Reviewer agreement levels were generally good to excellent. In cases where variation occurred it was often due to the depth of site review. Some information may have appeared in the opening page of a website but on others, information was on panels that required the reviewer click several tabs to reach it. When information was not visible on the website in a prominent manner it was harder to locate and probably accounts for some variation between reviewers. In addition, reviewers used their own judgment as to whether sites contained information consistent with HP initiatives. Perhaps a good example is diet and health. Some sites contained information on diet and health. However, many of those were to market a nutritional product or supplement and may not have indicated a level of dietary information related to HP initiatives. This may have accounted for variation among reviewers in general.
The Internet will get more and more use as a potential source of information on health and wellness. Smart-phone technology now allows a search from almost anywhere. The purpose of this study was to see what wellness-oriented content would appear on sites the public would likely come across on a routine search of chiropractic wellness. The findings presented here indicate a lack of sound wellness and health promotion information available on most of the sites analyzed.
Research into what consumers look for to determine the credibility of an Internet site may be a cause for more concern over content. One study found that people look more at the professional design of the site, whether they can get, "a quick lay-out of the site", the user-friendliness of the site, and speedy interface times rather than if the content is evidence-based or supported by the scientific literature . This is unfortunate but understandable. After all, these are laypersons and not providers. This same study found that patient markers for quality included if it "sounded plausible," sounded "scientific," looked "trustworthy." These have little to do with actual viability of content.
The depth of information on the sites analyzed was poor and was rarely evidence-based. Many sites may have mentioned one should walk for example but there was no evidence of information related to PA Guidelines for Americans  and information related to how one could get PA into their daily lives. This study also demonstrates that some chiropractors (those with web sites that are highly ranked by the search engines used) apparently still support the notion that chiropractic care is a viable substitute for medical care. Anti-medical, anti-drug, and anti-vaccine rhetoric was often displayed prominently on the sites evaluated. This is concerning. Worth noting is that several sites had very near identical content apparently having purchased a pre-manufactured website from one of a small number of vendors. Many practitioners may be purchasing these and paying little attention to the information that is on the sites. Nevertheless, content was poor on most sites lacking legitimate evidence-based wellness information. This is ultimately the responsibility of the provider.
Patients need information on how to become healthy and stay healthy. Many of the health conditions listed in HP documents and that this project assessed are the common causes of premature morbidity and mortality in Americans and typically, in a minority of sites was there any information that would likely help a patient restore or gain healthy ground. The sites typically marketed the chiropractor and offered promotional materials for services offered in the clinic and not wellness measures common to preventive medicine or health promotion. Even specific information on prevention of reoccurrence of back pain was scant on most sites. The anti-public health messaging could actually be seen by some as anti-prevention, therefore anti-wellness. This was discouraging as well since it could be seen on approximately 1/3 of sites reviewed.
Limitations of the study
There are some specific limitations of this study. First, this was a review of a minimum number of sites and they may not be representative of all chiropractic sites. Second, two reviewers who are researchers made the reviews and there is bias inherent to that process. However, agreement was consistent most of the time. Third, many content areas related to HP initiatives clearly would not be expected to be found on a site to promote an individual chiropractor as was the apparent intent of most of the websites reviewed. Therefore, content like safe sex practices, vision and hearing issues are not likely to be found here even if they might benefit patients who view the sites. Lastly, all of the sites netted by the search on these most popular search engines appear to be in North America and therefore, we cannot assume any of the results would generalize to Europe, Australia, or other parts of the world.