Real-World Effectiveness of Nirmatrelvir/Ritonavir on Coronavirus Disease 2019-Associated Hospitalization Prevention: A Population-based Cohort Study in the Province of Quebec, Canada.

BACKGROUND: Nirmatrelvir/ritonavir has shown to reduce COVID-19 hospitalization and death before Omicron, but updated real-world evidence studies are needed. This study aimed to assess whether nirmatrelvir/ritonavir reduces the risk of COVID-19-associated hospitalization among high-risk outpatients. METHODS: A retrospective cohort study of outpatients with SARS-CoV-2 between March 15 and 15 October 2022, using data from the Quebec clinico-administrative databases. Outpatients treated with nirmatrelvir/ritonavir were compared with infected ones not receiving nirmatrelvir/ritonavir using propensity-score matching. Relative risk (RR) of COVID-19-associated hospitalization within 30 days was assessed using a Poisson regression. RESULTS: A total of 8402 treated outpatients were matched to controls. Regardless of vaccination status, nirmatrelvir/ritonavir treatment was associated with a 69% reduced RR of hospitalization (RR: .31; 95% CI: .28; .36; number needed to treat [NNT] = 13). The effect was more pronounced in outpatients with incomplete primary vaccination (RR: .04; 95% CI: .03; .06; NNT = 8), while no benefit was found in those with a complete primary vaccination (RR: .93; 95% CI: .78; 1.08). Subgroups analysis among high-risk outpatients with a complete primary vaccination showed that nirmatrelvir/ritonavir treatment was associated with a significant decrease in the RR of hospitalization in severely immunocompromised outpatients (RR: .66; 95% CI: .50; .89; NNT = 16) and in high-risk outpatients aged ≥70 years (RR: .50; 95% CI: .34; .74; NNT = 10) when the last dose of the vaccine was received at least 6 months ago. CONCLUSIONS: Nirmatrelvir/ritonavir reduces the risk of COVID-19-associated hospitalization among incompletely vaccinated high-risk outpatients and among some subgroups of completely vaccinated high-risk outpatients.

Healthcare utilization after a first hospitalization for COPD: a new approach of State Sequence Analysis based on the '6W' multidimensional model of care trajectories.

BACKGROUND: Published methods to describe and visualize Care Trajectories (CTs) as patterns of healthcare use are very sparse, often incomplete, and not intuitive for non-experts. Our objectives are to propose a typology of CTs one year after a first hospitalization for Chronic Obstructive Pulmonary Disease (COPD), and describe CT types and compare patients' characteristics for each CT type. METHODS: This is an observational cohort study extracted from Quebec's medico-administrative data of patients aged 40 to 84 years hospitalized for COPD in 2013 (index date). The cohort included patients hospitalized for the first time over a 3-year period before the index date and who survived over the follow-up period. The CTs consisted of sequences of healthcare use (e.g. ED-hospital-home-GP-respiratory therapists, etc.) over a one-year period. The main variable was a CT typology, which was generated by a 'tailored' multidimensional State Sequence Analysis, based on the "6W" model of Care Trajectories. Three dimensions were considered: the care setting ("where"), the reason for consultation ("why"), and the speciality of care providers ("which"). Patients were grouped into specific CT types, which were compared in terms of care use attributes and patients' characteristics using the usual descriptive statistics. RESULTS: The 2581 patients were grouped into five distinct and homogeneous CT types: Type 1 (n = 1351, 52.3%) and Type 2 (n = 748, 29.0%) with low healthcare and moderate healthcare use respectively; Type 3 (n = 216, 8.4%) with high healthcare use, mainly for respiratory reasons, with the highest number of urgent in-hospital days, seen by pulmonologists and respiratory therapists at primary care settings; Type 4 (n = 100, 3.9%) with high healthcare use, mainly cardiovascular, high ED visits, and mostly seen by nurses in community-based primary care; Type 5 (n = 166, 6.4%) with high healthcare use, high ED visits and non-urgent hospitalisations, and with consultations at outpatient clinics and primary care settings, mainly for other reasons than respiratory or cardiovascular. Patients in the 3 highest utilization CT types were older, and had more comorbidities and more severe condition at index hospitalization. CONCLUSIONS: The proposed method allows for a better representation of the sequences of healthcare use in the real world, supporting data-driven decision making.

Pandemic Stringency Measures and Hospital Admissions for Eating Disorders.

Importance: Hospitalizations for eating disorders rose dramatically during the COVID-19 pandemic. Public health restrictions, or stringency, are believed to have played a role in exacerbating eating disorders. Few studies of eating disorders during the pandemic have extended to the period when public health stringency restrictions were lifted. Objective: To assess the association between hospitalization rates for eating disorders and public health stringency during the COVID-19 pandemic and after the easing of public health restrictions. Design, Setting, and Participants: This Canadian population-based cross-sectional study was performed from April 1, 2016, to March 31, 2023, and was divided into pre-COVID-19 and COVID-19-prevalent periods. Data were provided by the Canadian Institute for Health Information and the Institut National d'Excellence en Santé et Services Sociaux for all Canadian provinces and territories. Participants included all children and adolescents aged 6 to 20 years. Exposure: The exposure was public health stringency, as measured by the Bank of Canada stringency index. Main Outcomes and Measures: The primary outcome was hospitalizations for a primary diagnosis of eating disorders (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code F50), stratified by region, age group, and sex. Interrupted time series analyses based on Poisson regression were used to estimate the association between the stringency index and the rate of hospitalizations for eating disorders. Results: During the study period, there were 11 289 hospitalizations for eating disorders across Canada, of which 8726 hospitalizations (77%) were for females aged 12 to 17 years. Due to low case counts in other age-sex strata, the time series analysis was limited to females within the 12- to 17-year age range. Among females aged 12 to 17 years, a 10% increase in stringency was associated with a significant increase in hospitalization rates in Quebec (adjusted rate ratio [ARR], 1.05; 95% CI, 1.01-1.07), Ontario (ARR, 1.05; 95% CI, 1.03-1.07), the Prairies (ARR, 1.08; 95% CI, 1.03-1.13), and British Columbia (ARR, 1.11; 95% CI, 1.05-1.16). The excess COVID-19-prevalent period hospitalizations were highest at the 1-year mark, with increases in all regions: Quebec (RR, 2.17), Ontario (RR, 2.44), the Prairies (RR, 2.39), and British Columbia (RR, 2.02). Conclusion and Relevance: In this cross-sectional study of hospitalizations for eating disorders across Canada, hospitalization rates for eating disorders in females aged 12 to 17 years were associated with public health measure stringency. The findings suggest that future pandemic preparedness should consider implications for youths at risk for eating disorders and their resource and support needs.

Mental Health Hospitalizations in Canadian Children, Adolescents, and Young Adults Over the COVID-19 Pandemic.

Importance: The COVID-19 pandemic resulted in multiple socially restrictive public health measures and reported negative mental health impacts in youths. Few studies have evaluated incidence rates by sex, region, and social determinants across an entire population. Objective: To estimate the incidence of hospitalizations for mental health conditions, stratified by sex, region, and social determinants, in children and adolescents (hereinafter referred to as youths) and young adults comparing the prepandemic and pandemic-prevalent periods. Design, Setting, and Participants: This Canadian population-based repeated ecological cross-sectional study used health administrative data, extending from April 1, 2016, to March 31, 2023. All youths and young adults from 6 to 20 years of age in each of the Canadian provinces and territories were included. Data were provided by the Canadian Institute for Health Information for all provinces except Quebec; the Institut National d'Excellence en Santé et en Services Sociaux provided aggregate data for Quebec. Exposures: The COVID-19-prevalent period, defined as April 1, 2020, to March 31, 2023. Main Outcomes and Measures: The main outcome measures were the prepandemic and COVID-19-prevalent incidence rates of hospitalizations for anxiety, mood disorders, eating disorders, schizophrenia or psychosis, personality disorders, substance-related disorders, and self-harm. Secondary measures included hospitalization differences by sex, age group, and deprivation as well as emergency department visits for the same mental health conditions. Results: Among Canadian youths and young adults during the study period, there were 218 101 hospitalizations for mental health conditions (ages 6 to 11 years: 5.8%, 12 to 17 years: 66.9%, and 18 to 20 years: 27.3%; 66.0% female). The rate of mental health hospitalizations decreased from 51.6 to 47.9 per 10 000 person-years between the prepandemic and COVID-19-prevalent years. However, the pandemic was associated with a rise in hospitalizations for anxiety (incidence rate ratio [IRR], 1.11; 95% CI, 1.08-1.14), personality disorders (IRR, 1.21; 95% CI, 1.16-1.25), suicide and self-harm (IRR, 1.10; 95% CI, 1.07-1.13), and eating disorders (IRR, 1.66; 95% CI, 1.60-1.73) in females and for eating disorders (IRR, 1.47; 95% CI, 1.31-1.67) in males. In both sexes, there was a decrease in hospitalizations for mood disorders (IRR, 0.84; 95% CI, 0.83-0.86), substance-related disorders (IRR, 0.83; 95% CI, 0.81-0.86), and other mental health disorders (IRR, 0.78; 95% CI, 0.76-0.79). Conclusions and Relevance: This cross-sectional study of Canadian youths and young adults found a rise in anxiety, personality disorders, and suicidality in females and a rise in eating disorders in both sexes in the COVID-19-prevalent period. These results suggest that in future pandemics, policymakers should support youths and young adults who are particularly vulnerable to deterioration in mental health conditions during public health restrictions, including eating disorders, anxiety, and suicidality.

[Portrait of the use of mental health services before and after a suicide attempt requiring hospitalization]. / Portrait du recours aux services de santé mentale avant et après une tentative de suicide qui requiert une hospitalisation.

Health care systems play an important role in suicide prevention. Medical and administrative data allow analysis of patterns of mental health service use before and after hospitalization following a suicide attempt among Montreal residents diagnosed with schizophrenia or depression. Some results tend to show improvement in suicide prevention, especially among men with comorbid substance abuse disorders known to be particularly vulnerable. However, other observations are somewhat worrisome. The emergency room as an introduction to mental health services did not ensure adequate aftercare. Interventions are needed to improve access and coordination between different health care services.

Doctor shopping among chronic noncancer pain patients treated with opioids in the province of Quebec (Canada): incidence, risk factors, and association with the occurrence of opioid overdoses.

INTRODUCTION: Prescription opioids continue to be involved in the opioid crisis, and a better understanding of factors associated with problematic opioid use is needed. OBJECTIVES: The aim of this study was to assess the incidence of opioid doctor shopping, a proxy for problematic opioid use, to identify associated risk factors, and to assess its association with the occurrence of opioid overdoses. METHODS: This was a retrospective cohort study of people living with chronic noncancer pain (CNCP) and treated with opioids for at least 6 months between 2006 and 2017 in the province of Quebec (Canada). Data were drawn from the Quebec health administrative databases. Doctor shopping was defined as overlapping prescriptions written by ≥ 2 prescribers and filled in ≥3 pharmacies. RESULTS: A total of 8,398 persons with CNCP were included. The median age was 68.0 (Q1: 54; Q3: 82) years, and 37.1% were male. The 1-year incidence of opioid doctor shopping was 7.8%, 95% confidence interval (CI): 7.2-8.5. Doctor shopping was associated with younger age (hazard ratio [HR] 18-44 vs ≥65 years: 2.22, 95% CI: 1.77-2.79; HR 45-64 vs ≥65 years: 1.34, 95% CI: 1.11-1.63), male sex (HR = 1.20, 95% CI: 1.01-1.43), history of substance use disorder (HR = 1.32, 95% CI: 1.01-1.72), and anxiety (HR = 1.41, 95% CI: 1.13-1.77). People who exhibited doctor shopping were 5 times more likely to experience opioid overdoses (HR = 5.25, 95% CI: 1.44-19.13). CONCLUSION: Opioid doctor shopping is a marginal phenomenon among people with CNCP, but which is associated with the occurrence of opioid overdoses. Better monitoring of persons at high risk to develop doctor shopping could help prevent opioid overdoses.

[Databank use and issues in mental health and addiction services]. / Utilisation et enjeux des données clinico-administratives dans le domaine de la santé mentale et de la dépendance.

Clinical-administrative databanks are a key tool in support of public health decision-making. A number of databanks are available relevant to population needs, resources available, as well as performance indicators. Since the 2000s, considerable efforts have been dedicated to the consolidation of findings and development of tools aimed at improving surveillance with respect to the health status of populations and performance of the social and healthcare system. At the annual congress of the Association francophone pour le savoir (ACFAS), held in 2017 at McGill University, a seminar was organized on the utilization of databanks in mental health and in addiction. This seminar featured an expert discussion on subjects related to: identification of the principal clinical-administrative databanks, the extent of their use, their limitations, and solutions aimed at optimizing the development of databanks to better support the management of services. This article summarizes the content of this seminar. While databanks entail important strengths, including great potential for the generalization of information, they also present limitations regarding their capacity to respond to needs, quality and validation issues, as well as accessibility. Various recommendations were proposed to improve the management of databanks and optimize their impact, including their centralization in a single, and highly accessible autonomous organism, and societal and cultural change favoring performance evaluation in the interest of improving practices and better monitoring health results.

Geographic information systems (GIS) in the health field: an opportunity to bridge the gap between researchers and administrators.

This article starts by presenting some of the difficulties encountered by researchers and administrators in trying to work together. It then assesses the importance of the notion of territory in the planning and organization of health services. Last, the article presents the work achieved by the Agence de la santé de Montréal, where geographic information systems have contributed to bringing research and the field closer together.

Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France.

AIMS: To evaluate the associations between methadone and high-dose buprenorphine maintenance treatment and illicit drug use and injection among drug users in France. DESIGN: A cross-sectional study. Data were gathered using a questionnaire administered containing closed-ended questions. SETTING: Drug dependence clinics (DDC) and general practitioners' (GPs) offices in three French cities. PARTICIPANTS: Drug users undergoing maintenance treatment with methadone (n = 197) and buprenorphine (n = 142). MEASUREMENTS: Interviews covered the use of illicit drugs (heroin, cocaine or crack) and injection practices (illicit drugs and/or substitution drugs) during the last month, current treatment modalities, socio-demographic and health characteristics. Bivariate analysis and multivariate logistic regressions were conducted. FINDINGS: Overall, 35.4% of respondents (34.5% in the methadone group, 36.6% in the buprenorphine group, P= 0.69) had used at least one illicit drug, 25.7% reported having injected drugs and 15.3% had injected the substitution drug. Injection was more common among buprenorphine-maintained individuals (40.1%) than among users on methadone (15.2%) (P < 0.01). Multivariate analyses indicate that the type of substitution drug (buprenorphine versus methadone) was not associated with illicit drug use (OR = 1.1; 95% CI = 0.7-1.8). In the buprenorphine group, injection was related independently to social situation, as measured by housing (unstable versus stable housing, OR = 4.3; 95% CI = 1.6-11.5), but this was not the case in the methadone group. The risk of injection increased with buprenorphine dosage (high/low dosage OR = 6.2; 95% CI = 2.0-19.7), but this association was not observed in the methadone group. CONCLUSION: Further studies comparing the benefits of these two types of treatment should be carried out, taking outcomes such as physical health, mental health and social functioning into consideration.

The dental care pathway of welfare recipients in Quebec.

IN Quebec (Canada), the utilization of dental care services varies greatly from one social class to another: whereas the well-to-do visit the dentist often for check-ups, those most in need demonstrate a "wait-and-see" attitude. The objective of our research was to describe the dental care pathway of the underprivileged when confronted with symptoms, and to understand how this pathway might be interrupted and possibly lead to tooth extractions. We arranged 16 one-on-one interviews with adult Montrealers who had experienced a dental problem during the 12 months preceding the interview. These participants, 9 women and 7 men aged between 30 and 48, lived in great poverty: all were welfare recipients, and as such, enjoyed the benefits of a government programme that entitled them to free basic dental care. During the interviews, the interviewers asked the participants to describe their latest dental problem and their subsequent behaviour. The dental care pathway of our participants was characterized by a strategy of adapting to the symptoms. This process of adapting, which can last several months, is essentially an individual process in which the individuals often resort to self-medication to soothe their pain. They decide to visit a dentist when the pain is too great and self-medication is no longer effective. Once this decision is made, their dental care pathway may nevertheless be interrupted in two ways: first, in the failure to find a dentist, and second, later, in the failure to complete treatments that are not covered by the welfare program, such as endodontic treatment. The fragmented character of these dental care pathways refers us to two features of accessibility: financial accessibility and acceptability. With regard to financial accessibility, our study shows that the public coverage intended for welfare recipients presents major gaps. As for acceptability, our participants are strongly critical of the dental profession, and develop a culture of rejection of it.

[Utilization of preventive dental services by recent immigrants in Quebec]. / Utilisation des services dentaires de façon préventive par les mères immigrantes au Quèbec.

OBJECTIVES: Studies conducted in Canada show that recent immigrants tend to under-utilize preventive services provided by the health care system. The objective of our study was to learn whether this phenomenon also applies to dental care. METHODS: Our sample was composed of 5,795 women who live in Quebec and are between 30 and 44 years old. These women filled out a self-administered questionnaire regarding their immigration status and their habits concerning dental visits. In our analyses, we compared the use of dental services of recent immigrants (10 years or less in Canada), long-term immigrants (more than 10 years), and non-immigrants (Canadians of origin). RESULTS: 55% of recent immigrants are preventive service users compared to 69% of long-term immigrants and 76% of non-immigrants. The financial barrier partly explains this result: immigrants often have a modest income and rarely benefit from dental coverage. However, having private dental insurance does not in itself explain the gap between these groups. This suggests that there is a cultural barrier in dental services access. CONCLUSIONS: Under-use of preventive services by immigrants is not limited to the medical field, it extends to dental services as well. In order to facilitate immigrants' adaptation to the health system, we recommend that the government provide them with free dental services that respect their culture.

[Knowledge and perceptions of adolescents regarding oral health]. / Connaissances et perceptions des adolescents face à la santé dentaire.

OBJECTIVE: The objective of this study was to measure knowledge and perception related to oral health in Quebec children. METHOD: For this study, a provincial sample of Quebec adolescents, 13 to 14 years old, was set up. Adolescents answered a 46-item questionnaire, specifically designed for the study. The questionnaire was completed by over 1,300 adolescents (participation rate = 53.0%). RESULTS: The answers indicate that adolescents know the importance of toothbrushing and dental services utilization for dental caries prevention. However, their knowledge about dental sealant and fluoride is inadequate. Teenagers believe that they have a significant role to play in the prevention of dental diseases. However, many adolescents consider tooth loss to be a normal consequence of age. The majority of adolescents report their oral health as good. It is noted that dental aesthetics is a more significant factor for them than the quality of their teeth. Finally, dental care is a source of anxiety in one third of the adolescents. CONCLUSION: The study of teenagers' knowledge and perceptions related to oral health shows that these elements are strongly influenced by environment, norm and culture. To improve dental health concerns in teenagers, public health policies should concentrate on these elements.

Dental care pathway of Quebecers after a broken filling.

OBJECTIVES: The objectives were to 1) describe the dental care pathway of adults after sustaining a broken filling, and particularly, the patient delay in seeking care as well as the continuity of care, and 2) identify factors associated with the decisions taken. BASIC RESEARCH DESIGN: In 1998-99, 5,469 Quebec women aged 30 to 44 years completed a self-administered questionnaire in which they indicated whether they had experienced a dental problem in the previous 12 months. From then on, the questions identified the decisions they made during the process of consulting a dentist. RESULTS: 32.4% of the respondents had experienced a dental problem within the last 12 months. Among them, 38.0% reported a broken filling. 65.1% of those who identified a broken filling decided immediately to consult a dentist and 34.9% chose to wait and see. Patient delay was over one month in 44.0% of the cases. When asked by the dentist to come back in order to complete the treatment. 90.6% agreed, 3.2% decided to consult another dentist, and 6.21% chose not to consult. Logistic regression analyses show that patient delay was associated with low income, low degree of inconvenience (symptoms), low degree of perceived seriousness, and absence of a family dentist. CONCLUSIONS: This study reveals important social disparities: after sustaining a broken filling, which remains an important problem in industrialised societies, patient delay, interruption of the dental care episode and extraction are more frequent in low-income groups. It also reveals that a wait-and-see attitude is more frequent than an interruption of the dental care episode after the first visit.

Parental factors associated with regular use of dental services by second-year secondary school students in Quebec.

The aim of this study was to identify the parental factors associated with regular use of dental services by second year secondary school students in Quebec. Data were collected in 1996-97, as part of a provincial survey on the dental health of Quebec students. A stratified probabilistic sample of 1,351 students, representative at the provincial level, was obtained. Data about frequency of use of dental services, parents' socio-economic characteristics, dental insurance (private and public) and parents' utilization of dental services were selected for this study. Half of the students used dental services regularly (i.e., once every 6 months). Multivariate analysis showed that the strongest parental factors associated with regular use were (in decreasing order of importance) the date of the mother's most recent dental visit, dental insurance, household income and the date of the father's most recent dental visit. After adjustment for the parents' socio-economic characteristics and the availability of dental insurance, students with one parent (particularly the mother) who had visited the dentist within the previous year had better odds of using dental services every 6 months, as recommended by professional standards.

Service utilization by hospitalized suicide attempters with schizophrenia or depression in Montreal.

OBJECTIVE: The purpose of this study was to analyze patterns of mental health-related service utilization before and after hospitalization for attempting suicide. METHODS: This retrospective cohort study included all persons 15 years or older with a clinical diagnosis of schizophrenia (N=195) or depression (N=330) hospitalized in Montreal, Quebec, from April 2003 to December 2004 for attempting suicide. Data on the publicly managed health and social services system were retrieved from the linked administrative databases of Montreal's Health and Social Services Agency (April 2002 to March 2005). Twelve-month preattempt service utilization profile, health care contacts three months pre- and postattempt, and predictors of postattempt service utilization were analyzed for two diagnostic groups (schizophrenia and depression). RESULTS: Specialized outpatient care and hospital emergency departments were the services most used by both groups before and after attempting suicide. Use of hospital emergency services as a primary care service did not adequately ensure aftercare, whereas prior contact with services and concurrent substance use disorder predicted greater service utilization postattempt among men but not women. CONCLUSIONS: The publicly managed health and social services system in Montreal seems to respond rather well to severe suicide attempts, including those by men with a concurrent substance use disorder known to be at high suicide risk. However, better coordination among hospital emergency departments, primary care, specialized mental health services, and addiction services is needed in order to enhance continuity of care.

Associations between school deprivation indices and oral health status.

BACKGROUND: Despite an overall improvement in oral health status in several countries over the past decades, chronic oral diseases (COD) remain a public health problem, occurring mostly among children in the lower social strata. The use of publicly available indicators at the school level may be an optimal strategy to identify children at high risk of COD in order to organize oral health promotion and intervention in schools. OBJECTIVE: To investigate whether school deprivation indices were associated with schoolchildren oral health status. METHODS: This ecological study used a sample of 316 elementary public schools in the province of Quebec, Canada. Data from two sources were linked using school identifiers: (i) Two school deprivation indices (in deciles) from the Ministry of Education, a poverty index based on the low income cut-offs established by Statistics Canada and a socioeconomic environment index defined by the proportions of maternal under-schooling and of unemployed parents and (ii) Oral health outcomes from the Quebec Schoolchildren Oral Health Survey 1998-99 aggregated at the school level. These included proportions of children with dental caries and reporting oral pain. The relation between school deprivation indices and oral health outcomes was assessed with linear regression for dental caries experience and logistic regression for oral pain. RESULTS: The mean DMF-S (mean number of decayed, missing and filled permanent teeth surfaces) by school was 0.7 (SD = 0.5); the average proportions of children with dental caries and reporting oral pain were 25.0% and 3.0%, respectively. The poverty index was not associated with oral health outcomes. For the socioeconomic environment index, dental caries experience was 6.9% higher when comparing schools in unfavourable socioeconomic environments to the most favourable ones [95% confidence interval (CI): 2.1, 11.7%]. Furthermore, the most deprived schools, as compared to least deprived ones, were almost three times as likely to have children reporting oral pain in the previous week. CONCLUSION: The school socioeconomic environment index was associated with oral health outcomes, and should be studied for its potential usefulness in planning school-based oral health promotion and screening strategies.

Shortcomings of health information on the Internet.

Disseminating health and medical information on the Internet can improve knowledge transfer from health professionals to the population, and help individuals to maintain and improve their health. There are currently several medical information websites that directly target the general population with the aim of providing information about health problems, self-care and prevention. However, this new technology also hides several shortcomings, such as: (i) uneven quality of medical information available on the Internet; (ii) difficulties in finding, understanding and using this information; (iii) lack of access for the unconnected population; and (iv) the potential for harm and risks of over-consumption. To be able to overcome these dangers, it is important that public health practitioners and health professionals be involved in the design, dissemination and evaluation of Web-based health and medical information.