Rationale and Objectives
The US Department of Health and Human Services (USDHHS) recommends that Internet-based patient education materials (IPEMs) be written below the sixth-grade reading level to target the average American adult. This study was designed to determine the readability of IPEMs regarding mammography for breast cancer screening.
Materials and Methods
Three-hundred mammography-related Web sites were reviewed for IPEMs. Forty-two IPEMs that met the Health on the Net Foundation Code of Conduct were assessed for readability level with four readability indices that use existing algorithms based on word and sentence length to quantitatively analyze Internet sources for language intricacy including the following: Flesch–Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (Gunning FOG; GFOG). Results were compared to national recommendations, and intergroup analysis was performed.
Results
No IPEMs (0%) regarding mammography were written at or below the sixth-grade reading level, based on FKGL. The mean readability scores were as follows: FRES, 49.04 ± 10.62; FKGL, 10.71 ± 2.01; SMOG, 13.33 ± 1.67; and Gunning FOG, 14.32 ± 2.18. These scores indicate that the readability of mammography IPEMs is written at a “difficult” level, significantly above the recommended sixth-grade reading level ( P < .05) determined by the USDHHS.
Conclusions
IPEMs related to mammography are written well above the recommended sixth-grade level and likely reflect other IPEMs in diagnostic radiology.
The availability of Internet resources has allowed >113 million Americans (of various ethnic backgrounds, socioeconomic status, and so forth) to access the Internet for health care–related information . A majority of people who access Internet-based education materials (IPEMs) state that they influence medical treatment decision making . Health care professionals must keep the poor rates of health literacy—the “degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions” —in the United States in mind when authoring the IPEMs. Furthermore, health literacy is a “measure of patients’ ability to read, comprehend, and act on medical instructions” . It is a direct prognostic measurement of a patient’s health . Unfortunately, the average American adult reads only at a seventh–eighth grade level . Direct consequences of poor health literacy include increase risk of being admitted to the hospital and poorer self health maintenance, both of which lead to poorer patient outcomes and increased cost of health care .
Tackling the epidemic of poor health literacy may be a long and difficult process; however, health care physicians may be able to improve patient comprehension of IPEMs by improving readability—the level of comprehension a person must have to understand written materials . The US Department of Health and Human Services (USDHHS), American Medical Association, and the National Institutes of Health recommend that IPEMs be written at or below the sixth-grade level . Readability analyses have been established to evaluate IPEMs available to patients . Readability assessments have been used by the various fields of medicine to calculate readability of IPEMs available to their patient population . Readability assessments have recently been published in the radiology literature . Within radiology, mammography has been established as an effective tool for breast cancer screening. There are guidelines that exist, which provide physicians (and thus their patients) with recommendations for breast cancer screening. Thus, patients are inevitably exposed to mammography and may turn to IPEMs for medical information. In this study, we assess the readability of IPEMs from US hospitals and universities, professional societies, clinical practices, and miscellaneous health care–associated Web sites related to mammography.
Materials and methods
Experimental Design
Get Radiology Tree app to read full this article<
Search Procedure
Get Radiology Tree app to read full this article<
Text Editing
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Data Analysis
Readability Analyses
Get Radiology Tree app to read full this article<
Table 1
Description of Readability Algorithms
Readability Algorithm Mathematical Equation Qualitative Definition FKGL ∗ , ‡ (0.39 × average number of words per sentence) + (11.8 × average number of syllables per word) − 15.59 The comprehension required for a person to understand written text reported as an “academic grade” based on the US education system. FRES † , § 206.835 − (1.015 × average sentence length) − (84.6 × average number of syllables per word) Understandability of writing style ranging from “very easy” to “very difficult” reported on a scale of 0–100. SMOG ∗ 3.1291 + 1.043 × square root (number of polysyllables × [30/total number of sentences]) Intricacy of written text that corresponds to number of polysyllabic words reported as an “academic grade” based on the US education system. GFOG ∗ 0.4 × (average number of words per sentence + 100 [number of polysyllabic words/total number of words]). Intricacy of written text that corresponds to the length of a sentence and the percentage of polysyllabic words reported as an “academic grade” based on the US education system.
FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; GFOG, Gunning Frequency of Gobbledygook; SMOG, Simple Measure of Gobbledygook.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Statistical Analysis
Get Radiology Tree app to read full this article<
Results
Get Radiology Tree app to read full this article<
Table 2
Interpretation of FRES as Determined by the USDHHS ( n = 42)
Table modified from Flesch, 1948.
FRES Description of Writing Style Number of Web Pages, n (%) Correlating FKGL, n (%) 0–30 Very difficult 34/42 (81.0) Equal to or above tenth grade/difficult
32/42 (76.2) 31–50 Difficult Seventh to ninth grade/average difficulty
10/42 (23.8) 51–60 Fairly difficult 61–70 Standard 8/42 (19.0) 71–80 Fairly easy 0/42 (0) Equal to or below sixth grade/easy to read
0/42 (0) 81–90 Easy 91–100 Very easy
FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; USDHHS, US Department of Health and Human Services.
It is assumed that GFOG and SMOG scales correlating similarly as the FKGL as they all report grade levels.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 3
FRES, FKGL, SMOG, and GFOG of All IPEMs Pertaining to Mammography
Readability Scale Average Score (±Standard Deviation) 95% CI FRES 49.04 ± 10.62 45.84–52.24 FKGL 10.71 ± 2.01 10.1–11.32 SMOG 13.33 ± 1.67 12.83–13.83 GFOG 14.32 ± 2.18 13.66–14.98
CI, confidence interval; FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; GFOG, Gunning Frequency of Gobbledygook; IPEM, Internet-based patient education material; SMOG, Simple Measure of Gobbledygook.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 4
Average FRES, FKGL, SMOG, and GFOG Scores of Society-Affiliated, US Clinical Practices-Affiliated, and US Hospital-Affiliated IPEMs Pertaining to Mammography
Readability Scale US Hospitals/Universities ( n = 17) Professional Societies ( n = 9) Clinical Practices ( n = 5) Miscellaneous Web Sites ( n = 11) FRES 44.44 54.72 45.14 53.28 FKGL 11.49 9.66 11.26 10.11 SMOG 14.06 12.31 14.06 12.69 GFOG 15.20 13.10 15.26 13.52
FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; GFOG, Gunning Frequency of Gobbledygook; IPEM, Internet-based patient education material; SMOG, Simple Measure of Gobbledygook.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Discussion
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Improving IPEMs
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Conclusion
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
References
1. Berland G.K., Elliott M.N., Morales L.S., et. al.: Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA 2001; 285: pp. 2612-2621.
2. Fox S. Online health search 2006. Available at: http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf . Accessed May 24, 2008.
3. Committee On Health Literacy: Health literacy: prescription to end confusion.2004.The National Academies Press
4. Schillinger D., Grumbach K., Piette J., et. al.: Association of health literacy with diabetes outcomes. JAMA 2002; 288: pp. 475-482.
5. Weiss B.D., Hart G., McGee D.L., et. al.: Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1992; 5: pp. 257-264.
6. Walsh T.M., Volsko T.A.: Readability assessment of internet-based consumer health information. Respir Care 2008; 53: pp. 1310-1315.
7. Albright J., de Guzman C., Acebo P., et. al.: Readability of patient education materials: implications for clinical practice. Appl Nurs Res 1996; 9: pp. 139-143.
8. Goldstein A.K.A., Sikali E., White S.E.: National assessment of adult literacy (NAAL).2003.National Center for Education Statistics Available at: http://nces.ed.gov/naal
9. Dewalt D.A., Berkman N.D., Sheridan S., et. al.: Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004; 19: pp. 1228-1239.
10. D’Alessandro D.M., Kingsley P., Johnson-West J.: The readability of pediatric patient education materials on the World Wide Web. Arch Pediatr Adolesc Med 2001; 155: pp. 807-812.
11. Heilman C.B., Schmitt P.J., Prestigiacomo C.J.: Readability of neurosurgery-related patient education materials provided by the American Association of Neurological Surgeons, and the National Library of Medicine and National Institutes of Health. World Neurosurg 2013; 80: pp. e33-e39.
12. Sanghvi S., Cherla D.V., Shukla P.A., et. al.: Readability assessment of internet-based patient education materials related to facial fractures. Laryngoscope 2012; 122: pp. 1943-1948.
13. Hansberry D.R., John A., John E., et. al.: A critical review of the readability of online patient education resources from RadiologyInfo.org. AJR Am J Roentgenol 2014; 202: pp. 566-575.
14. Shukla P., Sanghvi S.P., Lelkes V.M., et. al.: Readability assessment of internet-based patient education materials related to uterine artery embolization. J Vasc Interv Radiol 2013; 24: pp. 469-474.
15. HONcode. Health On the Net Foundation. Available at: http://www.hon.ch/HONcode/Conduct.html .
16. Friedman D.B., Hoffman-Goetz L.: A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav 2006; 33: pp. 352-373.
17. McLaughlin G.: SMOG grading—a new readability formula. J Reading 1969; 12: pp. 639-946.
18. Flesch R.: A new readability yardstick. J Appl Psychol 1948; 32: pp. 221-233.
19. Kincaid J., Fishburne R., Rogers R., et. al.: Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Forumula) for Navy enlisted personnel.1975.National Technical Information Service Research B
20. Gunning R.: Technique of clear writing.1968.McGraw-Hillpp. 329.
21. Squiers L.B., Holden D.J., Dolina S.E., et. al.: The public’s response to the U.S. Preventive Services Task Force’s 2009 recommendations on mammography screening. Am J Prev Med 2011; 40: pp. 497-504.
22. Davidson A.S., Liao X., Magee B.D.: Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011; 205: pp. 30.e1. 30.e7
23. Aslam N., Bowyer D., Wainwright A., et. al.: Evaluation of Internet use by paediatric orthopaedic outpatients and the quality of information available. J Pediatr Orthop B 2005; 14: pp. 129-133.
24. Petitti D.B., Calonge N.: Media coverage of U.S. preventive services task force recommendations: a commentary. Am J Prev Med 2011; 40: pp. 579-580.
25. Hill-Briggs F., Schumann K.P., Dike O.: Five-step methodology for evaluation and adaptation of print patient health information to meet the <5th grade readability criterion. Med Care 2012; 50: pp. 294-301.
26. Tian C., Champlin S., Mackert M., et. al.: Readability, suitability, and health content assessment of web-based patient education materials on colorectal cancer screening. Gastrointest Endosc 2014; 80: pp. 284-290.
27. Jackson R.H., Davis T.C., Bairnsfather L.E., et. al.: Patient reading ability: an overlooked problem in health care. South Med J 1991; 84: pp. 1172-1175.
28. Sheridan S.L., Halpern D.J., Viera A.J., et. al.: Interventions for individuals with low health literacy: a systematic review. J Health Commun 2011; 16: pp. 30-54.
29. Doak C.C., Doak L.G., Root J.H.: Teaching patients with low literacy skills.2nd ed.1996.JB LippincottPhiladelphia, PA
30. Gerber B.S., Eiser A.R.: The patient physician relationship in the Internet age: future prospects and the research agenda. J Med Internet Res 2001; 3: pp. E15.
31. Wald H.S., Dube C.E., Anthony D.C.: Untangling the Web—the impact of Internet use on health care and the physician-patient relationship. Patient Educ Couns 2007; 68: pp. 218-224.
32. MedlinePlus. How to write easy-to-read health materials. Available at: http://www.nlm.nih.gov/medlineplus/etr.html , 2011.