What patients are reading about noninvasive prenatal testing: an evaluation of Internet content and implications for patient-centered care

Do online decision aids reflect new prenatal screening and testing options? An environmental scan and content analysis

Objective

Decision aids have been developed to help prospective parents make informed, shared decisions about medical tests, but these options are rapidly changing. This study aimed to identify and evaluate publicly available decision aids written in English for prospective parents seeking prenatal test information.

Methods

A systematic review process was followed using 3 sources: known decision aid repositories, fetal medicine organisations and Google. The search, screening process, quality assessment, and data extraction was performed by two independent researchers. The quality assessment of the decision aids was based on the International Patient Decision Aids Standards (IPDAS v.4.0).

Results

We identified 13 decision aids, which varied in the screening and diagnostic tests that they discussed. No decision aid met all the IPDAS v.4.0. criteria and no decision aid reported updated risk of miscarriage for amniocentesis and chorionic villus sampling (CVS). There was a lack of decision aids for some common decisions in the prenatal context.

Conclusion

We identified outdated content in current prenatal decision aids. The findings will inform healthcare professionals of the quality of current prenatal decision aids, which may facilitate their patients' informed decision-making about prenatal tests.

Innovation

Considerations for improving future decision aids are outlined.

Assessing the Content Quality of Online Parental Resources about Newborn Metabolic Disease Screening: A Content Analysis

Parents increasingly utilise the internet to obtain information on health practices, but the quality of online information about screening for inherited metabolic diseases (IMD) needs to be improved. A content analysis examined how IMD blood and urine tests were described online in local healthcare sectors between May and June 2021. Among the nine resources, four were blood test providers and five were urine test providers. All mentioned the test benefits and procedures. Other information, such as false-positive/negative or risk of pain, was infrequently mentioned. The descriptions of urine tests are advertised as outperforming blood tests and can be purchased from commercial laboratory sites without medical guidance. Two urine test providers claimed no false results were reported. A few commercial advertisements highlighted the simplicity of the urine test and potentially overstated the invasiveness of the blood test. We found that some advertisements described IMD as "silent killers" and emphasised the advantage of getting "reassurance" in controlling the child's developmental health and well-being. To better protect the parents, or broadly, the public interest, regulatory and oversight measures on the urine tests should be implemented to promote the proper use of genetic tests. Without timely regulation and oversight, the incorrect descriptions might create a public misconception about utilising these commercial laboratory tests to inform health decisions.

What's out there for parents? A systematic review of online information about prenatal microarray and exome sequencing

Objective

To identify what online patient information (presented in English) is available to parents about prenatal microarray (CMA) and exome sequencing (ES), and evaluate its content, quality, and readability.

Method

Systematic searches (Google and Bing) were conducted, and websites were categorised according to their purpose. Websites categorised as patient information were included if they were: in English, directed at patients, or were a text, video, or online version of an information leaflet. Author‐developed content checklists, the DISCERN Genetics tool, and readability tests (the Flesch Reading Ease Score, the Gunning Fog Index, and the Simple Measure of Gobbledygook Index) were then used to assess those sources of patient information.

Results

Of the 665 websites screened, 18 met the criteria. A further 8 sources were found through a targeted search of professional organisations, resulting in 26 sources available for further evaluation. In general, this was found to be low in quality, omitted details recommended by national or international guidance, and was written at a level too advanced for average readers.

Conclusion

Improvements should be made to the content, quality, and readability of online information so that it both reinforces and complements the discussions between parents and clinicians about testing options during pregnancy.

What's already known about this topic?

The Internet is an important source of information for parents during pregnancy

Little is known about the availability and standard of online information about newer prenatal genetic tests like chromosomal microarray (CMA) and prenatal exome sequencing (ES)

What does this study add?

Our results revealed limited online information aimed at parents about CMA and ES

The information we did identify was lacking the details recommended by professional guidelines, had low quality scores, and was written at an advanced level

Improvements to online information for parents are needed to support informed decision‐making regarding prenatal genetic tests

Sexual Health Literacy, a Strategy for the Challenges of Sexual Life of Infertile Women: A Qualitative Study

Background:

Sexual health literacy enables an understanding and application of sexual health information and has benefits beyond health. Health literacy is an important element for achieving cognitive skills in health promotion. One of the most important problems in sexual health and sexual function in women is infertility. This study aims to explore the dimensions of sexual health literacy among women with infertility.

Materials and Methods:

In this qualitative study, a total of 18 individual interviews with 15 Iranian women with infertility, and three key informants, were conducted in infertility centers in Rasht (the North of Iran). Data were collected through in-depth semi-structured interviews using interview guide questions. Data were analyzed using the conventional content analysis approach.

Results:

Five themes emerged: informational needs of sexual health, information seeking, informational perception, validation of information, and information application. Sexual issues are taboo in Iranian culture. They are not taught in health and educational centers. All the participants believed that there was a lack of information about the sexual response cycle, preventing sexually transmitted infections, targeted intercourse, and consequences of infertility in sexual life. Participants mentioned the embarrassment, privacy, and lack of centers for sexual health as information-seeking barriers. Searching different sources and questioning the informants were ways for understanding information. Women evaluated the accuracy of the information by considering the validity of the source of information, comparing information from different sources, and asking the experts. They applied the information received about sexual health, satisfaction, and especially targeted intercourse to increase the chance of pregnancy.

Conclusion:

Sexual health literacy in infertile women includes different dimensions. It can help promote sexual health, satisfaction, and increasing the chance of pregnancy.

Quality of consumer-oriented websites containing information about the second trimester ultrasound examination during pregnancy

Background

Providing information about prenatal tests is a clinical challenge and the public frequently accesses the Web to read pregnancy-related information. The overarching aim of this study was to investigate the quality of consumer-oriented websites addressing obstetric ultrasound examination in the second trimester of pregnancy.

Methods

Swedish websites were identified with Google, using 20 search strings and screening 400 hits (n = 71 included websites). Reliability and information about the examination were assessed with the DISCERN instrument, completeness was assessed according to national guidelines, and readability analyzed with the Readability Index. Popularity was determined with the ALEXA tool and search rank was determined according to Google hit lists.

Results

The mean total DISCERN score was 29.7/80 (SD 11.4), with > 50% having low quality for 15 of the 16 questions. The mean completeness score was 6.8/24 (SD 4.5). The Readability Index ranged between 22 and 63, with a mean of 42.7 (SD 6.8), indicating difficult readability. Weak and non-significant correlations were observed between ALEXA/search rank and the investigated quality variables, except for search rank and reliability.

Conclusions

The quality of consumer-oriented websites addressing the second trimester ultrasound examination is low. Health professionals need to discuss this with expectant parents considering undergoing the examination. There is a need for efforts that aim to improve the poor quality of online sources in the field of prenatal examinations.

Assessing the availability and quality of Spanish-language genetic resources for patients on the internet

In recent years, people increasingly are accessing health information on the Internet. A significant percentage of the United States (US) population has limited English proficiency with Spanish being the most common other language spoken. There is limited research on the presence or quality of Spanish-language health information, particularly in genetics, on the Internet overall. Therefore, we aimed to assess the availability and quality of patient-specific education resources in Spanish available on US-based support group websites for a wide range of genetic conditions. We assessed 630 websites through the Disease InfoSearch website (www.diseaseinfosearch.org), created by Genetic Alliance, for the presence of Spanish genetic resources for patients with a new diagnosis of a genetic condition. Of these, 261 (41.4%) websites met study criteria for further evaluation. Of the 99 websites (37.9%) that had any Spanish content, 45 Spanish resources and a paired English resource from the same site met criteria for a quality assessment. Scoring was performed by two independent raters using Ensuring Quality Information for Patients (EQIP), a previously validated tool to assess the quality of written health information. The mean scores for Spanish and English resources were 57.3% and 58.4%, respectively, corresponding to a good quality score according to guidelines proposed by authors of EQIP. An independent two-sample t test showed no significant difference in the mean quality scores between Spanish and English resources (p-value = .506). Overall, we found limited availability of Spanish resources on the websites analyzed, but of those identified, there was no difference between the quality of Spanish resources and the paired English resources from the same site. These results highlight the need for genetics professionals to advocate for the creation of more Spanish patient resources. However, genetics professionals can have some reassurance that if a support group does produce a Spanish resource, it likely has comparable quality to its English equivalent.

Quality of websites about long-acting reversible contraception: a descriptive cross-sectional study

Background

Today, there are various short- and long-acting contraceptive alternatives available for those who wish to prevent unintended pregnancy. Long-acting reversible contraception are considered effective methods with a high user satisfaction. High-quality information about contraception is essential in order to empower individuals to reach informed decisions based on sufficient knowledge. Use of the Web for information about contraception is widespread, and there is a risk that those who use it for this purpose could come in contact with sources of low quality.

Objective

The overarching aim was to investigate the quality of websites about long-acting reversible contraception.

Methods

Swedish client-oriented websites were identified through searches in Google (n = 46 included websites). Reliability and information about long-acting reversible contraceptive choices were assessed by two assessors with the DISCERN instrument, transparency was analyzed with the Journal of the American Medical Association benchmarks, completeness was assessed with inductive content analysis and readability was analyzed with Readability Index.

Results

The mean DISCERN was 44.1/80 (SD 7.7) for total score, 19.7/40 (SD 3.7) for reliability, 22.1/35 (SD 4.1) for information about long-acting reversible contraceptive choices, and 2.3/5 (SD 1.1) for overall quality. A majority of the included websites had low quality with regard to what sources were used to compile the information (n = 41/46, 89%), when the information was produced (n = 40/46, 87%), and if it provided additional sources of support and information (n = 30/46, 65%). Less than half of the websites adhered to any of the JAMA benchmarks. We identified 23 categories of comprehensiveness. The most frequent was contraceptive mechanism (n = 39/46, 85%) and the least frequent was when contraception may be initiated following an abortion (n = 3/46, 7%). The mean Readability Index was 42.5 (SD 6.3, Range 29–55) indicating moderate to difficult readability levels, corresponding to a grade level of 9.

Conclusions

The quality of client-oriented websites about long-acting reversible contraception is poor. There is an undeniable need to support and guide laypersons that intend to use web-based sources about contraceptive alternatives, so that they may reach informed decisions based on sufficient knowledge.

Balancing Needs and Autonomy: The Involvement of Pregnant Women's Partners in Decisions About cfDNA

Cell-free fetal DNA (cfDNA) screening is used to identify the presence of fetal genetic variants early in pregnancy. Patients' informed decision-making is central to the success of this new screen in clinical practice. Although research has focused on pregnant women's decision-making, little is known about partners' role and preferences as a member of the decision-making dyad. Using a grounded theory approach, this study analyzed 23 in-depth interviews to examine partners' perspectives about cfDNA screening and preferences with respect to their role in the decision-making process. Participants wished to be actively involved in testing decisions. They articulated a distinct set of needs and preferences in the decision-making process. Such involvement was hindered by several biological and logistical barriers. This study demonstrates the need to develop mechanisms that foster informed decision-making for cfDNA screening and related new reproductive genetic technologies that focus on not just the pregnant woman but also the decision-making dyad that includes her partner as well.

Accessibility and Applicability of Currently Available e-Mental Health Programs for Depression for People With Poststroke Aphasia: Scoping Review

Background

Depression affects approximately 60% of people with aphasia 1 year post stroke and is associated with disability, lower quality of life, and mortality. Web-delivered mental health (e-mental health) programs are effective, convenient, and cost-effective for the general population and thus are increasingly used in the management of depression. However, it is unknown if such services are applicable and communicatively accessible to people with poststroke aphasia.

Objective

The aim of this study was to identify freely available e-mental health programs for depression and determine their applicability and accessibility for people with poststroke aphasia.

Methods

A Web-based search was conducted to identify and review freely available e-mental health programs for depression. These programs were then evaluated in terms of their (1) general features via a general evaluation tool, (2) communicative accessibility for people with aphasia via an aphasia-specific communicative accessibility evaluation tool, and (3) empirical evidence for the general population and stroke survivors with and without aphasia. The program that met the most general evaluation criteria and aphasia-specific communicative accessibility evaluation criteria was then trialed by a small subgroup of people with poststroke aphasia.

Results

A total of 8 programs were identified. Of these, 4 had published evidence in support of their efficacy for use within the general population. However, no empirical evidence was identified that specifically supported any programs’ use for stroke survivors with or without aphasia. One evidence-based program scored at least 80% (16/19 and 16/20, respectively) on both the general and aphasia-specific communicative accessibility evaluation tools and was subject to a preliminary trial by 3 people with poststroke aphasia. During this trial, participants were either unable to independently use the program or gave it low usability scores on a post-trial satisfaction survey. On this basis, further evaluation was considered unwarranted.

Conclusions

Despite fulfilling majority of the general evaluation and aphasia-specific evaluation criteria, the highest rated program was still found to be unsuitable for people with poststroke aphasia. Thus, e-mental health programs require substantial redevelopment if they are likely to be useful to people with poststroke aphasia.

An evaluation of Spanish and English on-line information sources regarding pregnancy, birth and the postnatal period

OBJECTIVE

the aim of this study is to evaluate the quality of web pages found by women when carrying out an exploratory search concerning pregnancy, childbirth, the postpartum period and breastfeeding.

DESIGN/SETTING

a descriptive study of the first 25 web pages that appear in the search engines Google, Yahoo and Bing, in October 2014 in the Basque Country (Spain), when entering eight Spanish words and seven English words related to pregnancy, childbirth, the postpartum period, breastfeeding and newborns. Web pages aimed at healthcare professionals and forums were excluded. The reliability was evaluated using the LIDA questionnaire, and the contents of the web pages with the highest scores were then described.

FINDINGS

a total of 126 web pages were found using the key search words. Of these, 14 scored in the top 30% for reliability. The content analysis of these found that the mean score for "references to the source of the information" was 3.4 (SD: 2.17), that for "up-to-date" was 4.30 (SD: 1.97) and the score for "conflict of interest statement" was 5.90 (SD: 2.16). The mean for web pages created by universities and official bodies was 13.64 (SD: 4.47), whereas the mean for those created by private bodies was 11.23 (SD: 4.51) (F (1,124)5.27. p=0.02). The content analysis of these web pages found that the most commonly discussed topic was breastfeeding, followed by self-care during pregnancy and the onset of childbirth.

CONCLUSION

in this study, web pages from established healthcare or academic institutions were found to contain the most reliable information. The significant number of web pages found in this study with poor quality information indicates the need for healthcare professionals to guide women when sourcing information online. As the origin of the web page has a direct effect on reliability, the involvement of healthcare professionals in the use, counselling and generation of new technologies as an intervention tool is increasingly essential.

Quality of Patient Information Websites About Congenital Heart Defects: Mixed-Methods Study of Perspectives Among Individuals With Experience of a Prenatal Diagnosis

Background

When a heart defect is prenatally diagnosed in the fetus, expectant parents experience a great need for information about various topics. After the diagnosis, the Web is used for supplemental information, and the scarcity of research calls attention to the need to explore patient information websites from the perspectives of the intended consumers.

Objective

The overarching aim of this study was to explore the quality of Swedish patient information websites about congenital heart defects, from the perspectives of individuals with experience of a prenatal diagnosis of congenital heart defect in the fetus.

Methods

This was a mixed-methods study of websites identified through systematic searches in the two most used Web-based search engines. Of the total 80 screened hits, 10 hits led to patient information websites about congenital heart defects. A quality assessment tool inspired by a previous study was used to evaluate each website’s appearance, details, relevance, suitability, information about treatment choices, and overall quality. Answers were given on a 5-point Likert scale, ranging from 1, representing the lowest score, to 5, representing the highest score. Each website was assessed individually by persons with experience of continued (n=4) and terminated (n=5) pregnancy following a prenatal diagnosis. Assessments were analyzed with Kendall’s coefficient of concordance W, Mann-Whitney U test, Friedman’s test, and a Wilcoxon-Nemenyi-McDonald-Thompson test. In addition, each assessor submitted written responses to open-ended questions in the quality assessment tool, and two joint focus group discussions were conducted with each group of assessors. The qualitative data were analyzed with inductive manifest content analysis.

Results

Assessments represented a low score (median=2.0) for treatment choices and moderate scores (median=3.0) for appearance, details, relevance, suitability, and overall quality. No website had a median of the highest achievable score for any of the questions in the quality assessment tool. Medians of the lowest achievable score were found in questions about treatment choices (n=4 websites), details (n=2 websites), suitability (n=1 website), and overall quality (n=1 website). Websites had significantly different scores for appearance (P=.01), details (P<.001), relevance (P<.001), suitability (P<.001), treatment choices (P=.04), and overall quality (P<.001). The content analysis of the qualitative data generated six categories: (1) advertisements, (2) comprehensiveness, (3) design, (4) illustrations and pictures, (5) language, and (6) trustworthiness. Various issues with the included websites were highlighted, including the use of inappropriate advertisements, biased information, poor illustrations, complex language, and poor trustworthiness.

Conclusions

From the perspectives of the intended consumers, patient information websites about congenital heart defects are, to a large extent, inadequate tools for supplemental information following a prenatal diagnosis. Health professionals should initiate discussions with patients about their intentions to use the Web, inform them about the varied quality in the Web-based landscape, and offer recommendations for appropriate Web-based sources.

Expanding Use of cfDNA Screening in Pregnancy: Current and Emerging Ethical, Legal, and Social Issues

Purpose of Review

In 2011, screening platforms became available in the US that detect and analyze fragments of cell-free placental DNA (cfDNA) in maternal blood serum. Marketed as noninvasive prenatal tests (NIPT), cfDNA screening is more accurate than previously available serum screening tests for certain aneuploidies. The combination of a noninvasive procedure, high specificity and sensitivity, and lower false positive rates for some aneuploidies (most notably Down's syndrome) has led to broad clinician and patient adoption. New ethical, legal, and social issues arise from the increased use and expanded implementation of cfDNA in pregnancy.

Recent Findings

Recently, several professional associations have amended their guidelines on cfDNA, removing language recommending its use in only "high-risk" pregnancies in favor of making cfDNA screening an available option for women with "low-risk" pregnancies as well. At the same time, commercial cfDNA screening laboratories continue to expand the range of available test panels. As a result, the future of prenatal screening will likely include a broader range of genetic tests in a wider range of patients.

Summary

This article addresses the ethical, legal, and social issues related to the shift in guidance and expanded use of cfDNA in pregnant women, including concerns regarding routinized testing, an unmet and increasing demand for genetic counseling services, social and economic disparities in access, impact on groups living with disabling conditions, and provider liability.

Patient Perception of Negative Noninvasive Prenatal Testing Results

Objective To determine patient perception of residual risk after receiving a negative non-invasive prenatal testing result. Introduction Recent technological advances have yielded a new method of prenatal screening, non-invasive prenatal testing (NIPT), which uses cell-free fetal DNA from the mother's blood to assess for aneuploidy. NIPT has much higher detection rates and positive predictive values than previous methods however, NIPT is not diagnostic. Past studies have demonstrated that patients may underestimate the limitations of prenatal screening; however, patient perception of NIPT has not yet been assessed. Methods and Materials We conducted a prospective cohort study to assess patient understanding of the residual risk for aneuploidy after receiving a negative NIPT result. Ninety-four participants who had prenatal genetic counseling and a subsequent negative NIPT were surveyed. Results There was a significant decline in general level of worry after a negative NIPT result (p = <0.0001). The majority of participants (61%) understood the residual risk post NIPT. Individuals with at least four years of college education were more likely to understand that NIPT does not eliminate the chance of trisomy 13/18 (p = 0.012) and sex chromosome abnormality (p = 0.039), and were more likely to understand which conditions NIPT tests for (p = 0.021), compared to those women with less formal education. Conclusion These data demonstrate that despite the relatively recent implementation of NIPT into obstetric practice, the majority of women are aware of its limitations after receiving genetic counseling. However, clinicians may need to consider alternative ways to communicate the limitations of NIPT to those women with less formal education to ensure understanding.

Online direct-to-consumer messages about non-invasive prenatal genetic testing

Non-invasive prenatal testing (NIPT) has been integrated into clinical care at a time when patients and healthcare providers increasingly utilize the internet to access health information. This study evaluated online direct-to-consumer information about NIPT produced by commercial laboratories accessible to both patients and healthcare providers. A coding checklist captured areas to describe content and assess concordance with clinical guidelines. We found that the information presented about NIPT is highly variable, both within a single website and broadly across all websites. Variability was noted in how NIPT is characterized, including test characteristics and indications. All laboratories offer NIPT to test for common sex chromosome aneuploidies, although there is a lack of consistency regarding the conditions offered and information provided about each. Although indicated for a subset of women at increased risk of aneuploidy, some laboratories describe the use of NIPT for all pregnant women. A subset of laboratories offers screening for microdeletions, although clinical practice guidelines do not yet recommend for general use for this indication. None of the online materials addressed the ethical issues associated with NIPT. This study highlights the need for clear, consistent, and evidence-based materials to educate patients and healthcare providers about the current and emerging applications of NIPT.

Evaluation of patient education materials: the example of circulating cell free DNA testing for aneuploidy

Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment. When the analysis of circulating cell free DNA (ccfDNA) became commercially available in 2011 through the Prenatal Diagnostic Laboratory at Women & Infants Hospital of Providence, Rhode Island to "high-risk" women, it provided an opportunity to examine how commercial laboratories informed potential consumers. We identified, via an internet search, four laboratories offering such testing in the United States and one in Europe. We evaluated patient educational materials (PEMs) from each using the Flesch Reading Ease method and a modified version of the Suitability Assessment of Materials (SAM) criteria. Pamphlets were also reviewed for their inclusion of content recommendations from the International Society for Prenatal Diagnosis, the National Society of Genetic Counselors, the American College of Obstetricians and Gynecologists jointly with the Society of Maternal Fetal Medicine, and the American College of Genetics and Genomics. Reading levels were typically high (10th-12th grade). None of the pamphlets met all SAM criteria evaluated nor did any pamphlet include all recommended content items. To comply with readability and content recommendations more closely, Women & Infants Hospital created a new pamphlet to which it applied the same criteria, and also subjected it to focus group assessment. These types of analyses can serve as a model for future evaluations of similar patient educational materials.