Online Patient Resources for Liposuction: A Comparative Analysis of Readability

A cross-sectional quantitative analysis of the readability and quality of online resources regarding thumb carpometacarpal joint replacement surgery

Background

Thumb carpometacarpal (CMC) joint osteoarthritis is a common degenerative condition that affects up to 15 ​% of the population older than 30 years. Poor readability of online health resources has been associated with misinformation, inappropriate care, incorrect self-treatment, worse health outcomes, and increased healthcare resource waste. This study aims to assess the readability and quality of online information regarding thumb carpometacarpal (CMC) joint replacement surgery.

Methods

The terms "thumb joint replacement surgery", "thumb carpometacarpal joint replacement surgery", "thumb cmc joint replacement surgery", "thumb arthroplasty", "thumb carpometacarpal arthroplasty", and "thumb cmc arthroplasty" were searched in Google and Bing. Readability was determined using the Flesch Reading Ease Score (FRES) and the Flesch-Kincaid Reading Grade Level (FKGL). FRES >65 or a grade level score of sixth grade and under was considered acceptable. Quality was assessed using the Patient Education Materials Assessment Tool (PEMAT) and a modified DISCERN tool. PEMAT scores below 70 were considered poorly understandable and poorly actionable.

Results

A total of 34 websites underwent qualitative analysis. The average FRES was 54.60 ​± ​7.91 (range 30.30-67.80). Only 3 (8.82 ​%) websites had a FRES score >65. The average FKGL score was 8.19 ​± ​1.80 (range 5.60-12.90). Only 3 (8.82 ​%) websites were written at or below a sixth-grade level. The average PEMAT percentage score for understandability and actionability was 76.82 ​± ​9.43 (range 61.54-93.75) and 36.18 ​± ​24.12 (range 0.00-60.00) respectively. Although 22 (64.71 ​%) of websites met the acceptable standard of 70 ​% for understandability, none of the websites met the acceptable standard of 70 ​% for actionability. The average total DISCERN score was 32.00 ​± ​4.29 (range 24.00-42.00).

Conclusions

Most websites reviewed were written above recommended reading levels. Most showed acceptable understandability but none showed acceptable actionability. To avoid the negative outcomes of poor patient understanding of online resources, providers of these resources should optimise accessibility to the average reader by using simple words, avoiding jargon, and analysing texts with readability software before publishing the materials online. Websites should also utilise visual aids and provide clearer pre-operative and post-operative instructions.

The Readability of Patient-Facing Social Media Posts on Common Otolaryngologic Diagnoses

OBJECTIVE

To assess the readability of patient-facing educational information about the most common otolaryngology diagnoses on popular social media platforms.

STUDY DESIGN

Cross-sectional study.

SETTING

Social media platforms.

METHODS

The top 5 otolaryngologic diagnoses were identified from the National Ambulatory Medical Care Survey Database. Facebook, Twitter, TikTok, and Instagram were searched using these terms, and the top 25 patient-facing posts from unique accounts for each search term and poster type (otolaryngologist, other medical professional, layperson) were identified. Captions, text, and audio from images and video, and linked articles were extracted. The readability of each post element was calculated with multiple readability formulae. Readability was summarized and was compared between poster types, platforms, and search terms via Kruskal-Wallis testing.

RESULTS

Median readability, by grade level, by grade level, was greater than 10 for captions, 5 for image-associated text, and 9 for linked articles. Captions and images in posts by laypeople were significantly more readable than captions by otolaryngologists or other medical professionals, but there was no difference for linked articles. All post components were more readable in posts about cerumen than those about other search terms.

CONCLUSIONS

When examining the readability of posts on social media regarding the most common otolaryngology diagnoses, we found that many posts are less readable than recommended for patients, and found that posts by laypeople were significantly more readable than those by medical professionals. Medical professionals should work to make educational social media posts more readable to facilitate patient comprehension.

An Analysis of the Readability of Online Sarcoidosis Resources

Introduction Sarcoidosis is an inflammatory disease characterized by the formation of noncaseating granulomas in multiple organ systems. The presentation can vary widely; although some patients with sarcoidosis can be asymptomatic, sarcoidosis can also present in others with symptomatic multiorgan system involvement. Considering the potential severity of the disease, patients need to be well-informed about sarcoidosis to better manage their health. This study aims to assess the readability levels of online resources about sarcoidosis. Methods We conducted a retrospective cross-sectional study. The term "sarcoidosis" was searched online using both Google and Bing to find websites written in English. Each website was categorized by type: academic, commercial, government, nonprofit, and physician. The readability scores for each website were calculated using six different readability tests: the Flesch-Kincaid reading ease (FKRE), Flesch-Kincaid grade level (FKGL), Gunning fog score (GFS), Simple Measure of Gobbledygook (SMOG), automated readability index (ARI), and Coleman-Liau index (CLI). FKRE gives a score that corresponds to the difficulty of the text, while the remaining tests give a score that corresponds to a grade level in terms of reading ability. A one-sample t-test was used to compare all test scores with the national recommended standard of a sixth-grade reading level. Our null hypothesis was that the readability scores of the websites searched would not differ statistically significantly from the sixth-grade reading level and that there would be no significant differences across website categories. To evaluate the difference between the categories of websites, ANOVA testing was used. Results Thirty-four websites were analyzed. Each of the six readability tests for the websites had an average score, which corresponded to being significantly harder to read than the nationally recommended sixth-grade reading level (p<0.001). None of the mean readability scores showed a statistically significant difference across the five different website categories. Conclusions This is the first study, to our knowledge, to examine the readability of online English resources on sarcoidosis and calculate standardized readability scores for them. It implies that the online English material for sarcoidosis is above the health literacy recommended reading levels for patients. There is a need to simplify the material to be easier to read for patients.

Entering the Misinformation Age: Quality and Reliability of YouTube for Patient Information on Liposuction

Background: YouTube is currently the most popular online platform and is increasingly being utilized by patients as a resource on aesthetic surgery. Yet, its content is largely unregulated and this may result in dissemination of unreliable and inaccurate information. The objective of this study was to evaluate the quality and reliability of YouTube liposuction content available to potential patients. Methods: YouTube was screened using the keywords: "liposuction," "lipoplasty," and "body sculpting." The top 50 results for each term were screened for relevance. Videos which met the inclusion criteria were scored using the Global Quality Score (GQS) for educational value and the Journal of the American Medical Association (JAMA) criteria for video reliability. Educational value, reliability, video views, likes, dislikes, duration and publishing date were compared between authorship groups, high/low reliability, and high/low educational value. Results: A total of 150 videos were screened, of which 89 videos met the inclusion criteria. Overall, the videos had low reliability (mean JAMA score = 2.78, SD = 1.15) and low educational value (mean GQS score = 3.55, SD = 1.31). Videos uploaded by physicians accounted for 83.1% percent of included videos and had a higher mean educational value and reliability score than those by patients. Video views, likes, dislikes, comments, popularity, and length were significantly greater in videos with high reliability. Conclusions: To ensure liposuction-seeking patients are appropriately educated and informed, surgeons and their patients may benefit from an analysis of educational quality and reliability of such online content. Surgeons may wish to discuss online sources of information with patients.

Readability of Online Patient Education Materials for Total Joint Arthroplasty: A Systematic Review

BACKGROUND

As the demand for total joint arthroplasty continues to grow, patients increasingly turn to internet sources for accessible orthopaedic health information. We sought to evaluate the readability of online hip and knee arthroplasty patient education materials (PEMs).

METHODS

Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-P guidelines (PROSPERO registration of the study protocol: CRD42022358872, September 19th, 2022). PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were utilized to identify all studies evaluating online PEMs related to total joint arthroplasty between January 1, 2000, and August 1, 2022. The quality of studies was assessed with the Joanna Briggs Institute scale.

RESULTS

Our initial search yielded 360 publications which were then screened for appropriate studies aligned with our review's purpose. A total of eleven cross-sectional studies were included. The total sample size across the studies consisted of 662 PEMs. Five studies evaluated professional or academic orthopaedic websites, six evaluated PEMs through web engines, and three evaluated apps or commercial websites. Most included studies found PEMs to be well above the recommended 6th-grade reading level.

CONCLUSION

Arthroplasty PEMs produced by orthopaaedic websites, web searches, and apps have readability scores well above the recommended levels. Given the importance of health literacy on patient outcomes and satisfaction, work needs to be done to improve the readability of these materials.

An Analysis of the Readability of Phacoemulsification Online Resources

Introduction: Cataract is the leading cause of blindness worldwide. Phacoemulsification is now the gold standard for cataract extraction and is greatly needed in low socioeconomic status (SES) communities, rural and older patient populations, and patients with poor vision. This greatly increases the importance of high readability for online resources on this topic. This study aims to assess the readability of online information about phacoemulsification based on readability scores for each resource. 

Methods: We conducted a retrospective cross-sectional study. The term “phacoemulsification” was searched online, and each website was categorized by type: academic, physician, non-physician, commercial, social media, and unspecified. The readability scores for each website were calculated using six different readability tests and a composite score that reflects reading grade level was obtained. To evaluate the difference between the categories of websites, analysis of variance (ANOVA) testing was used. All test scores were compared with the 6^th grade standard recommendation using a one-sample t-test.

Results: A total of 20 websites were analyzed. Three websites (3/20; 15%) had a score which is correlated with a 6^th grade reading level or below. Seventeen websites had a score correlated with a college reading level or above (17/20; 85%). None of the readability scores had a mean below a 6^th grade reading level. No category had an average readability score at or below a 6^th grade reading level. None of the mean readability scores resulted in a statistically significant difference across categories. All readability tests had an average score which was significantly different from a 6^th grade reading level (p<0.001). 

Conclusions: This is the first study to focus on the accessibility of online English resources on phacoemulsification and implement multiple standardized readability scores with regards to cataract surgery resources. It provides further overwhelming evidence that online resources on phacoemulsification are too complex for the average patient to understand. Interventions should be implemented to improve readability.

Health Literacy in Plastic Surgery: A Scoping Review

Health literacy of plastic surgery patients may affect surgical decision-making and perioperative outcomes. In addition to consulting a plastic surgeon, patients often refer to online-based resources to learn about surgical options. The aim of this scoping review was to identify evidence detailing the state of health literacy of plastic surgery patients and available resources to highlight areas of improvement for clinical practice and future research.

Methods

Utilizing PubMed and Web of Science databases, 46 eligible studies that analyzed health literacy in plastic surgery patients and readability of plastic surgery resources were included. Extracted characteristics from eligible studies included study size, type of analysis, findings, and conclusions.

Results

Regardless of plastic surgery procedure or subspecialty, resources presenting plastic surgery information to patients exceeded the American Medical Association and National Institutes of Health recommended sixth- to eighth-grade reading level. Plastic surgery patients demonstrated greater knowledge of preoperative indications and surgical benefits compared with postoperative outcomes and surgical risks.

Conclusions

Most health literacy research in plastic surgery focuses on readability of written internet-based resources as opposed to direct assessment of health literacy in plastic surgery patients. Plastic surgery resources exceed the recommended mean reading grade level. Dedicated efforts to recognize and accommodate a patient's level of health literacy in plastic surgery should be considered.

A Comprehensive Evaluation of the Readability of Online Healthcare Materials Regarding Distal Radius Fractures

Introduction

Distal radius fractures (DRFs) are among the most common upper limb fractures reviewed in the emergency and orthopaedic departments. Approximately 40% of these fractures are unstable and require fixation to improve limb function. Confronted with an impending operation, many patients will access the internet, looking for information and reassurance. Previous studies have suggested that orthopaedic healthcare websites are beyond the comprehension of their target audience.

Objective

To assess the readability of healthcare websites regarding DRFs.

Methods

The terms distal radius fracture, broken wrist and wrist fracture were searched on Google and Bing. Of 101 websites initially considered, 52 unique websites underwent evaluation using readability software. Websites were assessed using two common methods for assessing readabilty; the Reading Grade Level (RGL) and the Flesch Reading Ease Score (FRES). In line with recommended guidelines and previous studies, an RGL of sixth grade and under and a FRES score above 65 was considered acceptable.

Results

The mean score for the FRES index was 56.67 (SD: ± 19.6), which resulted in the majority of pieces assessed being classified as ‘fairly difficult to read'. The mean RGL was 8.61 (SD: ± 2.86); 17.3% of the websites assessed fulfilled the criteria of having an RGL of six or less. One way T-tests comparing the FRES and RGL mean scores against the acceptable standards showed that they failed to meet the acceptable indexes (FRES: P<0.004; 95% CI: -13.8 to -2.8; RGL: P<0.0001; CI: 1.8-3.4). ANOVA testing showed no significant difference based on category (FRES: P=0.791; RGL: P=0.101).

Conclusion

The level of comprehension required for online healthcare education materials related to distal radius fractures exceeds the recommended guidelines. Improving the readability content of these websites would enhance the internet’s usability as an educational tool as well as improve patient post-operative outcomes.

Cleft Care Readability: Can Patients Access Helpful Online Resources?

OBJECTIVE

The present study identifies and analyzes online patient resources for cleft lip with or without cleft palate to survey the online educational landscape relative to the recommended difficulty set by the National Institutes of Health (NIH) and American Medical Association (AMA).

METHODS

An internet search of "cleft palate," "cleft lip," and 12 similar inputs were entered into a search engine. The first 50 links for each search term were identified, collected, and reviewed individually for relevance and accessibility. The content of the websites was analyzed with Readability Studio Version 2019.1. The following readability metrics were utilized in this study: (1) Coleman-Liau (grade levels), (2) New Dale-Chall, (3) Flesch-Kincaid, (4) Flesch Reading Ease, (5) FORCAST, (6) Fry, (7) Gunning Fog, (8) New Fog Count, (9) Raygor Readability Estimate, and (10) Simple Measure of Gobbledygook.

RESULTS

In no combination of search terms did any collection of links provide information within the mid-seventh grade levels recommended by the NIH. The analysis of 143 unique websites in the "Cleft Palate" group showed a readability level appropriate to high school students. The analysis of 144 unique websites in the "Cleft Lip" group showed a readability level appropriate for eighth grade students with 6 months of class complete.

CONCLUSIONS

The information presented to patients on cleft care is too complex and well above the recommended 7th-grade reading level target set forth by the NIH and AMA, which hinders functional health literacy.

Readability of Patient Educational Materials in Hip and Knee Arthroplasty: Has a Decade Made a Difference?

BACKGROUND

The Internet has become an increasingly popular resource among orthopedic patients for health education. Numerous organisations recommend that patient educational materials (PEMs) should not exceed the 6^th grade reading level. Despite this, studies have repeatedly shown the reading grade level (RGL) of PEMs to be too advanced across a range of surgical specialties. We aimed to determine the readability of online hip and knee arthroplasty PEMs.

METHODS

The readability of 134 articles pertaining to hip and knee arthroplasty from 5leading worldwide healthcare websites were assessed, using 8 readability formulae; the Flesch-Kincaid Reading Grade Level, the Flesch Reading Ease Score, Raygor Estimate, SMOG, Coleman-Liau, Fry, FORCAST and Gunning Fog. The mean RGL was compared to the 6^th and 8^thgrade reading level. The mean RGL of each website was also compared.

RESULTS

The mean cumulative RGL was 12 (range = 7-16.1). No articles (0%) were written at a 6^th grade reading level and only 4 articles (3%) were written at or below the 8^th grade reading level. The mean RGL was significantly higher than the 6^th (95% CI, 5.62-6.30; P < .0001) and 8^th grade reading level (95% CI, 3.63-4.30; P < .0001). There was a significant difference between the RGLs of the 5websites (P = .001).

CONCLUSION

Arthroplasty PEMs produced by leading worldwide healthcare organisations have readability scores that are above the recommended levels. Given the imperative role of health literacy in patient outcomes and satisfaction, and the increasing prevalence of Internet use among orthopedic patients, a substantial amount of work needs to be done to improve the readability of these materials.

Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources

INTRODUCTION

Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources.

METHODS

Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison.

RESULTS

Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003).

CONCLUSIONS

Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

SUFE and the internet: are healthcare information websites accessible to parents?

BACKGROUND

Slipped upper femoral epiphysis is an adolescent hip disorder requiring rapid surgical intervention. Faced with the prospect of their child undergoing surgery, many fearful parents will turn to the internet to provide information and reassurance. Previous studies have shown the orthopaedic information can be difficult to comprehend.

OBJECTIVE

Assess the readability of healthcare websites regarding slipped upper femoral epiphysis.

METHODS

The term Slipped Upper Femoral Epiphysis was searched in Google, Bing and Yahoo. The websites were evaluated using readability software with seven specialised readability tests including the Flesch-Kincaid Reading Grade Level, the Flesch Reading Ease Score, the Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index and the Gunning Fog Index. The reading grade level (RGL) was also calculated.A Flesich Read Ease Score (FRES) score above 65 and an RGL of sixth grade and under was considered acceptable. Websites were also assessed for translation services.

RESULTS

21 unique websites were assessed. The average FRES was 52.5±15.4. Only 3 websites scored 65 or higher (14%). There was a statistically significant difference between website scores based on affiliation, with physician websites having the overall highest mean(p=0.004).The average RGL was 8.67±1.8. Only two websites met the accepted RGL criteria (9.5%) while five websites were marked as extremely difficult to understand (23.8%). Only five websites offered translations (23.8%). There was no statistically significant difference in readability scores between websites which offered translation and those which did not.One-sample t-tests showed that both the RGL (p<0.001; CI 1.83 to 3.49) and the FRES (p<0.001, CI -19.4 to -5.4) scores were significantly different from the accepted standard.

CONCLUSION

Most websites reviewed were above the recommended RGL, making content inaccessible. Improving readability and translation services would enhance the internet's usability as a healthcare tool for parents.

Readability of online materials for Dupuytren's contracture

STUDY DESIGN

Descriptive.

BACKGROUND

Dupuytren's contracture is a common disorder involving fibrosis of the palmar fascia. As patients are increasingly using online materials to gather health care information, it is imperative to assess the readability and appropriateness of this content. The recommended grade level for patient educational materials is seventh to eighth grade according to the National Institutes of Health. This study aims to assess the readability and content of online patient resources for Dupuytren's contracture.

PURPOSE OF THE STUDY

Evaluate readability of online patient education materials for Dupuytren's contracture.

METHODS

The largest public search engine, Google, was queried using the term "Dupuytren's contracture surgery" on February 26, 2016. Location filters were disabled, and sponsored results were excluded to avoid any inadvertent search bias. The 10 most popular Web sites were identified, and all relevant patient-directed information within 1 click from the original site was downloaded and saved as plain text. Readability was analyzed using 6 established analyses (Readable.io, Added Bytes, Ltd, UK).

RESULTS

Analysis of 10 Web sites demonstrates an average grade level of at least 11th grade (Flesch-Kincaid grade level, 10.2; Gunning-Fog grade level, 13.1; Coleman-Liau grade level, 14.4; Simple Measure of Gobbledygook grade level, 10.0; automated readability grade level, 9.7; and average grade level, 11.5). Overall Flesch-Kincaid reading ease index was 46.4, which is difficult. No single article was at the recommended reading level.

CONCLUSIONS

Online materials available for treatment of Dupuytren's contracture are above recommended reading levels and do not include a comprehensive explanation of treatment options, which may negatively impact decision making in patients seeking treatment for this condition. Surgeons and hand therapists alike should be cognizant of available online patient materials and make efforts to develop and provide more appropriate materials.

LEVEL OF EVIDENCE

V.

Readability and Understandability Analysis of Online Materials Related to Abdominal Aortic Aneurysm Repair

Background:

Patients commonly use online materials as a source of health information. Since poor health literacy has been shown to correlate with negative outcomes, it is recommended that patient-directed materials be written at a sixth-grade reading level. This study evaluates the readability and understandability of commonly accessed online materials pertaining to both endovascular and open repair of abdominal aortic aneurysm.

Methods:

Searches for “endovascular repair abdominal aortic aneurysm” and “open repair abdominal aortic aneurysm” were performed on both Google and Bing, and the top 10 websites from each search engine were identified. Relevant websites (total N = 28, endovascular n = 15, open n = 15, and 2 redundant sites) with patient-directed content were analyzed. Readability was assessed using 9 established methods, and understandability was assessed using the Patient Education Materials Assessment Tool scoring system.

Results:

The average reading grade level for all sites was 12.8. Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 to 15.6. Open-repair websites had a grade-level average of 12.1 with a range from 9.9 to 14.1. Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of −0.551 ( P = .003). No website was written at or below the recommended sixth-grade reading level.

Conclusions:

Patient-directed online health information pertaining to open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level. Increasing complexity of health literature correlates with poor understandability. Modifications such as shorter sentences, fewer words with more than 6 letters, and increasing usage of clear visual aids can increase readability and understandability.

Quality and Health Literacy Demand of Online Heart Failure Information

BACKGROUND

The ubiquity of the Internet is changing the way people obtain their health information. Although there is an abundance of heart failure information online, the quality and health literacy demand of these information are still unknown.

OBJECTIVE

The purpose of this study is to evaluate the quality and health literacy demand (readability, understandability, and actionability) of the heart failure information found online.

METHODS

Google, Yahoo, Bing, Ask.com, and DuckDuckGo were searched for relevant heart failure Web sites. Two independent raters then assessed the quality and health literacy demand of the included Web sites. The quality of the heart failure information was assessed using the DISCERN instrument. Readability was assessed using 7 established readability tests. Finally, understandability and actionability were assessed using the Patient Education Materials Assessment Tool for Print Materials.

RESULTS

A total of 46 Web sites were included in this analysis. The overall mean quality rating was 46.0 ± 8.9 and the mean readability score was 12.6 grade reading level. The overall mean understandability score was 56.3% ± 16.2%. Finally, the overall mean actionability score was 34.7% ± 28.7%.

CONCLUSIONS

The heart failure information found online was of fair quality but required a relatively high health literacy level. Web content authors need to consider not just the quality but also the health literacy demand of the information found in their Web sites. This is especially important considering that low health literacy is likely prevalent among the usual audience.

Making Cancer Health Text on the Internet Easier to Read for Deaf People Who Use American Sign Language

People with relatively limited English language proficiency find the Internet's cancer and health information difficult to access and understand. The presence of unfamiliar words and complex grammar make this particularly difficult for Deaf people. Unfortunately, current technology does not support low-cost, accurate translations of online materials into American Sign Language. However, current technology is relatively more advanced in allowing text simplification, while retaining content. This research team developed a two-step approach for simplifying cancer and other health text. They then tested the approach, using a crossover design with a sample of 36 deaf and 38 hearing college students. Results indicated that hearing college students did well on both the original and simplified text versions. Deaf college students' comprehension, in contrast, significantly benefitted from the simplified text. This two-step translation process offers a strategy that may improve the accessibility of Internet information for Deaf, as well as other low-literacy individuals.

Readability, complexity, and suitability analysis of online lymphedema resources

BACKGROUND

Over 72% of Americans use online health information to assist in health care decision-making. Previous studies of lymphedema literature have focused only on reading level of patient-oriented materials online. Findings indicate they are too advanced for most patients to comprehend. This, more comprehensive study, expands the previous analysis to include critical elements of health materials beyond readability using assessment tools to report on the complexity and density of data as well as text design, vocabulary, and organization.

METHODS

The top 10 highest ranked websites on lymphedema were identified using the most popular search engine (Google). Website content was analyzed for readability, complexity, and suitability using Simple Measure of Gobbledygook, PMOSE/iKIRSCH, and Suitability Assessment of Materials (SAM), respectively. PMOSE/iKIRSCH and SAM were performed by two independent raters. Fleiss' kappa score was calculated to ensure inter-rater reliability.

RESULTS

Online lymphedema literature had a reading grade level of 14.0 (SMOG). Overall complexity score was 6.7 (PMOSE/iKIRSCH) corresponding to "low" complexity and requiring a 8th-12th grade education. Fleiss' kappa score was 80% (P = 0.04, "substantial" agreement). Overall suitability score was 45% (SAM) correlating to the lowest level of "adequate" suitability. Fleiss' kappa score was 76% (P = 0.06, "substantial" agreement).

CONCLUSIONS

Online resources for lymphedema are above the recommended levels for readability and complexity. The suitability level is barely adequate for the intended audience. Overall, these materials are too sophisticated for the average American adult, whose literacy skills are well documented. Further efforts to revise these materials are needed to improve patient comprehension and understanding.

Readability analysis of online resources related to lung cancer

BACKGROUND

Patients seeking health information commonly use the Internet as the first source for material. Studies show that well-informed patients have increased involvement, satisfaction, and healthcare outcomes. As one-third of Americans have only basic or below basic health literacy, the National Institutes of Health and American Medical Association recommend patient-directed health resources be written at a sixth-grade reading level. This study evaluates the readability of commonly accessed online resources on lung cancer.

METHODS

A search for "lung cancer" was performed using Google and Bing, and the top 10 websites were identified. Location services were disabled, and sponsored sites were excluded. Relevant articles (n = 109) with patient-directed content available directly from the main sites were downloaded. Readability was assessed using 10 established methods and analyzed with articles grouped by parent website.

RESULTS

The average reading grade level across all sites was 11.2, with a range from 8.8 (New Fog Count) to 12.2 (Simple Measure of Gobbledygook). The average Flesch Reading Ease score was 52, corresponding with fairly difficult to read text. The readability varied when compared by individual website, ranging in grade level from 9.2 to 15.2. Only 10 articles (9%) were written below a sixth-grade level and these tended to discuss simpler topics.

CONCLUSIONS

Patient-directed online information about lung cancer exceeds the recommended sixth-grade reading level. Readability varies between individual websites, allowing physicians to direct patients according to level of health literacy. Modifications to existing materials can significantly improve readability while maintaining content for patients with low health literacy.