# Consumer health 2.0 in Canada: a descriptive analysis of the use of Web 2.0 technologies on Canadian consumer health information websites

Christine Marton

**Abstract:** An examination of the top 10 consumer health information (CHI) websites in Canada revealed that while all of these CHI websites provide extensive and well-organized content, hypertext links, static images, and a site search engine, their adoption of Web 2.0 technologies is generally limited to well-known technologies, such as Facebook and Twitter, or is nonexistent. Furthermore, CHI websites that fail to integrate links to Web 2.0 technologies into the main navigation bar on the homepage make the links less visible to site visitors.

## Introduction

Many reputable consumer health information (CHI) websites were developed by healthcare institutions, disease-specific not-for-profit organizations, professional associations, government health ministries, and telecommunication and broadcasting companies in the late 1990s and early 2000s. These sites are authored by clinicians and medical writers who control the publication of content. Examples of established health portal sites include MedlinePlus (http://www.nlm.nih.gov/medlineplus/) and WebMD (http://www.webmd.com/) in the United States, and the Canadian Health Network (no longer in existence), Bell Sympatico's Healthy Way (no longer in existence); and MedBroadcast (http://www.medbroadcast.com/) in Canada. Clearly, these types of CHI websites function primarily as distributors of textbook-style biomedical information. The content is overwhelmingly static text with a limited selection of images of organs and organ systems; a few decision making tools, such as body mass indicator calculators; and optionally, one or more forms of computer-mediated communication, such as discussion forums. While these sites do not exemplify the latest trends in Web technology, they do meet the fundamental needs of those seeking health information: the need for factual biomedical information about diseases and their causes, symptomology, diagnostic tests, treatment options, and prognosis.

In the early 1990s, the Internet-based hypertext system known as the World Wide Web (WWW) was developed. Soon after, the first graphical Web browsers for accessing the WWW became widely available [1]. In this decade, the next stage of Web development has been characterized by the creation of many interactive technologies, collectively referred to as Web 2.0 or the Social Web [2]. Social websites

offer many opportunities for creating user-generated content on any topic of interest, around which an engaged community of interest can arise and grow, becoming a world-wide membership. Web 2.0 technologies facilitate information sharing and the ready use of multimedia elements, such as photos; audio clips; videos, often of personal activities, experiences, and events; as well as mixing these technologies and creating so-called mash-ups. Anyone can create content using readily available suites of online tools; sophisticated computing skills are not required.

Popular Web 2.0 technologies include blogs (Web diaries with entries in reverse-chronological order and comments from visitors); micro-blogging utilities such as Twitter; social networking sites such as Facebook, MySpace, and Foursquare, which feature user profiles, photos, contacts, and blog entries with comments from friends; YouTube, a video-sharing site featuring user-generated video content created by individuals as well as organizations and media corporations; Really Simple Syndication (RSS) feeds that enable users to subscribe to websites to obtain new content and view it through an RSS feeder, instead of visiting websites individually to scan for updater; podcasts, digital audio or video files that are released episodically and can be downloaded automatically to the user's computer and used offline; social bookmarking, the online storage, management, and searching of bookmarks on the Web; and folksonomy or social tagging, the addition of metadata to shared Web content.

The personalized approach to CHI on the Web, characteristic of Web 2.0 websites developed by individuals (and groups) with specific illnesses, presents an interesting contrast to the standardized biomedical textual content provided by conventional CHI websites. By comparison, these established CHI sites are late adopters of Web 2.0 technologies. In this
paper, the prevalence of Web 2.0 technologies on the foremost CHI websites in Canada is investigated.

## Methods

In 2010, the Consumer Health Information Providers Interest Group of the Canadian Health Libraries Association published a new version of its “Top 10 Canadian Consumer Health Websites” [3]. These reputable CHI websites cover specific health topics, e.g., cancer, mental health, sexuality, or a distinct population demographic, e.g., women, children, or Francophones. The list is presented below.

<table><tr><td>About Kids Health</td><td>aboutkidshealth.ca</td></tr><tr><td>Caring for Kids</td><td>caringforkids.cps.ca</td></tr><tr><td>Canadian Cancer Society</td><td>cancer.ca</td></tr><tr><td>Canadian Safety Council</td><td>safety-council.org</td></tr><tr><td>Dietitians of Canada</td><td>dietitians.ca</td></tr><tr><td>Heart and Stroke Foundation</td><td>heartandstroke.ca</td></tr><tr><td>Here to Help</td><td>heretohelp.ca</td></tr><tr><td>Sexualityandu.ca</td><td>sexualityandu.ca</td></tr><tr><td>PasseportSanté</td><td>passeportsante.net</td></tr><tr><td>Women's Health Matters</td><td>womenshealthmatters.ca</td></tr></table>

As well, honourable mentions were bestowed on the following Canadian CHI websites:

<table><tr><td>Canadian AIDS Treatment Information Exchange</td><td>catie.ca</td></tr><tr><td>Canadian Centre for Occupational Health and Safety</td><td>ccohs.ca</td></tr><tr><td>Canadian Women's Health Network</td><td>cwhn.ca</td></tr><tr><td>Canadian Virtual Hospice</td><td>virtualhospice.ca</td></tr><tr><td>HealthLinkBC</td><td>healthlinkbc.ca</td></tr><tr><td>Public Health Agency of Canada</td><td>phac-aspc.gc.ca</td></tr></table>

Visits to the 10 top-rated Canadian CHI websites, and inspections of their Web 2.0 technologies, were conducted on 25 November 2010. A descriptive analysis of the current use of Web 2.0 technologies on each of these reputable Canadian CHI websites is presented next.

## Results

### The Canadian Cancer Society

The Canadian Cancer Society (CCS) (http://www.cancer.ca) is the national not-for-profit organization of community-based volunteers in Canada dedicated to eradicating cancer and improving the quality of life of people living with cancer. The CCS website is primarily organized by geographic region (national and provincial) and provides extensive textual content centred in each webpage, with the sides of each webpage acting as navigation tools. Web 2.0 technologies are detailed on a separate webpage linked from the homepage; *Other Ways to Stay Connected* [4]. Although this link is not integrated into the top menu bar of the CCS website homepage, its large size renders its location on the centre-right side of the homepage visible to site visitors.

The CCS Twitter feed [5] has a total of 1151 tweets since 6 January 2009, with an average of one or two tweets per day. Topics include new cancer research, vitamin D supplements,

contraband tobacco, the financial burden of care-giving, the Ontario Health Study, and CCS events, services, and lottery. It has 4804 followers and is following 434 individuals and groups, among them are NDP leader Jack Layton (JackLayton), Relay For Life Toronto (RelayForLifeTO), and Community Living Ontario (CLOntario).

The CCS Facebook site [6] has many posts on its wall, both from the CCS itself, as well as from cancer patients and survivors and cancer groups. Over the past two months, there have been approximately 100 posts, many with comments, indicating considerable involvement from the cancer community. As well, the Facebook site has eight CCS photo albums and 136 photos posted by others; three CCS videos and two videos posted by others; and eight events. The content and interactivity on the CCS Facebook site is impressive.

Furthermore, the CCS has a YouTube channel [7] with 19 918 channel views; 224 380 total upload views, and 591 subscribers; an RSS feed [8] with comprehensive instructions on the use of RSS feeds [9]; and also offers personalization through iGoogle [10], which enables the clipping of content of personal interest from the Web.

### PassportSanté

PasseportSanté (http://www.passeportsante.net/Fr/Accueil/Accueil/Accueil.aspx) is a Francophone CHI website, which is affiliated with the Lucie et André Chagnon Foundation, a not-for-profit organization in Quebec dedicated to health promotion and disease prevention, and published by Totalmédia inc. It has over 2 million site visitors per month from all over the world. This website features extensive informational content and well-designed images and navigation tools.

PasseportSanté offers an extensive number of audio clips and videos on a range of health topics and features several types of Web 2.0 technologies, including: blogs authored by health professionals [11], which can be received as RSS feeds [12]; a Facebook site [13]; and an established Twitter feed [14].

The PasseportSanté Twitter account has a total of 1072 tweets since 25 March 2009, with an average of four tweets per day. Recent health topics include video lottery dependency, the AIDS epidemic in Africa, diabetes medication Avandia, cholesterol and triglycerides, airport scanners, and many others. It has 1186 followers and is following 585 individuals and groups on Twitter, among them, the American Diabetes Association, the New England Journal of Medicine, and Fondation de l'Institut universitaire de cardiologie et de pneumologie de Québec.

The PasseportSanté Facebook site features approximately 200 posts on its wall since 9 April 2010. All posts were authored by the organization. However, many of them have several comments from a diverse group of individuals, indicating some degree of community involvement. The PasseportSanté Facebook site also has 172 notes, five photo albums from the organization, and five photos posted by others, which represents a considerable amount of content.

### The Heart and Stroke Foundation of Canada

The Heart and Stroke Foundation of Canada (HSF) (http://www.heartandstroke.com/) is a national not-for-profit, volunteer-based organization dedicated to eliminating heart disease and stroke through health promotion,
advocacy, and the advancement of research. The HSF web-
site provides extensive informational content on heart
disease and stroke, healthy living, and the organization's
structure, mandate, and contact information. The design of
the website is conventional, with a top menu bar, graphic
icons on the right side that link to HSF events and pro-
grams, and hypertext links at the bottom of the homepage.
Major events and programs are detailed on the left side of
the homepage through text and images. The HSF site fea-
tures two popular Web 2.0 technologies; a Twitter feed [15]
and a Facebook site [16].

The HSF Twitter feed has a total of 1423 tweets, with 3078
followers, and it is following 2263 individuals and groups. The
first tweet was posted on 9 June 2009, and the tweeting fre-
quency is approximately six tweets per day. The content of the
tweets covers a diverse range of topics on heart disease and
stroke, including the HSF Heart Health Action Plan, CPR
training and new guidelines, vegetarian pizzas, and the
increased risk of heart disease for women with high job strain.

The HSF Facebook site features over 200 posts on its wall in the second half of 2010. Approximately one in three posts was authored by the organization and many of them have several comments from a diverse group of individuals. As well, many posts are authored by individuals and groups, indicating a high degree of community involvement. The HSF Facebook site also has 40 discussions and 37 YouTube videos; altogether an impressive amount of content.

Graphic icon links to these popular forms of Web 2.0
technology are prominently displayed in the centre-left text
panel on the homepage of the HSF website, and there is a
small “share” link at the bottom of the homepage. How-
ever, these links have not been included in the main nav-
igation panel located at the top of the homepage where they
would be more visible to site visitors. The lack of integ-
ration of these links unintentionally signifies the add-on
nature of Web 2.0 technologies to this otherwise conven-
tionally designed CHI website.

Sexualityandu.ca

Sexualityandu.ca (http://sexualityandu.ca/) is the CHI
website produced by the Society of Obstetricians and
Gynaecologists of Canada, a national, professional medical
association. It has won awards from Chatelaine Magazine,
Canadian Marketing Association, Wired Magazine's Inter-
national Web Page Awards, the United Nation's World
Summit Award, and the Health Improvement Institute's
Aesculapius Awards of Excellence. The overall design is
welcoming and features clever visual graphics, including
icons of computer mice designed with sexual themes in the
top right section of the homepage and large graphic icons
that stream leftward representing major topics on sexuality,
such as "sex over 50". Large blue graphic icons, below the
streaming images, provide links to the Twitter account [17]
and Facebook site [18], while three videos on Flowerplayer
are presented in the bottom right corner of the homepage.
However, these Web 2.0 technologies are not linked from
the main navigation bar located at the top of the homepage,
which may diminish their visibility to site visitors.

The sexualityandu.ca Twitter feed has a total of 109 tweets,
with 958 followers, and it is following 1502 individuals and
groups on Twitter. The first tweet was posted on 23 July

2009, and the tweeting frequency is approximately two tweets
per day. The content of the tweets covers a diverse range of
topics on sexuality, including date-rape drugs, menstruation,
STIs, sexual orientation, and transgender.

The sexualityandu.ca Facebook site features approximately 25 posts on its wall. All wall posts were authored by the organization. Only two posts have comments. The frequency of posts is difficult to ascertain as it is not continuous; many posts were created either in August 2009 or May 2010. Many posts are YouTube videos produced by the organization. Clearly, this Facebook site functions exclusively to push content at site visitors, instead of fostering an interactive community of interest on human sexuality.

Women's Health Matters

Women's Health Matters (WHM) (www.womenshealthmatters.ca) is the comprehensive CHI website on women's health, authored and published by Women's College Hospital, a University of Toronto-affiliated teaching hospital, and the Women's College Research Institute (WCRI). WHM features an extensive amount of informational content on women's health, primarily as text, with several navigational elements situated on the four sides of the homepage; many discussion groups (LeClub); a database of health information resources, Health A-Z; and a site search through Google search technology. WHM provides both a Twitter feed [19] and an RSS feed [20], which can be accessed from the homepage.

The WHM Twitter feed has a total of 419 tweets, with 1685 followers, and it is following 431 groups on Twitter, primarily healthcare institutions and government agencies, as well as not-for-profit health advocacy associations, including Rouge Valley Health System, the Children's Hospital of Eastern Ontario, Parkinsons Society of Canada, and Cancer Care Ontario. The first tweet was posted on 23 April 2009, and tweeting frequency of approximately one tweet every three days. The content of the tweets covers a diverse range of women's health topics and issues, and features current research findings from Women's College Hospital.

Links to these Web 2.0 technologies are located in the left
menu bar on the WHM homepage. However, they are
sandwiched in between other links, which may render their
presence less visible to site visitors. There do not seem to be
any links to Facebook, YouTube, or other Web 2.0 tech-
nologies on the WHM website, indicating that the exten-
sion of this authoritative consumer health information
website on women's health to the new world of Web 2.0
technologies is limited at this time.

Caring for Kids

Caring for Kids (http://www.caringforkids.cps.ca/) is a comprehensive CHI website on the health of children and youth developed by the Canadian Paediatrics Society (CPS), a professional medical association. The informational content is based primarily on CPS policy statements and documents developed and reviewed by the CPS public education subcommittee. The design of the site is welcoming, with images of children and parents on the homepage, as well as interesting graphical icons in the left menu bar that link to major health topics, such as immunization, safety, behavior, and pregnancy and babies. The Caring
for Kids website has both a Twitter feed [21] and a Face-
book site [22]. However, the icon links for the Twitter feed
and Facebook site are buried at the bottom of the left menu
bar of the homepage. Site visitors who do not scroll down
to the bottom of the homepage are likely to be unaware of
the existence of these Web 2.0 technologies.

The Caring for Kids Twitter feed has a total of 245 tweets, with 945 followers, and it is following 877 individuals and groups, including YATI, the youth advocacy program of the Ontario Lung Association, MS Society of Canada, the Toronto Star, and ParentsConnect (US). The first tweet was posted on 13 August 2009, and the tweeting frequency is approximately one tweet per day. Topics tweeted cover a diverse range of topics on keeping children and youth healthy, including but not limited to: Hallowe'en safety tips, rotavirus vaccination, head lice, good television habits, and over the counter cold and flu medications.

The Facebook site features healthy tips posted almost daily on the wall. The first post is dated 22 February 2010 and there are approximately 90 posts. The majority of posts were authored by the organization and have no comments. This communication practice suggests that the organization's use of Facebook is primarily as a push channel; there is little involvement from the community of parents who are the intended audience for this CHI website.

The Canadian Safety Council

The Canadian Safety Council (www.safety-council.org) is a national, not-for-profit organization on safety education for injury prevention and reduction. Its website consists overwhelmingly of static text and hypertext links. The presence of Web 2.0 technologies is limited to a Facebook site [23].

The Canadian Safety Council Facebook site seemingly
functions as a unidirectional information channel insofar
as all posts on the wall of this Facebook site are authored
by the organization. There are approximately 30 posts on
the wall, with the first post dated 21 April 2010. None of
the posts have comments. Furthermore, the link from the
homepage of the Canadian Safety Council website to the
organization's Facebook site is not located in the main
menu bar at the top of the homepage. Rather, it is found
within a set of links at the bottom of the homepage, greatly
diminishing its visibility to site visitors.

Here to Help

Here to Help (http://www.heretohelp.bc.ca/) is a CHI
website on mental health published by the regional part-
nership BC Partners for Mental Health and Addictions
Information. It has an RSS feed [24] on the homepage.
However, the graphic icon for the RSS feed is not located
in the main menu bars at the top and right sides of the
homepage. Rather, it is located centre-left on the home-
page, below the large graphic icons for the discussion
forum, screening self-tests, and interactive tool kits,
thereby reducing its visibility to site visitors. This CHI web-
sites does not feature any other Web 2.0 technologies.

AboutKidsHealth

AboutKidsHealth (aboutkidshealth.ca) is produced
by The Hospital for Sick Children (HSC) in Toronto.
HSC is a large and internationally renowned University

of Toronto-affiliated teaching hospital. The content on
AboutKidsHealth is written by professional writers and
editors, in collaboration with HSC clinicians, and is
assessed by an Editorial Review Board. The informa-
tional content on this paediatric CHI website is predomi-
nantly textual, with the judicious use of static images and
several video clips. There is an animated interactive atlas of
child anatomy and physiology, "How the Body Works".
While AboutKidsHealth does not feature Web 2.0 tech-
nologies such as Twitter and Facebook, content webpages
do have a "Share" link, enabling readers to send the content
to Web 2.0 social networking sites or to bookmark it using a
social bookmarking utility.

The Dietitians of Canada

The Dietitians of Canada (http://www.dietitians.ca/) is the
national professional association for dietitians in Canada. Its
mission is to advance the health of Canadians through food
and nutrition. The Dietitians of Canada website provides
informational content on nutrition on the Your Health sec-
tion (http://www.dietitians.ca/Your-Health/Assess-Yourself.
aspx) of the site, primarily as text with static images, as well
as several interactive tools, such as the body mass index cal-
culator. The "Find A Dietitian" feature enables users to
search for a dietitian in a specific region. While this CHI
website is well designed and offers useful information, it does
not feature any Web 2.0 technologies.

Discussion

Three of the top 10 CHI websites in Canada are leaders in the adoption of Web 2.0 technologies: the Canadian Cancer Society, PasseportSanté, and the Heart and Stroke Foundation of Canada. All three have a Twitter feed with thousands of tweets, a Facebook site with at least 100 wall posts, a YouTube channel or streaming video, and a “Share” button with icon links to many social sites such as Bebo and Delicious. Noteworthy is the observation that these CHI websites are all published by not-for-profit groups.

Reputable Canadian CHI websites that provide a mod-
erate number of Web 2.0 technologies include sexualityan-
du.ca, Women's Health Matters, and Caring for Kids. All
three have Twitter accounts with a minimum of 100 tweets.
Two of the three have Facebook sites, while one has an
RSS feed. Furthermore, two of the three are published by
professional physician associations, while one is published
by a healthcare institution.

Four of the top 10 Canadian CHI websites have either
little (Canadian Safety Council, Here to Help) or no
(AboutKidsHealth, Dietitians of Canada) Web 2.0 pres-
ence. It is not clear why these CHI websites offer so little
in the form of Web 2.0 technologies at present or whether
this will change in the near future.

Another measurement for determining the extent to
which Web 2.0 technologies are embedded in these Cana-
dian CHI websites is the Twitter feed date range. Exam-
ining the entire list of tweets in the Twitter feeds of these
established CHI websites reveals their recent nature; the
first tweets date back to 2009. This indicates that the adop-
tion of Web 2.0 technologies by conventional CHI websites
is a recent endeavour.
<table><caption>**Table 1.** Web 2.0 technologies on the top 10 Canadian consumer health information (CHI) websites.</caption><thead><tr><th>Name of CHI website</th><th>Twitter</th><th>Facebook</th><th>RSS feed</th><th>YouTube channel</th><th>Blog</th></tr></thead><tbody><tr><td>Canadian Cancer Society</td><td>1151 tweets<br>4804 followers<br>434 following</td><td>Approx. 100 posts<br>8 CCS photo albums<br>3 CCS videos<br>8 events</td><td>Yes</td><td>19 918 channel views<br>224 380 total upload views</td><td>No</td></tr><tr><td>Passeport Santé</td><td>1072 tweets<br>1186 followers<br>585 following</td><td>200 posts since April 2010<br>172 notes<br>5 photo albums</td><td>Yes</td><td>Streaming videos</td><td>Yes</td></tr><tr><td>Heart and Stroke Foundation</td><td>1423 tweets<br>3078 followers<br>2263 following</td><td>Over 200 posts in second half of 2010<br>40 discussions</td><td>No</td><td>37 YouTube videos on Facebook site</td><td>No</td></tr><tr><td>Sexualityandu.ca</td><td>109 tweets<br>958 followers<br>1502 following</td><td>25 posts</td><td>No</td><td>16 YouTube videos on Facebook site wall<br>3 videos on flowerplayer</td><td>No</td></tr><tr><td>Women's Health Matters</td><td>419 tweets<br>1685 followers<br>431 following</td><td>No</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>Caring for Kids</td><td>245 tweets<br>945 followers<br>877 following</td><td>Approx. 90 posts</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Canadian Safety Council</td><td>No</td><td>30 posts</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Here to Help</td><td>No</td><td>No</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>AboutKidsHealth</td><td>No</td><td>No</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Dietitians of Canada</td><td>No</td><td>No</td><td>No</td><td>No</td><td>No</td></tr></tbody></table>

Furthermore, an indicator of the pervasiveness of Web 2.0 technologies on CHI websites is the amount of content and interactivity on their Facebook sites. Apart from the number of posts on the wall, the authorship of the posts and the number of comments serve to demonstrate the extent of community involvement. The three Canadian CHI websites with the greatest number of Web 2.0 technologies are also leaders in interactivity on Facebook, with posts authored by individuals and groups, which are also commented upon.

As 2010 drew to a close, the inclusion of Web 2.0 technologies on the top 10 Canadian CHI websites was found to be highly variable. A detailed list of the types of Web 2.0 technologies deployed on reputable Canadian CHI websites is provided in Table 1. While 3 of 10 sites demonstrate considerable use of the two most common Web 2.0 technologies, Twitter and Facebook, and another 3 show substantial use of Twitter, the 4 remaining sites do not make much, if any, use of popular Web 2.0 technologies. None of these sites incorporated links to their Web 2.0 sites in their main navigation bar. Furthermore, many Web 2.0 technologies are deployed infrequently, if at all, on any of these reputable CHI websites, such as blogs, RSS feeds, podcasts, and folksonomies. Clearly, the use of Web 2.0 technologies on the top 10 Canadian CHI websites is in its infancy.

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