A number of factors complicated the review and assessment of health-related websites for this project, which reveal both the relative youth of the Internet as a medium of health communication and the challenges of improving it.

There was a noteworthy lack of consistency in how or where websites disclosed information relating to the criteria. With other communications media (such as print, broadcast, and film), conventions in practice have, over decades or centuries, emerged that make it fairly easy to know where to look (or watch or listen) for information on ownership, sponsorship, authorship, publication or production dates, copyright information, legal disclaimers, and other information that can help users determine the source or credibility of information conveyed. Few such conventions have yet emerged on Internet sites, however.

The disclosure elements reported here on which compliance was high are indicative of the few conventions that have emerged. For example, the name of the sponsoring organization, if it is not provided on the home page, can usually be found on a link labeled "About Us" (although contact information is found there less often). Privacy statements are common and usually clearly labeled, if not through a tab or link at the top of the home page, then through a link in small print at the bottom. Legal disclaimers—although the language used to label them varies considerably—are usually present, delimiting the purpose and uses of the information or services provided. Advertising content is usually clearly labeled as such and differentiated from other content through its placement on the web page and its graphic design.

No such conventions in practice, however, govern the disclosure of other critical pieces of information—notably, information on sources of funding, editorial oversight, authorship, or dating of information. It was not at all obvious where to begin to look for such information on most websites, and finding information within "two clicks" of the home page (as the disclosure criteria usually required) was often difficult. When information that appeared to relate to these disclosure elements was found, the wording or presentation was such that it was often not clear whether it satisfied the intentions of the criteria. For example, when sources of funding were identified, it was not always easy to determine whether the information provided referred to funding for the sponsoring organization or funding for the website. Similarly, editorial oversight policies, when present, were often vaguely worded, making it unclear as to what content they applied. There were few conventions for identifying the authors of health content, and authorship was especially ambiguous on websites where the content appeared to have been prepared by the site host.

The very qualities that make the Internet so appealing as a medium to search for information—the ability to navigate very quickly to and through multiple pages, sites, and sources—also complicate the task of finding and interpreting information relating to the disclosure criteria. It was precisely because many of the websites provided ready access to health information from a variety of different sources, for example, that they performed so poorly on disclosure elements that referred to specific items of health content. Few complied with disclosure elements relating to authorship and content updating on all three items of health content that we reviewed.

While some hyperlinks take users to other parts of the website, others may take them to separate websites altogether, including those of a partner, sister, or parent organization. It was often unclear, in our review, whether stated policies found through links to related or affiliated sites also applied to the home (sampled) site. This was especially problematic in the case of "nested" websites (for example, websites for government programs nested within the parent agency and/or department websites) where generic editorial or medical review policies were sometimes found at the parent (or grandparent) site. In other cases, although advertising may be clearly labeled on any given web page, hyperlinks to what appears to be health information may take the user to commercial promotions.

We acknowledge that our study has several limitations that could affect the generalizability of our findings to the universe of health websites of interest to ODPHP or the ability to replicate the study in the future. First, some of the websites in our initial sample did not conform to our working definition of health websites, which suggests that Hitwise's Health and Medical category was broader than needed. Nevertheless, we believe that the comprehensiveness of the Hitwise database best meets the need to define the denominator of health websites in inclusive terms that reflect actual and changing Internet use. Second, we excluded, for practical reasons, websites that limited access to registered users or subscribers. We were thus unable to review the disclosure practices of sites that may be an important source of health information to some Internet users. Third, the three items of health content we randomly selected to review may or may not have been representative of all or most of the health content on any given website, and it is quite possible that a different selection of material would have yielded different results. Fourth, the data that we purchased reflected Internet traffic for only one month (October 2005) and thus did not account for seasonal variation in the volume or patterns of traffic. Data drawn from a different time period may yield a stratified sample with different characteristics, even with the same sampling strategy. Fifth, as the earlier discussion suggests, there were also many gray areas of interpretation that required judgment calls on the part of the reviewers and the project team. While we have tried to document these as clearly as possible in the accompanying technical manual, others looking at the same information might reach different conclusions. Sixth, our small sample size limits both the reliability of several of our baseline estimates and the ability to detect statistically significant progress toward meeting the Healthy People 2010 Objective 11-4 on later assessments. The negligible rates of compliance that we detected in our sample precluded reliable estimates of compliance for some disclosure elements. The sample size, however, does permit reliable compliance estimates for the majority of criteria and their associated elements that can be used to track future improvements in adherence to the standards defined under this project.

Notwithstanding these challenges and limitations, we believe that the baseline estimates of health websites' compliance with the disclosure criteria clearly identifies the areas on which some progress has been made, as well as those on which future improvement efforts should focus. The consistently (and sometimes significantly) better performance of the websites most frequently visited, across almost all criteria and disclosure elements, suggests that the heavily trafficked health websites may be moving toward defining the conventions in practice that can improve disclosure in the future. A qualitative analysis of the practices used by the better-performing websites, which was beyond the scope of the current study, could offer useful insights and guidance for improvement.

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