research on internet safety

New Microsoft research illustrates the online risks and value of safety tools to keep kids safer in the digital environment

Feb 6, 2023 | Courtney Gregoire - Chief Digital Safety Officer

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Tomorrow is international Safer Internet Day , a global event bringing people together to create a safer internet. For the past six years, Microsoft has taken this opportunity to advocate for digital civility – treating those we meet online with dignity and respect – and released research to help better understand peoples’ online experiences. This year, we’ve evolved our research and we’re pleased to release our new Global Online Safety Survey 2023: Parents’ and Kids’ Perceptions of Online Safety as part of our contribution to making the internet a safer place to work, play and engage with others.

Our 2023 survey found that 69% of people surveyed had experienced an online risk in the last year. The most common risks encountered globally were misinformation and disinformation, and personal risks (including cyberbullying, hate speech and threats of violence). Respondents in the UK (50%) and Germany (56%) were least likely to experience an online risk, while respondents in the Philippines (86%) and Chile (79%) were most likely to experience an online risk.

Parents underestimate online risks to teens in every category

The research found that teens experienced online risks at a higher rate than parents believed: 74% of teens reported experiencing an online risk, whereas 62% of parents believed their teen had encountered a risk online – a 12-point difference.

We also found that parents not only underestimated the risks – but did so in every category. The biggest gaps pertained to hate speech, closely followed by threats of violence, exposure to suicide and self-harm content, and cyberbullying and abuse. For example, 39% of teens reported experiencing hate speech online while only 29% of parents reported their teen having such an experience.  Some 19% of teens experienced a threat of violence while only 11% of parents reported the same.

Teens also worry more about threats of violence in the future than do parents.

After experiencing an online risk 60% of teens talked to someone about it: 71% of those teens talked to their parents; 32% talked to friends; and 14% talked to another adult who wasn’t their parent.

Parents use safety tools because they believe they keep their kids safer online

Most parents report taking action to keep their kids safer online – including checking their children’s profiles and posts, receiving activity reports and regularly talking to their children about their online activities. This year’s research showed that parents generally viewed safety features as effective tools to help keep their children safe online, and 81% of parents report using at least one. Parents of younger children ages 6-12 were much more likely than parents of teens to use platform-based safety tools and used 4.4 tools compared to parents of teens (3.5). Tools that enabled parents to review friend/follow requests (71%) and limits to online spending (69%) were believed by parents to be most effective.

Microsoft’s commitment to digital safety

At Microsoft, we have a longstanding commitment and multifaceted approach to child online safety and this research shows us that we all – tech companies, governments, civil society and families – need to continue to work together for a better internet.

We remain committed to advancing digital safety across four pillars: platform architecture; content moderation; culture; collaboration. We know that safety by design is key to platform architecture, as well as building in safety features for families. And having clear safety policies coupled with consistent, proportionate action to enforce those policies is paramount to protecting users. Survey respondents overwhelmingly agree, with 85% expecting content moderation for illegal content (28%), and illegal and harmful content (57%).

Empowering users to create safe and inclusive online communities enables all to more fully participate in digital environments.  That includes helping people understand the risks they may face online and ways in which people can protect themselves and their families.

Finally, multistakeholder collaboration remains critical to tackling the intersection of real-world and digital harms. That’s why we were proud to join France’s President Macron and the Childhood Online Protection Laboratory launched at the Paris Peace Forum in November 2022, and why we will continue to work with policymakers and others around the world to shape effective, proportional responses to help make the internet a safe space for everyone.

We understand that many parents are looking for educational resources and guidance to help them customize the online safety experiences for their families, and are pleased to provide the following:

• Global survey results and tips for teens and parents
• Resource for families to setup a child account on Xbox and information for families for privacy and safety
• Empowers families to create healthy habits and protect them with digital and physical safety guidance and tools
• Manage children’s gaming console gaming activities
• Xbox’s evolving approach to safety, the new Privacy Prodigy from Minecraft Education, and tips and tools that parents can use with their families to play on Xbox

We also know that gaming can be an invaluable tool for learning, so this Safer Internet Day, Minecraft: Education Edition is releasing an immersive game-based learning adventure, Privacy Prodigy , for students ages 7-18. Players will take on the challenge of protecting their data as they venture further from home. They will be faced with scenarios that help them learn about the personal information that can be shared and what should be kept private. Privacy Prodigy is a continuation of the CyberSafe series introduced last year with Home Sweet Hmm , and will be available for free for both Minecraft Education and in the Marketplace.

Research methodology

This research was conducted using a web survey of over 16,000 parents, teens and other adults throughout 16 countries. [1] Parents were asked to respond about their child’s experiences. All participants were asked questions about their perceptions of life online and experience of 10 different risks, across five broad risk categories. The following are some key trends from this year’s research – you can find a summary along with country-specific data here.

[1] Canada, United States, Mexico, Columbia, Peru, Brazil, Chile, Argentina, United Kingdom, France, Germany, Italy, India, Philippines, Singapore, Australia. At least 1,000 interviews were conducted in each country, including 500 each among teens and adults.

Tags: digital safety , Global Online Safety Survey , Online Safety

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Reports of cyberbullying in public schools have risen over the past decade. During the 2019–2020 school year, 16% of public schools reported cyberbullying occurring among students at least once a week. In comparison, 8% of schools noted cyberbullying issues during the 2009–2010 school year, according to the Report on Indicators of School Crime and Safety: 2022 .

Research supported by the National Institute of Justice found that school-based programs specifically designed to prevent or curb cyberbullying are better at reducing cyberbullying than general anti-bullying programs.

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Related Information:

Internet safety research.

• Bark's Annual Report: 2022 Research on Kids and Technology
• Overuse of devices and social media top parent concerns (C.S. Motts Children's Hospital, August 21, 2023)
• AFRAID, UNCERTAIN, AND OVERWHELMED: A Survey of Parents on Online Sexual Exploitation of Children
• Online Grooming: Examining risky encounters amid everyday digital socialization (Thorn, April 2022)
• Annual Report: 2021 Research on Kids and Technology | Bark
• Managing the Narrative Young People’s Use of Online Safety Tools (Family Online Safety Institute, November 2021)
• Tools for Today’s Digital Parents The role of parental controls in the digital lives of American parents and children . (Family Online Safety Institute, November 2020)
• Essential Facts About the Video Game Industry (Entertainment Software Association, 2020) 
• Association of Screen Time and Depression in Adolescence   (JAMA Pediatrics. Published online July 15, 2019)
• Online Safety Across the Generations - Executive Summary (Family Online Safety Institute, 2018)
• Global Kids Online: Research Synthesis 2015-2016
• Keeping Up with Generation App: NCSA Parent/Teen Online Safety Survey - National Cyber Security Alliance (June 2016)
• C.S. Mott Children's Hospital National Poll on Children's Health (2014).
• 2014 Teen Internet Safety Survey (Cox Communications, 2014)
• Youth Internet Safety: Risks, Responses, and Research Recommendations (Center for Technology Innovation at Brookings, October 2014)
• In Their Own Words:What Bothers Children Online? (EU Kids Online, February 2013)
• Anonymity, Privacy, and Security Online (Pew Internet & American Life Project, September 2013)
• Study of Self - Generated Sexually Explicit Images & Videos (International Watch Foundation, 2012)
• McAfee and NCSA Cyber Security Study (November, 2011)
• Who Needs Parental Controls?: A Survey Of Awareness, Attitudes, And Use Of Online Parental Controls (Hart Research Associates, Family Online Safety Institute, September 2011)
• Teens and Mobile Phones: Exploring Safety Issues as Mobile Phones Become the Communications Hub for American Teens (Pew Internet & American Life Project, November 9, 2010)
• Adolescence, Mobile Technology & Culture (Pew Internet & American Life Project, November 8, 2010)
• Use of Social Networking Sites in Online Sex Crimes Against Minors: An Examination of National Incidence and Means of Utilization(http://www.jahonline.org/article/S1054-139X (Journal of Adolescent Health, Volume 47, Issue 2, Pages 183-190, August 2010)
• Millennials will make online sharing in networks a lifelong habit (Pew Internet & American Life Project, July 9, 2010)
• The Secret Lives of Online Teens (McAffee, June 24, 2010)
• Teens and Mobile Phones (Pew Internet & American Life Project, April 20, 2010)
• Generation M2: Media in the Lives of 8- to 18-Year-Olds (A Kaiser Family Foundation Study, January 2010).
• Sex & Tech: Results from a Survey of Teens and Young Adults (The National Campaign to Prevent Teen and Unplanned Pregnancy with CosmoGirl.com, January, 2009)
• Enhancing Child Safety and Online Technologies: Final Report of the Internet Safety Technical Task Force to the Multi-State Working Group on Social Networking of State Attorneys General of the United States (Internet Safety Technical Task Force, Berkman Center for Internet & Society at Harvard University, December, 2008).
• 2008 National Cyberethics, Cybersafety, and Cybersecurity Baseline Study (Davina Ptuitt-Mentle, Ph.D., Educational Technology, Policy, Research and Outreach, October, 2008)
• Teens Viewing Drug and Alcohol-Related Videos Online (Custom Study for the Office of National Drug Control Policy, Nielson Online, October, 2008)
• Study of the Internet and Youth "At Risk Behaviors" (Rochester Institute of Technology, September, 2008)
• Cox Communications Teen Internet Safety Survey, Wave II--in Partnership with the National Center for Missing and Exploited Children and John Walsh (2007)

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Trends in Internet Safety Education by Healthcare Providers

Introduction.

The purpose of this study was to explore healthcare provider training, comfort, and provision of internet safety counseling. Prior research has demonstrated increased parental concern regarding the pervasive access to the internet by children, including the potential impacts of risky internet behavior and adverse media exposure.

A self-reported survey was provided to a convenience sample of 31 healthcare providers during a mental health training seminar. Responses were analyzed using descriptive statistics.

Internet safety counseling, especially regarding risky online behavior, was not a focal point of provider-patient interaction in the sample population. This finding was reinforced with more than half of the respondents indicating that they infrequently or never provide internet safety counseling (n = 17, 56%). While research has placed an emphasis on the importance of discussing the risks of exposure to violence, drugs, and sexually explicit media online, this study found that the topics most often discussed were setting time limits (77%), limiting access to media devices (67%), and supervising internet use (50%). This may be due in part to the fact that most respondents (n = 17, 57%) reported never receiving training on internet safety counseling.

Conclusions

Overall, significant deficits were identified in internet safety counseling training for professionals and provision of education for families. These finding were inconsistent with the American Academy of Pediatrics recommendations around media use counseling and a point of urgent concern given the increasing time spent on media devices, particularly during the COVID pandemic.

INTRODUCTION

Internet access is nearly ubiquitous to American youth with access becoming virtually unlimited through mobile devices. The COVID pandemic has encouraged social distancing, and as a result, children’s access to the internet is becoming increasingly pervasive. As of 2015, 92% of adolescents go online daily. 1 , 2 Approximately 75% of adolescents own a smart phone with 25% reporting they are online “almost constantly”. In addition, 76% of adolescents maintain at least one social media profile. This prevalence is not only relevant in adolescent youth. Nearly all homes with small children (98%) own a mobile device, an increase from 75% in 2013 and 52% in 2011. 3 Further, 50% of five-year-old children go online daily and nearly 75% of four-year-old children have their own mobile device. 4 , 5 Although data were lacking on media use during the COVID pandemic, these prior statistics supported the American Academy of Child and Adolescent Psychiatry’s (AACAP) concern that quarantined youth have unprecedented access to potentially harmful media content and that risk needs to be mitigated. 6

Parents were concerned about potential adverse impacts of the internet on their children, most notably the impact of exposure to violent and sexual content. 7 Parental concerns were placed appropriately given research has shown poor outcomes of child exposure to risky behaviors. Specifically, children who consume media rich in alcohol advertisements were more likely to initiate use. 8 – 10 The same influential effect has been shown for sexually explicit media, including pornography. 11 , 12 These risks can be applied to other online safety concerns such as cyberbullying and increased risk of suicidal ideation. 13 To mitigate these risks, trusted adults need to engage in conversation with youth emphasizing media safety. 14 , 15 Taken together, parental mediation of media use has been shown to decrease risky behaviors. 16 , 17 More than ever, parents should be intentional about helping youth develop positive media habits. This can be done by modeling healthy behaviors, setting limits, and co-viewing. 7

In addition to parents, healthcare providers play an important role in delivering internet safety education to youth. 15 , 18 , 19 Parents trust healthcare providers to provide appropriate recommendations for the health and well-being of their children. The American Academy of Pediatrics (AAP) has released a policy statement, “Media Use in School-Aged Children and Adolescents”, outlining best practices for parents and pediatric healthcare providers. 18 This statement included information on the AAP’s Family Media Plan, which can be an asset to parents during quarantine as well as non-quarantine times. Healthcare providers have a unique opportunity to support parents in providing resources and anticipatory guidance on internet safety. Despite this policy statement, only one in five parents were aware of the AAP’s recommendation, indicating a gap in communication between parents and pediatric healthcare providers. Although pediatricians have been tasked with educating parents on this topic, to what extent this happens remained unclear.

Three study objectives were investigated:

• To explore the extent and type of counseling provided by healthcare providers on internet safety.
• To explore the type and extent of training that healthcare providers have received on internet safety, their comfort level, and barriers to providing counseling.
• To determine if internet safety counseling differs between provider demographic groups.

Prior to engaging in the study, Institutional Review Board approval was obtained through University of Kansas School of Medicine-Wichita Human Subjects Committee. An anonymous, self-reported, 14-item survey was developed to capture information related to healthcare provider demographics, training, and experience with internet safety counseling. Prior to use, the survey was reviewed by an expert panel for readability.

Healthcare providers attending a local mental health training seminar in late 2018 were asked to participate in this study. Participation was voluntary, informed consent was obtained, and no incentives were provided. Participants included community and academic physicians, resident physicians, and physician extenders (i.e., nurse practitioners, physician assistants) who provide primary care to children. Non-practicing healthcare providers and providers who do not serve children were excluded from the study.

Data were entered into the encrypted and HIPAA compliant REDCap ® online data capture application. Descriptive statistics were calculated from the database.

Of 31 potential participants, a total of 30 (n = 30, 97%) completed the survey. Of the 30 respondents, most were pediatricians (n = 24, 80%), female (n = 21, 70%), and had been in practice for an average of 10.5 years (SD = 9.8; Table 1 ). The majority of providers characterized their practice as urban (n = 20, 67%), and cared for children in all age ranges (≥ 80%). The mean provider’s age was 42.3 years (SD = 9.9). Most providers reported having children of their own, with only 17% (n = 5) reporting they had no children. No statistically significant correlations were found between provider demographics and provider delivery of internet safety counseling.

Descriptive demographics of sample population.

Most providers (n = 17; 57%) reported having never received training on internet safety counseling. Of those who had received training (n = 13; 43%), independent study and informal training were most common, followed by in-person lectures, and online courses ( Table 2 ). Few reported the adequacy of their training as good and none as very good. Regardless of training, few respondents (n = 8; 27%) felt comfortable or very comfortable with their knowledge on internet safety. An equal amount (n = 8; 27%) of providers reported that they felt uncomfortable with their level of knowledge.

Physician training and practice on internet safety counseling.

The majority (n = 17; 57%) of respondents reported providing internet safety counseling during well child and adolescent visits infrequently or never. When counseling was provided, only 3% (n = 1) waited to initiate counseling until the patients started high school. Topics discussed most often by providers included setting time limits (n = 23; 77%), limiting access to media devices (n = 20; 67%), and supervising internet use (n = 15; 50%; Figure 1 ). Topics involving avoidance of risky internet behavior were discussed routinely by 37% (n = 11) of respondents and risks of adverse internet exposure were discussed only by 27% (n = 8).

Provider report of topics routinely discussed.

Ninety percent of respondents (n = 27) indicated time constraint as a barrier to providing internet safety counseling, followed by 47% (n = 14) having limited knowledge on the topic, 40% (n = 12) forgetting to provide counseling, and 30% (n = 9) having a lack of resources.

The results of this study demonstrated provider training, comfort, and delivery of internet safety counseling were less than optimal with over half of providers never or infrequently providing counseling. Only 20% of providers reported counseling most of the time. Parents have reported internet safety as a top concern, specifically regarding exposure to sexual and violent content, or risky internet behaviors. 3 , 7 While providers in this study reported discussing risky internet behaviors, the rates of these discussions were at lower frequency than other topics, such as setting time limits. This result illustrated a gap in care, as media topics that parents were most concerned about were being discussed infrequently by their child’s healthcare provider.

The optimal time for introduction of internet safety to children is not known. Nevertheless, many key stakeholders, including parents, adolescents, teachers, and healthcare providers agreed that internet safety counseling should be started at a young age, between six to eight years. 20 However, given the increasing prevalence of very young children accessing the internet regularly, 3 – 5 it would be prudent for internet safety education to be introduced with the onset of internet use. This study found only 13% of providers initiated conversations about internet safety with the parents of very young children, and 33% start during elementary school.

The AAP has recognized that pediatricians have an important role in providing guidance to patients and families regarding internet safety in their policy statement “Media Use in School-Aged Children and Adolescents”. 18 In this statement, the AAP emphasized the development and use of a personalized Family Media Use Plan that considers the child’s age, health, temperament, developmental stage, and individual needs. The use of this tool has been encouraged during the COVID pandemic. 20 This study found that the primary barriers to providing internet safety counseling center around time constraints and lack of provider knowledge on the topic. Increasing awareness of the important role providers have in mitigating risks associated with unsafe internet use may reduce these barriers. Providers should be offered resources and education on adverse media exposure, including ways to initiate discussions with families. Some authors suggested expanding the HEADS (Home; Education/Employment; Activities; Drugs/Depression/Diet; Sex/Suicide/Safety) psychosocial history-taking pneumonic as a useful tool to include elements of media use, thereby assisting providers to engage patients and families on discussions of internet safety. 21 , 22

The AAP’s policy statement has provided much of the educational background needed for providers to offer internet safety counseling, although some providers would benefit from more structured education modalities. 18 In short, the AAP recommended that families include the following components in their Family Media Use Plan in addition to traditional media recommendations: 1) how media is accessed, 2) where it is accessed, 3) when it is accessed, 4) how long the child is spending on media, 5) who they are interacting with both on- and off-line, 6) what is appropriate to share online, 7) what the child is accessing, 8) risks and avoidance of inappropriate content, 9) consequences of accessing inappropriate content, 10) how to respond to online attacks, and 11) parental role modeling of healthy internet use.

Limitations

This study had several limitations. First, the small sample size may limit the generalizability of these results to the larger pediatric healthcare community, however, sampled providers came from various regions of the state representing diversity in healthcare practices. Second, the study survey did not delineate providers’ levels of training (i.e., attending physician, resident physician, or physician extender) which may have affected training experience. In addition, age and level of training also may impact providers’ personal level of comfort with the internet and technology in general which may in turn impact their comfort providing internet safety education to patients. Third, the survey was conducted during a voluntary mental health training event which may introduce a sample bias of respondents interested in mental health, including internet safety. Finally, the COVID pandemic emerged during compilation of this manuscript. Although data were collected prior to the pandemic, it was perhaps more valuable given the increased access youth have during this time and supported that internet safety counseling should be a priority. Despite these limitations, provider training, comfort, and delivery of internet safety counseling were insufficient to meet current recommendations.

Future Research

This study examined the trends in internet safety counseling by a small cohort of healthcare providers, practicing in the midwestern part of the United States. The results of the study found that provider training, comfort, and provision of internet safety counseling below optimum. To determine if these trends were reflective of the greater population of healthcare providers caring for children, future studies designed to target a larger, multi-regional study population may qualify the seriousness of this problem better. With a larger sample, future studies may consider exploring the influence of provider demographic characteristics on training and practice of internet safety counseling.

CONCLUSIONS

Healthcare providers have a unique opportunity to support parents and children in providing resources and anticipatory guidance on internet safety. Nonetheless, significant deficits were identified in provider training, comfort, and provision of internet safety counseling for families. Further studies need to be performed to evaluate the significance of these findings on a wider scale. Providers need to be cognizant of their role in mitigating risk associated with unsafe media exposure by offering internet safety counseling to patients and their families.

ACKNOWLEDGEMENTS

We would like to thank the University of Kansas School of Medicine-Wichita Department of Pediatrics and The REACH Institute for allowing us to survey the attendees of their mental health seminar. We also acknowledge Dr. Julian Dedeaux for his assistance in bringing this manuscript to completion.

Internet Safety Technical Task Force

The Internet Safety Technical Task Force (ISTTF) is a group of Internet businesses, non-profit organizations, academics, and technology companies that have joined together to identify effective tools and technologies to create a safer environment on the Internet for youth. It was created in February 2008 in accordance with the Joint Statement on Key Principles of Social Networking Safety announced by the Attorneys General Multi-State Working Group on Social Networking and MySpace in January 2008. The scope of the ISTTF’s inquiry is to consider those technologies that industry and end users can utilize to keep children safe on the Internet, with the bulk of the Task Force's attention concentrated on issues concerning contact: preventing harmful contact with adults, preventing harmful contact with other minors (including cyber bullying and sexual predation), and identity theft. As time allows, we will also address two content areas: preventing access to inappropriate content and preventing illegal content (such as child pornography). The solutions to be considered will include a broad range of technology tools and services. The Task Force recognizes also the importance of other solutions -– such as social norms, law, policy, and market factors –- and will situate technology-based solutions within the context of these other types of solutions. The Task Force submitted its Final Report to the Attorneys General in December, 2008.

This project is sponsored in part by Newscorp/Myspace, MTV Networks/Viacom, Symantec, Turner Broadcasting, Loopt, Linden Lab, Microsoft, AOL, and AT&T.

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Youth and Media

Youth and Media (YaM) encompasses an array of research, advocacy, and development initiatives around youth (age 12-18) and digital technology.

Youth Internet Safety Education: Aligning Programs With the Evidence Base

Affiliations.

• 1 Crimes Against Children Research Center, University of New Hampshire, Durham, NH, USA.
• 2 Faculty of Education, Queensland University of Technology, Brisbane, Queensland, Australia.
• 3 The Net Safety Collaborative, Salt Lake City, UT, USA.
• PMID: 32242503
• DOI: 10.1177/1524838020916257

Background: This review critically examines the messages of youth internet safety education programs in the light of research about both the dynamics of internet dangers and the efficacy of youth prevention education.

Methods: Using terms "internet safety education" and "digital citizenship," a Google search identified 12 multi-topic safety programs. Review articles were identified via Google Scholar for six forms of online harm to youth that have been targeted by many of these programs: cyberbullying (19 articles); online sexual exploitation (23 articles); sexting (19 articles); online fraud, hacking, and identity theft (6 articles); online suicide and self-harm promotion (18 articles); and internet overuse or addiction (15 articles).

Findings: There appear to be mismatches between dynamics revealed in the research about internet harms and the messages emphasized in educational programs, particularly on the issues of sexual exploitation and sexting. Overall, the review literature also suggests major advantages to integrating internet safety into already well-established and evidence-based programs currently addressing related off-line harms, for example, programs focusing on general bullying, dating abuse, or sexual abuse prevention. The advantages stem from four factors: (1) the considerable overlap between online harms and similar off-line harms, (2) the apparent greater prevalence of off-line harms, (3) the evidence that the same risk factors lie behind both online and off-line harms, and most importantly, (4) the substantially superior evidence base for the longer standing programs developed originally around the off-line harms.

Keywords: cybersafety; digital citizenship; online safety; technology education.

Publication types

• Research Support, Non-U.S. Gov't
• Bullying* / prevention & control
• Citizenship
• Cyberbullying*
• Sex Offenses*

• Research article
• Open access
• Published: 05 June 2013

Internet safety education for youth: stakeholder perspectives

• Megan A Moreno 1 , 4 ,
• Katie G Egan 2 ,
• Kaitlyn Bare 1 ,
• Henry N Young 3 &
• Elizabeth D Cox 1  

BMC Public Health volume  13 , Article number:  543 ( 2013 ) Cite this article

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Metrics details

Internet use is nearly ubiquitous among US youth; risks to internet use include cyberbullying, privacy violations and unwanted solicitation. Internet safety education may prevent these negative consequences; however, it is unclear at what age this education should begin and what group is responsible for teaching this topic.

Surveys were distributed to key stakeholders in youth safety education including public school teachers, clinicians, parents and adolescents. Surveys assessed age at which internet safety education should begin, as well as experiences teaching and learning internet safety. Surveys of adults assessed willingness to teach internet safety. Finally, participants were asked to identify a group whose primary responsibility it should be to teach internet safety.

A total of 356 participants completed the survey (93.4% response rate), including 77 teachers, 111 clinicians, 72 parents and 96 adolescents. Stakeholders felt the optimal mean age to begin teaching internet safety was 7.2 years (SD = 2.5), range 2-15. Internet safety was regularly taught by some teachers (20.8%), few clinicians (2.6%) and many parents (40.3%). The majority of teachers, clinicians and parents were willing to teach internet safety, but all groups surveyed identified parents as having primary responsibility for teaching this topic.

Conclusions

Findings suggest agreement among key stakeholders for teaching internet safety at a young age, and for identifying parents as primary teachers of this topic. Clinicians have a unique opportunity to support parents by providing resources, guidance and support.

Peer Review reports

While the internet has provided adolescents with numerous benefits, including increased social support, academic enrichment and worldwide cross-cultural interactions, there are concomitant risks to internet use [ 1 – 8 ]. The American Academy of Pediatrics’ (AAP) recent report on children’s social media use describes specific risks such as privacy violations and cyberbullying [ 9 ]. A previous study found that one-third of adolescents had given their internet password to friends and one-fourth were unaware that content uploaded online cannot be permanently deleted [ 1 ]. Cyberbullying, or internet harassment, impacts up to a third of youth and has been linked to a variety of health concerns, some as serious as suicidal ideation [ 10 – 15 ]. In addition, adolescents frequently display personal and identifiable information about themselves on the internet. These details may include their home location, revealing photographs, or descriptions of sexual behavior and substance use [ 16 – 18 ].

Internet safety is highly salient for today’s youth as they spend up to 10 hours a day using various forms of media [ 8 , 19 , 20 ]. The ever-increasing popularity of social media, including websites such as Facebook and Twitter, have contributed to youth’s time investment in the internet [ 7 ]. The vast majority of adolescents have internet access and most report daily use [ 21 , 22 ]. Several organizations, including the AAP, have offered expert advice regarding internet safety, but an evidence-based approach to educate youth about the dangers of being online does not currently exist [ 23 ]. Further, data to guide decisions about the age at which such education should begin, and who would have primary responsibility for teaching this topic are incomplete.

An ideal approach for teaching internet safety would likely involve a person or group who could reach most children in order to provide widespread dissemination of this knowledge. An ideal candidate would also have experience teaching about the internet or related safety issues, and be willing to invest in teaching this topic. Given that most US youth and adolescents attend public school, a first possibility is public school teachers. However, it is unclear at what grades and in which school subjects this material could be integrated into existing curricula. A second possibility is child health providers such as pediatricians or family medicine physicians. The AAP social media report argues that “pediatricians are in a unique position” to provide internet safety education [ 9 ]. Several resources exist to guide pediatricians in these discussions, but it is unclear whether pediatricians are comfortable in these discussions. Previous work has suggested that pediatrician’s performance of adolescent health behavior screening and prevention counseling regarding health risk behaviors is quite low [ 24 , 25 ]. A third potential candidate is the parent of the adolescent. While adults’ use of online media such as social networking sites continues to rise, data regarding parents’ comfort or experience with teaching internet safety remains elusive [ 26 ]. While all three groups undoubtedly should play a role in online safety education, it remains unclear which group is seen as holding primary responsibility among these stakeholders.

The purpose of this study was to investigate views of key stakeholders on internet safety education, including school teachers, clinicians who see children and adolescents, parents of adolescents, and adolescents themselves. Our goals were to investigate at what age internet safety education should begin, and to identify a primary candidate to teach this topic.

This study was conducted between July 1, 2009 and August 15, 2011 and received IRB approval from the University of Wisconsin Human Subjects Committee.

Setting and subjects

Participants in this study included public school teachers, health care providers who see children and adolescents, parents of adolescents, and adolescents themselves. School teachers were recruited from a summer continuing education conference within a public school district. This district includes 4 elementary schools, one middle and one high school. Inclusion criteria limited participants to teachers who taught kindergarten through 12 th grade within that public school district. Clinicians were recruited at a yearly regional continuing medical education conference; inclusion criteria limited participants to physicians (MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), and nurses, all of whose practice included pediatric patients. Parents of adolescents were identified within a large general pediatric practice that includes 8 pediatric providers. Inclusion criteria for parents were that they had a child between the ages of 11 and 18 years. Adolescents (ages 11-18 years) were identified and recruited within this same large general pediatric practice. Most parents and teens were recruited as dyads. We did not exclude parents or teens who elected to participate in the study separately because we did not compare data between parents and teens.

Data collection and recruitment

In each recruitment setting, potentially eligible participants were approached by a research assistant. After explaining the study and obtaining consent, participants completed a paper survey. Survey respondents were provided a $5 gift card as compensation.

Survey design

The goals of the survey were to understand at what age internet safety education should begin, explore the experiences of adult participants in teaching online safety or the adolescents learning about this topic, and to identify a group who has primary responsibility for teaching this topic. Thus, we included all potential survey participants in the survey design process. Surveys were designed after a review of the literature and conversations with a panel of physicians, parents and researchers. Questions were pilot-tested first with a panel and then among teachers and adolescents. In the final survey items some words were modified to make the survey clear to all groups of participants. For example, among health care provider groups the question: “For how many years have you been in practice?” was changed for teacher groups to read: “For how many years have you been teaching?” All four surveys are included as Additional files 1 , 2 , 3 and 4 .

Data sources and variables

Participants provided demographic data including gender and age. Teachers were asked to disclose the grade levels they taught, subjects taught and years of teaching experience. Clinicians were asked to provide their training background (i.e. MD, NP), field of practice (Pediatrics, Family Practice) and years in practice. Parents provided their age, gender and the ages of their children. Adolescents were asked for their age, gender and grade in school.

Age to begin teaching internet safety

Teachers, clinicians, parents and adolescents were asked to provide at what age internet safety education should begin. An “other” option was presented for write-in answers.

Candidates to teach internet safety

In order to identify potential candidates to teach internet safety, participants were asked about previous experiences teaching or learning about internet safety. Then participants were asked for their own willingness to teach this subject and to identify an ideal primary candidate to teach this topic.

Experiences teaching internet safety

To describe experiences in providing internet safety education, teachers were asked how frequently they had ever taught internet safety education. Clinicians were asked how frequently they had ever counseled patients on this topic. Answer options included regularly, sometimes, never and never but plan to do so soon. Parents were asked about how frequently they talked with their child about internet safety: regularly, sometimes, never and never but plan to do so soon (Table  1 ).

Adolescents’ experiences learning about internet safety

Adolescents were asked ways in which they had learned about internet safety. A list of answer options was developed through review of the literature and the web and then piloted with several adolescents to ensure completeness. Answer options included learning from friends, siblings, parents, teachers and clinicians as well as learning by self-teaching. A write-in “other” option was also provided. Adolescents were allowed to choose all applicable answers from this list.

Willingness to teach internet safety

Teachers were asked whether or not they supported teaching internet safety education in public schools. Health care providers were asked whether or not they supported teaching internet safety education in provider offices (yes or no).

All groups, including teachers, clinicians, parents and adolescents were asked to select a candidate group whom they felt had primary responsibility for teaching internet safety to children and adolescents. Based on a review of current groups engaged in teaching this subject, answer options included churches, community groups, health care providers, law enforcement, parents and teachers. An “other” option was presented for write-in answers.

All statistical data analyses were conducted using STATA version 11.0 (Statacorp, College Station, TX). Descriptive statistics were calculated for survey responses. ANOVA was used to compare mean age to begin teaching between teachers, clinicians, parents and adolescents. Logistic regression was used to assess whether experience teaching internet safety was associated with years of career experience.

Participants

A total of 356 participants completed the survey (93.4% response rate), including 77 teachers, 111 clinicians, 72 parents and 96 adolescents. Teachers had an average of 14.8 (SD = 8.4) years of teaching experience. The subjects that teachers taught included: health, social studies, language arts/English, special education, health and technology/computer skills. Clinicians included 68 (61.3%) physicians, 16 (14.4%) nurse practitioners, 15 (13.5%) physician assistants and 8 (7.2%) nurses. Their practice background was mainly pediatrics (61.3%) and family practice (27.9%). Clinicians’ years of experience averaged 14.5 (SD = 10.1). Parents were 81% female. Adolescents were 62.5% female and had an average age of 15.1 (SD = 2.3). Please see Table  2 for further descriptive information.

The overall mean age at which stakeholders indicated for starting to teach internet safety was 7.2 years (SD = 2.5), range 2-15. Teachers reported that the average age at which internet safety should be taught was 6.9 years (SD = 2.1), while clinicians felt the average age to start teaching this topic should be 7.3 years (SD = 2.4). Parents felt that internet safety education should begin at age 6.6 years (SD = 2.3). There were no statistically significant differences between these groups regarding age to begin teaching internet safety (p = .2). Adolescents reported that internet safety education should begin at age 8.7 years (SD = 2.4). Please see Figure  1 for a summary of recommended ages to begin internet safety education.

Age to begin teaching internet safety to youth.

Among teachers, 16 (20.8%) reported currently teaching internet safety, 51 (66.2%) had never taught it, and 4 (7.8%) had never taught it but planned to soon. The number of years teaching was not significantly associated with the likelihood to have taught internet safety.

Among clinicians, 3.6% regularly and 55% sometimes counseled patients on internet safety. One-third of clinicians (33.3%) had never counseled or taught patients about internet safety and a few clinicians (8.1%) had no experience with this but planned to begin soon. The number of years in practice was not associated with the likelihood to have taught internet safety (p = .6).

All parents reported discussing online safety with their children either sometimes (58.3%) or regularly (40.3%).

Experiences learning internet safety

Adolescents were asked to identify ways in which they had learned about online safety. Adolescents were permitted to select all options that applied. Adolescents selected people including teachers (87.5%), parents (75%), friends (41.7%), siblings (27.1%) and clinicians (11.5%). Some adolescents indicated that they had learned internet safety by being self-taught (27.5%).

Teachers uniformly reported supporting online safety education in public schools (100%). Clinicians almost uniformly supported providing online safety education in clinicians’ offices (99.1%).

All groups selected parents as the primary candidate to teach internet safety. Among teachers, 97% ranked parents as their first choice candidate, and 3% ranked teachers as first choice. Among clinicians 97% ranked parents as first choice candidate, and 3% ranked teachers as first choice. Among parents, 96% ranked themselves as first choice candidate, and 4% ranked teachers as first choice. Among adolescents, there was more variety in answers. Most adolescents (74.7%) ranked parents as first choice candidate, 13.8% ranked teachers as first choice, 5.7% ranked law enforcement as first choice, 1.5% ranked community as first choice, 3% ranked churches as first choice and 3% wrote in answers of making a movie related to online safety and making a powerpoint regarding online safety.

The results of this study illustrate several key points regarding promoting safe internet use among youth. Findings suggest general agreement among key stakeholders for teaching internet safety at a young age, and for identifying parents as primary teachers of this topic.

First, our findings regarding the suggested age to begin teaching online safety may seem younger than expected. The suggested age range of 6 to 8 years identified by participants suggests that internet safety education could begin in early grade school, around 1 st or 2 nd grade. However, given our current society’s focus on technology, it is likely that children are being introduced to computers at ever-younger ages. Data from 2010 suggests that almost 20% of 8 to 10 year olds spend time on social networking sites daily, in the past three years it seems likely that this percentage has grown [ 20 ]. Timing safety education with the onset of internet use may allow for the concomitant development of computer skills and safety skills. As with many health teachings such as nutrition or sexual behavior, providing education to children before dangers can arise is a key strategy to help youth integrate these lessons into their lives and prevent negative consequences.

Second, our findings include a general agreement among key stakeholders that parents should hold the primary responsibility for internet safety education. These findings are supported by a recent study in which teachers felt that parents should have the primary role in teaching this topic [ 27 ]. Interestingly, we found that while parents all reported that they regularly or sometimes teach internet safety, only 75% of adolescents reported hearing from parents on this topic. These conflicting findings may be due to social desirability on the part of parents reporting their teaching efforts, or that teens may underreport their parents counseling efforts as they may not recognize parent attempts to discuss these difficult topics. Previous work has found a similar disconnect between parent and pediatrician reporting of counseling on risk behaviors [ 28 ].

Finally, our findings suggest that parents are willing teachers in providing internet safety education, and that many report some experience in this area. However, while parents may be candidates to guide their children’s digital lives, some parents may feel underprepared for the task of instructing their children who have grown up as “digital natives.” Thus, health care providers and public health educators may have an unique opportunity to support parents by providing resources, guidance and support. Pediatricians who see adolescent patients have the opportunity to serve an important and perhaps familiar role. As with many other topics of health supervision including safety, nutrition and fitness, parents are the primary source of education for their children. However, in many of these health topics, clinicians and health educators are trusted sources for parents on how to talk with their children about these issues. Some child health providers may feel untrained or unprepared to answer questions about internet safety or cyberbullying given that these are relatively recent health concerns about which much remains unknown. Pediatricians can use American Academy of Pediatrics guidelines to recommend parental supervision of internet activities, decreasing or eliminating isolated screen time (ie, moving the computer to a public space), and having open discussions about the potential dangers of electronic media [ 23 ]. Pediatricians and educators can also partner with schools or other community groups, such as law enforcement, to provide consistent and reinforced messages about internet safety.

Limitations to this study include the regional focus of our data collection. Our study aimed to draw representation of populations of teachers, clinicians, parents and adolescents within our region, the excellent response rates and distribution of participants within each category support that our results are generalizable within our region. However, there are other groups who may engage in teaching internet safety that were not included in this study such as churches and community groups. Second, it is notable that our study did not provide data on what methods would be best to provide internet safety education, this is a logical next step for future study. Third, we did not specify in the context of this study whether online safety should include additional technologies such as cell phones or texting. Fourth, data was collected by self-report, thus recall bias or overestimation of experience or willingness could have impacted our findings. Based on the varied stakeholders included in this study, there was some variation in data collected from each group.

Technology is now an integral part of life, and thus, part of the health of our patients. Our findings illustrate consensus around several groups with experience and investment in working with children and adolescents that parents should have primary responsibility for teaching internet safety. Our study highlights an opportunity for pediatricians to play a collaborative role with parents, patients and teachers to address the critical topics towards improving internet safety. Given the importance of this topic for today’s youth, it is likely that collaborative efforts are needed to provide consistent education about safety in the digital world.

Authors’ information

MM is an adolescent medicine physician who conducts research on the intersection of technology and health. KE is a medical student interested in pediatrics. KB studied consumer science and is interested in ways to improve internet safety education for youth. HY is a pharmacist and researcher with interest in provision of education to patients and parents. EC is a pediatrician and researcher interested in improving health systems and communication.

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Acknowledgments

This project was supported by Award Number K12HD055894 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The funding organization had no role in the design, collection of data, analysis or interpretation on the data in this manuscript. The authors would like to acknowledge the contributions of Michael Swanson and Jay Farnsworth to this project.

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The authors declare that they have no competing interest.

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MM conceived of the study, participated in its design and coordination, participated in analysis and wrote the manuscript. KE and KB participated in data collection and helped to draft the manuscript. HY and EC participated in analysis and helped to draft the manuscript. All authors read and approved the final manuscript.

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Moreno, M.A., Egan, K.G., Bare, K. et al. Internet safety education for youth: stakeholder perspectives. BMC Public Health 13 , 543 (2013). https://doi.org/10.1186/1471-2458-13-543

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Getting Kids to Take Online Safety Seriously

When you ask students to think through their own scenarios about online safety, they’re more likely to look out for themselves and others.

The top-line statistics about online safety for kids are troubling: According to a 2019 study by the Center for Cyber Safety and Education, 40 percent of kids in grades 4-8 reported that they connected or chatted online with a stranger. Meanwhile, the Journal of Adolescent Health reports that approximately one in five youth experience unwanted online exposure to sexually explicit material. And the risks just come from strangers: Pew Research Center reports that 59 percent of kids have been bullied or harassed online.

ISTE standards for students don’t quite seem up to the task. While they touch on cyberbullying and data privacy and acknowledge that being a “digital citizen” means learning about the responsibilities and behaviors for interacting in this space, they don’t say a word about access to and sharing of inappropriate and explicit content—including the risk of kids making a naive but devastating misstep themselves.

That’s a big gap. The easy solution would be cut-to-the-chase lectures that treat cyber safety as a standalone topic, but lectures often fail to make meaningful connections with students. In our years of teaching cyber safety to kids, we’ve arrived at what we think is a better approach—one in which cyber safety instruction is woven into subjects such as language arts, social studies, math, PE, and electives like STEAM, health, or theater.

We’ve seen it again and again in our classes: When cyber safety is contextualized and personalized and provides students with an opportunity to create, apply, or synthesize higher-level ideas in their subject-specific areas, the learning is far more profound. Moreover, with a cross-curricular approach, students become more empowered digital citizens who want to share their stories, research the facts, and inform their peers.

Make use of compelling, relevant narratives

Narrative is relevant in most subjects, but we’ve discovered that in the context of ELA, sharing cyber safety narratives with an element of suspense gains students’ attention, gets them thinking critically, and gives them ideas for their own narratives. Start with short, narrative videos such as those from Storybooth , a site that animates real-life stories submitted by 7th-12th graders, including testimonies relevant to cyber safety. BrainPop , which is aimed at elementary teachers and students, also has cyber safety videos.

After watching a video, ask your students to pick a related prompt. For example, if you’ve just watched a video on private and personal information, offer these:

• Explain why it can be risky to share information online.
• What steps would you take to prevent your private information from being shared?
• Create a T-chart of safe and unsafe information to share online.

Then they can write a response to the prompt and then turn and talk to a peer or share their responses in a whole group, e.g., “This reminds me of…” or “I wonder what would happen if…”

Or have your students write real or imagined narratives around topics of cyber safety. Start with story prompts such as, “A friend tells you that they are planning to meet up with someone they met through social media and wants you to come along. How do you respond?”

We have students work collaboratively on different story prompts related to cyber safety, then use a jigsaw approach where each group rotates to a completed story prompt with sticky notes to ask questions, share “a-ha” moments, and give peers feedback.

Storytelling with avatars and comics

Comics can both inspire and educate kids . Consider having your students create virtual avatars and comic strips with a tool like Pixton . They can create representations of themselves, classmates, peers, family members, or teachers who will play a role in the narratives they create (with permission, of course, from the represented people—yet another opportunity to model consideration and consent).

For example, kids could envision a scenario in which a high schooler meets someone they think is a peer online, agrees to meet them in person, realizes the gravity of the situation, and flees, and then depict that entire storyline in a comic strip format. The same thing can be done with scenarios related to sharing photos or a bank account number.

With digital comics, students can change backgrounds to build settings, vary facial expressions and body posture of their avatars, and learn technical skills like camera zoom to edit. Digital comics can launch discussions about other important topics, too, like the importance of nonverbal communication and how to support their peers when warning signs of cyber safety arise.

Practice problem-solving with scenarios

When students act out scenarios, they explore possible solutions to complicated problems with their peers. Pose scenarios and ask cooperative groups to act them out. Here's an example:

A group of classmates asks for your help to create a website about a teacher at your school. They want to include inappropriate pictures, images, and comments about her. What do you do? 

With practice and trust, your students will likely want to write their own scenarios. Whether you teach health, theater, or creative writing, having kids write a script for a cyber safety situation can bring new energy into your classroom.

Integrate research

When students research facts about cyber safety issues, they build their critical thinking and media literacy skills and gain a clearer understanding of what cyber safety is and what affects it, both in terms of outside influences and their own behavior.

For example, in a social studies class, ask them to consider this scenario: “Your friend tags you in a picture at the beach on Instagram. Other users have begun to make comments that make you feel uncomfortable and don’t seem appropriate to post online. You’re worried that your mom will see it. What should you do?”

As part of the assignment, have students look at legislation related to cyber safety to understand the legal ramifications of bad (and sometimes illegal) behavior; advise them to add links and resources they’ve discovered. Using an online collaboration board such as Padlet, Jamboard, or with Nearpod or Pear Deck, you can also do “think-pair-share” activities rooted in online research.

Relevant research works in math, too, and the objectivity of numbers provides a nice counterbalance to personal narratives. A good infographic, for example, can prompt questions and robust discussion. Because infographics are data-rich, they can reinforce understanding of statistics and probability and help develop quantitative literacy.

Students can also create surveys using Google Forms and collect data from their peers about a cyber safety topic of their choice—they are often more interested in crunching numbers when working with a data set they’ve created or contributed to and care about. Once students have collected and analyzed their data, they can create a Canva infographic of their own, which can also be used for a “notice and wonder” conversation that they lead.

Cyber safety instruction helps students see the connections between good citizenship overall and digital citizenship . Students need to understand the facts, cause and effect, personal responsibility, and the importance of both etiquette and context. Most of all, they need to understand that the lessons of compassion they learn throughout their school years extend into the digital world. One of the best ways to be compassionate towards others (and themselves!) is to be safe online. 

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Top 15 internet safety rules and what not to do online

So much of our daily life revolves around the internet, from work to education and even talking with friends. A  2021 survey  found that the average US household had around 25 internet-connected devices, up from 11 in 2019. The more online accounts and devices you have, the greater the scope for cybercriminals to cause you harm. That’s why it's now ever more essential to understand internet safety rules which protect you and your family from threats that may harm your data and devices. Read on to find out about key internet dangers and the ways to stay safe online.

The Key Dangers of the Internet

When you and your family use the internet, you are (often unknowingly) exposing yourself to a wide range of potential online threats. Digital landscapes as we know them are constantly evolving as cybercriminals devise new ways to target internet users. Here is a list of just some of the biggest internet dangers you and your family need to watch out for:

• Identity theft.
• Data breaches.
• Malware and viruses.
• Phishing and scam emails.
• Fake websites.
• Online scams.
• Romance scams.
• Inappropriate content.
• Cyberbullying.
• Faulty privacy settings.

Essential Internet Safety Tips

To avoid all of these dangers, we recommend following our essential internet safety tips when you or your family are online:

1. Make sure you’re using a secure internet connection

Although using public Wi-Fi is not recommended, it’s sometimes unavoidable when you are out and about. However, when you go online in a public place and use a  public Wi-Fi  connection, you have no direct control over its security, which could leave you vulnerable to cyberattacks. So, if you are using public Wi-Fi, avoid carrying out personal transactions that use sensitive data, such as online banking or online shopping.

If you need to do any one of these, use a  Virtual Private Network or VPN . A VPN will protect any of the data you send over an unsecured network via real-time encryption. If you don't use a VPN, we recommend saving any personal transactions until you can use a trusted internet connection. You can find out more about what a VPN is here .

2. Choose strong passwords

Passwords are one of the biggest weak spots when it comes to cybersecurity. People often choose passwords that are easy to remember and, therefore, easy for hackers to crack with hacking software. In addition to this, using the same password for multiple sites puts your data at further risk. If hackers obtain your credentials from one site, they can potentially access other websites which use the same login details.

Select  strong passwords  that are harder for cybercriminals to crack. A strong password is:

• Long – made up of at least 12 characters (ideally more).
• A mix of characters – upper-case and lower-case letters plus symbols and numbers.
• Avoids the obvious – such as using sequential numbers (“1234”) or personal information that someone who knows you might guess (or that might already be online), such as your date of birth or a pet’s name.
• Avoids memorable keyboard paths.

Using a  password manager  can help. Password managers help users create strong passwords, store them in a digital vault (which is protected by a single master password) and retrieve them when logging into accounts online.

3. Enable multi-factor authentication where you can

Multifactor authentication (MFA) is an authentication method that asks users to provide two or more verification methods to access an online account. For example, instead of simply asking for a username or password, multifactor authentication goes further by requesting additional information, such as:

• An extra one-time password that the website's authentication servers send to the user's phone or email address.
• Answers to personal security questions.
• A fingerprint or other biometric information, such as voice or face recognition.

Multifactor authentication decreases the likelihood of a successful cyberattack. To make your online accounts more secure, it’s a good idea to implement multifactor authentication where possible. You can also consider using a third-party authenticator app, such as Google Authenticator or Authy, to help with your internet security.

4. Keep software and operating systems updated

Developers are constantly working to make products safe, monitoring the latest threats and rolling out security patches in case of vulnerabilities in their software. By using the latest versions of your operating systems and apps, you will benefit from the latest security patches. This is especially important for apps that contain payment, health or other sensitive information about a user.

5. Check that websites look and feel reliable

For any website you visit, especially ones you transact with (such as e-commerce sites), it's crucial that they are reliable. A key element to look out for is an SSL/security certificate . This means, lookout for URLs that start with “HTTPS” rather than “HTTP” (the “S” stands for “secure”) and have a padlock icon in the address bar. Other trust signals include:

• Text which is free from spelling and grammar mistakes – reputable brands will make an effort to ensure their websites are well-written and proofread.
• Images that are not pixelated and fit the screen's width correctly.
• Ads that feel organic and are not too overpowering.
• No sudden changes in color or theme. In some cases, where users have interacted with a particular website and returned to a familiar page from a link, subtle color or design changes might indicate forgery.
• The accepted standards of online payments – legitimate ecommerce websites use credit or debit card portals or PayPal, only. If a website is using another form of digital money transfer to accept payments, it is probably fraudulent.

6. Review your privacy settings and understand privacy policies

Marketers love to know all about you, and so do hackers. Both can learn a lot from your browsing and social media usage. But you can take charge of how much information third-parties can access. Both web browsers and mobile operating systems have settings to protect your privacy online. Social media sites, such as Facebook, Twitter, Instagram, LinkedIn, amongst others, have privacy-enhancing settings that you can activate. It’s worth taking a while to review your privacy settings across the board and make sure they are set to a level you are comfortable with.

Many of us accept privacy policies without reading them, but with so much data used for marketing and advertising (and hacking) purposes, it's a good idea to review the privacy policies of websites and apps you use, in order to understand how your data is collected and analyzed. However, bear in mind that even if your settings are set to private, very little data online is totally private. Hackers, website administrators and law enforcement could still have access to the information you regard as private.

7. Be careful of suspicious links and where you click

A careless click can expose your personal data online or infect your device with  malware . That’s why it's essential to browse consciously and avoid certain types of online content – such as links from untrusted sources and spam emails, online quizzes, clickbait, ‘free’ offers or unsolicited ads.

If you receive an email that you're not sure about, avoid clicking on any links in it or opening any attachments.

In fact, it's best to avoid opening untrusted emails at all. If you’re not sure whether an email is legitimate or not, go directly to the source. For example, if you receive a suspicious email from your “bank”, call your bank and ask them if the email is genuine.

When you’re on a website, make sure links click through to relevant or expected topics. For example, if you click on a link that you think is about safaris in Africa, but instead you're taken to a clickbait-style page about celebrity weight loss or a “where are they now?” style piece, then quickly close the page.

8. Make sure your devices are secure

With up to 60% of people using mobile devices for shopping and finding information online, instead of a desktop, it’s important that they are secured correctly. With all your devices – phones, computers, tablets, smartwatches, smart TVs, etc. – it's good practice to use passwords or passcodes and other security options like fingerprint readers or face-scanning technology. These measures will reduce the likelihood of a cyberattack or your personal data being stolen by hackers.

9. Backup data regularly

It's important to backup important personal information on external hard drives and regularly create new backups.  Ransomware  – a type of malware – involves cybercriminals locking your computer so you can’t access valuable files. Backing up your data – and your family’s data – helps mitigate the impact of a ransomware attack. You can protect yourself further with appropriate security software. Other forms of malware deny you access to your personal data by overwhelming your system or simply deleting files, so be careful.

10. Close unused accounts

Over the years, many of us accumulate old accounts that we no longer use. These can be a weak link in terms of safety when using the internet – not only are old accounts more likely to have weaker passwords, but some of those sites may have poor data protection policies. In addition, cybercriminals could piece together the information you have left in them, for example, old social media profiles – such as your date of birth or location, etc. – to build up a picture of your identity in an attempt to hack you later. As a result, we recommend closing your old online accounts and requesting that your data be deleted from the relevant third-party servers.

11. Be careful what you download

A top goal of cybercriminals is to trick you into downloading malware, which can be used to open a “backdoor” to your machine. Malware might be disguised as an app – anything from a popular game to something that checks traffic or the weather. Or, it could be hidden on a malicious website that attempts to install malware on your device.

Malware causes damage – such as disrupting how your device operates, stealing your personal data or allowing unauthorized access to your machine. This usually requires some action on your part, but there are also  drive-by downloads , where a website attempts to install software on your computer without asking for permission first. Think carefully before visiting a new website or downloading anything onto your device, and only download content from trusted or official sources. Regularly check your download folders and if unknown files appear on your system (potentially, from a drive-by), delete them immediately.

12. Be careful what you post and where

The internet does not have a delete key. Any comment or image you post online may stay online forever because removing the original won’t remove any copies that other people may have made. There is no way for you to ‘take back’ a comment you wish you hadn't made or remove an embarrassing image you posted. So, don't put anything online that you would not want a parent or prospective employer to see.

Similarly, be careful about disclosing personal information about yourself online. For example, avoid disclosing your social security number, address or date of birth in social media bios. You wouldn't hand personal information out to strangers individually, so don't hand it out to millions of people online.

Be careful about where you display or submit your email address. It's good to have a secondary, throwaway email account that you use solely for email sign-ups and subscriptions, separate from the one you use for friends and family, and separate from the one you use for work.

13. Be careful who you meet online

People you meet online are not always who they claim to be. Indeed, they may not even be real. Fake social media profiles are a popular way for hackers to groom unwary internet users and pick their cyber pockets. Apply the same caution in your online social life as you would for your in-person social life. This is particularly true with  the rise of online dating scams in recent years .

14. Double check online information

Sadly, fake news, misinformation and disinformation are all present on the internet. It's easy to feel lost with the flood of information we're exposed to every day. If you read something you are unsure of, do your own research to establish the facts. Reliable websites will have references to the original information and source materials. Suspicious pages won’t offer any references at all. Read  our guide to spotting fake news here .

15. Use a good antivirus and keep it updated

As well as following safety tips for online behavior, it's essential to use a good quality antivirus provider . Internet security software guards your devices and data and blocks common threats like viruses and malware (plus complex ones like spy apps, “cryptolockers” and XSS attacks). As with all operating systems and apps, it's essential to keep your antivirus updated to stay ahead of the latest cyberthreats.

3 Online safety rules for the kids

Although many of the tips to stay safe online are the same for adults and children, they are not easy or straightforward to explain. Often, children can accidentally be a gateway for malicious actors to gain access to your digital systems. It is therefore important to teach your kids the essentials of staying safe online in order to protect your home network from any unwanted accidents. Here are 3 areas that you should cover:

Digital Footprint

Your digital footprint, what exists of you online after usage, is an important concept that children need to know about. When teaching children about this, it’s important to focus on how information is readily available and how others could interact with this data (for example, email addresses and usernames that contain identifying information, which could be used for criminal activity). Wider discussions can also come from this, such as sharing content online (through social media, gaming accounts and emails). Make sure to clearly state what content is not allowed on the internet (photos, address, phone numbers and middle names).

Strong passwords are integral to modern cybersecurity measures today. Instructing children from a young age about the importance of strong passwords (ones that consists of at least 12 characters and are a mixture of letters, numbers and symbols) and their appropriate storage is one of the simplest ways to make the internet safer for your family. This is also why it can be very useful to have a password management system that can automatically fill in password credentials for different websites.

Communication

One of the most accessed routes for all manner of cybercriminal, online messaging and communication is a “must-have” conversation for your children’s safety. Primarily, it is important to explain how to identify and avoid messages, suspicious links, downloads or emails from strangers asking for identifying information online. This can also lead to a wider discussion about how to detect phishing scams and fake websites. The second most important part of safe online communication is correct engagement with others. Much like the real world, staying safe can sometimes depend on staying vigilant, engaging in polite communication and learning how to identify and not engage with bullying. Educate your child on what cyberbullying looks like and how to act kindly to others online.

Recommended products:

• Kaspersky Safe Kids
• Kaspersky Home Security
• Kaspersky Password Manager

Further reading:

• Do’s and don’ts for teaching internet safety to kids
• What is a security breach and how to avoid one?
• What is a Digital Footprint?
• Spam & Phishing | Phishing Scam Threats

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• Online research

Online safety research

Ofcom is the regulator for online safety in the UK. So, it's important for us to understand what people do online, how they can be exposed to harm and how it affects them.

Our research looks at specific aspects of online safety, particularly areas that aren’t as well understood or explored. It covers issues like illegal and harmful content, and the protection of children.

Here’s our latest work in this area:

Protection of children online, research Published 15 March 2024

One Click Away: a study on the prevalence of non-suicidal self injury, suicide, and eating disorder content accessible by search engines Published 31 January 2024

Assessing the risk of foreign influence in UK search results Published 19 September 2023

ISD reports into online terrorism, violence and hate Published 19 September 2023

Online content for use in the commission of fraud - accessibility via search services Published 18 September 2023

Sale of prohibited items on search services Published 18 September 2023

A model for understanding user journeys in online gaming environments Published 4 April 2023

Exploring Safety in the Online Content Journey Published 13 October 2021

The A-SPARC model of online platforms Published 13 October 2021

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Internet Safety  - Introduction to Internet Safety

Internet safety  -, introduction to internet safety, internet safety introduction to internet safety.

Internet Safety: Introduction to Internet Safety

Lesson 1: introduction to internet safety, introduction to internet safety.

There's almost no limit to what you can do online. The Internet makes it possible to access information quickly, communicate around the world, and much more. Unfortunately, the Internet is also home to certain risks , such as malware , spam , and phishing . If you want to stay safe online, you'll need to understand these risks and learn how to avoid them.

Adopting a safer mindset

Computers can often give us a false sense of security . After all, no one can physically harm you through a computer screen. But to stay safe online, you'll want to take a more cautious approach. Here's one way to think about it: Treat the Internet as you would a shopping mall .

Most people don't consider a mall to be an especially dangerous place. You can go there to shop and meet up with friends. But there are also small things you may do to stay safe, even if you don't think about them very often. For example, you probably wouldn't leave your car unlocked or give your credit card number to a stranger.

Apply this same mindset whenever you're online. You shouldn't be afraid to use the Internet, but remember that it comes with many of the same risks you'd face in the real world. Throughout this tutorial, we'll show you how to prepare for these risks so you can be online without putting yourself in danger.

So what are you waiting for? Let's get started!

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Stanford University

The Cyber Policy Center is a joint initiative of the  Freeman Spogli Institute for International Studies and Stanford Law School .

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How to fix the online child exploitation reporting system.

• Stanford Internet Observatory
• The CyberTipline is enormously valuable, and leads to the rescue of children and prosecution of offenders.
• Many online platforms submit low-quality reports. 
• NCMEC has faced challenges in rapidly implementing technological improvements that would aid law enforcement in triage.
• Legal constraints on NCMEC and U.S. law enforcement have implications for efficiency.
• These issues would be best addressed by a concerted effort to massively uplift NCMEC's technical and analytical capabilities, which will require the cooperation of platforms, NCMEC, law enforcement and, importantly, the U.S. Congress.
• DOWNLOAD REPORT

The CyberTipline is the main line of defense for children who are exploited on the internet. It leads to the rescue of children and the arrest of abusers. Yet after 26 years many believe the entire system is not living up to its potential. A new Stanford Internet Observatory report examines issues in the reporting system and what the technology industry, the nonprofit that runs the tipline, and the U.S. Congress must do to fix it.

If online platforms in the U.S. become aware of child sexual abuse material (CSAM), federal law requires that they report it to the CyberTipline. This centralized system for reporting online child exploitation is operated by the National Center for Missing and Exploited Children (NCMEC), a nonprofit organization. NCMEC attempts to identify the location of the users who sent and received the abuse content, and may attempt to locate the victim. These reports are then sent to local or national law enforcement agencies in the U.S. and abroad.

The report is based on interviews with 66 respondents across industry, law enforcement, and civil society. Researchers also visited NCMEC’s headquarters for three days of extensive interviews.

While our research focuses on CyberTipline challenges, we want to note that many respondents highlighted that the entire CyberTipline process is enormously valuable and the fact that U.S. platforms are required to report CSAM is a strength of the system. “The system is worth nurturing, preserving, and securing,” one respondent said.

Law enforcement officers are overwhelmed by the high volume of CyberTipline reports they receive. However, we find that the core issue extends beyond volume: officers struggle to triage and prioritize these reports to identify offenders and reach children who are in harm. An officer might examine two CyberTipline reports – each documenting an individual uploading a single piece of CSAM – yet, upon investigation, one report might lead nowhere, while the other could uncover ongoing child abuse by the uploader. Nothing in the reports would have indicated which should be prioritized.

We identify three key challenges for law enforcement to prioritize reports for investigation.

First, while some tech companies are known for providing careful and detailed CyberTipline reports, many reports are low quality. Executives may be unwilling to dedicate engineering resources to ensure the accurate completion of fields within the reporting API. Trust and safety staff turnover and a lack of documentation on reporting best practices cause knowledge gaps in consistency and effective reporting. This is especially true for platforms that make fewer reports. That said, submitting a high volume of reports is not necessarily correlated with submitting high quality reports.

Second, NCMEC has faced challenges in rapidly implementing technological improvements that would aid law enforcement in triage. NCMEC faces resource constraints and lower salaries, leading to difficulties in retaining personnel who are often poached by industry trust and safety teams. While there has been progress in report deconfliction—identifying connections between reports, such as identical offenders—the pace of improvement has been considered slow. Additionally, varied case management interfaces used by law enforcement to process CyberTipline reports make it difficult to ensure linked reports are displayed. Integration difficulties with external data sources, which could enrich reports and facilitate triage, are partly attributed to the sensitive nature of CyberTipline data and potentially staffing constraints for technical infrastructure upgrades. Legal restrictions on NCMEC’s use of cloud services hampers their ability to leverage advanced machine learning tools, although opinions vary on the appropriateness of cloud storage for their sensitive data.

Third, there are legal constraints on NCMEC’s and law enforcement’s roles. A federal appeals court held in 2016 that NCMEC is a governmental entity or agent, meaning its actions are subject to Fourth Amendment rules. As a result, NCMEC may not tell platforms what to look for or report, as that risks turning them into government agents too , converting what once were voluntary private searches into warrantless government searches (which generally requires suppression of evidence in court). Consequently, NCMEC is hesitant to put best practices in writing. Instead, many trust and safety staff who are new to the CyberTipline process must learn from more established platforms or industry coalitions. 

Another federal appeals court held in 2021 that the government must get a warrant before opening a reported file unless the platform viewed that file before submitting the report.  Platforms often do not indicate whether content has been viewed; if they have not so indicated, then NCMEC, like law enforcement, cannot open those files. Platforms may automate reports to the CyberTipline on the basis of a hash match hit to known CSAM instead of having staff view each file, whether due to limited review capacity or not wanting to expose staff to harmful content. Where reported files weren’t viewed by the platform, law enforcement may need a warrant to investigate those reports, and NCMEC currently cannot help with an initial review. 

This review process makes it difficult to process the high volume of reported viral and meme content. Such content commonly gets shared widely, for example out of outrage or a misguided attempt at humor; nevertheless, if it meets the definition of CSAM, it is still illegal and must be reported. Platform staff don’t always review meme content (to avoid repeated unnecessary exposure to known material), but if these reports with unviewed files are submitted without checking the CyberTipline report form’s box for memes, it creates an enormous amount of work for law enforcement to close out these unactionable reports. Meanwhile, since platforms are required to preserve reported material for only 90 days, the time it takes to process a report means preserved content has often been deleted by the time law enforcement follows up with the platform in actionable cases.

Recommendations

• Online platforms should  prioritize child safety staffing with expertise for in-depth investigations that proactively identify and address child sexual abuse and exploitation to stay ahead of measures taken by bad actors to avoid detection.
• Platforms should invest dedicated engineering resources in  implementing the NCMEC reporting API . Ensure there is an accurate and (where possible) automated process for completing all relevant fields Our interviews suggest reports are more actionable when they provide offender information (including location information, particularly an upload IP address), victim information (including location information), the associated file (a hash alone is insufficient) or chat, and the time of the incident (including a description of how the platform defines the incident time). 
• To avoid state actor concerns, an NGO that is not NCMEC should  publish the key CyberTipline form fields that platforms should complete to increase the likelihood that law enforcement will be able to investigate their reports.
• Congress should  increase NCMEC’s budget  to enable it to hire more competitively in the technical division, and to dedicate more resources to CyberTipline technical infrastructure development. This funding should not be taken out of the budget for Internet Crimes Against Children Task Forces.  
• NCMEC should prioritize  investment in technical staff and the technical infrastructure of the CyberTipline to speed up implementation of their technical roadmap.
• NCMEC and Internet Crimes Against Children Task Forces should  partner with researchers to bring insights into the CyberTipline reporting flow along with the relationship between CyberTipline reports, arrests, and victim identification.
• Congress should pass legislation that  extends the required preservation period to at least 180 days, but preferably one year.
• The U.S. Supreme Court should  resolve the split in authority over whether the private search doctrine requires human review by platform personnel in order for law enforcement to open a file without a warrant, or whether the doctrine is satisfied where a reported file is a hash match for a previously-viewed file. 

Investigation Finds AI Image Generation Models Trained on Child Abuse

Addressing child exploitation on federated social media, an update on the sg-csam ecosystem.

The Internet Has Made Health Anxiety Worse Than Ever

“Don’t google your cancer,” the oncology nurse said to me as she drew my blood ahead of my first round of chemotherapy. It was 2006 and I was 17 years old. I was very confused by the emphasis she put on this advice. Still, I took the print-out of “safe” web addresses she gave me home and pinned it on the noticeboard in the kitchen, where it stayed, ignored, as I slowly progressed through six months of cancer treatment.

I was confused because the opportunities for me to use the internet to research my recent diagnosis of Hodgkin’s Lymphoma, a kind of blood cancer, were minimal anyway. I didn’t own a smartphone or a laptop and my only access to the internet was in communal spaces: at school or via my family’s shared computer with its dial-up connection. The notion that I could use these public facilities to explore something as intensely private as my cancer didn’t even register as a possibility for me.

Read More: The Unique Hell of Getting Cancer as a Young Adult

Everything changed a year later when I learned that the treatment had not been effective and the cancer was back. Or it had never gone away in the first place, it was hard to tell. Standing petrified in my college dorm room, I found the lump in my neck myself and its malignant properties were quickly confirmed by scans and tests. The chance of this happening, I was told by my doctors, was less than 5%. I had been “unlucky.”

Now, I was no longer a regularly supervised schoolgirl and I owned my own computer. I was free to look up symptoms and side effects and death rates as much as I liked. The medical professionals were doing their best with my case, but naturally they couldn’t give me absolute certainty about what was going to happen. Desperately craving some concrete information about my future, I kept searching and searching until I literally scared myself sick. I would have to snap the laptop shut and lie down until this internet-induced nausea passed, worn out from a rigorous schedule of in-patient treatments and college classes.

With hindsight, I can now recognize this as an early sign of the hypochondria that would become such a feature of my life in my 20s The popular conception of hypochondria, or health anxiety as it is often termed in the modern medical lexicon, is that it is rooted in ignorance. Unable to know the full scientific story about this suspected lump or that twinge of pain either because of a lack of access to healthcare or fear of what a doctor might say, the anxious brain writes in a narrative to explain it—usually one that involves the worst possible scenario and a terminal illness.

This idea of the hypochondriac’s ignorance being “cured” with knowledge is a very old one. As I delved deeper into the fascinating yet convoluted history of this condition with my own searches, I became preoccupied with the so-called “glass men”   of the middle ages, who experienced something called the glass delusion. Widely documented across Europe, these sufferers believed they were partly or wholly made of glass rather than human flesh, and the obsession with their fragile and breakable nature could come to dominate their whole life.

The 14th century French King Charles VI was a notable sufferer and in 1613 Cervantes published a whole novella about a “glass graduate” who experienced this. The treatment was simple: the “glass man” must be made to understand that he was not, in fact, made of glass. This was usually done by beating or squeezing him soundly until he acknowledged that he had not shattered into fragments. This proof, this extra knowledge of his resilience, would then cure him of the delusion.

But if hypochondria were truly cured by knowledge, advances in medicine would have made it a thing of the past. Yet anxiety disorders , including health anxiety, continue to be prevalent in countries with the most advanced healthcare systems. Hypochondria evolves and changes to keep pace with scientific knowledge. Where once people feared that they were made of glass or that an excess of black bile was making them melancholy, now they worry that they have brain tumours or long COVID-19. At every stage of medical progress, hypochondria is right there with us.

Read More: How to Tell If Your Health Concerns Are Normal—Or a Sign of Something More

Indeed, research shows that the prevalence of health anxiety is increasing among those who attend medical clinics—suggesting that more contact with medical knowledge is making our fears worse, rather than ridding us of them. This has been partly attributed to the rise of “cyberchondria,” in which anxieties about health escalate as a result of information found online. First used in the early 2000s, this word describes the pattern of excessive internet searching that I fell into after my cancer was declared cured, when my every twinge and sniff seemed to me to be a sign that the tumours were back.

I rationalized this behavior, as I think a lot of people with pre-existing conditions do, as simply being responsible or cautious about my health. Having already found a tumour once when my disease was supposed to be cured, I was hypervigilant against it happening again. Googling my every symptom and falling down a never-ending rabbit hole of research papers, online forums and wellness podcasts was just me being a good patient, I would tell myself.

It wasn’t excessive because I had such a complicated medical history. Doctors had told me to “keep an eye out” for possible symptoms and that was all I was doing. It took a lot of therapy and self-examination for me to realise that all of this extra information wasn’t affecting my medical outcomes positively at all: if anything, it was making me feel worse, not better.

Even with this awareness, it can be difficult to escape the clutches of cyberchondria. At times, it feels as though the whole internet is designed to magnify my fears. Typing “does headache mean…” into Google gives me, among others, the suggestions “miscarriage”, “concussion” and “brain tumour”, which are all rather more serious issues than the far more common and likely causes of “dehydration”, “stressed about work” and “lack of fresh air”.

The “escalation” mechanism that experts have identified as a tool in online political radicalisation operates in this field too. Just typing what feels like a mundane health query into a search engine can be the first step in a journey that leads to disinformation, self-diagnosis, and severe anxiety. Worse, there is evidence that the so-called “worried well”, with their health anxiety and their cyberchondria, can be up to 70% more likely to develop cardiac problems. All this worrying can make the worst happen, it would seem.

Knowing what I do now, I have immense respect for the foresight of my oncology nurse back in 2006. She said then that googling my cancer was a bad idea, and she was right, even though the true power of cyberchondria had not yet been unleashed by our constantly-online existence. The list of approved resources she gave me that day included only my healthcare provider’s website, a patient’s guide published by a cancer charity, a couple of online medical dictionaries and some academic publishers. This is what I restrict myself to today, even though sometimes my fingertips tingle with the desire to search more widely. I could click, and click, and click, until I am sick forever.

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Quarter of UK’s three- and four-year-olds own a smartphone, data shows

Campaigners express concern at new Ofcom figures, which also show that half of under-13s are on social media

A quarter of three- and four-year-olds in the UK now own a smartphone, while half of children under 13 are on social media, according to new data that comes as ministers consider banning all children under 16 from owning a mobile phone.

The figures, from the communications regulator Ofcom, show high and rising rates of online activity by children of infant-school age, with 38% of five- to seven-year-olds using social media, compared with 30% a year ago, and 76% of them using a tablet.

The findings will boost the argument of those close to Rishi Sunak who have been urging him to clamp down on phone and social media use by young children.

Ministers will launch a consultation on what measures to take within weeks, according to government sources.

The consultation will include a proposal to ban mobile phone sales to under-16s, one to make it easier for parents to put parental controls on devices, and one to raise the minimum age for social media sites from 13 to as high as 16. Ofcom also found that half of children aged three to 12 use at least one social media app, despite the minimum age requirement of 13.

Michelle Donelan, the technology secretary, said in a statement: “Children as young as five should not be accessing social media, and these stark findings show why our Online Safety Act is essential.

“Most platforms say they do not allow under-13s on to their sites, and the act will ensure companies enforce these limits or they could face massive fines. If they fail to comply with Ofcom decisions and keep children safe, their bosses could face prison.”

She added: “Protecting children online is our No 1 priority and we will not hesitate to build on the act to keep them safe.”

The figures come amid growing evidence of the impact of widespread social media use among children. The US government has warned that social media poses a “profound risk” to the mental health and wellbeing of children and teenagers, with the number of children and adolescents dealing with depression and anxiety having risen almost 30% in recent years.

Jonathan Haidt, a US academic whose book The Anxious Generation has been cited as influencing No 10’s thinking on children and social media, told the Guardian the mobile phone ownership figures were “very disturbing”. Ofcom research also showed around a quarter of five- to seven-year-olds owned a smartphone.

“Something must be done to reverse this trend,” said Haidt, a social psychologist at New York University’s Stern School of Business. He added that parents should work with schools to set a new norm: “Don’t give children a smartphone before the end of secondary education, around age 16.”

Child online safety campaigners also called on the government to act. The Molly Rose Foundation said Ofcom had to crack down on platforms that “turn a blind eye” to age requirements, while the NSPCC called for “robust enforcement” of the Online Safety Act, which has provisions on enforcing social media age limits.

Joe Ryrie, co-founder of the group Smartphone Free Childhood , said the statistics showed that social media and smartphone use “is a systemic problem and it’s only getting worse.”

Ofcom’s annual study of children’s online habits also found the proportion of five- to seven-year-olds sending messages or making voice and video calls had risen from 59% to 65% compared with a year ago. The number of children in that cohort using WhatsApp rose from 29% to 37% and the proportion using TikTok increased from 25% to 30%.

Overall, 96% of all children aged between three and 17 go online, with the vast majority of the 4% who are still offline being aged three or four. Even among that demographic – the youngest children surveyed – 84% use the internet.

Generally, younger children who are allowed online use a tablet, while secondary-school-age children are more likely to have a smartphone, with more than 95% of 12- to 15-year-olds being given their own mobile phone.

The smartphone figures were based on an Ofcom survey of 2,480 parents of children aged between three and 17. It defined a smartphone as a handset that allows individuals to easily download apps, view websites and generally go online.

• Smartphones
• Mobile phones
• Parents and parenting
• Social media

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Anger from campaigners as WhatsApp lowers age limit to 13 in UK and EU

Puberty makes teenagers’ armpits smell of cheese, goat and urine, say scientists

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Children as young as 10 demanding anti-ageing products, say UK dermatologists

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• Open access
• Published: 19 April 2024

A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact

• Aklilu Endalamaw 1 , 2 ,
• Resham B Khatri 1 , 3 ,
• Tesfaye Setegn Mengistu 1 , 2 ,
• Daniel Erku 1 , 4 , 5 ,
• Eskinder Wolka 6 ,
• Anteneh Zewdie 6 &
• Yibeltal Assefa 1  

BMC Health Services Research volume  24 , Article number:  487 ( 2024 ) Cite this article

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Metrics details

The growing adoption of continuous quality improvement (CQI) initiatives in healthcare has generated a surge in research interest to gain a deeper understanding of CQI. However, comprehensive evidence regarding the diverse facets of CQI in healthcare has been limited. Our review sought to comprehensively grasp the conceptualization and principles of CQI, explore existing models and tools, analyze barriers and facilitators, and investigate its overall impacts.

This qualitative scoping review was conducted using Arksey and O’Malley’s methodological framework. We searched articles in PubMed, Web of Science, Scopus, and EMBASE databases. In addition, we accessed articles from Google Scholar. We used mixed-method analysis, including qualitative content analysis and quantitative descriptive for quantitative findings to summarize findings and PRISMA extension for scoping reviews (PRISMA-ScR) framework to report the overall works.

A total of 87 articles, which covered 14 CQI models, were included in the review. While 19 tools were used for CQI models and initiatives, Plan-Do-Study/Check-Act cycle was the commonly employed model to understand the CQI implementation process. The main reported purposes of using CQI, as its positive impact, are to improve the structure of the health system (e.g., leadership, health workforce, health technology use, supplies, and costs), enhance healthcare delivery processes and outputs (e.g., care coordination and linkages, satisfaction, accessibility, continuity of care, safety, and efficiency), and improve treatment outcome (reduce morbidity and mortality). The implementation of CQI is not without challenges. There are cultural (i.e., resistance/reluctance to quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes, and systems), and strategic (inadequate planning and inappropriate goals) related barriers that were commonly reported during the implementation of CQI.

Conclusions

Implementing CQI initiatives necessitates thoroughly comprehending key principles such as teamwork and timeline. To effectively address challenges, it’s crucial to identify obstacles and implement optimal interventions proactively. Healthcare professionals and leaders need to be mentally equipped and cognizant of the significant role CQI initiatives play in achieving purposes for quality of care.

Peer Review reports

Continuous quality improvement (CQI) initiative is a crucial initiative aimed at enhancing quality in the health system that has gradually been adopted in the healthcare industry. In the early 20th century, Shewhart laid the foundation for quality improvement by describing three essential steps for process improvement: specification, production, and inspection [ 1 , 2 ]. Then, Deming expanded Shewhart’s three-step model into ‘plan, do, study/check, and act’ (PDSA or PDCA) cycle, which was applied to management practices in Japan in the 1950s [ 3 ] and was gradually translated into the health system. In 1991, Kuperman applied a CQI approach to healthcare, comprising selecting a process to be improved, assembling a team of expert clinicians that understands the process and the outcomes, determining key steps in the process and expected outcomes, collecting data that measure the key process steps and outcomes, and providing data feedback to the practitioners [ 4 ]. These philosophies have served as the baseline for the foundation of principles for continuous improvement [ 5 ].

Continuous quality improvement fosters a culture of continuous learning, innovation, and improvement. It encourages proactive identification and resolution of problems, promotes employee engagement and empowerment, encourages trust and respect, and aims for better quality of care [ 6 , 7 ]. These characteristics drive the interaction of CQI with other quality improvement projects, such as quality assurance and total quality management [ 8 ]. Quality assurance primarily focuses on identifying deviations or errors through inspections, audits, and formal reviews, often settling for what is considered ‘good enough’, rather than pursuing the highest possible standards [ 9 , 10 ], while total quality management is implemented as the management philosophy and system to improve all aspects of an organization continuously [ 11 ].

Continuous quality improvement has been implemented to provide quality care. However, providing effective healthcare is a complicated and complex task in achieving the desired health outcomes and the overall well-being of individuals and populations. It necessitates tackling issues, including access, patient safety, medical advances, care coordination, patient-centered care, and quality monitoring [ 12 , 13 ], rooted long ago. It is assumed that the history of quality improvement in healthcare started in 1854 when Florence Nightingale introduced quality improvement documentation [ 14 ]. Over the passing decades, Donabedian introduced structure, processes, and outcomes as quality of care components in 1966 [ 15 ]. More comprehensively, the Institute of Medicine in the United States of America (USA) has identified effectiveness, efficiency, equity, patient-centredness, safety, and timeliness as the components of quality of care [ 16 ]. Moreover, quality of care has recently been considered an integral part of universal health coverage (UHC) [ 17 ], which requires initiatives to mobilise essential inputs [ 18 ].

While the overall objective of CQI in health system is to enhance the quality of care, it is important to note that the purposes and principles of CQI can vary across different contexts [ 19 , 20 ]. This variation has sparked growing research interest. For instance, a review of CQI approaches for capacity building addressed its role in health workforce development [ 21 ]. Another systematic review, based on random-controlled design studies, assessed the effectiveness of CQI using training as an intervention and the PDSA model [ 22 ]. As a research gap, the former review was not directly related to the comprehensive elements of quality of care, while the latter focused solely on the impact of training using the PDSA model, among other potential models. Additionally, a review conducted in 2015 aimed to identify barriers and facilitators of CQI in Canadian contexts [ 23 ]. However, all these reviews presented different perspectives and investigated distinct outcomes. This suggests that there is still much to explore in terms of comprehensively understanding the various aspects of CQI initiatives in healthcare.

As a result, we conducted a scoping review to address several aspects of CQI. Scoping reviews serve as a valuable tool for systematically mapping the existing literature on a specific topic. They are instrumental when dealing with heterogeneous or complex bodies of research. Scoping reviews provide a comprehensive overview by summarizing and disseminating findings across multiple studies, even when evidence varies significantly [ 24 ]. In our specific scoping review, we included various types of literature, including systematic reviews, to enhance our understanding of CQI.

This scoping review examined how CQI is conceptualized and measured and investigated models and tools for its application while identifying implementation challenges and facilitators. It also analyzed the purposes and impact of CQI on the health systems, providing valuable insights for enhancing healthcare quality.

Protocol registration and results reporting

Protocol registration for this scoping review was not conducted. Arksey and O’Malley’s methodological framework was utilized to conduct this scoping review [ 25 ]. The scoping review procedures start by defining the research questions, identifying relevant literature, selecting articles, extracting data, and summarizing the results. The review findings are reported using the PRISMA extension for a scoping review (PRISMA-ScR) [ 26 ]. McGowan and colleagues also advised researchers to report findings from scoping reviews using PRISMA-ScR [ 27 ].

Defining the research problems

This review aims to comprehensively explore the conceptualization, models, tools, barriers, facilitators, and impacts of CQI within the healthcare system worldwide. Specifically, we address the following research questions: (1) How has CQI been defined across various contexts? (2) What are the diverse approaches to implementing CQI in healthcare settings? (3) Which tools are commonly employed for CQI implementation ? (4) What barriers hinder and facilitators support successful CQI initiatives? and (5) What effects CQI initiatives have on the overall care quality?

Information source and search strategy

We conducted the search in PubMed, Web of Science, Scopus, and EMBASE databases, and the Google Scholar search engine. The search terms were selected based on three main distinct concepts. One group was CQI-related terms. The second group included terms related to the purpose for which CQI has been implemented, and the third group included processes and impact. These terms were selected based on the Donabedian framework of structure, process, and outcome [ 28 ]. Additionally, the detailed keywords were recruited from the primary health framework, which has described lists of dimensions under process, output, outcome, and health system goals of any intervention for health [ 29 ]. The detailed search strategy is presented in the Supplementary file 1 (Search strategy). The search for articles was initiated on August 12, 2023, and the last search was conducted on September 01, 2023.

Eligibility criteria and article selection

Based on the scoping review’s population, concept, and context frameworks [ 30 ], the population included any patients or clients. Additionally, the concepts explored in the review encompassed definitions, implementation, models, tools, barriers, facilitators, and impacts of CQI. Furthermore, the review considered contexts at any level of health systems. We included articles if they reported results of qualitative or quantitative empirical study, case studies, analytic or descriptive synthesis, any review, and other written documents, were published in peer-reviewed journals, and were designed to address at least one of the identified research questions or one of the identified implementation outcomes or their synonymous taxonomy as described in the search strategy. Based on additional contexts, we included articles published in English without geographic and time limitations. We excluded articles with abstracts only, conference abstracts, letters to editors, commentators, and corrections.

We exported all citations to EndNote x20 to remove duplicates and screen relevant articles. The article selection process includes automatic duplicate removal by using EndNote x20, unmatched title and abstract removal, citation and abstract-only materials removal, and full-text assessment. The article selection process was mainly conducted by the first author (AE) and reported to the team during the weekly meetings. The first author encountered papers that caused confusion regarding whether to include or exclude them and discussed them with the last author (YA). Then, decisions were ultimately made. Whenever disagreements happened, they were resolved by discussion and reconsideration of the review questions in relation to the written documents of the article. Further statistical analysis, such as calculating Kappa, was not performed to determine article inclusion or exclusion.

Data extraction and data items

We extracted first author, publication year, country, settings, health problem, the purpose of the study, study design, types of intervention if applicable, CQI approaches/steps if applicable, CQI tools and procedures if applicable, and main findings using a customized Microsoft Excel form.

Summarizing and reporting the results

The main findings were summarized and described based on the main themes, including concepts under conceptualizing, principles, teams, timelines, models, tools, barriers, facilitators, and impacts of CQI. Results-based convergent synthesis, achieved through mixed-method analysis, involved content analysis to identify the thematic presentation of findings. Additionally, a narrative description was used for quantitative findings, aligning them with the appropriate theme. The authors meticulously reviewed the primary findings from each included material and contextualized these findings concerning the main themes1. This approach provides a comprehensive understanding of complex interventions and health systems, acknowledging quantitative and qualitative evidence.

Search results

A total of 11,251 documents were identified from various databases: SCOPUS ( n  = 4,339), PubMed ( n  = 2,893), Web of Science ( n  = 225), EMBASE ( n  = 3,651), and Google Scholar ( n  = 143). After removing duplicates ( n  = 5,061), 6,190 articles were evaluated by title and abstract. Subsequently, 208 articles were assessed for full-text eligibility. Following the eligibility criteria, 121 articles were excluded, leaving 87 included in the current review (Fig.  1 ).

Article selection process

Operationalizing continuous quality improvement

Continuous Quality Improvement (CQI) is operationalized as a cyclic process that requires commitment to implementation, teamwork, time allocation, and celebrating successes and failures.

CQI is a cyclic ongoing process that is followed reflexive, analytical and iterative steps, including identifying gaps, generating data, developing and implementing action plans, evaluating performance, providing feedback to implementers and leaders, and proposing necessary adjustments [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ].

CQI requires committing to the philosophy, involving continuous improvement [ 19 , 38 ], establishing a mission statement [ 37 ], and understanding quality definition [ 19 ].

CQI involves a wide range of patient-oriented measures and performance indicators, specifically satisfying internal and external customers, developing quality assurance, adopting common quality measures, and selecting process measures [ 8 , 19 , 35 , 36 , 37 , 39 , 40 ].

CQI requires celebrating success and failure without personalization, leading each team member to develop error-free attitudes [ 19 ]. Success and failure are related to underlying organizational processes and systems as causes of failure rather than blaming individuals [ 8 ] because CQI is process-focused based on collaborative, data-driven, responsive, rigorous and problem-solving statistical analysis [ 8 , 19 , 38 ]. Furthermore, a gap or failure opens another opportunity for establishing a data-driven learning organization [ 41 ].

CQI cannot be implemented without a CQI team [ 8 , 19 , 37 , 39 , 42 , 43 , 44 , 45 , 46 ]. A CQI team comprises individuals from various disciplines, often comprising a team leader, a subject matter expert (physician or other healthcare provider), a data analyst, a facilitator, frontline staff, and stakeholders [ 39 , 43 , 47 , 48 , 49 ]. It is also important to note that inviting stakeholders or partners as part of the CQI support intervention is crucial [ 19 , 38 , 48 ].

The timeline is another distinct feature of CQI because the results of CQI vary based on the implementation duration of each cycle [ 35 ]. There is no specific time limit for CQI implementation, although there is a general consensus that a cycle of CQI should be relatively short [ 35 ]. For instance, a CQI implementation took 2 months [ 42 ], 4 months [ 50 ], 9 months [ 51 , 52 ], 12 months [ 53 , 54 , 55 ], and one year and 5 months [ 49 ] duration to achieve the desired positive outcome, while bi-weekly [ 47 ] and monthly data reviews and analyses [ 44 , 48 , 56 ], and activities over 3 months [ 57 ] have also resulted in a positive outcome.

Continuous quality improvement models and tools

There have been several models are utilized. The Plan-Do-Study/Check-Act cycle is a stepwise process involving project initiation, situation analysis, root cause identification, solution generation and selection, implementation, result evaluation, standardization, and future planning [ 7 , 36 , 37 , 45 , 47 , 48 , 49 , 50 , 51 , 53 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ]. The FOCUS-PDCA cycle enhances the PDCA process by adding steps to find and improve a process (F), organize a knowledgeable team (O), clarify the process (C), understand variations (U), and select improvements (S) [ 55 , 71 , 72 , 73 ]. The FADE cycle involves identifying a problem (Focus), understanding it through data analysis (Analyze), devising solutions (Develop), and implementing the plan (Execute) [ 74 ]. The Logic Framework involves brainstorming to identify improvement areas, conducting root cause analysis to develop a problem tree, logically reasoning to create an objective tree, formulating the framework, and executing improvement projects [ 75 ]. Breakthrough series approach requires CQI teams to meet in quarterly collaborative learning sessions, share learning experiences, and continue discussion by telephone and cross-site visits to strengthen learning and idea exchange [ 47 ]. Another CQI model is the Lean approach, which has been conducted with Kaizen principles [ 52 ], 5 S principles, and the Six Sigma model. The 5 S (Sort, Set/Straighten, Shine, Standardize, Sustain) systematically organises and improves the workplace, focusing on sorting, setting order, shining, standardizing, and sustaining the improvement [ 54 , 76 ]. Kaizen principles guide CQI by advocating for continuous improvement, valuing all ideas, solving problems, focusing on practical, low-cost improvements, using data to drive change, acknowledging process defects, reducing variability and waste, recognizing every interaction as a customer-supplier relationship, empowering workers, responding to all ideas, and maintaining a disciplined workplace [ 77 ]. Lean Six Sigma, a CQI model, applies the DMAIC methodology, which involves defining (D) and measuring the problem (M), analyzing root causes (A), improving by finding solutions (I), and controlling by assessing process stability (C) [ 78 , 79 ]. The 5 C-cyclic model (consultation, collection, consideration, collaboration, and celebration), the first CQI framework for volunteer dental services in Aboriginal communities, ensures quality care based on community needs [ 80 ]. One study used meetings involving activities such as reviewing objectives, assigning roles, discussing the agenda, completing tasks, retaining key outputs, planning future steps, and evaluating the meeting’s effectiveness [ 81 ].

Various tools are involved in the implementation or evaluation of CQI initiatives: checklists [ 53 , 82 ], flowcharts [ 81 , 82 , 83 ], cause-and-effect diagrams (fishbone or Ishikawa diagrams) [ 60 , 62 , 79 , 81 , 82 ], fuzzy Pareto diagram [ 82 ], process maps [ 60 ], time series charts [ 48 ], why-why analysis [ 79 ], affinity diagrams and multivoting [ 81 ], and run chart [ 47 , 48 , 51 , 60 , 84 ], and others mentioned in the table (Table  1 ).

Barriers and facilitators of continuous quality improvement implementation

Implementing CQI initiatives is determined by various barriers and facilitators, which can be thematized into four dimensions. These dimensions are cultural, technical, structural, and strategic dimensions.

Continuous quality improvement initiatives face various cultural, strategic, technical, and structural barriers. Cultural dimension barriers involve resistance to change (e.g., not accepting online technology), lack of quality-focused culture, staff reporting apprehensiveness, and fear of blame or punishment [ 36 , 41 , 85 , 86 ]. The technical dimension barriers of CQI can include various factors that hinder the effective implementation and execution of CQI processes [ 36 , 86 , 87 , 88 , 89 ]. Structural dimension barriers of CQI arise from the organization structure, process, and systems that can impede the effective implementation and sustainability of CQI [ 36 , 85 , 86 , 87 , 88 ]. Strategic dimension barriers are, for example, the inability to select proper CQI goals and failure to integrate CQI into organizational planning and goals [ 36 , 85 , 86 , 87 , 88 , 90 ].

Facilitators are also grouped to cultural, structural, technical, and strategic dimensions to provide solutions to CQI barriers. Cultural challenges were addressed by developing a group culture to CQI and other rewards [ 39 , 41 , 80 , 85 , 86 , 87 , 90 , 91 , 92 ]. Technical facilitators are pivotal to improving technical barriers [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ]. Structural-related facilitators are related to improving communication, infrastructure, and systems [ 86 , 92 , 93 ]. Strategic dimension facilitators include strengthening leadership and improving decision-making skills [ 43 , 53 , 67 , 86 , 87 , 92 , 94 , 95 ] (Table  2 ).

Impact of continuous quality improvement

Continuous quality improvement initiatives can significantly impact the quality of healthcare in a wide range of health areas, focusing on improving structure, the health service delivery process and improving client wellbeing and reducing mortality.

Structure components

These are health leadership, financing, workforce, technology, and equipment and supplies. CQI has improved planning, monitoring and evaluation [ 48 , 53 ], and leadership and planning [ 48 ], indicating improvement in leadership perspectives. Implementing CQI in primary health care (PHC) settings has shown potential for maintaining or reducing operation costs [ 67 ]. Findings from another study indicate that the costs associated with implementing CQI interventions per facility ranged from approximately $2,000 to $10,500 per year, with an average cost of approximately $10 to $60 per admitted client [ 57 ]. However, based on model predictions, the average cost savings after implementing CQI were estimated to be $5430 [ 31 ]. CQI can also be applied to health workforce development [ 32 ]. CQI in the institutional system improved medical education [ 66 , 96 , 97 ], human resources management [ 53 ], motivated staffs [ 76 ], and increased staff health awareness [ 69 ], while concerns raised about CQI impartiality, independence, and public accountability [ 96 ]. Regarding health technology, CQI also improved registration and documentation [ 48 , 53 , 98 ]. Furthermore, the CQI initiatives increased cleanliness [ 54 ] and improved logistics, supplies, and equipment [ 48 , 53 , 68 ].

Process and output components

The process component focuses on the activities and actions involved in delivering healthcare services.

Service delivery

CQI interventions improved service delivery [ 53 , 56 , 99 ], particularly a significant 18% increase in the overall quality of service performance [ 48 ], improved patient counselling, adherence to appropriate procedures, and infection prevention [ 48 , 68 ], and optimised workflow [ 52 ].

Coordination and collaboration

CQI initiatives improved coordination and collaboration through collecting and analysing data, onsite technical support, training, supportive supervision [ 53 ] and facilitating linkages between work processes and a quality control group [ 65 ].

Patient satisfaction

The CQI initiatives increased patient satisfaction and improved quality of life by optimizing care quality management, improving the quality of clinical nursing, reducing nursing defects and enhancing the wellbeing of clients [ 54 , 76 , 100 ], although CQI was not associated with changes in adolescent and young adults’ satisfaction [ 51 ].

CQI initiatives reduced medication error reports from 16 to 6 [ 101 ], and it significantly reduced the administration of inappropriate prophylactic antibiotics [ 44 ], decreased errors in inpatient care [ 52 ], decreased the overall episiotomy rate from 44.5 to 33.3% [ 83 ], reduced the overall incidence of unplanned endotracheal extubation [ 102 ], improving appropriate use of computed tomography angiography [ 103 ], and appropriate diagnosis and treatment selection [ 47 ].

Continuity of care

CQI initiatives effectively improve continuity of care by improving client and physician interaction. For instance, provider continuity levels showed a 64% increase [ 55 ]. Modifying electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives in post-natal follow-up care increased continuity of care to 74% in 2018 compared to baseline 13% in 2012 [ 84 ].

The CQI initiative yielded enhanced efficiency in the cardiac catheterization laboratory, as evidenced by improved punctuality in procedure starts and increased efficiency in manual sheath-pulls inside [ 78 ].

Accessibility

CQI initiatives were effective in improving accessibility in terms of increasing service coverage and utilization rate. For instance, screening for cigarettes, nutrition counselling, folate prescription, maternal care, immunization coverage [ 53 , 81 , 104 , 105 ], reducing the percentage of non-attending patients to surgery to 0.9% from the baseline 3.9% [ 43 ], increasing Chlamydia screening rates from 29 to 60% [ 45 ], increasing HIV care continuum coverage [ 51 , 59 , 60 ], increasing in the uptake of postpartum long-acting reversible contraceptive use from 6.9% at the baseline to 25.4% [ 42 ], increasing post-caesarean section prophylaxis from 36 to 89% [ 62 ], a 31% increase of kangaroo care practice [ 50 ], and increased follow-up [ 65 ]. Similarly, the QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7%, and correct active third-stage labour management, a 19.6% improvement from the baseline, but not significantly associated with improvement in contraceptive service uptake [ 61 ].

Timely access

CQI interventions improved the time care provision [ 52 ], and reduced waiting time [ 62 , 74 , 76 , 106 ]. For instance, the discharge process waiting time in the emergency department decreased from 76 min to 22 min [ 79 ]. It also reduced mean postprocedural length of stay from 2.8 days to 2.0 days [ 31 ].

Acceptability

Acceptability of CQI by healthcare providers was satisfactory. For instance, 88% of the faculty, 64% of the residents, and 82% of the staff believed CQI to be useful in the healthcare clinic [ 107 ].

Outcome components

Morbidity and mortality.

CQI efforts have demonstrated better management outcomes among diabetic patients [ 40 ], patients with oral mucositis [ 71 ], and anaemic patients [ 72 ]. It has also reduced infection rate in post-caesarean Sect. [ 62 ], reduced post-peritoneal dialysis peritonitis [ 49 , 108 ], and prevented pressure ulcers [ 70 ]. It is explained by peritonitis incidence from once every 40.1 patient months at baseline to once every 70.8 patient months after CQI [ 49 ] and a 63% reduction in pressure ulcer prevalence within 2 years from 2008 to 2010 [ 70 ]. Furthermore, CQI initiatives significantly reduced in-hospital deaths [ 31 ] and increased patient survival rates [ 108 ]. Figure  2 displays the overall process of the CQI implementations.

The overall mechanisms of continuous quality improvement implementation

In this review, we examined the fundamental concepts and principles underlying CQI, the factors that either hinder or assist in its successful application and implementation, and the purpose of CQI in enhancing quality of care across various health issues.

Our findings have brought attention to the application and implementation of CQI, emphasizing its underlying concepts and principles, as evident in the existing literature [ 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 , 43 , 45 , 46 ]. Continuous quality improvement has shared with the principles of continuous improvement, such as a customer-driven focus, effective leadership, active participation of individuals, a process-oriented approach, systematic implementation, emphasis on design improvement and prevention, evidence-based decision-making, and fostering partnership [ 5 ]. Moreover, Deming’s 14 principles laid the foundation for CQI principles [ 109 ]. These principles have been adapted and put into practice in various ways: ten [ 19 ] and five [ 38 ] principles in hospitals, five principles for capacity building [ 38 ], and two principles for medication error prevention [ 41 ]. As a principle, the application of CQI can be process-focused [ 8 , 19 ] or impact-focused [ 38 ]. Impact-focused CQI focuses on achieving specific outcomes or impacts, whereas process-focused CQI prioritizes and improves the underlying processes and systems. These principles complement each other and can be utilized based on the objectives of quality improvement initiatives in healthcare settings. Overall, CQI is an ongoing educational process that requires top management’s involvement, demands coordination across departments, encourages the incorporation of views beyond clinical area, and provides non-judgemental evidence based on objective data [ 110 ].

The current review recognized that it was not easy to implement CQI. It requires reasonable utilization of various models and tools. The application of each tool can be varied based on the studied health problem and the purpose of CQI initiative [ 111 ], varied in context, content, structure, and usability [ 112 ]. Additionally, overcoming the cultural, technical, structural, and strategic-related barriers. These barriers have emerged from clinical staff, managers, and health systems perspectives. Of the cultural obstacles, staff non-involvement, resistance to change, and reluctance to report error were staff-related. In contrast, others, such as the absence of celebration for success and hierarchical and rational culture, may require staff and manager involvement. Staff members may exhibit reluctance in reporting errors due to various cultural factors, including lack of trust, hierarchical structures, fear of retribution, and a blame-oriented culture. These challenges pose obstacles to implementing standardized CQI practices, as observed, for instance, in community pharmacy settings [ 85 ]. The hierarchical culture, characterized by clearly defined levels of power, authority, and decision-making, posed challenges to implementing CQI initiatives in public health [ 41 , 86 ]. Although rational culture, a type of organizational culture, emphasizes logical thinking and rational decision-making, it can also create challenges for CQI implementation [ 41 , 86 ] because hierarchical and rational cultures, which emphasize bureaucratic norms and narrow definitions of achievement, were found to act as barriers to the implementation of CQI [ 86 ]. These could be solved by developing a shared mindset and collective commitment, establishing a shared purpose, developing group norms, and cultivating psychological preparedness among staff, managers, and clients to implement and sustain CQI initiatives. Furthermore, reversing cultural-related barriers necessitates cultural-related solutions: development of a culture and group culture to CQI [ 41 , 86 ], positive comprehensive perception [ 91 ], commitment [ 85 ], involving patients, families, leaders, and staff [ 39 , 92 ], collaborating for a common goal [ 80 , 86 ], effective teamwork [ 86 , 87 ], and rewarding and celebrating successes [ 80 , 90 ].

The technical dimension barriers of CQI can include inadequate capitalization of a project and insufficient support for CQI facilitators and data entry managers [ 36 ], immature electronic medical records or poor information systems [ 36 , 86 ], and the lack of training and skills [ 86 , 87 , 88 ]. These challenges may cause the CQI team to rely on outdated information and technologies. The presence of barriers on the technical dimension may challenge the solid foundation of CQI expertise among staff, the ability to recognize opportunities for improvement, a comprehensive understanding of how services are produced and delivered, and routine use of expertise in daily work. Addressing these technical barriers requires knowledge creation activities (training, seminar, and education) [ 39 , 42 , 53 , 69 , 86 , 90 , 91 ], availability of quality data [ 86 ], reliable information [ 92 ], and a manual-online hybrid reporting system [ 85 ].

Structural dimension barriers of CQI include inadequate communication channels and lack of standardized process, specifically weak physician-to-physician synergies [ 36 ], lack of mechanisms for disseminating knowledge and limited use of communication mechanisms [ 86 ]. Lack of communication mechanism endangers sharing ideas and feedback among CQI teams, leading to misunderstandings, limited participation and misinterpretations, and a lack of learning [ 113 ]. Knowledge translation facilitates the co-production of research, subsequent diffusion of knowledge, and the developing stakeholder’s capacity and skills [ 114 ]. Thus, the absence of a knowledge translation mechanism may cause missed opportunities for learning, inefficient problem-solving, and limited creativity. To overcome these challenges, organizations should establish effective communication and information systems [ 86 , 93 ] and learning systems [ 92 ]. Though CQI and knowledge translation have interacted with each other, it is essential to recognize that they are distinct. CQI focuses on process improvement within health care systems, aiming to optimize existing processes, reduce errors, and enhance efficiency.

In contrast, knowledge translation bridges the gap between research evidence and clinical practice, translating research findings into actionable knowledge for practitioners. While both CQI and knowledge translation aim to enhance health care quality and patient outcomes, they employ different strategies: CQI utilizes tools like Plan-Do-Study-Act cycles and statistical process control, while knowledge translation involves knowledge synthesis and dissemination. Additionally, knowledge translation can also serve as a strategy to enhance CQI. Both concepts share the same principle: continuous improvement is essential for both. Therefore, effective strategies on the structural dimension may build efficient and effective steering councils, information systems, and structures to diffuse learning throughout the organization.

Strategic factors, such as goals, planning, funds, and resources, determine the overall purpose of CQI initiatives. Specific barriers were improper goals and poor planning [ 36 , 86 , 88 ], fragmentation of quality assurance policies [ 87 ], inadequate reinforcement to staff [ 36 , 90 ], time constraints [ 85 , 86 ], resource inadequacy [ 86 ], and work overload [ 86 ]. These barriers can be addressed through strengthening leadership [ 86 , 87 ], CQI-based mentoring [ 94 ], periodic monitoring, supportive supervision and coaching [ 43 , 53 , 87 , 92 , 95 ], participation, empowerment, and accountability [ 67 ], involving all stakeholders in decision-making [ 86 , 87 ], a provider-payer partnership [ 64 ], and compensating staff for after-hours meetings on CQI [ 85 ]. The strategic dimension, characterized by a strategic plan and integrated CQI efforts, is devoted to processes that are central to achieving strategic priorities. Roles and responsibilities are defined in terms of integrated strategic and quality-related goals [ 115 ].

The utmost goal of CQI has been to improve the quality of care, which is usually revealed by structure, process, and outcome. After resolving challenges and effectively using tools and running models, the goal of CQI reflects the ultimate reason and purpose of its implementation. First, effectively implemented CQI initiatives can improve leadership, health financing, health workforce development, health information technology, and availability of supplies as the building blocks of a health system [ 31 , 48 , 53 , 68 , 98 ]. Second, effectively implemented CQI initiatives improved care delivery process (counselling, adherence with standards, coordination, collaboration, and linkages) [ 48 , 53 , 65 , 68 ]. Third, the CQI can improve outputs of healthcare delivery, such as satisfaction, accessibility (timely access, utilization), continuity of care, safety, efficiency, and acceptability [ 52 , 54 , 55 , 76 , 78 ]. Finally, the effectiveness of the CQI initiatives has been tested in enhancing responses related to key aspects of the HIV response, maternal and child health, non-communicable disease control, and others (e.g., surgery and peritonitis). However, it is worth noting that CQI initiative has not always been effective. For instance, CQI using a two- to nine-times audit cycle model through systems assessment tools did not bring significant change to increase syphilis testing performance [ 116 ]. This study was conducted within the context of Aboriginal and Torres Strait Islander people’s primary health care settings. Notably, ‘the clinics may not have consistently prioritized syphilis testing performance in their improvement strategies, as facilitated by the CQI program’ [ 116 ]. Additionally, by applying CQI-based mentoring, uptake of facility-based interventions was not significantly improved, though it was effective in increasing community health worker visits during pregnancy and the postnatal period, knowledge about maternal and child health and exclusive breastfeeding practice, and HIV disclosure status [ 117 ]. The study conducted in South Africa revealed no significant association between the coverage of facility-based interventions and Continuous Quality Improvement (CQI) implementation. This lack of association was attributed to the already high antenatal and postnatal attendance rates in both control and intervention groups at baseline, leaving little room for improvement. Additionally, the coverage of HIV interventions remained consistently high throughout the study period [ 117 ].

Regarding health care and policy implications, CQI has played a vital role in advancing PHC and fostering the realization of UHC goals worldwide. The indicators found in Donabedian’s framework that are positively influenced by CQI efforts are comparable to those included in the PHC performance initiative’s conceptual framework [ 29 , 118 , 119 ]. It is clearly explained that PHC serves as the roadmap to realizing the vision of UHC [ 120 , 121 ]. Given these circumstances, implementing CQI can contribute to the achievement of PHC principles and the objectives of UHC. For instance, by implementing CQI methods, countries have enhanced the accessibility, affordability, and quality of PHC services, leading to better health outcomes for their populations. CQI has facilitated identifying and resolving healthcare gaps and inefficiencies, enabling countries to optimize resource allocation and deliver more effective and patient-centered care. However, it is crucial to recognize that the successful implementation of Continuous Quality Improvement (CQI) necessitates optimizing the duration of each cycle, understanding challenges and barriers that extend beyond the health system and settings, and acknowledging that its effectiveness may be compromised if these challenges are not adequately addressed.

Despite abundant literature, there are still gaps regarding the relationship between CQI and other dimensions within the healthcare system. No studies have examined the impact of CQI initiatives on catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness.

Limitations

In conducting this review, it has some limitations to consider. Firstly, only articles published in English were included, which may introduce the exclusion of relevant non-English articles. Additionally, as this review follows a scoping methodology, the focus is on synthesising available evidence rather than critically evaluating or scoring the quality of the included articles.

Continuous quality improvement is investigated as a continuous and ongoing intervention, where the implementation time can vary across different cycles. The CQI team and implementation timelines were critical elements of CQI in different models. Among the commonly used approaches, the PDSA or PDCA is frequently employed. In most CQI models, a wide range of tools, nineteen tools, are commonly utilized to support the improvement process. Cultural, technical, structural, and strategic barriers and facilitators are significant in implementing CQI initiatives. Implementing the CQI initiative aims to improve health system blocks, enhance health service delivery process and output, and ultimately prevent morbidity and reduce mortality. For future researchers, considering that CQI is context-dependent approach, conducting scale-up implementation research about catastrophic health expenditure, effective service coverage, patient-centredness, comprehensiveness, equity, health security, and responsiveness across various settings and health issues would be valuable.

Availability of data and materials

The data used and/or analyzed during the current study are available in this manuscript and/or the supplementary file.

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Endalamaw, A., Khatri, R.B., Mengistu, T.S. et al. A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Serv Res 24 , 487 (2024). https://doi.org/10.1186/s12913-024-10828-0

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Online shopping has grown rapidly in U.S., but most sales are still in stores

Thanksgiving – and, more specifically,  Black Friday  – is the semiofficial start of the holiday shopping season in the United States. And if history is any guide, a lot of this year’s holiday shopping will be done online, and not just on Cyber Monday .

Like retail sales generally, online shopping reliably surges in the fourth quarter of every year. In 2022, for example, online sales – or, as the U.S. Census Bureau calls them,  “retail e-commerce sales” – totaled $303.1 billion in the October-December period. That was 23.4% higher than the quarterly average for the first nine months of the year, which was $245.6 billion. (Figures in this analysis are not adjusted to account for seasonal variations.)

But it’s not just the dollar volume of sales that peaks in the fourth quarter – the online share of all retail sales ticks higher at year’s end, too. In the fourth quarter of 2022, for instance, online sales accounted for 16.3% of all retail sales, compared with an average of 14.1% in the first three quarters.

The fourth quarter of 2023 could be another big one for online shopping . Through the first three quarters of the year, retail e-commerce totaled $793.7 billion, or 14.9% of all retail sales.

 Related: For shopping, phones are common and influencers have become a factor – especially for young adults

As the 2023 holiday shopping season begins, Pew Research Center wanted to find out just how significant online sales are as a share of total retail sales in the United States.

The primary keeper of such data is the U.S. Census Bureau, which, since 2000, has produced a  quarterly report on “retail e-commerce sales.”  The estimates in that report are based on the same sample of 10,800 retail firms the Census Bureau uses for its  Monthly Retail Trade Survey (MRTS). The MRTS sample is weighted and benchmarked to represent the full universe of more than 2 million retail firms.

It’s important to note that bars and restaurants are not considered retailers for the purposes of the bureau’s surveys. Online travel services, ticket sellers and financial-services brokers and dealers likewise are excluded from coverage.

This analysis uses data that has not been adjusted to account for seasonal variations. Figures for the third quarter of 2023 are preliminary, based on data released Nov. 17, 2023.

Online sales have grown over time

Between 2000 and 2020, growth in online sales followed a predictable pattern. The online share of retail sales jumped in the fourth quarter and then fell back, but not all the way to where it had been. Then it jumped again, to an even higher level, in the fourth quarter of the following year.

By such stepwise moves, the online share of total retail sales grew from 0.7% in the fourth quarter of 1999, when the U.S. Census Bureau began tracking online sales, to 12.4% in the fourth quarter of 2019.

The COVID-19 pandemic that swept the globe disrupted that pattern, at least temporarily, beginning in early 2020. With many physical stores shuttered and millions of Americans sheltering in their homes, online sales soared. In the second quarter of 2020, for instance, e-commerce sales totaled $205.3 billion, up 55% from the $132.3 billion recorded a year earlier. In the fourth quarter of 2020, e-commerce accounted for 16.7% of all retail sales, still the record-high share.

That share fell back as stores reopened and consumers gradually resumed their old shopping habits. But the e-commerce share of all retail sales has remained well above pre-pandemic levels, suggesting that the COVID-19 outbreak gave online shopping a lasting boost. In the fourth quarter of 2022, 16.3% of retail sales were online, compared with 16.1% in 2021.

Which retailers benefit most from online sales?

The retailers that are getting the highest share of online sales tend to be those without physical stores.

Nonstore retailers , as the Census Bureau calls them, took nearly 62% of all retail e-commerce sales in the third quarter of 2023, versus just over 59% a year earlier. E-commerce sales at nonstore retailers rose 12.4% year over year, faster than the online sales sector as a whole.

Among retailers that do have physical stores, online sales rose 8.7% at general merchandise stores, 5.1% at food and beverage stores, and 4.7% at health and personal care stores. But online sales fell 1.6% at electronics and appliance stores, 3.2% at motor vehicle and parts dealers, and 16.2% at furniture and home furnishings stores.

Where does Black Friday get its name?

For years, the claim circulated that Black Friday got its name because of its role in retailers’ profitability. The notion was that most retailers operated at a loss, or  “in the red,”  for most of the year and relied on holiday sales to become profitable, or “in the black.”

However, the  actual origins appear to be more prosaic . Philadelphia police began calling the day after Thanksgiving “Black Friday” in the 1950s because the floods of holiday shoppers into downtown  made their jobs extra difficult .

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Drew DeSilver is a senior writer at Pew Research Center

On alternative social media sites, many prominent accounts seek financial support from audiences

Majority of americans aren’t confident in the safety and reliability of cryptocurrency, for shopping, phones are common and influencers have become a factor – especially for young adults, payment apps like venmo and cash app bring convenience – and security concerns – to some users, 16% of americans say they have ever invested in, traded or used cryptocurrency, most popular.

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