JMIR Publications

ABSTRACT

Background:

Background The global shortage of healthcare workers has exacerbated the challenges faced by health systems worldwide. The World Health Organization (WHO) projects a deficit of 10 million healthcare workers by 2030. While low- and lower-middle income countries will be the most affected, all countries will face significant challenges [1]. In the UK, the National Health Service (NHS) is already under considerable strain [2], with significant effects on the quality of care and health outcomes of patients [3]. At the same time, there is a growing demand for health information and increasing consumer empowerment [4]. In this context, the reliance on digital health tools has surged, particularly decision support tools including online symptom checkers (OSCs) [5, 6]. The ubiquitous access to the internet supports this trend, with 96% of households in the UK having internet access in 2020 [7], which accelerated following the advent of the COVID-19 pandemic given the need of health services to avoid face-to-face contact and preserve urgent care capacity [8]. Symptom checkers are available as websites or applications and can generate a prioritised list of potential diagnoses based on the entered symptoms and suggest suitable actions, such as self-care, consulting a general practitioner (GP), or seeking urgent medical care [9]. By providing preliminary diagnostic guidance and triage recommendations, these tools could potentially alleviate some of the burdens on healthcare systems with the potential to reduce unnecessary healthcare visits by providing timely medical advice and empowering individuals to make informed decisions about their health [10, 11]. The diagnostic and triage accuracy have been found to vary greatly among OSCs, thus raising concerns and calling for caution [12, 13]. The use of OSCs globally varies as: users tend to be young [12, 13], women [6, 14, 15] and more highly educated [6, 14-16]. Having a chronic health condition has also been associated with greater use in one study [16]. A 2022 systematic review on user experience of symptom checkers identified eight relevant aspects of user experience that have been explored in the literature, including motivation, trust, acceptability, satisfaction, accuracy, usability, safety/security and functionality [17]. Of the 31 included studies only 3 were carried among the UK population [18-20] and focused either on cancer symptom checking [19], users with inflammatory arthritis [20] or the use of one specific OSC [18]. Data on the experience and perspectives of potential users living in the UK on the use of OSCs remains scarce and no study has yet quantified or ranked the various factors associated with the use of OSCs.

Objective:

The aim of this study was to identify, characterise and quantify the factors associated with the use of OSCs among community-dwelling adults in the UK. Specifically, we sought to (i) assess the demographic characteristics of OSC users, (ii) evaluate user perceptions of the usability and effectiveness of OSCs, (iii) identify concerns related to the privacy, security and accuracy of OSCs, and (iv) quantify the weight of these various factors on the adoption and utilisation of OSCs.

Methods:

Study design This cross-sectional study aimed to explore factors influencing the use of OSCs among community-dwelling adults in the UK. The study employed a quantitative methodology using an electronic survey tool (eSurvey). Data collection This was an open eSurvey, accessible to anyone with the survey link, and required less than 10 minutes to complete. The eSurvey was developed and tested to ensure clarity, usability and technical functionality before fielding. The link to the eSurvey was active on the Imperial College Qualtrics platform between 23 February and 25 March 2024. Study information was disseminated including the Participant Information Sheet (PIS) and link to the survey. Participants were recruited through convenience sampling. The researcher’s personal and professional networks were mobilised to respond and further disseminate the eSurvey among potentially eligible participants. Most participants were recruited via Prolific Academic’s panel [21]. The PIS included information regarding the study’s aims, the protection of participants’ personal data, their right to withdraw from the study at any time, which data were stored, where and for how long, who the investigator was, the purpose of the study and survey length. Participants were informed that this was a voluntary survey. Informed consent was obtained from all participants. Data collected were stored on a secure database at Imperial College London and only accessible to the researcher team. All responses were pseudo-anonymised to ensure confidentiality. The selection of factors which may affect the use of OSCs to be included in the survey was guided by a review of existing literature of the topic. Demographic factors including age and gender, as well as perceptions such as perceived usability, effectiveness, reliability, accuracy, safety and privacy have been identified as influential factors from prior studies [6, 16-18, 20, 22]. Before publication, the survey was tested, piloted and revised internally by the study team. In its final version, the survey comprised a total of 25 questions displayed across four screens and gathered data regarding respondents’ awareness, use and perspectives regarding OSCs, as well as basic demographic information (Table 1). Data analysis Only questionnaires fully completed were included in the analysis. Duplicate entries from the same IP address within a 24-hour period were also eliminated before analysis. Participant characteristics and responses were summarised using total (n) and relative (%) frequencies. For inferential analyses, 'strongly agree' and 'somewhat agree' were categorised into 'agree,' and 'strongly disagree' and 'somewhat disagree' were categorised into 'disagree, to create binary variables for logistic regression analysis. Relationships between (i) demographic factors, (ii) usability and effectiveness, (iii) reliability and accuracy, (iv) risks and concerns and the use of OSC were assessed using univariable and multivariable logistic regression models, adjusting for age, gender, ethnicity, education level, parenting status, disability and long-term health conditions. Results were deemed statistically significant at a p-value <0.05. The odds ratios for these relationships were quantified to understand the influence of each factor on the use of OSCs and compare them. All analyses were performed using STATA, version 17 (StataCorp LP, College Station, TX, USA). The Checklist for Reporting Results of Internet E Surveys (CHERRIES) was used to guide reporting [23] (Supplementary file 1).

Results:

Participants characteristics A total of 641 individuals took part in the survey with complete responses obtained from 634 respondents. A full description of participants according to age, gender, ethnicity and educational background is provided in Table 2. The largest proportion were between 26 and 35 years old (32.7%), followed by participants aged 36-45 (24.6%). Gender distribution showed a slight predominance of females (46.5%) over males (41.8%), with a smaller percentage identifying as "other" (10.3%). Ethnicity predominantly comprised individuals identifying as White (84.2%), followed by Asian/Asian British (7.1%) and Black/African, Caribbean/Black, British (3.9%). The majority held a college or university degree (71.5%), nearly a third (31.5%) had children under 16 years, 15.1% of respondents reported having disabilities, and 22.9% had one or more long-term health conditions. Main survey findings Use of OSC The majority (85.7%) of participants had used an OSC, while 14.4% reported never having used one. The reasons for non-use of OSC reported by the largest proportion (45.1%) was preference of consulting a healthcare professional directly rather than using OSC, followed by having never heard of them (39.6%); 24.2% of respondents did not trust them. However, two-thirds of the non-users (64.8%) expressed a likelihood of using a symptom checker in the future (Supplementary Table 1). The most utilised OSC was NHS 111, with 78.6% of respondents indicating that they had used this tool, followed by Healthline (22%). Participants predominantly used symptom checkers before seeking medical advice (94.5%), primarily to better understand symptoms (79.0%) and to determine the need for medical care (77.4%). Most respondents (77.9%) indicated that symptom checkers offered recommendations for action or triage. Among those who received such recommendations, a significant proportion (79.7%) were directed to seek a consultation with a healthcare professional. Regarding adherence, most participants (59.8%) reported following the recommendations most of the time, 27.7% stated they always adhered to the suggestions provided by the symptom checker, while a smaller proportion (12.3%) admitted to rarely doing so. Association between demographics and use of OSC An increase in age was associated with a decrease in OSC use. Specifically, individuals aged 46-55, 56-65 and >65 showed significantly decreased odds of using OSC (adjusted odds ratio (aOR)=0.29, 95%CI 0.11 - 0.72), (aOR=0.27, 95%CI 0.10 - 0.71) and (aOR=0.22, 95%CI 0.06 - 0.78) respectively, compared to the younger (18-25) age group. Similarly, females exhibited higher odds of using OSC compared to males (aOR=1.79, 95%CI 1.05 – 3.06). Having children under 16 years of age also showed significantly higher odds of using OSC (aOR= 3.19, 95%CI 1.56 - 6.51) compared to those who do not have children under 16 years of age. In contrast, neither ethnicity nor educational background exhibited any statistically significant association with the use of OSC. Similarly, disability and long-term health conditions did not contribute to the outcome of using OSC; Table 3. Associations between OSC use & users’ perceptions of OSCs The main survey findings are shown in Supplementary Table 1. The segment below highlights key associations between perceived usability and effectiveness, reliability and accuracy, and risks and concerns with using OSCs Perceived usability and usefulness and use of OSCs Most of the participants found OSCs easy to use (89.3%), believed they could help with medical decisions (86.0%) and to support their health literacy and self-care (84.7%). A great proportion also (94.6%) agreed that OSCs are useful tools in scenarios with limited access to healthcare professionals, such as rural settings or out-of-hours situations. Participants who found the symptom checkers easy to use were more than eight times more likely to utilise them compared to those who did not (aOR=8.17, 95% CI 4.25-15.71). Similarly, individuals who found these tools helpful in making better medical care choices were almost three times more likely to use them than those who did not (aOR=2.96, 95% CI 1.62-5.42). Moreover, those who agreed that the symptom checkers improved health literacy and supported self-care showed a heightened likelihood of use (aOR=2.36, 95% CI 1.30-4.28). Participants who perceived the OSC as useful in scenarios with limited access to healthcare professionals were twice as likely to utilise them compared to those who disagreed (aOR=2.15, 95% CI 1.01-4.59); Table 3. Perceived reliability and accuracy and use of OSCs Just over half of the respondents expressed confidence and trust in OSCs’ information (57.3%). The perceived accuracy of OSCs’ diagnosis was slightly higher (63.0%) while 79.2% of respondents said they trusted the triage provided by the tools. 69.2% of respondents found using a symptom checker reassuring and made them feel less anxious about their health. Participants who trusted the suggested diagnosis to be accurate were over twice as likely to use the symptom checkers compared to those who disagreed (aOR=2.24, 95%CI 1.32-3.79). Similarly, individuals who trusted the triage recommendation provided by these tools showed a heightened likelihood of use (aOR=2.33, 95% CI 1.33-4.06). Participants who found using symptom checkers reassuring and anxiety-reducing were significantly more likely to utilise them (aOR=3.85, 95% CI 2.28-6.50). Additionally, the encouragement from family and friends to use symptom checkers significantly influenced their use (aOR=2.05, 95%CI 1.24-3.41). However, encouragement from GPs was not significantly associated with the use of symptom checkers (aOR=1.34, 95%CI 0.79-2.24); Table 4. Perceived risks and concerns and use of OSCs Reported concerns included safety (75.9%), privacy (41.7%) and exacerbating inequalities (41.6%). More than half of the respondents (65.9%) worried about replacing traditional consultations and more than a quarter (26.9%) would not feel confident discussing the outcomes of their symptom checker consultation with their GP. Participants who agreed that symptom checkers are not yet safe enough to rely solely on them and may put their health at risk did not show a significant association with use compared to those who disagreed (aOR=0.59, 95% CI 0.30-1.17). However, concerns regarding privacy and health information security were significantly inversely associated with use, with individuals expressing such worries being less likely to utilise symptom checkers (aOR=0.58, 95% CI 0.35-0.97). Similarly, those who believed that symptom checkers might increase inequalities between patients were less likely to use them (aOR=0.47, 95% CI 0.28-0.79). Concern about OSCs replacing face-to-face or phone consultations was significantly associated with decreased use (aOR=0.47, 95% CI 0.26-0.87); Table 5. Figure 1 represents the weight of each factor on the use of OSCs. The main factor that significantly increased the probability of using OSCs was the tools’ ease of use (aOR=8.17, 95% CI 4.25-15.71). This was followed by feeling reassured by using the tool and having children. Users of OSCs also usually thought of OSCs as improving their healthcare choices, their health literacy and self-care capacity. Encouragement from friends and family limited healthcare access, better. being female. and trust in the triage and diagnostic accuracy. Demographic factors associated with a decreased odd of using OSCs included male gender and older age. Concerns regarding privacy and data security, as well as the risk of increased inequalities and loss of face-to-face consultations due to OSCs were also identified as reducing the likelihood of using these tools.

Conclusions:

Principal results This study investigated the factors influencing the use of OSC in the UK through a cross-sectional survey of community dwelling adults. Among the key findings, we observed that most participants (86%) had used a symptom checker at some point, with the NHS 111 platform being the most widely used (79%), followed by Healthline (22%). These tools were predominantly employed before seeking medical advice (95%) primarily to better understand symptoms and to determine the need for care. Interestingly, while most OSC non-users expressed a strong likelihood of future use, we observed varying concerns regarding the accuracy of information, safety, privacy and potential increase of inequalities. Older individuals (aged between 46-55, 56-65 and older than 65) showed significantly decreased odds of using OSC compared to the 18-25 age group independently from other variables. However, females exhibited higher odds of utilising these tools compared to males, and individuals with children under 16 years of age were more than three times more likely to use OSC compared to those who did not have children. Further, although trust in the accuracy of diagnoses and triage recommendations, as well as encouragement from family and friends, positively influenced use, concerns regarding privacy, health information security, inequalities and the potential displacement of traditional consultations were significantly associated with decreased use (Figure 1). No significant associations were found between the use of OSCs and encouragement from GPs to use these tools, concerns about the safety of relying solely on symptom checkers nor potential health risks. Study strengths and limitations This study examined a wide range of variables, including demographics, motivations, perceived effectiveness, reliability and concerns regarding OSC and associations with their use providing valuable insights into the complexities surrounding the wide scale adoption and diffusion of these tools in the contemporary setting. While supporting existing evidence on this topic, we identified additional factors associated with the use of OSCs, including the perceived family and friends support as well as having children. By employing regression models, we were also able to quantify the associations between the use of OSCs and a variety of factors, including both demographic factors and respondents’ perceptions regarding the usability, safety, accuracy and concerns associated with OSCs. Crucially, we identified significant predictors of use while controlling for potential confounders and enhancing the internal validity. This study's large, diverse and representative sample closely reflects the ethnic distribution of the UK population [24], which enhances the generalisability of the findings. However, this study is also has several limitations. Firstly, cross-sectional studies cannot establish causality and temporal relationships between the factors examined. Secondly, since the survey was only accessible online, it is likely that potentially eligible participants with limited access to internet and / or those less confident with digital technology were excluded and their views absent or at least under-reported. Lastly, this study relies on self-reported data, which may be subject to recall and social desirability biases. Participants' responses regarding their use patterns, preferences and adherence to recommendations may therefore not fully reflect their actual behaviours. Longitudinal studies are indicated to follow-up users over a longer time horizon to better understand how their interactions with OSC evolve and how it influences their health behaviours, healthcare utilisation and health outcomes. Comparison with existing literature The findings of this study are in line with prior research, including primary studies and reviews reporting on the socio-demographics of OSC users who tend to be young [6, 14, 15], women [6, 14-16] and with higher education levels [6, 14, 16]. Although having a chronic health condition or a disability was associated with greater use in a study by Meyer et al. [16], we did not find this association in this study’s sample. Regarding the motivations for using OSCs, a better understanding of the causes of symptoms has also been found to be the primary motivation among US users of the Isabel Symptom Checker [16], followed by support for deciding whether to seek care. The finding that users of OSCs tend to find these tools easy to use and helpful was corroborated by Meyer et al. [16] and Pairon et al. [6]. The strong correlation identified in this study highlights the importance of user-friendly interfaces in promoting the adoption of OSCs. The review by Pairon et al. [6] also emphasized that users value OSCs for their ability to support health-related decisions, especially in determining whether to seek medical care. The results of this study reinforce this by showing that individuals who perceived OSCs as helpful in making better medical care choices were nearly three times more likely to use them. Compliance with OSC recommendations has also been a point of focus in the literature. Previous studies reported varying levels of adherence to OSC advice, with compliance rates ranging from 57% to 67% [6], whereas this study reports a higher compliance rate, with 87.5% of participants following OSC recommendations most or all of the time. This higher rate of adherence may reflect an increasing reliance on digital health tools, particularly in the context of the COVID-19 pandemic which has accelerated the adoption of telemedicine and online health resources. Further research is needed to continue monitoring these trends and to explore the long-term impact of OSC use on healthcare outcomes. Finally, issues relating to perceived accessibility, accuracy, security and privacy of OSCs were also identified by Aboueid et al. [22] in their qualitative study exploring young adults’ perspectives on the use of OSCs. Most of their respondents thought of OSCs as more useful to self-triage than self-diagnosis, which reflects the fact that only 63% of the respondents in this study trusted the diagnosis provided by the OSC, compared to 79.2% for the triage suggestion. Implications for research Although this study identified demographic disparities in the use of OSCs, further research is warranted to understand the underlying reasons for these disparities. Research focusing on the socio-cultural factors, digital literacy and healthcare-seeking behaviours among different demographic groups could provide valuable insights into addressing disparities and promoting equitable access to OSC. In addition, this study’s findings highlight the importance of usability, effectiveness and trust in driving the adoption and utilisation of OSCs. Future research could investigate deeper into the specific features and functionalities of these tools, such as user interface design and decision support algorithms that contribute to their perceived usability, effectiveness and adherence to the recommendations. This study highlighted concerns regarding the privacy and health information security of OSC, which could impact their acceptance and use, necessitating the development of robust frameworks, regulatory standards and guidelines for OSC platforms to ensure transparency, accuracy and user privacy. Additionally, studies investigating the potential implications of OSC on healthcare inequalities and the doctor-patient relationship are essential for informing policy and practice, whereas research exploring effective strategies for educating users about the capabilities and limitations of these tools, as well as enhancing communication and collaboration between users and healthcare providers, could help build trust and confidence in OSC. Future research should focus on understanding the socio-cultural factors influencing OSC use and developing strategies to address privacy and security concerns. Additionally, efforts to improve the usability and reliability of OSCs, alongside targeted interventions to promote equitable access, are essential for integrating these tools effectively into the healthcare system. By addressing these issues, OSCs can play a key role in supporting self-care and improving healthcare accessibility and efficiency in the UK. Conclusion This study provides insights into the factors influencing the use of OSCs in the UK, highlighting both their increasing and widespread adoption and some of the concerns associated with these digital health tools. The findings indicate that most adults have used OSCs, particularly the NHS 111 service, primarily for understanding symptoms and determining the need for medical care, and that younger individuals, females and those with children are more likely to use OSCs overall. Ease of use, perceived helpfulness in medical decision-making, and trust in the accuracy of diagnoses and triage recommendations are key factors driving OSC use, but these are coupled to concerns about privacy, health information security and the potential for OSCs to exacerbate healthcare inequalities, posing significant barriers to their adoption. The fear of OSCs replacing traditional consultations with healthcare professionals remains common among users, and these concerns must be addressed to enhance user trust and maximize the benefits of OSCs in healthcare delivery.