Summary
We conducted a face-to-face cross-sectional survey of a representative sample of the UK population to investigate the self-reported behaviour of the public in reading and writing online feedback in relation to health services. Descriptive and logistic regression analyses were used to describe and explore the use of online feedback. A total of 2036 participants were surveyed, and of the 1824 internet users (90% of the sample), 42% (n = 760) had read online health-care feedback in the last year and 8% (n = 147) had provided this feedback in the same period. People who were more likely to read feedback were younger, female, with a higher income, experiencing a health condition, urban-dwelling and more frequent internet users. For providing feedback, the only significant association was with more frequent internet use. The most frequent reasons for reading feedback were finding out about a drug, treatment or test, and informing a choice of treatment or provider. For writing feedback, the most frequent reasons were to inform other patients, praise a service or improve standards of services. Ninety-four per cent of internet users in the general population had never been asked to leave online feedback by their health-care provider. In conclusion, many people read online feedback from others and some write feedback, although few are encouraged to do so. This emerging phenomenon can support patient choice and quality improvement, but needs to be better harnessed.
This chapter is based on material reproduced from van Velthoven and colleagues.77 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
This chapter is based on material reproduced from van Velthoven and colleagues77 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Introduction
Given the absence of any recent or robust data on use of online feedback of UK health services, despite huge interest in this area in the UK and elsewhere, to our knowledge, we undertook the first nationally representative UK survey on providing and using online feedback about health and health services among the general population. In this chapter, we describe the results of a survey measuring the frequency of use, user characteristics and self-reported behaviour of members of the public in reading and writing online feedback on health services, health professionals and medical treatments or tests. Previous work on the use of online feedback by patients has been relatively limited.14,36,75,106 Surveys found that those who are more likely to use online feedback of health services include people who are younger,14,75 live in (sub)urban areas and have higher levels of education.75 Prior to us starting this project, to the best of our knowledge, the last UK survey75 was published in 2012. The survey75 was conducted among a small non-representative sample of 200 people living in one borough in London and showed that just 29 people (15%) were aware of doctor-rating websites and only six people had used them. In a US survey conducted in 2012, 65% of 2137 participants were aware of online patient feedback websites and 23% had used them.42 Of 854 respondents in another US survey in 2013, 16% said that they had previously visited a patient feedback website.36 Although there are some caveats in the non-comparability of studies that have been conducted in different settings, using different questionnaires, it seems that the number of people using online feedback is rising rapidly from a very low baseline over time. Subsequent to undertaking this project, a separate study108 conducted in 2016 has been published examining the prevalence of knowledge and use of online feedback specifically in relation to UK general practice, showing a very low prevalence of usage in relation to feedback specifically about GPs (0.4% prevalence), in combination with a low awareness among the public of GP rating sites (15% awareness).
Methods
Study design
A cross-sectional face-to-face questionnaire-based household survey was conducted with members of the UK public about their use of online ratings and reviews (see Appendix 2). A market research agency, ICM Unlimited (London, UK), conducted the fieldwork. ICM Unlimited had previously conducted the OxIS on behalf of the Oxford Internet Institute, which uses similar methodology and which collaborated on this project, advising on design of the survey and choice of provider.109 Similar to the OxIS, a two-stage design was used for sampling. First, a random sample of output areas stratified by region was selected. Second, within each selected output area a random selection of addresses was used. ICM Unlimited recruited and interviewed participants by sending interviewers to the homes of selected people in February 2017.
Ethics approval and consent
The survey received institutional ethics approval from the University of Oxford Central University Research Ethics Committee (reference SSH_OII_C1A_074).
Participants
We included adult members of the UK general public who were willing and able to give informed consent for participation in the study, lived in the UK, were able to speak and read English and were aged ≥ 16 years. To select participants, a random location sampling system was used in which we randomly selected output areas as the geographical sampling unit. Each output area consisted of around 150 households and all properties were available to the interviewer to achieve the target number of interviews (usually four or five per point). Demographics quotas were applied to ensure that the profile of achieved interviews in each sample point reflected the known population of the area.109
Variables
We collected data on participant’s characteristics, including age, sex, ethnicity, annual household income, education level, living in an urban or rural area, health status and internet use (see Appendix 3). There were also 20 questions relating to online feedback (see Appendix 2, Table 15).
These questions were principally designed based on items from previous surveys14,75 and on policy documents and reports by online feedback organisations,110 and were informed by our concurrent survey of health-care professionals (see Chapter 4). We piloted the questionnaire with a patient and public reference group and tested it using two rounds of cognitive interviews (also with the public). Questions were asked about if, where and why participants read or wrote online ratings or reviews of health services, individuals, drugs, treatments or tests.
Data sources
All data were obtained through face-to-face interviews with participants. Surveys were completed on a tablet and transferred to the study team in a Microsoft Excel® spreadsheet (Microsoft Corporation, Redmond, WA, USA). The names and any other identifying details of participants were not collected in any of the surveys.
The survey was a fully representative sample of the population of Great Britain aged ≥ 16 years. A sample size of 2000, with a margin of error percentage of 2, was chosen to maximise accuracy within reasonable resource constraints.109 Data were weighted to the sociodemographic profile [census data that included sex, age, socioeconomic grade, region and ACORN (A Classification Of Residential Neighbourhoods) group of the target population (UK citizens aged ≥ 16 years)].
Quantitative variables and statistical methods
All analyses were conducted using the statistical software package IBM SPSS Statistics version 22 (IBM Corporation, Armonk, NY, USA). Descriptive analyses of participants’ characteristics and the prevalence of providing and of reading online feedback were conducted. Non-internet users were excluded from these analyses, as they would not be reading or writing online content.
We coded the outcome as binary: use of any type of feedback compared with no use. Logistic regression was used to explain the use of online feedback (as the dependent variable), with the following independent variables that were considered to be potentially relevant: age, sex, education, income, living in rural or urban area and frequency of internet use. These sociodemographic and internet use variables have been shown to influence the uptake of a wide range of online activities, including health.111 Ethnicity was not included in the logistic regression analyses because of the small number of participants in the ethnicity subgroups. In the results, we present the model fit (%), chi-squared, p and R2 (Nagelkerke) values. We used binary logistic regression in SPSS and included all variables that were found to be statistically significant in univariate analysis in the model. Missing data were not imputed.
Results
This section has been reproduced from van Velthoven and colleagues.77 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Our total sample comprised 2036 participants, of whom 1824 used the internet over the past year; it is this group of internet users in the general population who were included in further analyses (their characteristics are shown in , as well as the characteristics of those who read and provided feedback). Appendices 3 and 4 show characteristics of the 10% of our sample who were non-users of the internet (n = 212). Our main findings were that of the 1824 internet users, 42% (n = 760) had read feedback about health services, or about health professionals or about medical tests or treatments during the past year, whereas 8% (n = 147) had written such feedback in the same period.
Public survey: number and proportion of participants reading and writing online feedback per characteristic
Associations between people’s characteristics and use of online feedback
Age, sex and ethnicity
The highest proportions of feedback readers and writers were among those aged 16–34 years and the lowest proportions were among those aged ≥ 65 years (see ). People aged 16–34 years were significantly more likely to read online feedback [odds ratio (OR) 1.695, 95% confidence interval (CI) 1.278 to 2.246; p = 0.000] than those aged ≥ 65 years (). Of women, 45% (n = 416) read and 9% (n = 82) gave feedback, compared with 38% (n = 344) and 7% (n = 65) of men, respectively (see ). Men were significantly less likely to read online feedback than women (OR 0.742, 95% CI 0.615 to 0.894; p = 0.002) (see ). Among people with an ethnicity other than white, 48% (n = 120) read and 10% (n = 25) wrote reviews, compared with 41% (n = 635) and 8% (n = 120) of people with a white ethnicity, respectively (see ).
Public survey: univariate logistic regression analyses for reading and writing feedback (n = 1824)
Education and household income
The highest proportion of readers and writers were also among those with degree-level qualifications and above (see ), and these people were significantly more likely to read online feedback than those with other qualifications (see ). People in the highest income bracket of ≥ £100,000 were significantly more likely to read online feedback than those with the lowest income (≤ £24,999) (OR 1.784, 95% CI 1.088 to 2.924; p = 0.022).
Health status
Of people with a long-term condition, health problem or disability, 49% (n = 183) read and 10% (n = 39) wrote online feedback (see ), and they were significantly more likely to read it than those without such a health condition (OR 1.463, 95% CI 1.164 to 1.839; p = 0.001) (see ).
Area and internet use
Of people living in urban areas, 48% (n = 240) read and 10% (n = 52) wrote online feedback (see ), and they were significantly more likely to read it than those living in rural areas (OR 1.697, 95% CI 1.241 to 2.320; p = 0.001) (see ). People accessing the internet several times a day were significantly more likely to read (OR 2.680, 95% CI 1.808 to 3.974; p = 0.000) and write (OR 3.206, 95% CI 1.216 to 8.449; p = 0.018) online feedback than those who went online less than once a day (see ).
Regression analysis
Our multivariate regression model for ‘reading feedback’ showed a model fit of 55%, which increased to 61% when the following significant variables were included: age, sex, education, income, health status, area and internet use (see ). For writing reviews, the only significant variable was internet use, and no multivariate model is presented.
Frequency of reading and writing online feedback for different domains: health services, health professionals, and medical treatments and tests
Of the 1824 internet users, 28% (n = 507) had read feedback about (NHS) health-care organisations, 18% (n = 331) had read feedback about health professionals and 32% (n = 579) had read feedback about drugs, treatments or tests (see Appendices 7 and 8). Far fewer participants had written reviews: 6% (n = 105) about health-care organisations, 4% (n = 69) about health professionals and 4% (n = 69) about drugs, treatments or tests (see Appendix 9). Most participants who read or wrote feedback had done this once or every few months/monthly over the past year ( and see Appendix 10).
Public survey: frequency of writing and reading feedback
Of the 760 participants who read feedback about a health-care organisation, a health professional or a treatment or test, 42% (n = 320) read feedback about one of these, 29% (n = 223) read feedback about two and 28.6% (n = 217) read feedback about three. Appendices 9 and 11 show that, of the 147 participants who wrote feedback about a health-care organisation, a health professional or a treatment or test, 53% (n = 79) wrote feedback about one of them, 26% (n = 39) about two and 20% (n = 29) about three. In comparing readers and non-readers with writers and non-writers, we first found that 7% of the whole sample of internet users (128/1824) had both read and written a review. Of the 760 participants who read feedback, 83% (n = 633) had not written a review. Of the 147 participants who wrote feedback, 13% reported not reading feedback. Fifty-seven per cent of the whole sample of internet users (1044/1824) had not read or written feedback over the past year.
Websites on which online feedback of health services was read and written
The most frequently used formal review website for both reading and writing feedback was NHS Choices (used by 49% of ‘readers’ and 35% of ‘writers’), followed by WebMD (15% and 5%, respectively) and Care Opinion, formerly Patient Opinion (6% and 9%, respectively) (see Appendix 12). The most frequently used social media outlets for reading and writing online feedback were Google Reviews (Google Inc., Mountain View, CA, USA) (31% and 14%, respectively) and Facebook (25% and 23%, respectively).
Reasons for using online feedback of health services
shows the most frequent reasons among 760 ‘readers’ for reading reviews: finding out about a drug, treatment or test (41%); choosing where to have treatment (19%); or choosing a health-care professional (17%). The most common reasons for providing reviews were to inform other patients (39%), praise a service (36%) or improve standards of NHS services (16%). Of the total sample, only 112 (6%) participants had been asked to write a review. Of those people who were asked to write a review, only 28 (25%) had written a review. The eight people who said they had often been asked to write a review had not done so.
Public survey: reasons for reading and writing feedback
For 147 ‘writers’ (36%), writing a review to provide praise for a service was a far more common motivation than to complain about a service (6%), treatment (5%) or professional (4%).
This section has been reproduced from van Velthoven and colleagues77 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Copyright © Queen’s Printer and Controller of HMSO 2019. This work was produced by Powell et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Discussion
The striking findings from this work are that about 1 in 12 members (8%) of the general population who use the internet had provided online feedback about some aspect of health care in the last year, and two in five people (42%) had read such online feedback in the past year. To the best of our knowledge, this survey provides the first representative UK population data on the use of online feedback about health care. As such, it provides key baseline prevalence data for future engagement with online feedback by patients. Although the majority of the population had not used online feedback of health services over the past year, these figures show that this phenomenon can now be considered a mainstream activity for many people, and, although writing feedback remains unusual (but not rare), the frequency of reading feedback suggests that this user-generated content has the potential to have a wide influence. As might be expected, the least represented users of online feedback of health services were people aged ≥ 65 years, without formal qualifications, at lower social grades, accessing the internet less often than once a day and those living in rural areas.
The findings of this survey are representative of the general population of internet users in the UK. Not everyone in the general population uses health services in a 1-year period, so it is not surprising that reading feedback is not universal. Overall, people are still far less likely to read and write reviews of health services than they are to do so for non-health-related commercial services.112 On average, 42% of internet users in our survey read online feedback on some aspect of health care in our study. This is higher than shown in previous studies.36,42 For example, the previous work in the UK, from 2012, had shown very low awareness (15%) and usage (3%) of doctor rating sites in a convenience sample survey of 200 people in London.75 More recently, a study by Patel and colleagues,82 conducted in 2016, looked only at the use of rating sites in relation to GPs and showed a low prevalence (0.4%) for this very specific form of online feedback. The higher figures found in our survey compared with previous work can be explained by our broader scope across the whole of health care, as well as by increasing use over time.
Our findings on age and sex are in line with those of a German study87 that examined the characteristics of patients using a national public reporting instrument to leave feedback on their health-care experiences. This study87 found that 60% of 107,148 patients rating physicians were female and 51% were aged 30–50 years. Only 14% of writers in our study left feedback to complain, which is in line with a survey in the USA,36 in which 9% of 854 patients provided an unfavourable review. Likewise, the German study87 found that only 3% of 127,192 ratings of 53,585 physicians were rated with an insufficient score and 5% with a deficient score in their overall performance, and in a UK study78 the NHS services received three times more positive (total 223,439) than negative (total 73,363) reviews.
About 1 in 10 people did not use the internet in our study, which is in line with Ofcom data112 and shows an increase in use of the internet compared with the OxIS conducted in the UK in 2013, in which about 2 in 10 people were non-internet users.14 In line with previous research, people with a lower level of education, lower income or social grade, of older age or living in rural areas were less likely to be regular internet users.111 We also found that these variables were associated with lower use of reading online feedback. It may be that people in urban areas use feedback more, as they have more genuine choice in terms of health-care provider in their locality.
Strengths and weaknesses of the study
To the best of our knowledge, this is the largest representative general population survey conducted across the UK. It addressed an evidence gap in a fast-moving and under-researched area. This survey method relies on participant self-report to a face-to-face questionnaire; for this reason it may be influenced by recall bias, presentation bias and social desirability bias. Cognitive interviews with members of the public were conducted to optimise the design of questions, with the aim of minimising other response bias caused by question wording or item order. As a result, we had a relatively small number of ‘other’ and ‘do not know’ responses. Non-English speakers were excluded as the survey was conducted in English. Data from cross-sectional surveys can be used only to investigate associations between variables, not causation, and the nature of quantitative findings means that, although we can identify prevalence of use, in this study we cannot provide any deeper, qualitative understanding of the phenomenon of using online feedback of health services.
Conclusion
To the best of our knowledge, we have provided the first UK-wide representative data on the use of online feedback, which show that although many people (> 40% of internet users) read online feedback about health care, fewer currently provide it and very few have been asked to provide it. Encouragingly, users are motivated to become more informed, to make choices, to provide praise and to improve standards of care.
