title: Web-based self-assessment health tools: who are the users and what is the impact of missing input information?
abstract: BACKGROUND
  Web-based health applications, such as self-assessment tools, can aid in the early detection and prevention of diseases. However, there are concerns as to whether such tools actually reach users with elevated disease risk (where prevention efforts are still viable), and whether inaccurate or missing information on risk factors may lead to incorrect evaluations.
  
  
  OBJECTIVE
  This study aimed to evaluate (1) evaluate whether a Web-based cardiovascular disease (CVD) risk communication tool (Heart Age tool) was reaching users at risk of developing CVD, (2) the impact of awareness of total cholesterol (TC), HDL-cholesterol (HDL-C), and systolic blood pressure (SBP) values on the risk estimates, and (3) the key predictors of awareness and reporting of physiological risk factors.
  
  
  METHODS
  Heart Age is a tool available via a free open access website. Data from 2,744,091 first-time users aged 21-80 years with no prior heart disease were collected from 13 countries in 2009-2011. Users self-reported demographic and CVD risk factor information. Based on these data, an individual's 10-year CVD risk was calculated according to Framingham CVD risk models and translated into a Heart Age. This is the age for which the individual's reported CVD risk would be considered "normal". Depending on the availability of known TC, HDL-C, and SBP values, different algorithms were applied. The impact of awareness of TC, HDL-C, and SBP values on Heart Age was determined using a subsample that had complete risk factor information.
  
  
  RESULTS
  Heart Age users (N=2,744,091) were mostly in their 20s (22.76%) and 40s (23.99%), female (56.03%), had multiple (mean 2.9, SD 1.4) risk factors, and a Heart Age exceeding their chronological age (mean 4.00, SD 6.43 years). The proportion of users unaware of their TC, HDL-C, or SBP values was high (77.47%, 93.03%, and 46.55% respectively). Lacking awareness of physiological risk factor values led to overestimation of Heart Age by an average 2.1-4.5 years depending on the (combination of) unknown risk factors (P<.001). Overestimation was greater in women than in men, increased with age, and decreased with increasing CVD risk. Awareness of physiological risk factor values was higher among diabetics (OR 1.47, 95% CI 1.46-1.50 and OR 1.74, 95% CI 1.71-1.77), those with family history of CVD (OR 1.22, 95% CI 1.22-1.23 and OR 1.43, 95% CI 1.42-1.44), and increased with age (OR 1.05, 95% CI 1.05-1.05 and OR 1.07, 95% CI 1.07-1.07). It was lower in smokers (OR 0.52, 95% CI 0.52-0.53 and OR 0.71, 95% CI 0.71-0.72) and decreased with increasing Heart Age (OR 0.92, 95% CI 0.92-0.92 and OR 0.97, 95% CI 0.96-0.97) (all P<.001).
  
  
  CONCLUSIONS
  The Heart Age tool reached users with low-moderate CVD risk, but with multiple elevated CVD risk factors, and a heart age higher than their real age. This highlights that Web-based self-assessment health tools can be a useful means to interact with people who are at risk of developing disease, but where interventions are still viable. Missing information in the self-assessment health tools was shown to result in inaccurate self-health assessments. Subgroups at risk of not knowing their risk factors are identifiable and should be specifically targeted in health awareness programs.
authors.affiliation: Nutrition & Health Department, Unilever Research & Development, Vlaardingen, Netherlands. nicole.neufingerl@unilever.com.
authors.forename: Nicole
authors.identifier: http://orcid.org/0000-0002-8060-2321
authors.initials: N
authors.lastname: Neufingerl
authors.forename: Mark R
authors.identifier: http://orcid.org/0000-0003-2511-4197
authors.initials: MR
authors.lastname: Cobain
authors.forename: Rachel S
authors.identifier: http://orcid.org/0000-0001-5603-1875
authors.initials: RS
authors.lastname: Newson
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000503:physiopathology / Q000517:prevention & control*; D002784:Cholesterol / Q000097:blood; D059026:Diagnostic Self Evaluation; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D002784:Cholesterol
keywords: Web applications; blood pressure; cardiovascular disease; cholesterol; consumer health information; preventive health services; risk assessment