children. Figure 14. Web sites or initiatives by WHO region WHO sites or initiatives by Web Figure 14. Figure 13. Web sites or initiatives by World Bank income group Bank income World by sites or initiatives Web Figure 13. The European (44%), Americas (14%), South-East Asia (12%), and African Regions were the most proactive were the African Regions Asia (12%), and South-East Americas (14%), The European (44%), 52 Analysis and discussion of survey results Figure 17. Specific websitesorinitiatives toprotectchildren,by WHOregion Figure 16. Specific websitesorinitiativestoprotectchildren,by World Bankincomegroup Figure 15.Existenceofeffortsaimedspecificallyatprotectingchildren,globally Percent of countries Percent of countries Percent of countries 100% 40% 20% 50% 30% 10% 40% 20% 50% 30% 10% 60% 40% 80% 20% 0% 0% 0% High income Africa Mediterranean Eastern Yes Upper-middle World Bankincomegroups Europe Child protection Child protection WHO regions Child protection Americas Lower-middle South-East Asia No Low income Western Pacific Analysis and discussion of survey results 53 Less than a quarter (22%) of responding countries legally require the use of safety tools the use of safety tools of responding countries and legally require (22%) Less than a quarter the Internet. in public places where children access security technologies Even in for these safety in high-income countries only requirements features legal 26% have public Internet facilities used by children. of countries with legislation percentages higher have Europe and Americas of the The Regions WHO regions. than other Key findings Key mean that countries responding negatively do not have protective measures in in public places where do place have protective measures negatively not mean responding that countries percentages were still low, with just 26% of high-income and 43% of upper-middle income countries of upper-middle with just 26% of high-income and 43% still low, were percentages income upper-middle between gap large disproportionately The 19). (Figure technologies such requiring public places with Internet facilities used by children. public places with responsible choices and avoid potentially dangerous situations online, technology situations online, technology solutions public dangerous potentially and choices avoid and responsible the determine current countries asked regulatory environment, were To policy equally important. are in public Internet facilities used by children, by WHO region. The results show that the Regions of the results show that the Regions The WHO region. by by children, in public Internet facilities used in public places where children access the Internet (Figure 18). Even when stratified by income the However, just because there is no legal requirement for safety tools and security technologies does not for safety requirement is no legal there just because However, Figure 20 shows the prevalence of legal requirements for the use of safety tools and security technologies security and tools safety of use the for requirements legal of prevalence the shows 20 Figure Nearly half (48%) of responding countries do not safety tools Nearly half (48%) and security legally require technologies children children access the Internet. For example, in Paraguay security keys/passwords are generally used to limit systems. filter simply requirements, legal specific no are There children. for inappropriate sites web to access countries and high-income countries is notable; no correlation is observed between high-income between no correlation is observed countries is notable; high-income countries and for this question. countries and technology-focused legislation whether safety tools and security by technologies required law for schools, were and other libraries, While social and educational strategies are important for empowering children and adolescents to make children While social and adolescents for empowering are important strategies and educational to make Americas (67%) and Europe (28%) have a higher percentage of countries with legislation than other regions. a higher percentage of countries and Europe (28%) have (67%) Americas Safety and security requirements Safety 54 Analysis and discussion of survey results Figure 20. Legalrequirementsforsafetytoolsandsecuritysystems,by WHO region Figure 19.Legalrequirementsforsafetytoolsandsecuritysystems,by Figure 18.Legalrequirementsforsafetytoolsandsecuritysystems,globally Percent of countries Percent of countries Percent of countries 40% 20% 50% 30% 10% 60% 40% 80% 20% 50% 30% 10% 70% 40% 20% 50% 30% 10% 0% 0% 0% High income Africa Yes Mediterranean Eastern Upper-middle World Bankincomegroups Legal requirements Europe Legal requirements No Legal requirements WHO regions Americas Lower-middle Do notknow South-East Asia Low income No answer Western Pacific World Bankincomegroup Analysis and discussion of survey results 55 Implications need to evaluate and identify potential online hazards for children and adolescents living within and identify potential online hazards for children their to evaluate need teenagers have Internet access on demand in developing nations, there is still the potential for significant significant for potential the still is there nations, developing in demand on access Internet have teenagers percentages of high- and upper-middle income countries backing initiatives dedicated to educating to educating dedicated backing initiatives income countries and upper-middle of high- percentages negative. As a result, safety education for children, adolescents, teachers, parents, and other caregivers As a result, safety education for teachers, children, adolescents, parents, and caregivers other negative. progressively more accountable for their personal well-being online. Their individual choices and and individual choices Their online. well-being for their personal more accountable progressively is becoming increasingly important. is becoming increasingly borders and develop a targeted approach to education, prevention, and intervention. a targeted approach to education, prevention, borders and develop behaviours on the Internet can help determine whether their online experiences are positive or or online experiences are positive their whether determine can help on the Internet behaviours child exploitation online. online. child exploitation children and teenagers about online safety. While this may be partly because fewer children and and children fewer partly because be While this may online safety. about children and teenagers appropriate online behaviour in children and adolescents in order to protect them from the many them from the many in order to protect adolescents and in children online behaviour appropriate dangers that lurk online. Because online content is increasingly ‘user-driven,’ users are becoming Unfortunately, online education initiatives seem to be linked to income level, with much higher much higher with level, to income to be linked seem initiatives education online Unfortunately, Social and educational strategies are central to the development of responsible decision-making and and decision-making of responsible development to the are central strategies educational Social and As different children in different regions of the world are subject States to varyinglevels of risk, Member 56 Analysis and discussion of survey results 3 To evaluate current governmentpractices,surveyeHealth qualitycontrol participantswere asked to the Internethasbeenon thesubjectofdebate of healthinformation The qualityforadecade. While 20% ofcountriesaffirmvoluntarycompliance,government interventionandtechnologymechanisms. 70% of high-andupper-middle 33%oflow- employ voluntary compliance,whileonly income countries Asia Region report voluntary compliance, with significantly lower levels of government interventions, of government levels lower significantly with compliance, voluntary report Region Asia Voluntaryreported compliancewasthe most commonlyclimatewith55%ofresponding of control, While the pattern of results is consistent for allincomelevels,While thepattern ofresultsisconsistent the highestlevels recorded for voluntary give details about their country’s approaches for ensuring the quality of health-related content on the on content health-related of quality the ensuring for approaches country’s their about details give compliance and the lowest levels for official approval and other methods show that the magnitude of magnitude the that show methods other and approval official for levels lowest the and compliance were utilizedbyasmallpercentage(16%and5%respectively). it fortheircountry.indicating countries Technology(28%), (26%),andeducation government intervention Internet. The particularmechanismsincludedinthesurvey were: iue 3 rvds n diinl esetv, ipaig h sm cutis y H rgo. t is It region. WHO by countries same the displaying perspective, additional an provides 23 Figure Figure 22 shows the use of the various quality control measures based on World Bank income group. income Bank World on based measures control quality various the of use the shows 22 Figure mechanisms. control quality aforementioned the of use overall the of overview an gives 21 Figure user mustbeevaluate ablecritically to claimsbeforehighlightingthe the sourceanditstakingaction, utilization is appreciably different between developed and developing countries. For example, nearly example, For countries. developing and developed between different appreciably is utilization interesting tonotethat100% of analbeit small number of responding countries(eight) in the South-East income countriesdoso. importance ofdigitalliteracy. of dubiousquality,information widespread fraud, dangerous potentially claimsandahighriskofexposure technology, education,mechanisms(between and other 0 and38%). In the RegionAfrican approximately online. exist harmalso to methods, the engines andother search found through all information with As there areanumber of high-quality, wellinformed researched, eHealthsitesavailable, clinically health programmes (23%) were also used by responding countries, while official approval or other methods other or approval official while countries, responding by used also were (23%) programmes . 4 Digital literacy information health online and quality Key findings • • • • • responding countriesinallregionsandincomelevels. Voluntarymechanism indicatedby control quality common compliance (55%)wasthemost voluntary compliance by content providers voluntary compliancebycontent orweb site ownerstoqualitycriteriaforhealth- other. official approval (e.g.certification, accreditation,sealsofapproval,qualityseals);and education programmesforconsumersandprofessionals; technology (e.g. filtersandcontrols); related sites; Analysis and discussion of survey results 57 Low income Lower- middle Upper- middle High income Other Official approval Education Technology Govt. Intervention Voluntary compliance Other Other Pacific Western Western Official Official approval approval Asia South-East Education Education Americas WHO regions Technology Europe Technology Quality control mechanisms Quality control mechanisms Quality control mechanisms Quality control mechanisms Quality control mechanisms Govt. Govt. Eastern Intervention Intervention Mediterranean Africa Voluntary Voluntary Voluntary Voluntary compliance compliance 0%
0%
0% 10% 30%
50% 20% 40% 60%
70% 10% 30% 50% 20% 80% 40% 60% 20% 80% 40% 60% Percent of countries of Percent
Percent of countries of Percent 100% Percent of countries of Percent Figure 23. Quality control mechanisms for health information, by WHO region Quality control mechanisms for health information, by Figure 23. Figure 22. Quality control mechanisms for health information, by World Bank income group World Quality control mechanisms for health information, by Figure 22. Figure 21. Quality control mechanisms for health information, globally for health control mechanisms Quality Figure 21. 58 Analysis and discussion of survey results Table 7. Other qualitycontrolsemployedbyMember States Table 7summarizesthe responses. Government-sponsored eHealthalsoserve sitesprovidingcanasacomplement authoritative contentto digital initiatives. literacy Such siteswouldotheronline health provide bywhich a benchmarkofquality option maybetoinvestineducationalprogrammesincreasedigitalliteracy. governance establish to required be would money and effort, time, of amount significant a As content. online. Currently, itistheresponsibilityofindividualdetermine siteto the qualityofhealth-related ensure theaccuratevery littlebeingdoneto the Internet,thereis on health information reportingof Erroneous anddeceitful health informationisparticularlydangerous if acteduponunquestioningly. By find they information on decisions health important base people of number large a that fact the Despite Responding wereaskedto elaborateonthe countriesmethods employed. whoreplied with“other” better, moreinformed decisionsaboutthehealthcontentfoundonline. information canbejudged. mrvn te ulcs rtcl vlain f elh nomto, iies il e moee t make to empowered be will citizens information, health of evaluation critical public’s the improving mechanisms to facilitate thedevelopmentto mechanisms and legal andimplementationpolicyframeworks, of abetter Implications Nigeria Sri Lanka India Canada Cameroon Bhutan Bangladesh Country Disclaimer notices. Awareness creationamongthepublicusingmedicalstudents. Technology, Ministryof Communications &IT, Government ofIndia. www.nhicindia.org Sites aredeveloped wheretheprocessesensurequalityofinformation(e.g. health informationontheirwebsites. used sourceofhealthinformation.Provincialministriesalsopost sites. Surveys haveindicatedthattheHealth Canada websiteisafrequently have themselvesprovidedconsiderablehealthinformationontheirownweb Governments atvariouslevels in Canada, includingthefederalgovernment, Informal. related informationontheInternet. Some verbalcautionisgiventoconsumersregardingauthenticityofhealth- pharmaceutical products. Permission neededfromappropriateauthorityforuploadinginformationon Elaboration ofthe"other"response ). ITlawlaiddownbytheDepartmentofInformation Analysis and discussion of survey results 59
curation curation ' —Dr Bertalan Mesko /. http://www.webicina.com/perssonalized Image Courtesy of Dr Bertalan Mesko. PeRSSonalized Medicine: PeRSSonalized Mesko. Courtesy of Dr Bertalan Image How one medical student 'crowd-sourced student one medical . How I realized how hard it is themselves for either up- medical professionals or empowered patients to keep national versions to develop as to-date in a medical specialty or condition…Later it was we need clear (178). Medicine now are available in PeRSSonalized languages well, that is why 17 tools (blogs, podcasts, tagging, search, wikis, etc.) – founded on principles of open source and user generated content, generated and user source on principles of open wikis, etc.) – founded tools (blogs, podcasts, tagging, search, especially from the online community rather than from traditional employees or suppliers. than from traditional employees community rather from the online especially . (177) education collaborate, and promote health care, health as well as the power of networks – to personalize The practice of obtaining needed services, ideas, or content services, or content by a andThe practice of obtaining needed ideas, soliciting contributions from large group of people Used by actors in health care including doctors, patients, and scientists, Medicine 2.0 / Health 2.0 is a specific set of Web of set specific a is 2.0 Health / 2.0 Medicine scientists, and patients, doctors, including care health in actors by Used http://www.webicina.com/perssonalized/?cat=35.
of quality online health information in 17 languages in 17 languages health information online of quality While PeRSSonalized medicine now stands as a massive resource that is freely available to anyone, it is available now stands resource that is freely medicine as a massive PeRSSonalized While more a testament to the potential for one person to help a make difference, especiallywhen that person taps into the cognitive philanthropy of the crowd. As this resource evolved, the capacity for any As this resource evolved, was all the feeds to hand-select one individual the now Dr Bertalan Mesko and exceeded Web capitalized on the collaborative nature of 2.0. He began to ‘crowd-source’ information by putting out a call to his social networks for items to be included and eventually to grew encompass medicine PeRSSonalized conditions and specialties medical different 80 he started Similarly, that are curated today. to solicit contributions, additional which in resulted health information resources being aggregated in 17 different languages including English, Spanish, Hungarian, French, German, Japanese, and Indonesian. Chinese, This tool functions similarly to existing RSS (Really Simple Syndication) in that it aggregates ‘feeds’ what little it removed However, of push to the end-user. set to automatically be information that could tool. a configuring than menu a from items choosing to similar more it making by exist did that complexity information was based of medical This menu patient or on the interests of the individual conditions and included provider such as and cardiology, depression, specialties like other categories such as a customized feed Organization American Health for the Pan (PAHO). A young man named Bertalan Mesko attending medical school in Debrecen, Hungary was using his blog as a Hungary was using attending medical school in Debrecen, Mesko Bertalan A young man named world.the over all from others with network and 2.0’ ‘Medicine on information share and collect to platform identifying,in had patients and professionals health-care savvy Internet fairly even that difficulty the Noting of new abreast and keeping information online of health sources reputable managing, and organizing . (176) medicine PeRSSonalized tool called aggregation a new to develop he elected medical developments, Box 3 Box 91011 10 11 9
Conclusions 61
Conclusions 4 from Internet-based threats? This a snapshot has provided of current practices, responses to publication threats? from Internet-based processes regarding Internet pharmacies and online safety and information quality. These conclusions processes Internet pharmacies and online regarding safety and information quality. makers, practitioners, and patients in the interest of a sustainable provision of equitable health care. The practitioners, and patients in sustainable provision the interest of a health care. of equitable makers, participatory medicine model? What protections need to be in place to safeguard citizens and their children in place to safeguard be What protections to need participatory medicine model? pharmacies – increasingly advertised through spam messages – still plague those using the Internet. Due those using the Internet. – still plague messages through spam – increasingly pharmacies advertised to untrustworthy high-quality online mostly health information, people have access to a dearth of vetted, issues by Member States, and case studies examining the transformation of cautionary to tales tales issues by Member juxtaposition of intelligent legislation, good practices, and coordinated vigilance? How can we best health information online, and are putting themselves at risk of virus programs and phishing scams. Spam health information online, and are putting themselves at risk of and phishing virus programs scams. Is the answer to Internet pharmacies a blanket ban? Unconditional, unrestricted access? Or the Unconditional, unrestricted access? ban? a blanket Is the answer to Internet pharmacies are derived from feedback supplied by Member States in responding to a subset of items on the 2009 to a subset of items on States in responding the 2009 by Member supplied from feedback derived are WHO. on eHealth administered by global survey summary conclusions that follow are intended to assist stakeholders in informing their decision-making summary conclusions that follow are intended to assist stakeholders of success. The information contained within this volume is provided for stakeholders including policy- for stakeholders is provided The information contained within this volume of success. capitalize on freely available Internet-based health information to empower patients for the evolving health information to patients for the evolving empower capitalize on Internet-based freely available also continues to be the bane of e-mail users worldwide. extension as a potentially trusted source of medications and pharmaceutical care. However, rogue care. However, pharmaceutical source of medications and extension as a potentially trusted The Internet pharmacy has moved beyond its nascent stage into and legislated a more widely adopted The Internet pharmacy has moved beyond 62 Conclusions A two-pronged approach is recommended to counter distribution andreceiptofspambasedthe two-pronged approach isrecommendedcounteron A to Spamhaus), as well as consolidation of fragmented educational efforts. It may also behove Member behove also States to develop stronger definitions, penalties, and enforcement for spam along with aligning with may the It efforts. educational fragmented of consolidation as well as Spamhaus), Spam –unsolicitedmessages senttoe-mail andmobiledevices inbulk–andothertypesofInternet States againstspam. While governmental intervention andeducational programmes are alsomechanisms Overall, theresultsdescribe anatmosphereofuncertainty regardingInternet pharmacy. Despite existing findings in this volume, including continued international support of non-profit-making efforts(e.g. of non-profit-making support international continued including volume, this in findings viruses, spyware) and specifically increase vigilance regarding medical identity theft in upper-middle and and, when feasible, create an alternative but secure distribution channel for delivery of essential medicines. deliverysecurechannelfor ofessentialmedicines. whenbut distribution and, feasible,createanalternative stance, Member States shouldadoptformalpositionsregulating Internet pharmacytoprotectpublichealth correspondingly were more likely than developing countries to have general legislation and specific policies ways –toeducational programmes to help avoid the more serious threats thatcanaccompany spam (e.g. enforcement. Additionally, findings suggest reallocating existing resources – currently diluted in multiple and/or a lack of media coverage stifled awareness about its existence thereby compromising capacity for countries responding Some (ITU). Union International Telecommunication the of efforts cybersecurity to resources significant States Member and citizens costing scourge: a be to continue threats security current legislationmayagainserveasresources. external online sale of pharmaceuticals shouldbe considered a priority. Evenfewer Member States have as a business and practice model in some parts of the world for over ten years, Internet pharmacy remains as abusinessandpractice modelinsome partsofthe worldforover tenyears,Internet pharmacyremains In concert with,orfollowingdetermination In concert of, abasicdomesticlegislative approach, regulating the Latvia, Poland, Portugal, USA) canbeavaluablepointofcontactanddataforother countries wishingto volume Member this in identified legislation existing with States (China, Czech Finland,Republic, Germany, used tocombatit,thesetactics aremore prevalent in World Bankdesignated high-income countries. high-income countries. Member for defence of line primary the remain 9) (Figure levels ISP and business) (e.g. local the at both bolster Internet and e-mail security, as well as mitigate the effects of successful attacks. Technology filters in place.However, even amongthe minorityofcountrieswhohave broached thetopic,asamatterofpolicy indicated that legislative addressing spamhadbeencreated, indicated thatacts but hadneverlaw beenenacted into in eachrespective Member State alsomeritconsultingbased ontheir workinthese areas. they have elected to simply prohibit their operations rather than permit them (Figure 1). Regardless of the the Regardlessof 1). (Figure them permit than rather operations their prohibit simply to elected have they reactionary andtemporallyrelated totheemergence ofthismodel ofpharmacy, developed countries neighbouring countries or trade partners. International pharmacy law expertsandMember pharmacy tradeInternational or partners. neighbouring countries States with requirements maybeplacewith harmonization thatin any supports publichealthwhilesatisfying that legislation enforceable enacting and developing in is deficit this addressing to key question. The the to restricted (Figures 6 and 7). Significantly, almost 80% of responding countries did not have consequences are legallypermitted countries or medications fromother placedetermining not in whetheror policies pharmacy of boards as well as FIP the including institutions arena. and this Organizations in forward move eiltvl uadesd y h mjrt o rsodn cutis Fgr 1. s oiis ee likely were policies As 1). (Figure countries responding of majority the by unaddressed legislatively for breach oflaw using Internet pharmacies, were awareordid not ofsuchconsequences,respond Conclusions 63 mHealth: , the face of Internet access has changed. , the face of Internet access (179)
libraries, schools, and community centres granting Internet access to children and teenagers are natural natural are and teenagers to children schools,libraries, and community centres granting Internet access foci for directing legislative and intervention efforts to enhance child Guidance safety. in these efforts requisite schooling and adult education. progressive WHO region in implementing these measures is the Region of the Americas (Figure 20). Americas (Figure the of Region implementing these measures is the WHO region in progressive predatory adults, cyberbullying from peers, and poor personal judgment by teens that by teens that elect to in and poor personal judgment engage from peers, cyberbullying predatory adults, polarizing public health threat presented by the Internet may be as a means to intentionally as a means or unwittingly Internet may be by the threat presented health public polarizing regions should consider prioritizing this area; lower rates of Internet penetration insulated the youth of insulated penetration of Internet rates lower this area; regions should consider prioritizing as in reported but with the explosion of accessibility mobile those areas to an extent previously, responding countries utilize government-sponsored web sites or official initiatives to educate citizens may be sought in the form of the Family Online Safety Institute (FOSI). Given the sometimes slow wheels slow sometimes the Given (FOSI). Institute Safety Online Family the of form the in sought be may is great variability based on World Bank classifications: nearly 70% of high- and upper-middle income information. It is anticipated that the importance of these issues will become even more prominent as information. a It is anticipated that the importance of will become even these issues help ensure the quality of health information online (Figure 21). However, within this approach there jeopardize the safety of children and adolescents. Threats from this medium encompass those from encompass medium from this Threats adolescents. of children and the safety jeopardize new horizons for health through mobile technologies For those Member States contemplating introduction, prioritization, or strengthening of such legislation, such of strengthening or prioritization, introduction, contemplating States Member those For European Region and – to a much lesser extent – the Region of the Americas have the highest rates Americas have of the Region and – to a much lesser extent – the Region European Moving into the next decade, Internet safety Moving into Internet the next decade, and literacy present enormous challenges, considering basic as indicated by the spectrum of answers received to the “other” category for this survey item (Table 7). as indicated by the spectrum of answers received to the “other” item (Table category for this survey countries employ voluntary compliance, whereas only 33% of low-income countries take such action countries employ voluntary compliance, whereas only 33% of low-income countries take greater percentage of the global public gains ready access to the Internet and health information seekers information seekers health and to the Internet access gains ready public of the global percentage greater grow more likely to take action based upon what they Thusfind. far, voluntary compliance by web site States to operators and content providers is the most commonly control cited mechanism by Member codifying educational practices to integrate digital literacy and awareness of online safety issues into literacy and awareness digital codifying practices to integrate educational activities like ‘sexting’ without thought of consequence. Despite this state of affairs, less than a quarter of responding countries require the legally use of safety tools and security technologies in public places however, countries, income upper-middle and high- Among 18). (Figure Internet the access children where a collective 69% have those legal requirements in place to protect children Overall (Figure the 19). most of initiatives specifically directed at protecting children and adolescents (Figure17). Countries in other about Internet safety and literacy. Paralleling its Paralleling proclivity early adoption of technology for and innovation, about Internet safety and literacy. are there Asia Region; South-East seen most commonly sponsored initiatives are in the government also strong programmes in the European Americas and Regions (Figure 14). Echoing these findings, the and health literacy are still hurdles to be overcome in most Member States. Currently, less than half of Currently, States. in most Member overcome to be still hurdles and health literacy are of the legislative process and for deriving maximum benefit, child safety programmatic initiatives should initiatives programmatic safety child benefit, maximum deriving for and process legislative the of manner. also be considered in a similarly geographically-targeted Universally, Universally, Member States would benefit both from existing efforts and could exploreformalizing or While security issues such as spam create problems numbering in the billions of any currency, the most of any currency, in the billions numbering problems create such as spam security issues While (Figure 22). Interestingly, strategies to address health quality online by Member States were wide-ranging, were States Member by online quality health address to strategies Interestingly, 22). (Figure The capacity for digital literacy is intertwined with accessibility to, and quality of, online health online health to, and quality of, The capacity literacy is intertwined with accessibility for digital 64 Conclusions (like seal; 1)havealsobeen theHONcode Boxexamined. have These toolslimited utility considering
Solutions formanaging the qualityofhealthinformationproposed were inclusive oftown,state, and security, as well as benefit national health systems as they increasingly integrate the Internet into into Internet the integrate increasingly they as systems health national benefit as well as security, and solve. alone to of governments with measuresconsumers forprivacy Thestandards wouldprotect creation ofthedothealth(.health) TLD. Development of adothealth TLD as arecognizable label for Developing countries would benefit from being able to use a domain where standards are not the problem quality issues. It would overcome a serious shortcoming of existing codes of conduct by enabling codes to by enablingcodes of conduct codes of existing issues. Itwouldovercomeaseriousshortcoming quality health information the Internetwouldraiseawarenessof health-related on quality sources information be enforced;however, itwouldnotregulate,restrictorcensurehealthcontentontheInternet. government or geography of regardless party third a by conferred approval’ of ‘seals and explored been international organizationandwithamembershipofhigh-level stakeholders withinterests inpublichealth. their operations. Dot health’s operational model is most likely to be a consortium led by an appropriate appropriate an by led consortium a be to likely most is model operational health’s Dot operations. their the rapidInternet. globalof expansion the date is andambitiousplanproposedto holistic The most levels.provincial, andcountry Technologicalapproaches suchasmedically focusedsearchengineshave Conclusions 65
References 67 , accessed , accessed , 2007, 29(12):2758– , 2007, , 2007, 29(12):2758–2767. , 2007, www.worldmapper.org/posters/ Clinical Therapeutics , accessed 10 October 2011). 10 , accessed
Clinical Therapeutics
References , 1998, 42(4):475–90. -e-commerce-sales-head-1-trillion-mark, accessed 9 October 2011). 9 -e-commerce-sales-head-1-trillion-mark, accessed , accessed 2 March 2011). 2 March , accessed Policy implications of importation. drug Policy
. 5 Policy implications of drug importation. Policy . Internet use Internet 1990. Sheffield, University of Sheffield, 2006 ( worldmapper_map335_ver5.pdf Palumbo FB et al Flannery MA. Building a retrospective collection in pharmacy: a brief history of the literature with some Davis D. Global e-commerce sales head for the $1 trillion mark. Chicago, Vertical Web Media, 2011 (http://www. 2011 Media, Web Vertical Chicago, for the $1 trillion sales head mark. e-commerce Global Davis D. Barbosa GT. Barbosa GT. Internetretailer.com/2011/01/04/global Internet usage statistics. Internet World Stats, 2011 (http://www.Internetworldstats.com/stats.htm Stats, 2011 World statistics. Internet usage Internet 89(2):212–221. files/resources/THE-COST-OF-CYBER-CRIME-SUMMARY-FINAL.pdf considerations for U.S. health sciences library professionals. Bulletin of the Medical Library Association, 2001, Association, 2001, health sciences library professionals. Bulletin of Library the Medical U.S. considerations for Weiss AM. Buying prescription drugs on the Internet: promises and pitfalls. Cleveland Clinic Journal of Medicine, Clinic Cleveland AM. Buying prescription drugs on promises and pitfalls. the Internet: Weiss Ovaskainen H. Internet pharmacies: advantages and risks. WHO Drug Information, 2001, 15(3/4):149–151. WHO Drug Information, 2001, Ovaskainen H. Internet pharmacies: advantages and risks. George C. Internet pharmacies: Global threat requires a global approach to approach regulation. Hertfordshire Law a global Global threat requires C. Internet pharmacies: George 1(1):16–25. Palumbo FB et 1(1):16–25. al 13 October 13 2011). Assurance DeticaOffice. Surrey, in Limited, 2011.Cabinet the (http://www.cabinetoffice.gov.uk/sites/default/ Atkin DJ, Jeffres LW, Neuendorf KA. Understanding Internetadoption as telecommunications behavior. Anand A et al. Internet pharmacy: need to be implemented in India. Chronicles of Young Scientists, 2010, Scientists, 2010, Young Chronicles of in A et al. Internet pharmacy: to India. need be implemented Anand The cost of cybercrime. A Detica report in partnership with the Office Cyberof Security and Information 2767. 2006, 73(3):282–288. 2006, Journal, 2006, 4(1):12–25. Journal, 2006, Journal of Broadcasting and Electronic Media 8. 6. 11. 1. 10. 9. 3. 7. 5. 2. 4. 68 References 21. 20. 29. 28. 27. 24. 23. 22. 26. 25. 15. 31. 30. 19. 32. 18. 33. 17. 14. 16. 13. 12. 2009, 6:1e. 2010 (http://www.fbi.gov/news/stories/2010/october/cyber-banking-fraud, accessed 10 October 2011). 2011). 2010, 125(4):756–767. 2011). 2009, 52(9):99–107. Jones-Kavalier BR, Flannigan SL. Connecting the digital dots: literacy of the 21st Century.the of literacy dots: digital Flannigan the SL. BR, Connecting Jones-Kavalier 2006, 29(2). 7:45. Anderson C et al. The WHO UNESCO FIP Pharmacy Education Taskforce.Pharmacy FIP UNESCO al. WHO The et C Anderson 10 October 2011). 10 October 103(1):31–36. Orthopsychiatry Cyber banking fraud. arrests lead tomajor Global partnerships Symantec.cloudIntelligence: February 2011MessageLabs Mountain intelligence report. View, 2011Symantec Symantec, 2010(http://www.symantec.com/connect/blogs/pharmacy-spam-pharmaceutical-websites-fall- Symantec.cloud Intelligence: MessageLabs May 2011 intelligence report. Mountain View, Symantec, 2011 (http:// StanleyJ. adolescents. and children on media of effects Health E. Donnerstein AB, Jordan VC, Strasburger Spamhaus Project. The definitionofspam. Available from:http://www.spamhaus.org/definition.html. Co-Operation and Development, 2005 (www.oecd.org/dataoecd/5/47/34935342.pdf, accessed 10 October United States of America of United States ht:/w.yatclu.o/lrpr/L_010_erayFNLe.D, cesd 0 October 10 accessed (http://www.symanteccloud.com/mlireport/MLI_2011_02_February_FINAL-en.PDF, Gilster P. Aprimerondigitalliteracy Nursing Education Prevention&Policy , 2005, 12(1):75–80. Research UNIS-UN. Journal of Adolescenceof students. Journal aifs.gov.au/nch/pubs/issues/issues15/issues15.html, accessed 10 October 2011). and Human Services, 2009 (http://www.hhs.gov/healthit/documents/MedIdTheftReport011509.pdf, accessed Hu H et al. WiFi networks and al. networks et WiFi H Hu Kako-Batt Y. Dowdell EB, Bradley PK. Risky Internet behaviors: a case study of online and offline stalking. Marsh L et al. Brief report: text bullying and traditional bullying among New Zealand secondary school Ramasubramanian S. Hamilton. Allen Booz Mancilla D, Moczygemba J. Exploring medical identity theft.PerspectivesInformation Management in Health Fogel J, Shlivko S. Weightproducts. loss weight for e-mail spam and problems Kanich C et al. Spamalytics: anempirical analysis ofspam marketing conversion. two-distinct-operations, accessed 10 October 2011). Littlejohn study.drug prescription sales:across-sectional et al.Internetpharmaciesandonline C Drugs Mishna F et al. Cyber bullying behaviors among middle and high school students. school high and middle among behaviors bullying Cyber al. et F Mishna Paper. New York, United Nations,2011. Ivanitskaya L, O’Boyle I, Casey AM. Health information literacy and competencies of information age students; www.symanteccloud.com/mlireport/MLI_2011_05_May_FINAL-en.pdf, accessed 10 October 2011). results from the interactive online Researchresults fromtheinteractiveonline Readiness Self-AssessmentMedical Internet (RRSA). Journalof , 2010, 26(6):436–442. , 2006, 8(2):e6. Child abuse and the InternetMelbourne, and the.National abuse Child Protection Child Clearinghouse, 2001 (http://www. The web: wiring our world web: wiring The Pharmacy spam: pharmaceutical websites fall into two distinct operations distinct two fall into websites spam: pharmaceutical Pharmacy , 2010, 80(3):362–374. TaskForce on Spam. developing countries.Paris, in Spam issues for Economic Organisation Medical identity theft final report. final theft identity Medical , 2009, 106(5):1318–1323. malware , 2010, 33(1):237–240. . Mississauga, Ontario, John Wiley & Sons, 1997. . 35 th epidemiology. Annual International Student Conference 3–4March2011. A Working Proceedings of the National the Proceedings of Academy of the Sciences of Washington, DC, United States Department of Health . Washington, DC, Federal Bureau of Investigation, Human Resources for Health for Resources Human Southern Medical Journal,2010, Southern Communicationsof the ACM, The American Journal of American Journal The Educause Quarterly, . Mountain View, . Journal of School of Journal Pediatrics , 2009, , , References 69 , 2008, , 2008, , accessed 26 accessed , , 2009, 12(6):713– , 2009, Computers in Biology Computers , 2010, 12(2):e11. , 2010, British Journal of Clinical Pharmacology Journal of British Cyberpsychology and Behavior and Cyberpsychology , 2001, 285(20):2612–2621. , 2001, , 2005, 51:116–118. , 2005, . Washington, DC, Pew Internet & American Life Project, . Washington, DC, Pew Internet & American Life Project, 2010 2010 Project, Life American & Internet Pew DC, Washington, . Journal of Medical Internet Research Journal of Medical Internet Proceedings of the 2nd International Conference on Theory and Practice of on Conference Proceedings of the 2nd International . Philadelphia, Health Populi, 2011 (http://healthpopuli.com/2011/01/06/health- 2011 Health Populi, . Philadelphia, , 2009, 38(10):1476–1483. , 2009, . Washington, DC, Department of Health and Human Services, 2006. (http://www. 2006. Services, of Health Washington, DC, Department and Human . . NY, NY, Manhattan Research, LLC, 2008. LLC, Manhattan Research, NY, . NY, . London, The London School of The London health: Online untangling the web. London, 2010. Health Pulse BUPA Health citizens in emerging countries seek health information online even more than their Chronic disease the Internet and , 1998, 28(5):603–610. Presse Medicale The social health life of information 2011 Washington, Online health search 2006. DC, Pew Internet & American Life Project, 2006 (http://www. in France]. in France]. pewInternet.org/Reports/2006/Online-Health-Search-2006.aspx, accessed 10 October 2011). 2011). October 10 accessed pewInternet.org/Reports/2006/Online-Health-Search-2006.aspx, health.gov/communication/healthypeople/obj1104/default.htm, accessed 9 October 2011). 9 accessed health.gov/communication/healthypeople/obj1104/default.htm, www.harrisinteractive.com/vault/HI-Harris-Poll-Cyberchondriacs-2011-09-15.pdf, accessed 26 October 2011). 26 accessed www.harrisinteractive.com/vault/HI-Harris-Poll-Cyberchondriacs-2011-09-15.pdf, Holmes ER, Tipton DJ, Desselle SP. The impact of the Internet on community pharmacy practice: a comparison SP. Desselle Tipton DJ, Holmes ER, Berland GK et al. Health information on the Internet: accessibility, quality, and readability in and readability English and quality, GK et al. Health information on the Internet: accessibility, Berland countries: Use of websites for health information disseminating in developing A. Thabrew M, Kommalage in A study of dissemination of health information via Internet. Studies A. Satiman A, Oumtanee S, Prachusilpa Internet pharmacy: of mistrust? a web DJ. Webb SR, Maxwell Boyer C, personal communication, 2011. Boyer Certification desNabarette sitesH dédiéset [Certification àal. of la health-related santé web en sites France. Studies in Health Studies online health information quality. to improving devoted A decade A. Geissbuhler C, Boyer Norman CD, Skinner HA. eHealth literacy: essential skills for consumer health in a networked world. Journal of Skinner HA. eHealth literacy: in for consumer health essential skills a networked CD, Norman K. Purcell S, Fox sites. On the Net code of conduct and health web for medical The Health C et al. Boyer Journal of Postgraduate Medicine Indian population. Journal of Postgraduate Eshet-Alkalai Y, Chajut E. Changes over time in digital literacy. Changes time in over literacy. digital Chajut E. Y, Eshet-Alkalai Economics and Political Science, 2011. Science, 2011. Economics and Political Fox S. McDaid D, Park A. Park McDaid D, Fox S. Ivanitskaya L et al. Dirt cheap and without prescription: how susceptible are young US consumers to purchasing US young are without prescription: how susceptible and al. Dirt cheap et Ivanitskaya L peers in developed economies an experience from Sri Lanka. In: an from experience drugs from rogue Internet pharmacies? drugs from rogue Internet used to assess their quality and Medicine consumer relationships , 2002, 20(2):3–29. of a Delphi panel‘s forecast with emerging trends. Health Quarterly, 2002, Marketing citizens-in-emerging-countries-seek-health-information-online-even-more-than-their-peers-in-developed- October 2011). 10 economies/, accessed , 2006, 122:775. and Informatics, 2006, Technology Health . Cairo, 2nd International Conference on Theory and Practice of Electronic Governance, Theory and Practice of Electronic Conference on Cairo, 2nd International Electronic Governance. 66(2):196–198. , 2006, 8(2):e9. Research, 2006, Medical Internet Report on objectiveestimating 11-4: the proportion of health related web sites disclosing information that can be (http://pewinternet.org/~/media//Files/Reports/2010/PIP_Chronic_Disease_with_topline.pdf, (http://pewinternet.org/~/media//Files/Reports/2010/PIP_Chronic_Disease_with_topline.pdf, accessed 26 October 2011). October 2011). October 2011). The Journal of the American Medical Association American Medical Journal of the Spanish. The Sarasohn-Kahn J. Sarasohn-Kahn J. Cybercitizen Health Europe. Connecting with Europeans online for health: digital marketing strategies for building for health: digital with online marketing Europeans Connecting Health Europe. Cybercitizen Akerkar SM et al. Use of the Internet as a resource of health information by patients: A clinic-based study in the A clinic-based Use of the Internet as a resource of health information by patients: SM et al. Akerkar 715. 2008. 2011 (http://pewinternet.org/~/media/Files/Reports/2011/PIP_Social_Life_of_Health_Info.pdf 2011 Technology and Informatics, 2005,116:891–896. Technology . NY, NY, Harris Interactive, 2011 (http:// 2011 Harris Interactive, NY, online. NY, obtained information care health of use and influence growing The 34. 36. 35. 37. 54. 50. 51. 53. 52. 39. 38. 48. 49. 44. 47. 43. 45. 46. 41. 40. 42. 70 References 71. 55. 56. 57. 59. 58. 78. 74. 73. 70. 76. 75. 77. 72. 69. 68. 67. 66. 65. 64. 63. 62. 61. 60. Journal ofPsychiatry 2008. (http://v35.pixelcms.com/ams/assets/312296678531/455_EAASM_counterfeiting%20report_020608. 56(5):403–404. 78(7):818–820. 320. Armstrong K, Armstrong Schwartz JS, New overtheInternet.The Direct saleofsildenafil(Viagra)consumers DA. to Asch Veronin MA, Nguyen NT. Comparison ofsimvastatintablets from the US and international markets obtained Veronin M.Packagingandlabeling ofpharmaceutical products obtained from the Internet.Journal of Medical Solomon Hetal. Viagra on theInternet:unsafe sexual practice. International Journal of Clinical Practice , 2002, Orizio G et al. “Save 30% if youbuy today”. Online pharmacies and the enhancementofperipheral thinking in Orizio G etal. Cyberdrugs:pharmacies characteristics. study ofonline a cross-sectional Orizio G etal. incyberpharmacies: Online consultations completeness andpatient safety. Telemedicine and Gallagher CT, of suppliers web-based of LE. legitimacy Chapman and location theClassification, to Viagra UK. Medicine, 1999,131:830–833. Dependence Internet Research,2011, 13(1):e22. Public Health International Journal ofPharmacyPractice England Journal ofMedicine,1999,341(18):1389–1392. WHO. Growing threat from counterfeit medicines. Westenberger BJ etal. Quality assessmentofInternetpharmaceutical productsusingtraditionalandnon- Medicines: counterfeit medicines. Geneva, World Health Organization, 2010 (http://www.who.int/mediacentre/ Dermatology and Venereology Dermatology consumers. e-Health survey bycommunitypharmacies. via theInternet.The Annals ofPharmacotherapy Fittler A, Bosze G, Botz L. Attitude of patients and customers toward on-line purchase of drugs--a Hungarian drugs--a of purchase on-line toward customers and patients L. of Fittler Botz Bosze Attitude G, A, Drug and Alcohol Inciardi drugs JA etal.Prescriptionpurchasedaretheendusers?Drug through theInternet:who Becher E, Glina S. Erectile dysfunction in Latin America and treatment with sildenafil citrate (Viagra): citrate sildenafil with treatment and America Latin in dysfunction Erectile S. Glina E, Becher Khalaf IM, LevinsonIP. the in Erectile dysfunction Africa/Middle Region:East epidemiology andexperience ushe J DelA Kee F Ilgl ucae f scorpc rg fo te Internet. the from drugs psychotropic of purchase Illegal F. Kiefer A, Diehl J, Mutschler European Alliance for Access to Safe Medicines. Bloom BS, Iannacone RC.Internetavailability of prescriptionpharmaceuticals tothepublic. Raine C, Webb DJ, Maxwell SRJ. The availabilityanalgesicspurchasedfromtheInternetin of prescription-only Miller L,Nielsen C. Internetavailabilityofcontraceptives. Memmel LM, Miller L, Gardner J. Over-the-Internet availability of hormonalcontraceptivesregardless of risk Mahe E et al. Shopping forpsoriasismedicationsontheInternet. Forman RF et al. The availability of web sites offering to sell opioid medications without prescriptions. Bate R,HessK. Assessing websitepharmacydrugquality:saferthanyouthink? traditional analyticaltechniques. the UK. with sildenafilcitrate(Viagra). introduction. pdf, accessed 9 October 2011). factors. factsheets/fs275/en/, accessed 12 October 2011). British Journal of Clinical Pharmacology Contraception, 2006, 73(4):372–375. , 2009, 15,10:1022–1025. , 2010, 110(1–2):21–29. Pharmacoepidemiology andDrug Safety , 2009, 19(4):375–377. International Journal ofImpotence Research , 2006, 163:1233–1238. , 2009, 23(9):1050–1055. International Journal ofImpotenceResearch International Journal ofPharmaceutics Orv Hetil , 2010, 18(6):341–345. , 2010, 151(48):1983–1990. , 2008, 67(2):250–254. , 2008, 42(5):613–620. The counterfeiting superhighway The counterfeiting Bulletin of the World Health Organization , 2010, 19(9):970–976. , 2002, 14(Suppl 2):S1–S2. Obstetrics & Gynecology Obstetrics , 2005, 306(1–2):56–70. Journal of theEuropean Academy of , 2003, 15(Suppl 1):S1–S2. PLoS One . Surrey, Medicom Group Ltd, , 2001, 97(1):121–126. , 2010, 5(8):e12199. European Journal of European Journal Annals ofInternal , 2010, 88(4):241– Nervenarzt, 2007, American References 71 , , Journal of Journal Journal of Disease Management and Journal of Medical Systems Journal of Medical 2006, 24(4):507–515. , 2006, Journal of Interactive Advertising Journal of Interactive . Washington, DC, Government U.S. . Akron, University of Akron, 2010 (http:// Akron, 2010 University of Akron, . Irvine, M86 Security, 2008 (http://www.marshal. 2008 Security, Irvine, M86 2009, 35(1):125–184. , 2009, , 2008, in Medicine, 2008, Communication Visual Journal of , First Session , 2007, 23:318–332. , 2007, , accessed 20 October 2011). 20 , accessed , 108th Congress , 2005, 48(4):39–43. , 2005, ACM of the Communications , 2008, 69(5):703–708. , 2008, . Mount Prospect, IL, National Association of Boards of Pharmacy, 2011 (http:// 2011 Association of Boards of Pharmacy, National . Mount Prospect, IL, Computers in Human Behavior in Human Computers . Washington, DC, Business Source Alliance, Source Washington, DC, Business attitudes toward spam in six countries. Consumer , 2010, 24:114–121. , 2010, , 2002, 10:679–691. , 2002, , drugs and software lead spam purchase growth. . Washington, DC, Pew Internet and American Life Project, 2007 (http://www.pewInternet. Project, 2007 American Life Internet and Washington, DC, Pew Spam. Sex , 2010, 15(1):1–10. , 2010, Commerce products. Journal of Internet Banking and 4(9):e274. products. PLoS Medicine, 2007, marketing methods: Intrusiveness, perceived loss of methods: perceived control, Intrusiveness, and irritation. marketing www.nabp.net/news/assets/IDOIReportJuly11.pdf www.cs.uakron.edu/~chan/DataMining/References/Detecting Pharma Spam --Liszka et al.pdf, accessed 10 accessed et al.pdf, --Liszka Spam Pharma www.cs.uakron.edu/~chan/DataMining/References/Detecting American Journal of Law and Medicine Journal American illicit online drug sales. Law E, Youmans SL. Combating counterfeit medications: The California pharmacist perspective. California The Combating counterfeit medications: SL. Youmans E, Law Marshal. Printing Office, 2003 (http://energycommerce.house.gov/108/action/108-35.pdf, accessed 10 October 2011). October accessed 10 (http://energycommerce.house.gov/108/action/108-35.pdf, 2003 Office, Printing children in fitness and activity physical promoting for programs activity physical School-based al. et M Dobbins Fallows D. Research. Forrester Fogel J, Shlivko S. Consumers with sexual performance problems and spam e-mail for sexual performance Holt R. Legislative efforts to combat spam. Joint hearing before the Subcommittee on, and Commerce, Trade Morimoto M, Chang S. Consumers’ attitudes toward unsolicited commercial e-mail and postal mail direct mail direct mail postal and e-mail commercial unsolicited toward attitudes Consumers’ S. Chang M, Morimoto National Association of Boards of Pharmacy. Internet Association of Boards of Pharmacy. National Drug Outlet Identification Program progress report for Liszka KJ et al. Detecting pharmaceutical spam in microblog messages Boyer EW, Wines JD Jr. Impact of Internet pharmacy regulation on opioid analgesic availability. of Impact Internet pharmacy on regulation availability. opioid analgesic Jr. JD Wines Boyer EW, for accountability site, and provider web search engine, for safety: addressing Searching T. BA, Mackey Liang providers. consumers and on pharmaceutical Internet the of effect The FM. Dupuits attitudes and actions. , 2002, 23:85. , 2002, VIPPS for on-line pharmacies. Drug Topics Canada adopts C. Ukens and Commerce House of Representatives Commerce and state regulators and federal client/oem2.html/step/pr/article/17, accessed 10 October 2011). 10 accessed client/oem2.html/step/pr/article/17, org/~/media//Files/Reports/2007/PIP_Spam_May_2007.pdf.pdf, accessed 10 October 2011). 10 accessed org/~/media//Files/Reports/2007/PIP_Spam_May_2007.pdf.pdf, October 2011). 10 =news, accessed com/pages/newsitem.asp?article=748&thesection Pharmacy Practice Results of the SpamCatcher attitude survey. SpamCatcher Results of the San Francisco, Mailshell, 2003 (http://www.mailshell.com/mail/ Practices. Division of Marketing A report by the FTC’s False claims in spam. Washington, DC, Federal Trade Health Outcomes Grech V, Hugo AM. AM. Email spam: Hugo a single user’s perspective. V, Grech Catizone C, personal communication, 2011. Catizone costs, and regulation. quality, of access, Internet pharmacy: issues SY. Crawford Cerf VG. Spam, spim, and spit. VG. Cerf affected by spam. Social Online behaviors Computer Science Review GA. Grimes Gernburd P, Will AR. Jadad spam Gernburd overwhelm P, our defenses? Evaluating offerings for drugs and natural health October 2011). October 2011). 10 accessed (http://www.ftc.gov/reports/spam/030429spamreport.pdf, Commission, 2003 to group age and of gender relations spam: and users end E-mail ML. Signorella GA, Hough MG, Grimes Studies on Alcohol and Drugs Alcohol on Studies Consumer Protection and the Subcommittee on Telecommunications of the Internet of the Committee on Energy Committee of the Internet of the Telecommunications Subcommittee on Protection and the Consumer 31(3):110–112. 2003, 27(1):57–65. 2003, 2004 (http://www.bsa.org/country/Research%20and%20Statistics/~/media/87F4037F2B7044ECBF448A227B8 2004 2006, 7(1):8–20. 2006, 4BE86.ashx, accessed 10 October 2011). 10 4BE86.ashx, accessed 86. 87. 85. 84. 88. 83. 82. 89. 80. 81. 101. 100. 97. 93. 94. 95. 98. 99. 91. 92. 79. 96. 90. 72 References 122. 121. 120. 119. 118. 117. 116. 113. 112. 115. 114. 111. 110. 109. 108. 107. 106. 105. 104. 103. 102. Journal of Child Sexual AbuseSexual , 2007,of Child 16(4):99–114. Journal J. KaiserFamilyFoundation,2010 (http://www.kff.org/entmedia/upload/8010.pdf, accessed 10 October 2011). 2009, 45(4):368–375. 2009 (http://www.pewInternet.org/Reports/2009/8-The-Social-Life-of-Health-Information/01-Summary-of- American Medical Association American Quarterly, 2002, 10(2):3–8. Criminal BehaviourandMentalHealth Silberg WM, Lundberg GD, MusacchioRA. and assuringthequalityofmedical controlling, Assessing, Research Psychologist Health Wolak J. Online ‘predators’ and their victims: myths, realities and implications for prevention. for implications and realities myths, victims: their and ‘predators’ Online J. Wolak Wang J, RJ, Iannotti Nansel TR. bullying amongadolescentsinthe School United verbal, States: physical, extent of ‘sexting’ amongst extent of UK teens.London,RochesterHouse, 2009 (http://www.beatbullying.org/dox/ of theNew York Academy of Sciences and Treatment sextech/, accessed 10 October 2011). Risk A, Dzenowagis J. Review of Internet health informationquality initiatives.Journal of MedicalInternet Karp S, Monroe AF. Quality of healthcare information on the Internet: caveat emptor still rules. Rideout VJ, Foehr UG, Roberts DF.Roberts UG, Rideout Foehr VJ, Neutze J et al. Predictors of Predictors al. et J Neutze Nielssen O et al. Child pornography al. Child et Nielssen O BeatBullying.org. Marcum CD. InterpretingofInternetpredators: the intentionsanexaminationofonlinepredatory behavior. Deirmenjian JM. Pedophilia ontheInternet.JournalofForensic Sciences Katzman D. Sexting: Keepingand Child teens safe and responsible in asavvyworld.Paediatricstechnologically viii. representative survey ofteensandyoung representative adults school children. National Campaign To Prevent Teen and Unplanned Pregnancy. Sexanationally and from tech: results Kelley AE, Schochet T, Landry CF. Risk taking and novelty seeking in adolescence: introduction to part I. Journal, 2009.McCrea B.Managingsocialmediarisks.The Fuld GL. Social networking and adolescents. and networking Social Fuld GL. and adolescentsaged6-18. Mitchell KJ et al. Internet-facilitated commercial sexual commercial Internet-facilitated al. et KJ Mitchell information ontheInternet:caveat lector et viewor—let the reader and viewer beware. Kayiran SM, Soyak G, levelmedia families use bychildreninofhighsocioeconomic Gürakan Electronic B. and ee e a. o excessive Do al. et A Bener pedophiles andhebephiles. Results ofanationalsurvey. Archivos Argentinos dePediatría Melamud children between with 4and18yearsold.Parent’set al.Internetusagehouseholds A in supervision. Findings.aspx, accessed 10 October 2011). Fox S, Jones S. Jones S, Fox media-centre/press-releases/press-release-040809.html, accessed 9 October 2011). relational, andcyber. representative sample of lawenforcementagenciesinthe United Research States. Sexual Abuse:of A Journal familial factors.The Turkish Journal ofPediatrics , 2010, 15(1):41–45. , 2001, 3(4):E28. , 2008, 63(2):111–128. , 2011, 23(1):43–71. The social life of health information health of life The social Journal of Child Health CareHealth , 2010, 14(4):375–385.of Child Journal Truthamongst sexting of Leading children’sUK teens. true Beatbullying uncovers charity The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, The Cochrane Databaseof Systematic Reviews Sexual Abuse: A Journal ofResearchand Treatment , 1997,277(15):1244–1245. child pornography child Internet GenerationM2. Media in the lives of 8- lives to18-yearGenerationM2. Mediainthe olds.MenloPark, Henry , 2004, 1021:27–32. offenders detected by surveillance of the Internet and by other methods. other by and Internet the of surveillance by detected offenders , 2011, 21(3):215–224. s, eeiin iwn ad or lifestyle poor and viewing television use, Adolescent Medicine: Statethe of Reviews Art . Washington, DC,2008 (http://www.thenationalcampaign.org/ , 2010, 52(5):491–499. offenses and child sexual abuse in a community sample of sample community a in abuse sexual child and offenses . Washington, DC, Pew Internet & American Life Project, Life American & Internet Pew DC, Washington, . exploitation , 2009, 107(1):30–36. of , 2002, 47(5):1090–1092. , 2009, (1):CD007651. children: findings from a nationally a from findings children: , 2011, 23(2):212–242. habits affect low vision in vision low affect , 2009, 20(1):57–72, The Journal of the Managed Care The American The Annals References 73 , , 1997, Pediatrics Journal of Annals of
The Journal Research in Informatics for The of English and Finnish British Medical Journal, , 2002, 287(20):2691–700. , 2002, , 2005, 74(7–8):675–683. , 2005, , 2010, 47(2):206–208. , 2010, Journal of Women’s Health Women’s Journal of , 2000, 19:148–156. , 2000, evaluation resources and management tools. (In press). , 2008, 102(7):441–448. , 2008, online Health Affairs Health Perspective Perspective Infirmière: Revue Officielle de l’Ordre information: An , 2011, 43(1):33–40. , 2011, (in press). , 2010, 18(2):148–152. , 2010, Atención Primaria Atención , 2010, 8(5):285–291. , 2010, antidepressant drug , 2009, 6(5):11. , 2009, International Journal of Medical Informatics Journal International , 2006, 2(4):479–498. , 2006, online Eating Disorders , 2003, 5:e25. , 2003, , 2011, 40(6):382–386. , 2011, , 2003, 48(4):222–227. , 2003, Fortbildung und Qualität im Gesundheitswesen Qualität im , Fortbildung und Research in Social and Administrative Pharmacy: RSAP Administrative Social and Research in , 2008, 42(12):1814–1821. , 2008, 2010, 38(3):182–188. , 2010, Control Journal of Infection American language web sites. pages using a validated questionnaire. information on the Internet. Buhi ER et al. Quality and accuracy of sexual health information web sites visited by young people. sites visited web health information of sexual Quality and accuracy Buhi ER et al. Bazaz R, Green E, Green ST. Quality of malaria information provided on Internet travel operator websites. on Internet travel information provided Quality of malaria ST. Green E, Green Bazaz R, Bernstam EV et al. Usability of quality measures for online health information: Can commonly used technical technical Can commonly used health information: for online quality measures Usability of al. EV et Bernstam Fiore F. Medications in Wikipedia. Comparison of reliability. Mühlhauser I, Oser F. Does Wikipedia provide evidence-based health care information? A content analysis. Pandolfini C, Clavenna A, Bonati M. Qualityof cystic fibrosis information on Italian websites. Eysenbach G et al. Empirical studies assessing the quality of health information for consumers on the World World G et al. Empirical studies assessing information for consumers on the quality of health the Eysenbach McClung HJ, Murray HD, Heitlinger LA. The Internet as a source for current patient information. Heitlinger LA. McClung HJ, Murray HD, Impicciatore P et al. Reliability of health information for the public on the World Wide Web: systematic survey systematic survey Web: Wide World of health information for the public on the P et al. Reliability Impicciatore plastique et esthétique quality criteria be reliably assessed? be reliably assessed? quality criteria Prusti M et al. The quality of Eysenbach G, Köhler C. How do consumers search for and appraise health information on the World-Wide- Reynolds Reynolds J, Griffiths K, Christensen H. Anxiety and depression - Journal study. an observational Internet: Adolescents searching for health information on the al. Hansen D et Illman J. WHO’s plan to police websites rejected. British WHO’s 321(7272):1308. Medical Journal, 2000, J. Illman antibiotics. the American Medical Informatics Association des Infirmières et Infirmiers du Québec des Infirmières et Infirmiers du of Adolescent Health: Official Publication of the Society for Adolescent Medicine for Society of the Publication Official Health: Adolescent of of Medical Internet Research of advice on managing fever in children at home. British of advice on managing fever , 1997, 314:1875–1879. Medical Journal Wootton The JC. Wootton quality of information on women’s health on the Internet. Weitzman ER et al. Social but safe? Quality and safety of diabetes-related online social networks. Quality and safety of diabetes-related Social but safe? ER et al. Weitzman The Journal of the American Medical Association American Medical Journal of the The a systematic review. Web: Wide Pharmacotherapy Health 34(1):10–17. , 2009, and Social Care 6(5):575–581. Web? Qualitative study using focus groups, usability tests and in-depth interviews. in-depth tests and usability study using focus groups, Qualitative Web? Ghoshal M, Walji Quality MF. of medication information available on retail pharmacy websites. Goldsmith J. How will the Internet change our health system? J. How will the Internet Goldsmith Conesa Fuentes MC, Aguinaga Ontoso E, Hernández Morante JJ. An evaluation of the quality of health web C. the quality of Eating disorders blogs: testing Wanden-Berghe J, Sanz-Valero R, Guardiola-Wanden-Berghe Wikipedia. information of drug in accuracy Scope, completeness, and Clauson KA et al. Smarrito S et al. Do we need a chart of quality for websites related to cosmetic surgery? Annales de chirurgie to cosmetic related surgery? for websites a chart of quality need S et al. Do we Smarrito Scanfeld D, Scanfeld V, Larson EL. Dissemination of health information through social networks: twitter and information through social networks: twitter EL. Dissemination of health Larson V, Scanfeld D, Scanfeld Social and Administrative Pharmacy Administrative Social and , 2000, 118:4–9. Orthopedics, 2000, Orthodontics and Dentofacial 1998, 101:1–4. Australian Family Physician Australian Zeitschrift für Evidenz Jiang YL. Quality evaluation of orthodontic information on the World Wide Web. American Journal Web. of Wide World of orthodontic information on the Quality evaluation YL. Jiang 2002, 324:573–577. 2002, Travel Medicine and Infectious Disease Travel 127. 126. 125. 123. 136. 137. 135. 128. 129. 124. 139. 138. 132. 130. 131. 133. 134. 140. 141. 142. 145. 144. 146. 143. 74 References 167. 166. 165. 168. 164. 163. 162. 161. 160. 159. 158. 157. 151. 154. 153. 152. 150. 156. 155. 149. 148. 147. 2011, 13(1):e14. Jansen BJ, Spink A. Howare we searching the World Wide Web? ofninesearchengine A comparison transaction 2008, 198(6):682.e1–5. 2003:225–229. American MedicalInformatics Association American Medical Association American American MedicalInformation Association 52(8):1046–1050. Coberly E et al. Linking clinic patients to Internet-based, condition-specific information prescriptions. information Internet-based,condition-specific to patients clinic Linking al. et E Coberly Greenberg L, D’Andrea G, Lorence D. Setting the public agenda for online health search: a white paper and paper white a search: health online for agenda public the Setting D. Lorence D’AndreaG, L, Greenberg Oulasvirta A, Hukkinen JP, Schwartz B. When more is less: the paradox of choice in search engine use. SIGIR ’09. of quality. Urology education ontheInternet. Medical Informatics Association Informatics Medical online experiment. Walji Metal. Searching forcancer-related unintended retrievalonline: information complementary and of of theMedicalLibrary Association events/sec11/tech/full_papers/Leontiadis.pdf, accessed 10 October 2011). osteoarthritis. of American College Health American Collegeof decision making?Journalofthe American MedicalInformatics Association Ilic D, Risbridger G, Green S. Searchingscreening: anassessment theInternetforinformation onprostatecancer Ilic Detal. Specialized medical search enginesare no better than general engines insourcingconsumer ’lsado M t l rnoie cnrle til f n nomto pecito fr eiti patient pediatric for prescription information an of trial controlled randomized A al. et DM D’Alessandro search engineresultsandwebpageviews. Lau AY, Coiera EW. be reducedimprove searches to health information biases duringconsumer cognitive Can alternative medicineinformation. action agenda.JournalofMedicalInternetResearch Lau AY, Coiera EW. Dopeople experience cognitive biases while searchingforinformation?Journal of the Lau AY, Coiera EW.making: aprospective decision feedback consumer and socialon web searching Impact of AMIA Annual Symposium Proceedings, Annual Symposiumand ofsearchengine quantitative analysisqueries on theInternet.AMIA Rose S, Bruce J, Maffulli N. Accessing the Internet for patient information about orthopedics. about information patient for Internet the Accessing N. Maffulli J, Bruce S, Rose Laurent MR, Vickers TJ. Seeking health informationonline:does Wikipedia matter? Heilman JM etal. Wikipedia: a keyfor global tool publichealth promotion. Law MR, Mintzes B,Morgan SG. The sourcesand popularity of onlinedrug information: ananalysisoftop In: Proceedingsofthe32ndinternational ACM research anddevelopmentSIGIR on conference in information Buhi ERetal. observational studyofhowyoungpeople An searchforonlinesexual health information.Journal information aboutandrogendeficiency. HumanReproduction,2003, 18:557–561. Leontiadis N,Moore T, online the illicit Measuring search-redirectin N. andanalyzingattacks Christin Kaimal AJ etal. & Gynecology who iseducating Google obstetrics:ourpatients?American Journal Obstetrics Lissman TL, Boehnlein JK. reviewA critical Services, 2001,about depression.Psychiatric ofInternetinformation Boston, 2009:516–523. Dickerson S et al. PatientInternetuse for healthinformationatthree urban primary care clinics. Eysenbach G, Köhler C. What is the prevalence of health-related searches on the World Wide Web? Qualitative Maloney S, IlicD, Green S. Accessibility,the Internet:asurveyon of healthinformation natureandquality on prescription drugprescription trade. In: Proceedingsofthe20th USENIX Security Symposium. 2011 (https://db.usenix.org/ retrieval. The 32ndinternational ACM SIGIR conference onresearch anddevelopment in informationretrieval, logs. Information Processing&Management Rheumatology , 2004, 64:112–116. Journal ofMedicalInternetResearch , 2009, 58(2):101–111. Archives ofPediatrics & Adolescent Medicine , 1998,280:1309–1310. , 2005, 44(3):382–385. , 2009, 16(4):471–479. , 2010, 98(2):160–164. International Journal ofMedicalInformatics , 2007, 14(5):599–608. , 2004, 11(6):499–504. The Annals ofPharmacotherapy , 2006, 42(1):248–263. , 2004, 6(2):e18. , 2008, 10(1):e2. , 2004, 158(9):857–862. , 2009, 16(1):54–65. Journal of Medical InternetResearch Journal of , 2011, 45(3):350–356. , 2005, 74(7–8):685–693. Journal of the Journal of American Journal of the Journal of Journal of the Journal , , References 75 Journal of American Journal of , 2005, 116(5):e643– , 2005, http://www.ic.gc.ca/ , accessed 25 October October 25 , accessed Pediatrics http://www.ic.gc.ca/eic/site/ecic-ceac.nsf/eng/h_ . Geneva, World World Health Organization, . Geneva, 2011 , accessed 29 October 2011. October 29 , accessed . Third Session. Third Fortieth Parliament, C-28. 59 Elizabeth II, 2010 Bill . 2011 (http://www.colloque-rsi.com/files/2011/presentations/A-Leduc. . 2011 , 2010, 67(15):1290–1293. , 2010, , accessed 25 October 2011). 25 , accessed . Canada for An anti-spam plan action Canada’s anti-spam legislation Canada’s , accessed 29 October 2011). 29 , accessed pdf windowsteamblog.com/windows_live/b/windowslive/archive/2010/01/12/fighting-the-war-on-spam.aspx, windowsteamblog.com/windows_live/b/windowslive/archive/2010/01/12/fighting-the-war-on-spam.aspx, Ritterband LM et al. Using the Internet to provide information prescriptions. information prescriptions. Internet to provide Using the al. et LM Ritterband Leduc A. Leduc Parliament of Canada. House of Commons. Commons. Canada. House of of Parliament Industry Canada. Working Group on Anti-Spam Technology and Network Management. Network Management. and Technology Anti-Spam on Group Working Canada. Industry Hughes B, Wareham J. Joshi Health I, 2.0 and Medicine 2.0: tensions and controversies in the field. B, personal communication, 2011. Mesko mobile technologies mHealth: new horizons for health through Industry Canada. , accessed 29 October 2011. 29 , accessed gv00246.html accessed 25 October 2011). October 2011). 25 accessed download/pls/15C103.txt Controlling the Assault of Non-Solicited Assault of Non-Solicited the Controlling Congress. 108-177. Public Law America. 108th States of United e647. eic/site/ecic-ceac.nsf/eng/gv00292.html#TechnologyWG Health-System Pharmacy Health-System 10(3):e23 Medical Internet Research, 2008, . 15 USC 7701. 117 STAT2699. December 16, 2003 (http://uscode.house.gov/ 16, 2003 December STAT2699. 117 USC 7701. . 15 and Marketing Pornography (http://www.parl.gc.ca/HousePublications/Publication.aspx?Docid=4547728&file=4 Clauson KA, Seamon MJ, Fox BI. Pharmacists’ duty to warn in the age of social media. Craddock D. Inside Windows Live: fighting the war on spam. Blog post from 12 January 2010 (http:// 2011).
169. 173. 170. 174. 172. 171. 176. 177. 178. 175. 179.
Appendix 1 77
.
Methodology global survey survey global of the second the second of on eHealth Appendix 1 Appendix Purpose technology, ministries of telecommunications, academics, researchers, eHealth professionals, professionals, eHealth researchers, academics, ministries of telecommunications, technology, sector partners. nongovernmental organizations involved in eHealth, donors, and private rich source of data that is being used to create a series of eight publications – The Global Observatory for Global The publications – of eight a series to create used that is being rich source of data reliable information and guidance on best practices, policies and standards in eHealth. reliable information and guidance on best practices, policies and standards their own development as well as a way to compare their own progress with that of other Member States. as well as a way to compare their own progress with that of other Member their own development response to the eHealth resolution, the Global Observatory for eHealth (GOe) was established to monitor was established Observatory for eHealth (GOe) Global the response to the eHealth resolution, these areas is predicated on a fifth strategic direction: monitoring, documenting and analysing trends partnerships in ICT development and deployment for health; supporting capacity building for the and deployment for health; supporting capacity building partnerships in ICT development knowledge base generated by the first survey. While the first survey conducted in 2005 was more general more was 2005 in conducted survey first the While survey. first the by generated base knowledge Each publication in the series is primarily targeted to ministries of health, ministries of information to ministries of health, targeted Each is primarily publication in the series eHealth Series – due for publication during 2010 and 2011. Series – due for publication during 2010 eHealth and primarily asked high-level questions at the national level, the 2009 survey designed was thematically survey the 2009 questions level, at the national high-level asked and primarily GOe with a the has provided the survey The thematic design of questions. more detailed and presented at national, regional and global levels in the adoption of the necessary in the adoption of the necessary foundation actions to support the levels and global at national, regional The aim was to provide governments with data that could be used as benchmarks for growth of eHealth. and analyse the evolution of eHealth in countries and to support national of eHealth through the provision planning and analyse the evolution of strategic information. and developments in in the results to understanding. In direct eHealth and publishing promote better and developments application of eHealth in Member States; and the development and adoption of standards. Success in Success and adoption of standards. States; and the development application of eHealth in Member strengthening health systems in countries through the use of eHealth (1); building public-private public-private building (1); of eHealth through the use strengthening health systems in countries The second global survey on eHealth was conducted in late 2009 and was designed to build upon the to build was designed and 2009 was conducted in late on eHealth survey The second global The survey is part of the mandate defined during the GOe’s inception – to provide Member States with The GOe’s first objective was to undertake a global survey on eHealth to determine a series of benchmarks of series a determine to eHealth on survey global a undertake to was objective first GOe’s The The World Health Organization’s eHealth resolution WHA 58.28 was adopted in 2005 and focused on 78 Appendix 1 Survey instrument Survey implementation The instrumentfocused on issuesrelating to processesand outcomes inkey eHealth areas. Objectives for and analysingtheresults. Based on the experience of the first global survey, the GOe benefited from many of the lessons learned in creatingthe second survey, disseminating the instrumentindigitalformat,workingwith WHO the survey weretoidentifyandanalysetrendsinthe: regional offices and Member States to encourage survey completion, as well as processing the data the processing as well as completion, survey encourage to States Member and offices regional • • • • • • • • Action concerning onlinechild safety, Internet pharmacies, healthinformationonthe Adoption ofeLearningforhealthprofessionalsandstudents Application oftelemedicinesolutions Governance andorganizationofeHealthincountries. Collection, processingandtransferofpatientinformation Uptake ofeHealthfoundationpoliciesandstrategies,buildingonthe2005 results Internet, andspam Development oflegalandethicalframeworksforpatientinformationindigitalformat Deployment ofmHealthinitiativesincountries Appendix 1 79 Action paper to digital records. Identify actions to be taken in countries to to be taken paper to digital records. Identify actions procurement, funding approaches, capacity building for eHealth, model approaches for the development of eHealth policies including model approaches for the development possible trends. Systematically review the content and structure of the content and Systematically review possible trends. personally identifiable data and health-related data in digital format personally identifiable data and health-related increase the uptake of digital patient records. increase the uptake information at three levels – local health care facility, regional/ facility, – local health care information at three levels health sciences for students and health professionals. by WHO region as well as World Bank income groups to establish World WHO region as well as by Describe the issues relating to the management of patient Describe the issues relating to the Analyse the trends in transition from district, national levels. around the world and the effectiveness of these approaches. and the effectiveness of these approaches. around the world mHealth important obstacles to implementing Highlight the most mHealth can overcome the digital Consider whether solutions. divide. innovative the globe as well as emerging and approaches across to encourage the necessary actions to be taken solutions. Propose and particularly in of telemedicine, acceptance global growth and countries. developing Presentation of all participating Member States eHealth data Presentation of all participating Member aggregated by country to act as ready reference of the state of to selected indicators. according eHealth development and multilingual communications. scope and content. actions to support of foundation trends in the uptake Review including: eGovernment, eHealth, ICT eHealth at the national level existing strategies highlighting strengths and weaknesses. Propose existing strategies highlighting strengths as well as the right to access and control one's own record. Identify and as well as the right to access States. by Member and analyse the control of online pharmacies action for child safety on the Internet. government to provide Review Review the trends in the introduction of legislation to protect Review Identify the diverse ways mobile devices are being used for health are being ways mobile devices Identify the diverse most frequently used telemedicine the Identify and review Identify the uptake of eHealth policies across the globe and analyse of eHealth Identify the uptake Analyse the extent of use and effectiveness of eLearning for the Theme mHealth information frameworks for eHealth Legal and ethical Management of patient eHealth country profiles eLearning eHealth foundation actions eHealth policies – a systematic review Telemedicine Table A1 shows the seven themes of the survey. the seven A1 shows Table Table A1. Survey themes Table 80 Appendix 1 Survey development The survey instrument was developed by the GOe withbroadandinputfromeHealth. consultation The variouslanguage versions ofthesurvey instrumentandsupporting documentationwere entered into This is the first time that DataCol has been used as the primary method of implementing an online survey A draft questionnaire was developeddraft questionnaire A review for and postedonline tested the partnersandwaspilot by A set of questions was developed and circulated in the first quarter of 2009 for comments to selected to comments for 2009 of quarter first the in circulated and developed was questions of set A (ITU) and for Economic Organisation Co-Operation andDevelopment (OECD). forum discuss online to An 13 12 Over 50 experts worldwide were involved in the process. Collaborative efforts extended to other WHO other to extended efforts Collaborative process. the in involved were worldwide experts 50 Over of thesurveyinstrument wasenhancedbasedthecommentsandobservationsreceived on from the data collection and management,data collectionData (DataCol) Collector facilitate In orderto and analysis. compilation availability for the managementdataandits was onof as thevolumeofdataenteredandstoredonline. that ensure to required was testing and preparation Significant questions. and text of pages 40 over of for file by Excel maintained database Microsoft a as exported be can and administrators, database WHO available onlineandthereforestreamliningthecollectionprocessingofdata. government, WHO regional and country offices, collaborating centres and professional associations. andprofessional centres collaborating offices, country and regional WHO government, Innovation basedatthe University ofHawaiiatManoainthe United States of America. Planning for the2009Planning global survey2008started in thereviewwith ofthe2005/2006 surveyresults, DataCol bylanguage. In addition, individual login names country and passwords were assigned to ensure and collection data for creation form online simplifies that tool web-based a is Data Collector,DataCol, in March 2009 in five countries: Canada, Lebanon, Norway, Philippines, and Thailand. The final version final and Thailand. The Philippines, Norway, Lebanon, Canada, countries: five in 2009 March in instrument and feedback from participating countries. One of the constraints identified in the first survey procedures weretranslatedintoall WHO officiallanguages plus Portuguese. surveyrespond, the to anddataentry order encouragecountries In instructions testing. questions, pilot responsible forcompletingtheformsafterobtainingagreement fromtheexpertinformantgroup. multiple rather thanentries. submittedwas percountry entry one only that were coordinators Country the systemwasrobustandable to accommodate from aroundtheworld, the dataprocess as well entry management and isdesigned, developed and supported by WHO. The collecteddata are stored ina SQL partners in all regions through virtualteleconferences. all regions partners in from partners includedthose The rangeof the survey andsurveyinstrument was developedprocess theInstitutefor and hostedby Triple Helix programmes as well as internationalorganizations,suchtheInternational Telecommunications Union further analysisusingotherstatisticalsoftware. Data Collector Data
Web-based toolforonline creation offormsinsurveys developed by WHO. http://www.triplehelixinstitute.org/. 12 wasusedmaketo thesurveyinstrument 13
Appendix 1 81
Publication of eHealth series Publication GOe data processing and analysis Identification of expert informants of expert Identification
Regional coordination (WHO regional office) (WHO regional coordination Regional Submission of one national survey per country survey Submission of one national National consensus meeting to complete survey consensus National Global coordination (Global Observatory for eHealth) Observatory (Global Global coordination National coordination (WHO Country Office or designee) Country (WHO coordination National Figure A1. GOe survey and report process GOe survey A1. Figure Preparation to launch the survey launch to Preparation productive working relationships with regional counterparts, without whom it would not have been not have without whom it would counterparts, working relationships with regional productive can also be implementation survey of the success The such a task. undertake possible to successfully the survey process with countries in their respective region. Instructions for the survey were procedures process countries with region. Instructions in respective their for the survey the survey the regional level who can liaise directly with countries. who can liaise directly the regional level included eHealth activities. For this reason many regional offices had to assign staff to assist in coordinating in assist to staff assign to had offices regional many reason this For activities. eHealth included Due to differing priorities across WHO regions, notall regional offices have staff whose responsibilities attributed to the assistance of regional and national office colleagues directly who with worked national counterparts in completing the questionnaire. circulated and were followed by a series of teleconferences. followed by a series of teleconferences. circulated and were One significant outcome during surveythe implementation was the development of strong and One of the most important tasks in executing an international survey is to build a network of partners at a network of partners is to build survey an international tasks in executing most important One of the 82 Appendix 1 Survey The surveyThe 15 launched on was June 2009,levelhigh 15 andduethe until to close interest, didnot of The scope of thesurveyThe scope was broad, andsurveycovered diversefrompolicy questions areasofeHealth– surveyThe were basedself-reportingresponses on participating each group for expert informant the by At the national level, coordinators managed the task. Their responsibilities included finding experts in all Coming to a consensus could be difficult in cases where the situation varies widely within the country, the within widely varies situation or the where cases in difficult be could consensus a to Coming While the survey was circulated with a set of detailed instructions and terminological definitions, there is could be collectively completed by theentire group. The number of expert informants, per country, of theareasaddressed by thesurvey,a full-day andorganizinghostingmeeting where the survey effort was made to select the best national experts to complete the instrument; however, it is not possible consistency andaccuracy, itwasnotpossibletoverifytheresponsesforevery question. eHealth activityatthesubnationallevel. localized measure to attempt not does survey opinion. The in differences significant were there where come upthatwasmostrepresentativeasawhole. withasingleresponse foreachquestionofthecountry December 2009. Regionalworkedpoints focal encourage to Member participate. Insomecases States to Member State. Although survey administrators were given detailed tomaintainconsistency,instructions Member were required expert informantsto thus, the per country; response were limitedone States to important tobuildmomentumandmaintainenthusiasm. issues and legal frameworks to specific types of eHealth initiatives being conducted in-country. Every in-country. conducted being initiatives eHealth of types specific to frameworks legal and issues no guaranteethatthesewereusedwhenresponding. now consistsofover800eHealthexperts. 15. to ranged from5 surveyThe helps build process the globe and around the informants of network GOe participation have to be conveyed and to nationalcoordinators thensurvey expert informants. It is participation. a globalsurveyConducting likeis a campaign:thepurposeandrewardsof conducting were it requirednotallofwhichsuccessfulwas easy;inothersextensivediscussions, this inachieving to determine whether the focus groups had the collectiveeHealthknowledge to answer each question. particularly to forthedescriptive, open-ended questions. While survey responseswere checked for responses, the in detail of level and quality the in States Member across variation significant was there Limitations Appendix 1 83
14 Disadvantages population, or population age. interpret or act on GOe data. interpret or act on from an economic, health care, Does not account for income Does not account ongoing armed disparity, conflicts, health of the Limited country commonality or ethnic perspective. Less useful for other agencies or institutions wishing to Advantages integrated into WHO strategic integrated into based on GNI per capita. based on criteria across all countries. analysis and planning, and operational action. Consistent application of WHO regional approach Clear economic definition Simple four-level scale. Simple four-level
/. for more information http://www.r-project.org See Country grouping WHO region
World Bank income group World Data processingData follow-up to ensure accurate reporting of results. Data were exported from DataCol in Microsoft Excel exported Data were reporting of results. accurate to ensure follow-up programming language. analysis was performed using R statistical format and the data percentages were often not directly comparable, particularly at the regional level, as the sets of responding as the sets level, regional at the particularly comparable, often not directly were percentages results were probed in greater depth as warranted. External health and technology indicators, such as as warranted. depth in greater probed results were into the analysis for comparison purposes where relevant. mobile phone penetration, were introduced per capita (Spearman ρ=0.93, Therefore, p=10-16). these results were not included in this report. Cross- however, as the subject matter covered by the 2009 survey was considerably broader, and the survey broader, was considerably survey 2009 by the matter covered as the subject however, questions were worded somewhat differently, there was little scope for this sort of analysis. In addition, the addition, In analysis. of sort this for scope little was there differently, somewhat worded were questions question analysis where two was performed or more questions thought to and the were be related, Results from the current survey were compared to those from the previous survey wherever possible; wherever survey from the previous to those compared were survey the current from Results Preliminary analysis based on aggregation by ICT Development Index showed similar results as for World World results as for showed similar Index on by ICT Development Preliminary analysis based aggregation GDP and Index This to is due the high correlation ICT Development between (2). Bank income group Data were analysed by thematic section. For closed-ended questions, percentages were computed for countries were different, and the expert informants in each iteration of the survey were also different. expert informants in each iteration of the survey and the different, were countries each possible response to obtain the global level results. In addition, the data were aggregated and aggregated were the data In addition, results. level obtain the global response to each possible Bank income trends by group to see region and by income level. World WHO region and analysed by On receipt of the completed questionnaires, all non-English responses were translated into translated all non-English questionnaires, On English. were responses completed receipt of the Survey responses were checked for consistency and other errors, and countries contacted were for responses checked were Survey 14 Table A2 shows the advantages and disadvantages of the groupings used in the survey. A2 shows the advantages and disadvantages of the groupings used in the Table Table A2. Advantages and disadvantages of the country groupings A2. Table 84 Appendix 1 The “Internet safety and security” section of thesurvey,The “Internetsafetyandsecurity”section thispublicationisbased which on,wascompleted States for this module States forthisofthesurvey. Tables and A3 thedistributionofrespondingcountries A4 show Figure A2. Responding Member States by WHO regionand World Bankincomegroup. Member responding the shows A2 Figure States). Member WHO all of (59% countries 114 of total a by Response rate Response the or c on Th th e b re on e p ma ou ce Not applicable Data notavailable Reponding MemberState ar nd rn y t o no ing a ries f th t ye th a e e t b nd Wo de e na lim ful rld m ita He l a es tio gre a sh n o lth em ow f it Or e n nt. s f ga an ron
niz d t at tie he ion rs de co or si bo nc gn un er ati ni da on rie g s u the s. se Do le d o ga te n Responding WHOMemberStates l s thi d ta lin s m us es ap of on d an m o y ap no cou s r t im ep n pl try, res y th te en e rito t a ex p ry pre , ci ro s xim ty o ion at r a o e b f a re or ny a o de op r o r lin in f i ion ts a e s fo w u tho ha r w tso rit hi ch es ev
, er Wo an Ma Da d G ta p P rld So He eo ro urc du g a rap lth cti e: hi W on Or c In : P orld ga fo ub niz H rm lic at ea atio He ion lth n al O Sy th rga Inf ste ni orm m za s (G tio at n ion IS ) © WHO2010. All rightsreserved. Appendix 1 85 13 27 48% Pacific Western Western 14 21 67% Eastern Mediterranean 53 36 68% European 8 11 WHO region 73% East Asia South- 12 35 34% Americas 29 46 63% African
Response rate Response No. of responding countries countries
Total number of Total Response rate by region WHO rate Response from 34% for the Americas to 73% for the South-East Asia Region. Numerous Member States, particularly States, Numerous Member Asia Region. South-East Americas to 73% for the from 34% for the middle income brackets were high. Past surveys have shown have that countries in these groups generally high. Past were surveys income brackets middle response rate was the highest since the region consists of a total of 11 Member States. Self-selection Self-selection States. response rate was the highest since the region consists of a total of 11 Member region. The response rates for the Eastern Mediterranean, African and European Regions were over 60%. over 60%. were Regions African and European Eastern Mediterranean, The response rates for the region. those in the Region of the Americas, indicated that they would not be able to participate in the 2009 in the 2009 to participate able not be would that they indicated Americas, of the those in the Region to present high-level eHealth analyses at the regional level as this reflects the organizational structure have less eHealth activity in comparison to high and upper middle-income brackets. Thus, in some cases, have less eHealth activity in comparison brackets. to high middle-income and upper urgent public health issues such as conflict situations. The Western-Pacific Region hasWestern-Pacific many small island The urgent public health issues such as conflict situations. Member States participating in the survey may reflect a commitment to moving forward with eHealth. States participating in the survey Member For the South-East Asia Region, although the number of responding countries was the lowest, the Member States of which only a few responded to the survey, yielding a response rate of 48% for the for of 48% rate response a yielding to the survey, States of which onlyresponded a few Member of the sample often occurs in surveys of this nature, where responding countries are more likely to have responding countries of this where are more likely nature, in surveys often of the sample occurs A4 shows that response rates in low and lower- Table of interest and/or activity in eHealth. a high level care as they may not be representative of the entire region. may not be representative of the entire care as they survey due to resources being diverted to prepare and respond to the H1N1 pandemic or due to and respond to to or due other prepare the H1N1 to diverted pandemic due resources being survey and operational framework of WHO. of and operational framework States differ with respect to size, economy, and healthStates carediffer challenges. with it Nevertheless, respect is to still size, important economy, African and European Regions. Results from regions with low response rates should be interpreted with with interpreted be from regions with low response rates should Results African and European Regions. A breakdown by WHO regional responses is presented in Table A3. A3. It shows variation ranging considerable Table WHO regional responses is in presented by A breakdown Administratively WHO is made up of six geographical regions, which are quite heterogeneous: Member regions, which six up of WHO are quite heterogeneous: geographical is made Administratively This was particularly encouraging for regions consisting of a large number of Member States such States such as the This of Member was particularly encouraging for regions consisting number of a large Table A3. Response rate by WHO region rate by A3. Response Table 86 Appendix 1 ‘developing’ economiesandhigh-incomecountriesas‘developed’, forconvenience. Table A4. Response rateby World Bankincomegroup The World Bank classifies all economies with a population greater than 30 000 into four income groups income four into 000 30 than greater population a with economies all classifies Bank The World Table the surveyA4 shows response rateby World Bankincomegroup.Low-incomehadthe countries (US$ 11 906 or more).or 906 (US$ 11 enabling a analysis, basis for and practical These incomegroupsareaconvenient 15 exactly to levelto exactly ofdevelopment; however, lowandmiddle-income are sometimesreferred countries as to based on grossnationalincome(GNI) per capita. highest responserate(70%),followed(63%).Intermsofrawnumbers, closely byhigh-incomecountries review of trends in the survey results based on income level. Classification by income does not correspond the high-income, lower-middlethe lower numbercountries income, andlow-incomegroups,aslightlyof was remarkably responding countrieseven,the distributionofrespondingfrom countries 31 30 to with less), lower-middle(US$ 976–3,855),upper-middle income income 905),andhigh (US$ 3856–11 income from theupper-middle incomegroup. Response rate World by income Bank group References Totalno. Countries Response rate countries No. ofresponding 2. 1. http://data.worldbank.org/about/country-classifications Telecommunications Union, 2009 (http://www.itu.int/ITU-D/ict/publications/idi/2009/index. files/WHA58/WHA58_28-en.pdf f etn] Gnv, ol Hat Ognzto, 05 (http://apps.who.int/gb/ebwha/pdf_ 2005 Organization, Health World Geneva, meeting]. of Measuring –theICTDevelopmentthe informationsociety Index. Geneva, International ResolutionFifty-eighth In: eHealth. 58.28. WorldWHA Health Assembly, dates [insert Geneva, html, accessed 17 May2011). High income 63% 49 31 , accessed 18May2011). World Bankincomegroup 15 The classification is as follows: low income (US$ 975 or income middle Upper- 48% 44 21 income middle Lower- 57% 30 53 Low income 70% 43 30
Safety and security on the Internet Challenges and advances in Member States
Based on the findings of the second global survey on eHealth
Global Observatory for eHealth series - Volume 4
ISBN 978 92 4 156439 7