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Informatics for Health and Social Care
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/imif20
Predictors of high trust and the role of confidence
levels in seeking cancer-related information
Lea Sacca, Veronica Maroun & Milad Khoury
To cite this article: Lea Sacca, Veronica Maroun & Milad Khoury (2021): Predictors of high trust
and the role of confidence levels in seeking cancer-related information, Informatics for Health and
Social Care, DOI: 10.1080/17538157.2021.1925676
To link to this article: https://doi.org/10.1080/17538157.2021.1925676
Published online: 20 May 2021.
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Predictors of high trust and the role of condence levels in seeking
cancer-related information
Lea Sacca
a
, Veronica Maroun
b
, and Milad Khoury
c
a
Center for Health Promotion Disease Prevention, University of Texas School of Public, Health, TX, Houston, 77030,
USA;
b
Lebanese American University, Beirut, Lebanon;
c
Department of Endocrinology, Penn State University, Hershey,
PA, USA
ABSTRACT
One of the most commonly searched topics on the internet in the United
States is cancer. Our study aims to provide a general overview of the
predictors of trust for two health information sources, doctors and the
internet, when seeking cancer-related information. The data were obtained
from the 2018 HINTS 5 Cycle 2 survey, which was administered from January
through May to a total of 3,504 respondents. We carried out next a series of
ordinal logistic regression models to identify predictors of high trust in
doctors and the internet separately for cancer-seeking information.
Demographic predictor variables varied as predictors of high trust for cancer
knowledge across both sources. Respondents who reported less condence
in their ability to seek cancer information had signicantly higher odds of
high trust in both doctors (OR = 8.43, CI: 5.58–12.73) and the internet
(OR = 2.93, CI: 1.97–4.35) as compared to those who reported being “com-
pletely condent” in their ability to obtain cancer information.
Understanding the key predictors of trust in doctors and the internet is
crucial to the enhancement of health. The role of condence as a predictor
of trust in seeking cancer information has been shown to consistently
inuence the levels of trust attributed to each topic.
KEYWORDS
Trust; confidence levels;
cancer information; doctor
trust; internet trust; hints
survey; sociodemographic
predictors
Introduction
Over the past decade, establishing trust relationships between public health researchers and the
community on one hand, and between patients and physicians on the other hand has been essential
due to the role of trust in predicting desired behavioral outcomes.
1–123
Traditionally, effective doctor-
patient communication processes are a key function in building a trustworthy relationship enabling
patients to share their concerns with their healthcare provider. It is crucial in the delivery of high-
quality care while avoiding any dissonance that might hinder proper diagnosis, counseling, and
seeking effective treatment options.
4–6
Constructive conversations led by doctors can aid their patients
in regulating emotions, facilitating comprehension of technical medical information, and allowing
a better disclosure of needs, perceptions, and expectations.
4,7,8
Moreover, patients who reported
having valuable in-person conversations with their doctors were more likely to be satisfied with the
care they received and were more likely to adhere to the prescribed treatment and to recover
expeditiously.
4,6,9–18
Since the rise of modern search engines, social networks, and pervasive technological devices, data
about a wide array of topics has been made available for individuals, which in turn enhanced their
accessibility to needed health information and impeded their motivation to seek professional help.
19,20
Patients consider online health information as a complementary source of information that can be
CONTACT Lea Sacca lea.sacca@uth.tmc.edu Lea Sacca, MPH, PhD Candidate, Center for Health Promotion Disease
Prevention, University of Texas School of Public, Health, 7000 Fannin, Houston, TX, 77030
INFORMATICS FOR HEALTH AND SOCIAL CARE
https://doi.org/10.1080/17538157.2021.1925676
© 2021 Taylor & Francis Group, LLC
used in synergy with their interactions with their physicians. They are empowered to find answers for
personal inquiries as well as having the opportunity to explore sensitive questions they might not feel
comfortable sharing with their doctors in the comfort and privacy of their own household.
21,22
Furthermore, with the widespread information rendered available on the internet, patients are more
enticed to seek quick information about health issues affecting them, regardless of the quality of the
figures they are exposed to.
23
Regulation of online information is difficult to control, and assessment of
the quality of the received knowledge is a daily challenge, particularly among patients with low health
literacy. This in turn places individuals at risk for detrimental health effects if they base their decision-
making process on misleading information promoted by esoteric and unscientific websites.
24,25
One of the most commonly searched topics on the internet in the United States is cancer, where in
2010, the National Cancer Institute revealed that cancer information seekers relied primarily on the
internet as a source of information to learn about the types of cancer followed by reliance on
healthcare providers.
26
Although the behavior of seeking cancer information is highly prevalent
among the US adult population, disparities still exist among minority groups, elderly people, and
individuals with low socioeconomic statuses.
27
The Health Information National Trends Survey
(HINTS) is a population-based survey collecting nationally representative data about changing
patterns, needs, and opportunities in the healthcare field within the U.S and Puerto Rico.
28
Several
researchers have used HINTS to investigate the extent of cancer information seeking activities and
cancer-related outcomes.
29,30
Our study aims to provide a general overview of the predictors of trust
for two health information sources, doctors and physicians, when seeking cancer-related information.
The results of the study derived from the HINTS5 Cycle 2 dataset would guide future researchers in
understanding nationally representative estimates for internet-based versus physician-based health
consultations, the level of trust associated with each information source, and the predictors of trust for
each source, particularly the role of the degree of confidence in influencing the level of trust allocated
to each information source.
Methods
For the purpose of this report, the data were obtained from the 2018 HINTS 5 Cycle 2 survey. The
HINTS data collection program aims to monitor trends in the field of health communication by
looking at the utilization of different communication channels by adults 18 years and older to obtain
vital health information regarding critical diseases such as cancer.
28
The survey was administered from
January through May to a total of 3,504 respondents. It consisted of a single-mode mail survey, using
the Next Birthday Method for respondent selection, and was divided into two stages. First, an equal-
probability sample of addresses was derived from each explicit sampling stratum. After that, a single
adult was selected from each sampled household. To increase the precision of estimates for minority
subpopulations, the high and low minority strata were established using the census tract level
characteristics from the 2012–2016 American Community Survey file. The high-minority stratum
consisted of addresses in census tracts having a population proportion of Hispanics or African
Americans that equaled or exceeded 34%. Even though the overall response rate was set at 32.9%,
differences between strata emerged. The response rate was only 23.2% for the high-minority strata
while the low-minority strata exhibited the highest response rate (36.6%). The rate of undeliverable
households was also slightly higher for the low-minority strata (12.1% vs 12%).
31
Denitions and measures
The survey administered to participants encompassed questions related to the utilization of different
health communication channels such as books, brochures, internet, cancer organizations, and health-
care providers among others. It also included inquiries about the frequency of cancer-seeking
information and the level of confidence and trust participants had toward the sources they sought
2L. SACCA ET AL.
for such type of information. Respondents were asked to rate their trust for each source on a 4-Likert
scale ranging from “a lot” to “not at all”.
The sociodemographic variables used for this study included age (18–39, 40–64, and >64 years),
gender, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, and
non-Hispanic Other), and level of education (less than high school, high school graduate, some
college/vocational training, college graduate, postgraduate).
Table 1. Frequencies of Participant’s Sociodemographic Characteristics (Health
Information National Trends Survey 2018).
Variable Full Sample (N = 3,504)
Gender (N = 3,448)
Male 1,394 (39.78%)
Female 2,054 (58.62%)
Missing 56 (1.6%)
Age (N = 3,417)
18–39 608 (17.35%)
40–64 1,569 (44.78%)
>64 1,240 (35.39%)
Missing 87 (2.48%)
Education (N = 3,453)
Less than 8 years 66 (1.88%)
8 through 11 years 209 (5.96%)
High School graduate 631 (18.01%)
Post high school/vocational training 229 (6.54%)
Some college 810 (23.12%)
College graduate 910 (25.97%)
Postgraduate 598 (17.07%)
Missing 51 (1.46%)
Race/Ethnicity (N = 3,151)
Non-Hispanic White 1,983 (56.59%)
Non-Hispanic Black or African American 444 (12.67%)
Hispanic 461 (13.16%)
Non-Hispanic Asian 138 (3.94%)
Non-Hispanic Other 125 (3.57%)
Missing 353 (10.07%)
Seeking Cancer Information (N = 2,782)
Yes 1,499 (42.78%)
No 1,283 (36.62%)
Missing 722 (20.6%)
Sources of Health Information (N = 2,388)
Books 88 (2.51%)
Brochures, pamphlets 87 (2.48%)
Cancer Organization 11 (0.31%)
Family 64 (1.83%)
Friend/coworker 25 (0.71%)
Doctor or healthcare provider 390 (11.13%)
Internet 1,664 (47.49%)
Library 9 (0.26%)
Magazines 18 (0.51%)
Newspapers 6 (0.17%)
Telephone information number 20 (0.57%)
Complementary, alternative, or unconventional 6 (0.17%)
Missing 1,116 (31.84%)
Confidence Level in Seeking Cancer Information (N = 3,457)
Completely Confident 931 (26.57%)
Very Confident 1,175 (33.53%)
Somewhat Confident 1,011 (28.85%)
A Little Confident 220 (6.28%)
Not Confident at All 120 (3.42%)
Missing 45 (1.28%)
Multiple responses selected in error 2 (0.06%)
INFORMATICS FOR HEALTH AND SOCIAL CARE 3
Trust in doctors and healthcare providers in seeking cancer-related information was assessed using
one item: “In general, how much would you trust information about cancer from each of the
following?”. We analyzed data for two of the identified health sources, “internet” and “healthcare
providers”. A 4-point ordinal scale (1 a lot, 2 some, 3 a little, or 4 not at all) was used to indicate the
level of trust. High source trust was dichotomized as “a lot” as opposed to all other responses to
understand the difference between respondents who harbor high levels of trust in these two sources
compared to those displaying feelings of hesitancy. Individuals who fail to show high levels of trust are
more likely to have doubt or mistrust that prohibits them from understanding actions recommended
by these health sources.
Confidence in seeking cancer information was measured using the following item: “Overall, how
confident are you that you could get advice or information about cancer if you needed it?” A 5-Likert
scale was used to rate the response from 1 “completely confident” to 5 “not confident at all”. This item
was recoded so that the highest level of confidence in obtaining cancer information had a higher value
(5 “completely confident”).
Statistical analyses
Data analysis was carried out with STATA IC (version 16) using replicate weights. Descriptive
statistics were first conducted to examine the prevalence of trust across the two selected health
information sources (internet and doctors). Next, ordinal logistic regression models were generated
to calculate the odds of high trust in seeking cancer information from healthcare providers vs. internet.
The parallel odds assumption was satisfied, and tests of statistical significance were calculated
at p < .05.
Results
Participant characteristics
A total of 3,504 participants completed the full survey sample. More than half of respondents were
female (58.62%) and non-Hispanic white (56.59%). The majority had more than a high school degree
(72.68%). Around 42% reported seeking cancer information, and the two most frequently sought
sources of health information were the internet (47.49%) and healthcare providers (11.13%). Table 1
includes all characteristics for the study sample.
Amount of reported trust across health information sources
Table 2. Amount of Reported Trust across Health Information Sources
Table 2. Displays the calculated unadjusted frequencies and unweighted percentages of participants’
amount of trust in healthcare providers and the internet across one health context: cancer knowledge.
We specifically focused on participants reporting high amounts of trust (“a lot”) in the two selected
cancer communication channels. The bolded row in Table 2 refers to the unweighted percentage of
respondents who reported high trust in the internet and healthcare providers in terms of seeking
cancer-related knowledge. For this particular health topic, significantly more Americans reported high
level of trust in their healthcare providers (70.18%) compared to the internet (14.27%).
Amount of reported trust on cancer Doctor (N = 3,435) Internet (N = 3,257)
A lot 2,459 (70.18%) 500 (14.27%)
Some 814 (23.23%) 1,751 (49.97%)
A little 125 (3.57%) 715 (20.41%)
Not at all 37 (1.06%) 291 (8.3%)
4L. SACCA ET AL.
Regression analyses
We carried out next a series of ordinal logistic regression models (Table 3) to identify predictors of
high trust in each of the two sources separately for cancer-seeking information. Demographic
predictor variables varied as predictors of high trust for cancer knowledge across both sources. For
instance, females reported higher levels of trust in doctors (OR = 1.04, CI: 0.89–1.2) and lower levels of
trust in the internet (OR = 0.83, CI: 0.73–0.94) compared to males, with significance seen only for the
association between low trust levels and the internet as a source of information. Differences across the
two age categories (18–39 and 40–64) compared to the reference group were not significant in terms of
the level of trust associated with doctors (OR = 0.82, CI: 0.67–1.02 & OR = 1.05, CI: 0.89–1.23) and the
internet (OR = 1.18, CI: 0.99–1.4 & OR = 0.9, CI: 0.78–1.04) respectively. Additionally, education was
a significant predictor for trust levels associated with the internet, whereby the lower the education
level, the higher the trust levels felt for the internet in seeking cancer-related information (OR = 2.23,
CI: 1.3–3.85). Concerning race, non-Hispanic Blacks (OR = 0.67, CI: 0.55–0.82) and non-Hispanic
Asians (OR = 0.61, CI: 0.43–0.85) were around 30% less likely to trust the internet compared to non-
Hispanic Whites.
Levels of confidence in seeking cancer information deemed to be significant in determining the
level of trust allocated for both doctors and the internet. Respondents who reported less confidence
in their ability to seek cancer information had significantly higher odds of high trust in both doctors
(OR = 8.43, CI: 5.58–12.73) and the internet (OR = 2.93, CI: 1.97–4.35) as compared to those who
Table 3. Ordinal Logistic Regression Models Displaying Predictors of High Trust across Sources (Health Information National Trends
Survey (HINTS 5) Cycle 2 2018).
Variable
Trust in Cancer-Information Source (Doctor)
(OR, 95% CI)
Trust in Cancer-Information Source (Internet)
(OR, 95% CI)
Gender
Female 1.04 (0.89–1.2) 0.83 (0.73–0.94)
Male (Ref) Ref Ref
Age
18–39 0.82 (0.67–1.02) 1.18 (0.99–1.4)
40–64 1.05 (0.89–1.23) 0.9 (0.78–1.04)
>64 (Ref) Ref Ref
Education
Less than 8 years 1.42 (0.83–2.44) 2.23 (1.3–3.85)
8 through 11 years 1.18 (0.83–1.67) 0.7 (0.5–0.97)
High School graduate 1.18 (0.92–1.5) 0.96 (0.78–1.19)
Post high school/vocational
training
1.5 (1.09–2.08) 1.08 (0.81–1.44)
Some college 1.09 (0.86–1.38) 0.96 (0.79–1.17)
College graduate 1 (0.8–1.26) 0.98 (0.81–1.18)
Postgraduate (Ref) Ref Ref
Race/Ethnicity
Non-Hispanic White (Ref) Ref Ref
Non-Hispanic Black or African
American
1.08 (0.86–1.36) 0.67 (0.55–0.82)
Hispanic 1.14 (0.91–1.42) 0.84 (0.69–1.02)
Non-Hispanic Asian 1.01 (0.69–1.47) 0.61 (0.43–0.85)
Non-Hispanic Other 0.94 (0.63–1.41) 1.05 (0.74–1.48)
Confidence Level in Seeking Cancer Information
Not confident at all 8.43 (5.58–12.73) 2.93 (1.97–4.35)
A little confident 6.07 (4.39–8.38) 2.46 (1.84–3.3)
Somewhat confident 3.31 (2.67–4.11) 1.34 (1.89)
Very confident 1.59 (1.28–1.98) 1.35 (1.14–1.59)
Completely confident Ref Ref
INFORMATICS FOR HEALTH AND SOCIAL CARE 5
reported being “completely confident” in their ability to obtain cancer information. What is
important to highlight here is that the level of trust in retrieving cancer-information from doctors
decreased when patients reported higher levels of confidence “very confident” (OR = 1.59, CI:
1.28–1.98) and lower odds of trust in the internet (OR = 1.35, CI: 1.14–1.59). Even though the
overall regression analyses for relationships between trust and confidence levels was significant
(p = .00), it is crucial for future interventions to focus on confidence as a possible modifier of
behavior to increase adherence to reliable sources of information, especially when seeking critical
facts about cancer conditions.
Discussion
The following study aimed to compare the level and predictors of high trust in two cancer-seeking
information sources-doctors and internet. Overall, findings suggest a high amount of public trust in
doctors (70.18%) compared to the internet (14.27%) in seeking cancer information. However, more
people reported “some” (49.97%) and “a little” (20.41%) amount of trust for the internet compared to
the amount of trust for doctors (23.23% and 3.57% respectively).
The ordinal regression analysis carried out highlighted interesting findings for trust and confidence
levels for internet sources that align with the available literature on this topic. For instance, Wong &
Cheung (2019) explored the reasons behind online health information seeking among a group of
patients attending a primary care clinic in Hong Kong. The major reason for choosing the internet to
seek answers related to appearance of new symptoms is convenience (55.41%). High eHealth literacy
scores, fair or poor self-rated health, having a chronic medical condition, and using the internet on
multiple times per day were identified as significant predictors of online health information seeking
behavior. Additionally, the main barrier for the lack of communication with doctors was the lack of
interest of doctors regarding their patients’ online searches (56.1%). Only 26.88% felt comfortable
disclosing the information they found with their doctors.
32
Therefore, it is highly suggested that
doctors increase recognition of their patients’ e-health information seeking behavior to guide them in
searching for credible sources and engage them in making decisions revolving around their health.
32
As for the low confidence levels that were seen to correlate with higher levels of trust in doctors, this
could be explained by the hesitancy of patients to seek information from other sources that might deem
unreliable in providing them with the accurate cancer-related information they need. However, as their
confidence levels increase, they might explore other options to gather sensitive information they might
be more comfortable in gathering from other available sources, which in turn can increase their risk of
accessing ingenuine data. Hesse et al. (2005) suggested amplifying the amount of attention to modify
incentive policies for time spent with patients explaining printouts, for incorporating shifts toward
informed and patient-centered decision-making, for directing consumers toward reliable sources of
information, as well as dealing with the needs of those who become victims of false internet claims.
19
When looking at individual-level predictors of high trust, it was seen that people who reported low
levels of confidence in obtaining cancer information had higher odds of trust for both sources.
33
Corritore et al. (2012) stressed upon credibility and objectivity of information as direct predictors of
trust for online health websites.Yet, patients should always be reminded that the availability of
alternative information sources are not equivalent
34
to the medical information obtained from
doctors.Even though the HINTS database is derived from a cross-sectional survey, it can be presumed
that lower trust in doctors might be due to lack of interest on the provider’s side or lack of comfort in
disclosing embarrassing symptoms, particularly by millennials, who rely greatly on technology to
satisfy most of their needs. Lower trust and confidence in seeking information from internet sources
might result from low health literacy in distinguishing between evidence-based sources and other low
credible websites. For that reason, physicians should act as facilitators of seeking information from
both in-patient visits and online platforms.
Concerning sociodemographic predictors, predictors of high trust were inconsistent for seeking
cancer-related information from both sources. This is consistent with varying predictors of trust in
6L. SACCA ET AL.
other information sources from previous studies. For instance, individuals having less than a college
degree had higher odds of high trust in the internet compared to participants with a postgraduate
degree. The association seen can be explained in terms of the lack of awareness of the benefits of
seeking credible information from doctors compared to false information from easily accessible
websites. Chen et al. (2018) concluded that low levels of trust for viewing TV and the internet as
reliable sources of information were seen among those with a college degree or a higher level of formal
education. Additionally, being female was associated with lower odds of trust for internet sources
compared to males.Older age groups were associated with higher levels of trust for healthcare provider
and lower levels of trust for the internet. Gordon & Honbrook (2018) stated that older adults have less
access to digital tools and are less confident in their ability to go online for health information, which
could hence clarify the high odds of trust seen for doctors among this age group.
35
African Americans
and Non-Hispanic Asians were more likely to show low levels of trust for the internet compared to
non-Hispanic Whites. The following observation can be explained by the value African Americans
place on trust in the establishment of relationships with their physicians due to its role in facilitating
care-seeking behavior and enhancing honesty and adherence to recommended treatment.
36
Limitations of the study
This study has several limitations related to its cross-sectional nature. The data was derived from the
HINTS 5 Cycle 2 survey which was administered to a nationally representative sample in the form of
a structured interview by phone. The random digit-dial telephone survey can lead to low response rates
along with diminished validity of some of the measures at baseline. Moreover, social desirability bias
might have been introduced by having participants report higher levels of trust for doctors.
Furthermore, since HINTS is a cross-sectional study, then causality cannot be established, and the
differences seen in the levels of trust across both sources cannot be confirmed. Despite these limitations,
this study is one of the few studies comparing predictors of trust and the influence of confidence levels
on trusting two-different cancer-information sources. Future research should look further in accessing
the role of confidence in increasing trust-based relationships between physicians and patients to
ameliorate not only in-person interaction but also health literacy when surfing wellness websites.
Conclusion
Understanding the key predictors of trust in doctors and the internet is crucial to the enhancement of
health, particularly among vulnerable populations. This study suggests that the findings might not be
generalizable to other health topics beyond cancer-related information since trust tends to vary across
contexts. Communication campaigns and interventions should target not only people but also
physicians to ameliorate the communication processes that result in seeking adequate cancer informa-
tion. However, the role of confidence as a predictor of trust in seeking cancer information has been
shown to consistently influence the levels of trust attributed to each topic. This further emphasizes the
need for researchers to focus on confidence as a key factor in obtaining health information.
Communication of national health information sources should incorporate trust and perceived
confidence as part of effective health information seeking.
Disclosure of potential conicts of interest
The authors do not have any conflicts of interest to report.
INFORMATICS FOR HEALTH AND SOCIAL CARE 7
ORCID
Lea Sacca http://orcid.org/0000-0002-0629-2863
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