Accessibility of web sites containing colorectal cancer information to adults with limited literacy (United States)

Development of 'OXIS Classification' calibration website for dental researchers

PURPOSE

The variations in interproximal contact areas have been categorised open (O), point (X), straight (I), and curved contact (S). This is based on their shapes and termed as OXIS classification. The interactive OXIS calibration website was developed to assist researchers seeking appropriate knowledge, minimise the overload of material, optimise efficiency in calibration and, to provide repositories for clinicians, healthcare workers, and policymakers.

METHODS

The website was developed in two phases. The first phase of development included expert group discussion, Focus Group Discussion (FGD), and the implementation of FGD recommendations. The second phase emphasised registration and development of the interactive web portal on OXIS classification. The developed website was subjected to user experience testing, functional testing, performance testing, security testing, device, platform testing, and then hosted. Calibrated students and faculties evaluated it with the help of Suitability Assessment of Materials (SAM) and System Usability Scale (SUS). Finally, after amendments, the website was evaluated by non-calibrated researchers and multidisciplinary experts.

RESULTS

The total agreement was 74% for overall SAM category. Pooled mean total score of SUS was 52.7 (SD 7.17; range 45-67.5), indicating an average score.

CONCLUSION

The content of the developed website has been evaluated as "satisfactory" and its technical quality as "of higher standards".

Leveraging Patient Education to Amplify Colorectal Cancer Screening in the United States: Strategies and Implications

Despite several available screening modalities, colorectal cancer (CRC) remains a leading cause of cancer deaths, especially among populations with lower screening rates. Barriers to screening include cost, access, awareness, and education disparities, with interventions such as patient education programs and mailed screening kits showing promise in increasing participation rates. The current review elucidates the correlation between patient awareness/knowledge and screening rates in the United States, highlighting the pivotal role of education in mitigating these deficiencies. Different educational models, including online resources, mailed information, community programs, direct provider-based interventions, and narratives, are explored in terms of their effectiveness and limitations. We also offer a blueprint for primary care providers (PCPs) that highlights the importance of tailored education, barrier identification, and utilization of available resources to enhance CRC screening uptake. Large-scale adoption of educational strategies has the potential to significantly increase CRC screening rates and consequently reduce mortality associated with this preventable malignancy.

Communicating Critical Information to Cancer Survivors: an Assessment of Survivorship Care Plans in Use in Diverse Healthcare Settings

Survivorship care plans (SCPs) serve to communicate critical information needed for cancer survivors' long-term follow-up care. The extent to which SCPs are tailored to meet the specific needs of underserved patient populations is understudied. To fill this gap, this study aimed to assess the content and communication appropriateness of SCPs collected from diverse healthcare settings. We analyzed collected SCPs (n = 16) for concordance with Institute of Medicine (IOM) recommendations for SCP content and for communication appropriateness using the Suitability Assessment of Materials (SAM) instrument. All plans failed to incorporate all IOM criteria, with the majority of plans (n = 11) incorporating less than 60% of recommended content. The average reading grade level of all the plans was 14, and only one plan received a superior rating for cultural appropriateness. There is significant variation in the format and content of SCPs used in diverse hospital settings and most plans are not written at an appropriate reading grade level nor tailored for underserved and/or minority patient populations. Co-designing SCPs with diverse patient populations is crucial to ensure that these documents are meeting the needs and preferences of all cancer survivors.

Commentary: 20 years online with "Your Disease Risk"

The Your Disease Risk tool (yourdiseaserisk.wustl.edu) went live to the public in January 2000 and was one of the first personalized health risk assessment sites on the Internet. Its launch marked the culmination of years of work by a large, multi-disciplinary university team whose primary goal was to translate the science on cancer prevention into accurate, engaging, and useful messages for the public. Today, 20 years on, Your Disease Risk has expanded from its initial four cancers to include 18 different tools designed for today’s users. This commentary reviews important moments and lessons learned in the first two decades of Your Disease Risk.

What Patients Look for When Browsing Online for Pancreatic Cancer: The Bait Behind the Byte

BACKGROUND

Suitability is a patient-centered metric defined as how appropriately health information is targeted to specific populations to increase knowledge. However, suitability is most commonly evaluated exclusively by healthcare professionals without collaboration from intended audiences. Suitability (as rated by intended audiences), accuracy and readability have not been evaluated on websites discussing pancreatic cancer.

METHODS

Ten healthy volunteers evaluated fifty pancreatic cancer websites using the suitability assessment of materials (SAM instrument) for the materials' overall suitability. Readability and accuracy were correlated.

RESULTS

Ten recruited volunteers (ages 23-63, 50% female) found websites to be on average "adequate" or "superior" in suitability. Surgery, radiotherapy and nonprofit websites had higher suitability scores as compared to counterparts (p ≤ 0.03). There was no correlation between readability and accuracy levels and suitability scores (p ≥ 0.3). Presence of visual aids was associated with better suitability scores after controlling for website quality (p ≤ 0.01).

CONCLUSION

Suitability of websites discussing pancreatic cancer treatments as rated by lay audiences differed based on therapy type and website affiliation, and was independent of readability level and accuracy of information. Nonprofit affiliation websites focusing on surgery or radiotherapy were most suitable. Online information should be assessed for suitability by target populations, in addition to readability level and accuracy, to ensure information reaches the intended audience.

Ethical issues with colorectal cancer screening-a systematic review

RATIONALE, AIMS, AND OBJECTIVES

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

METHODS

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

RESULTS

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

CONCLUSION

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.

Randomized Trial of a Computerized Touch Screen Decision Aid to Increase Acceptance of Colonoscopy Screening in an African American Population with Limited Literacy

The goal of this study was to assess the effectiveness of a touch screen decision aid to increase acceptance of colonoscopy screening among African American patients with low literacy, developed and tailored using perceptual mapping methods grounded in Illness Self-Regulation and Information-Communication Theories. The pilot randomized controlled trial investigated the effects of a theory-based intervention on patients' acceptance of screening, including their perceptions of educational value, feelings about colonoscopy, likelihood to undergo screening, and decisional conflict about colonoscopy screening. Sixty-one African American patients with low literacy, aged 50-70 years, with no history of colonoscopy, were randomly assigned to receive a computerized touch screen decision aid (CDA; n = 33) or a literacy appropriate print tool (PT; n = 28) immediately before a primary care appointment in an urban, university-affiliated general internal medicine clinic. Patients rated the CDA significantly higher than the PT on all indicators of acceptance, including the helpfulness of the information for making a screening decision, and reported positive feelings about colonoscopy, greater likelihood to be screened, and lower decisional conflict. Results showed that a touch screen decision tool is acceptable to African American patients with low iteracy and, by increasing intent to screen, may increase rates of colonoscopy screening.

Who Avoids Cancer Information? Examining a Psychological Process Leading to Cancer Information Avoidance

Although cancer information avoidance (CIA) is detrimental to public health, predictors of CIA have not been fully investigated. Based on uncertainty management theory, this study viewed CIA as a response to uncertainty related to the distress associated with cancer information and illustrated the psychological process leading to CIA. Given the current information context, it was hypothesized that cancer information overload (CIO), accompanied by confusion and stress about cancer information, causes CIA. As trait anxiety is a strong predictor of CIO, it was also hypothesized that trait anxiety has an indirect effect on CIA through CIO. Study 1 tested this relationship in a U.S. sample (N = 384); the results showed that CIO was positively associated with CIA and that trait anxiety indirectly influenced CIA through CIO. Whereas Study 1 tested the relationship with cross-sectional data in the general cancer context, Study 2 replicated Study 1 with 3-wave longitudinal data in the context of a specific cancer (i.e., stomach cancer) in South Korea (N = 1,130 at Wave 1, 813 at Wave 2, and 582 at Wave 3). Trait anxiety at Wave 1 predicted CIO at Wave 2, which in turn increased CIA at Wave 3, suggesting that some people are inherently inclined to avoid cancer information due to their trait anxiety, which results in confusion about cancer information.

Correlates of Cancer Information Overload: Focusing on Individual Ability and Motivation

The present study defined cancer information overload (CIO) as an aversive disposition wherein a person is confused and overwhelmed by cancer information, which occurs when he or she fails to effectively categorize new information due to a lack of resources for effective learning. Based on the definition and informed by previous studies on information overload and the cognitive mediation model, we hypothesized that low ability and motivation to process cancer information would lead to CIO. We used education level and trait anxiety as factors related to ability. Cancer history and the use of active media channels (such as the Internet and print media) were adopted as motivational factors. Four samples (three from the United States and one from South Korea) were used to explore the relationship between ability/motivation and CIO. Among them, only Sample 4 participants answered questions about stomach cancer, and other participants were asked about cancer in general. In all four samples, trait anxiety was positively associated with CIO. Health information use from active media channels (print or the Internet) was negatively associated with CIO in three samples. The associations between family history and CIO, and between education and CIO, were found in two samples. In short, the present study demonstrated that CIO partly depends on individual ability and motivation, thereby showing that CIO is influenced by personal characteristics as well as environmental factors.

Adding Dimensions to the Analysis of the Quality of Health Information of Websites Returned by Google: Cluster Analysis Identifies Patterns of Websites According to their Classification and the Type of Intervention Described

Background and aims

Most of the instruments used to assess the quality of health information on the Web (e.g., the JAMA criteria) only analyze one dimension of information quality (IQ), trustworthiness. In this study, we analyzed the type of intervention that websites describe, whether supported by evidence-based medicine (EBM) or not, to provide a further dimension of IQ, accuracy, and correlated this with the established criteria.

Methods

We searched Google for “migraine cure” and analyzed the first 200 websites for: (1) JAMA criteria (authorship, attribution, disclosure, currency); (2) class of websites (commercial, health portals, professional, patient groups, no-profit); and (3) type of intervention described (approved drugs, alternative medicine, food, procedures, lifestyle, drugs still at the research stage). We used hierarchical cluster analysis to identify different patterns of websites according to their classification and the information provided. Subgroup analysis on the first 10 websites returned was performed.

Results

Google returned health portals (44%), followed by commercial websites (31%) and journalism websites (11%). The type of intervention mentioned most often was alternative medicine (55%), followed by procedures (49%), lifestyle (42%), food (41%), and approved drugs (35%). Cluster analysis indicated that health portals are more likely to describe more than one type of treatment while commercial websites most often describe only one. The average JAMA score of commercial websites was significantly lower than for health portals or journalism websites, and this was mainly due to lack of information on the authors of the text and indication of the date the information was written. Looking at the first 10 websites from Google, commercial websites are underrepresented and approved drugs overrepresented.

Conclusion

Analyzing the type of therapies/prevention methods provides additional information to the trustworthiness measures, such as the JAMA score, and could be a convenient and objective indicator of websites whose information is based on EBM.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Identification of gain- and loss-framed cancer screening messages that appeared in municipal newsletters in Japan

Background

Research suggests that cancer screening messages are more persuasive when framed in terms of the costs of not obtaining screening (i.e., loss-framed) than when framed in terms of the benefits of obtaining screening (i.e., gain-framed). However, to what extent these findings have been integrated into public health practice is unknown. To analyze message framing of cancer screening information, the present study examined message framing of cancer screening announcement articles that appeared in municipal newsletters published from 23 wards in central Tokyo, Japan. Two independent raters coded the articles. Gain- and loss-framed sentences in each article were identified, and based on what the sentences conveyed, articles were classified into gain-framed, loss-framed, mixed-framed, and non-framed.

Result

Inter-rater reliability was acceptable (intraclass correlation coefficient = 0.88). Of the 129 articles evaluated, the total number of gain-framed sentences was 87, while that of loss-framed sentences was six. The total number of gain-framed articles was 32 (24.8%) while that of loss-framed articles was zero (0%). Five (3.9%) articles were mixed-framed. Ninety-two (71.3%) articles were non-framed.

Conclusions

Cancer screening announcement articles of municipal newsletters were mostly non-framed or gain-framed in 23 Tokyo wards in Japan. The absence of loss-framed articles and only a small number of loss-framed messages indicate a missed opportunity to persuade readers to obtain cancer screenings. Loss-framed messages and articles need to be increased to enhance the persuasiveness of cancer screening information in municipal newsletters.

Suitability assessment of health education brochures in Qassim province, Kingdom of Saudi Arabia

Background:

Health education is the cornerstone of primary health care. Health education materials distributed to the community should, therefore, be suitable and effective. The purpose of this study was to evaluate the health education brochures, designed and disseminated by Ministry of Health institutions in the Qassim province.

Materials and Methods:

The study was a cross-sectional review of health education brochures. We used a structured evaluation form, comprising general information on the brochures and a modified Suitability Assessment of Materials (SAM) score sheet. The SAM consisting of 22 criteria in six groups, includes content, literacy demands, graphics, layout/typography, learning stimulation/motivation, and cultural appropriateness. SAM criteria categorize written material into “superior,” “adequate” and “not suitable.” Two qualified consultant family physicians evaluated the brochures. Data were analyzed using Epi Info version 3.4 statistical package.

Results:

We evaluated 110 brochures, the majority of which addressed chronic health conditions such as mental health, diabetes mellitus and hypertension. Seventy-four (67.3%) brochures were evaluated as “adequate,” 34 (30.9%) as “not suitable” and 2 (1.8%) as “superior.” “Cultural appropriateness” was the highest scoring factor, with 92 (83.6%) brochures falling into either the “superior” or “adequate” category. With regard to “content,” 88 (80.0%) brochures fell into either the “superior” or “adequate” category. This was the second highest scoring factor. Graphics was the factor that scored the least. Seventy-five (68.2%) brochures were rated in this factor as “not suitable.”

Conclusions:

Although two-thirds of our brochures were considered “adequate,” the majority needed improvement to their graphics and learning stimulation factors. We recommend that guidelines for designing health education brochures should be formulated to improve the quality of health education brochures.

A nationwide evaluation on electronic medication-related information provided by hospital websites

RATIONAL, AIMS AND OBJECTIVES

The aim of this study was to describe the characteristics of electronic medication-related information (e-MRI) via Internet offered by the hospital settings in Taiwan.

METHODS

The structured Internet search and comprehensive review were performed on the most commonly used search engines in Taiwan. The assessment checklists were developed to describe the characteristics of general, e-MRI in the years 2008 and 2010, and specific digoxin information in 2011 based on the operational definitions derived from other studies. The descriptive analyses and chi-square tests for the retrieved data were performed.

RESULTS

With approximately 15% of hospital settings providing general, e-MRI on their websites, their content varied but was not statistically significant, and different among the providers from different levels of hospitals and in different years. More medical centres provided the information with the updated dates and contact approaches than the smaller scale hospitals. Little was found about reference citation and authorships for those general, e-MRI websites. More medical centres created the accesses to search for the individual prescription in the corresponding settings and the specific information about digoxin storage. However, more district hospitals provided the precaution and dosage form information about digoxin.

CONCLUSIONS

The providers to offer the e-MRI via hospital websites in Taiwan could be more responsible for its update, authorship and evidence. Further, the provision of electronic medication-related information via the Internet should be regularly examined or audited by the neutral personnel or organizations to ensure its quality.

Association of eHealth literacy with colorectal cancer knowledge and screening practice among internet users in Japan

Background

In rapidly developing Internet-user societies, eHealth literacy has become important in promoting wellness. Although previous studies have observed that poor health literacy is associated with less knowledge and screening practice of colorectal cancer (CRC), little is known about whether eHealth literacy is associated with these variables.

Objective

The present study examined associations between eHealth literacy, knowledge of CRC, and CRC screening practices.

Methods

Data were analyzed for 2970 Japanese adults (men, 49.9%; mean age ± SD, 39.7 ± 10.9 years) who responded to an Internet-based cross-sectional survey. Knowledge of the definition of CRC, its risk factors and screening practice, previous experience of CRC screening, score on the Japanese version of the eHEALS (J-eHEALS), sociodemographic attributes (sex, age, marital status, educational attainment, and household income level), and frequency of Internet usage were obtained. Sociodemographic attributes and frequency of Internet usage were used as control variables in the multiple regression and logistic regression models.

Results

eHealth literacy was positively associated with CRC knowledge (β = .116, < .001), when the covariables of both eHealth literacy and CRC knowledge were used in the multiple regression model. Moreover, after controlling for sociodemographic factors, which were significantly associated with eHealth literacy and CRC screening practice, an increase of 1 point in the eHEALS score signified that participants were 1.03 times (95% CI = 1.01–1.05) more likely to undergo CRC screening.

Conclusions

Internet users with high eHealth literacy are more likely to have knowledge and previous screening practice related to CRC compared to those with low eHealth literacy.

Assessing the suitability of written stroke materials: an evaluation of the interrater reliability of the suitability assessment of materials (SAM) checklist

PURPOSE

Written materials are frequently used to provide education to stroke patients and their carers. However, poor quality materials are a barrier to effective information provision. A quick and reliable method of evaluating material quality is needed. This study evaluated the interrater reliability of the Suitability Assessment of Materials (SAM) checklist in a sample of written stroke education materials.

METHODS

Two independent raters evaluated the materials (n = 25) using the SAM, and ratings were analyzed to reveal total percentage agreements and weighted kappa values for individual items and overall SAM rating.

RESULTS

The majority of the individual SAM items had high interrater reliability, with 17 of the 22 items achieving substantial, almost perfect, or perfect weighted kappa value scores. The overall SAM rating achieved a weighted kappa value of 0.60, with a percentage total agreement of 96%.

CONCLUSION

Health care professionals should evaluate the content and design characteristics of written education materials before using them with patients. A tool such as the SAM checklist can be used; however, raters should exercise caution when interpreting results from items with more subjective scoring criteria. Refinements to the scoring criteria for these items are recommended. The value of the SAM is that it can be used to identify specific elements that should be modified before education materials are provided to patients.

Effects of text cohesion on comprehension and retention of colorectal cancer screening information: a preliminary study

Increasing readability of written cancer prevention information is a fundamental step to increasing awareness and knowledge of cancer screening. Instead of readability formulas, the present study focused on text cohesion, which is the degree to which the text content ties together. The purpose of this study was to examine the effect of text cohesion on reading times, comprehension, and retention of colorectal cancer prevention information. English-speaking adults (50 years of age or older) were recruited from local communities. Participants were randomly assigned to read colorectal cancer prevention subtopics presented at 2 levels of text cohesion: from higher cohesion to lower cohesion, or vice versa. Reading times, word recognition, text comprehension, and recall were assessed after reading. Two weeks later, text comprehension and recall were reassessed. Forty-two adults completed the study, but five were lost to follow up. Higher text cohesion showed a significant effect on reading times and text comprehension but not on word recognition and recall. The effect of text cohesion was not found on text comprehension and recall after 2 weeks. Increasing text cohesion facilitates reading speed and comprehension of colorectal cancer prevention information. Further research on the effect of text cohesion is warranted.

Health Literacy INDEX: development, reliability, and validity of a new tool for evaluating the health literacy demands of health information materials

There is no consensus on how best to assess the health literacy demands of health information materials. Comprehensive, reliable, and valid assessment tools are needed. The authors report on the development, refinement, and testing of Health Literacy INDEX, a new tool reflecting empirical evidence and best practices. INDEX is comprised of 63 indicators organized into 10 criteria: plain language, clear purpose, supporting graphics, user involvement, skill-based learning, audience appropriateness, user instruction, development details, evaluation methods, and strength of evidence. In a sample of 100 materials, intercoder agreement was high: 90% or better for 52% of indicators, and above 80% for nearly all others. Overall scores generated by INDEX were highly correlated with average ratings from 12 health literacy experts (r = 0.89, p < .0001). Additional research is warranted to examine the association between evaluation ratings generated by INDEX and individual understanding, behaviors, and improved health. Health Literacy INDEX is a comprehensive tool with evidence for reliability and validity that can be used to evaluate the health literacy demands of health information materials. Although improvement in health information materials is just one aspect of mitigating the effects of limited health literacy on health outcomes, it is an essential step toward a more health literate public.

Attitudes to colorectal cancer screening after reading the prevention information

Some of the biggest barriers to increase colorectal cancer screening are negative attitudes to screening tests. These negative attitudes might be evoked through reading cancer prevention information and impede the decision to get screened. Forty-two adults aged ≥50 years completed a 12-item attitude questionnaire after reading colorectal cancer prevention information. African-Americans perceived that others had higher cancer risk than themselves whereas Caucasians did not show the difference. Regardless of ethnicity and adherence to screening guidelines, no participants had strong feelings of fear and embarrassment. However, non-adherent Caucasians had higher anxiety than adherent Caucasians. The degree of negativity was not associated with intention to get screened in non-adherent participants. Adequate health literacy of participants may account for flat responses in negative attitudes. Further research in individuals with limited health literacy is recommended. Moreover, additional education about self-relevance of cancer risk is considered necessary to increase cancer awareness in African-Americans.

An examination into audience targeting and the use of storytelling or statistical evidence on breast cancer websites

OBJECTIVE

This research sought to address the presence of information targeting low literacy, racially diverse, non-English speaking, and age diverse audiences on breast cancer websites. In addition, this study documented the utilization of evidence strategies, either statistics or storytelling, for these audiences.

METHODS

This research examined these relationships on 157 breast cancer websites through content analysis.

RESULTS

Nearly half of websites did not contain any of the elements targeting diverse literacy, racial/ethnic, language, and age audiences. Websites with multiple languages were more likely than monolingual websites to use statistics, and websites with low literacy sections were less likely than others to do so. Websites with ethnic or racial diversity and age diversity were more likely than other websites to use first person storytelling about breast cancer.

CONCLUSION

Current breast cancer websites demonstrate promising use of targeting specific audiences and employing evidence strategies prescribed as effective by past research, however there is room for improvement.

PRACTICE IMPLICATIONS

Tip sheets for incorporating audience targeting, readability, and storytelling should be created for health organizations to use in the process of developing their websites, as these constructs were found only sparingly on the assessed sites.

How accessible was information about H1N1 flu? Literacy assessments of CDC guidance documents for different audiences

We assessed the literacy level and readability of online communications about H1N1/09 influenza issued by the Centers for Disease Control and Prevention (CDC) during the first month of outbreak. Documents were classified as targeting one of six audiences ranging in technical expertise. Flesch-Kincaid (FK) measure assessed literacy level for each group of documents. ANOVA models tested for differences in FK scores across target audiences and over time. Readability was assessed for documents targeting non-technical audiences using the Suitability Assessment of Materials (SAM). Overall, there was a main-effect by audience, F(5, 82) = 29.72, P<.001, but FK scores did not vary over time, F(2, 82) = .34, P>.05. A time-by-audience interaction was significant, F(10, 82) = 2.11, P<.05. Documents targeting non-technical audiences were found to be text-heavy and densely-formatted. The vocabulary and writing style were found to adequately reflect audience needs. The reading level of CDC guidance documents about H1N1/09 influenza varied appropriately according to the intended audience; sub-optimal formatting and layout may have rendered some text difficult to comprehend.

Lay interpersonal sources for health information related to beliefs about the modifiability of cancer risk

OBJECTIVE

Causal beliefs about cancer may influence preventive behaviors and medical care. We examined the relationship between beliefs about causation for lung, colon, and skin cancer and the use of lay interpersonal sources of health information (community organizations, family, friends).

METHODS

Data from a nationally representative sample of 5,119 adult respondents to the 2005 Health Information National Trends Survey were analyzed.

RESULTS

About 40% of respondents reported that community organizations provided them with health information, while 15% discussed health information “very frequently” with their family or friends. In multivariate models, individuals who never spoke with family or friends about health were more likely to believe that colon cancer risk is not modifiable; those provided with health information by community organizations were less likely to believe that skin cancer risk is not modifiable. Speaking with family or friends about health was also associated with endorsing the belief that skin cancer is caused by behavior or lifestyle.

CONCLUSION

These findings showed that lay interpersonal health information sources are associated with beliefs about the modifiability of colon and skin cancer risk. Future research is needed to investigate whether and how such information sources might influence decisions about engaging in preventive behaviors.

Beyond reading level: a systematic review of the suitability of cancer education print and Web-based materials

Consideration of categories related to reading comprehension--beyond reading level--is imperative to reach low literacy populations effectively. "Suitability" has been proposed as a term to encompass six categories of such factors: content, literacy demand graphics, layout/typography, learning stimulation, and cultural appropriateness. Our purpose was to describe instruments used to evaluate categories of suitability in cancer education materials in published reports and their findings. We searched databases and reference lists for evaluations of print and Web-based cancer education materials to identify and describe measures of these categories. Studies had to evaluate reading level and at least one category of suitability. Eleven studies met our criteria. Seven studies reported inter-rater reliability. Cultural appropriateness was most often assessed; four instruments assessed only surface aspects of cultural appropriateness. Only two of seven instruments used, the suitability assessment of materials (SAM) and the comprehensibility assessment of materials (SAM + CAM), were described as having any evidence of validity. Studies using Simplified Measure of Goobledygook (SMOG) and Fry reported higher average reading level scores than those using Flesh-Kincaid. Most materials failed criteria for reading level and cultural appropriateness. We recommend more emphasis on the categories of suitability for those developing cancer education materials and more study of these categories and reliability and validity testing of instruments.

Consumers' use of web-based information and their decisions about multiplex genetic susceptibility testing

BACKGROUND

Few data exist to inform concerns raised by online direct-to-consumer marketing of genetic susceptibility tests, such as those offered by commercial entities like 23andme, Navigenics, and DNA Direct. The Multiplex Initiative, a population-based study of healthy adults, provides the first opportunity to evaluate how use of a Web-based decision tool that conveyed information about a genetic susceptibility test influenced individuals' test decisions.

OBJECTIVE

To inform the ongoing debate over whether individuals offered genetic susceptibility testing without the involvement of a health care provider (eg, through direct-to-consumer testing) can make informed decisions about testing when guided by online decision aids.

METHODS

Participants were 526 members of a large health maintenance organization aged 25 to 40 years old who visited a study website. Multivariate logistic regression models were tested to examine the association of website usage with downstream test decisions.

RESULTS

Participants viewed an average of 2.9 of the 4 pages introducing the multiplex test, 2.2 of the 8 pages describing the health conditions, and 3.2 of the 15 pages describing the genes. For each page viewed, participants were more likely to describe their decision-making as easy (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07) and to decide to be tested (OR 1.08, 95% CI 1.05-1.11).

CONCLUSIONS

Healthy adults in this study perceived Web-based genomic information presented using evidence-based communications approaches to be helpful in supporting both decisions to test and not to test. Continued research is needed to ensure that these results generalize to target groups with lower literacy and less Internet savvy.

Informational content, literacy demands, and usability of websites offering health-related genetic tests directly to consumers

PURPOSE

As direct-to-consumer genetic testing becomes more available, a diverse group of consumers, including those with limited health literacy, may consider testing. In light of concerns raised about direct-to-consumer genetic testing, this study sought to critically examine whether the informational content, literacy demands, and usability of health-related direct-to-consumer websites met existing recommendations.

METHODS

A content analysis was performed on 29 health-related direct-to-consumer websites. Two coders independently evaluated each website for informational content (e.g., benefits, limitations), literacy demands (e.g., reading level), and usability (e.g., ease of navigation).

RESULTS

Most sites presented health conditions and some markers for which they tested, benefits of testing, a description of the testing process, and their privacy policy. Fewer cited scientific literature, explained test limitations, or provided an opportunity to consult a health professional. Key informational content was difficult to locate on most sites. Few sites gave sample disease risk estimates or used common language and explained technical terms consistently. Average reading level was grade 15.

CONCLUSION

The quality of informational content, literacy demands, and usability across health-related direct-to-consumer websites varied widely. Many users would struggle to find and understand the important information. For consumers to better understand the content on these sites and evaluate the meaning of the tests for their health, sites should lower the demands placed on users by distilling and prioritizing the key informational content while simultaneously attending to the reading level and usability elements. In the absence of regulation compelling such changes, government agencies or professional organizations may need to increase consumer and provider awareness of these issues.

Subjective well-being as a determinant of individuals' responses to symptoms: a biopsychosocial perspective

BACKGROUND

Although many models have been developed to explain health behaviour, differences in individual response to symptoms remain largely unexplained; moreover, they tend to underestimate affective (i.e., emotional) processes and they neglect the construct of well-being, despite its predominant role in the definition of health.

AIM

The development of a novel conceptual framework to explain and predict variability in individuals' responses to symptoms, through a bio-psychosocial perspective, considering also the potential role of subjective well-being.

MATERIALS & METHODS

The most widely used health behaviour models were being reviewed, as well as their limitations. Based on the evidence in the literature, major domains that influence response to symptoms are identified and analysed.

RESULTS

A new conceptual framework that is not limited to explanation of common health behaviours such as treatment seeking or problem identification, but draws attention to a broad spectrum of individual reactions and experiences following the physical experience of a symptom or medical condition. The role of subjective well-being and its determinants are considered as a central concept in the proposed framework.

DISCUSSION

The present conceptual framework provides a comprehensive bio-psychosocial perspective on behavioural outcomes related to individual response to symptoms.

CONCLUSION

The proposed framework opens a new window to patient centred care. Research to evaluate the proposed framework may improve the quality of clinical care and overall patient satisfaction.

Evaluation of online disaster and emergency preparedness resources

INTRODUCTION

Increasingly, individuals are relying on the Internet as a major source of health information. When faced with sudden or pending disasters, people resort to the Internet in search of clear, current, and accurate instructions on how to prepare for and respond to such emergencies. Research about online health resources ascertained that information was written at the secondary education and college levels and extremely difficult for individuals with limited literacy to comprehend. This content analysis is the first to assess the reading difficulty level and format suitability of a large number of disaster and emergency preparedness Web pages intended for the general public.

OBJECTIVES

The aims of this study were to: (1) assess the readability and suitability of disaster and emergency preparedness information on the Web; and (2) determine whether the reading difficulty level and suitability of online resources differ by the type of disaster or emergency and/or Website domain.

METHODS

Fifty Websites containing information on disaster and/or emergency preparedness were retrieved using the Google search engine. Readability testing was conducted on the first Web page, suggested by Google, addressing preparedness for the general public. The reading level was assessed using Flesch-Kincaid (F-K) and Flesch Reading Ease (FRE) measures. The Suitability Assessment of Materials (SAM) instrument was used to evaluate additional factors such as graphics, layout, and cultural appropriateness.

RESULTS

The mean F-K readability score of the 50 Websites was Grade 10.74 (95% CI = 9.93, 11.55). The mean FRE score was 45.74 (95% CI = 41.38, 50.10), a score considered "difficult."A Web page with content about both risk and preparedness supplies was the most difficult to read according to F-K (Grade level = 12.1). Web pages with general disaster and emergency information and preparedness supplies were considered most difficult according to the FRE (38.58, 95% CI = 30.09, 47.08). The average SAM score was 48% or 0.48 (95% CI = 0.45, 0.51), implying below average suitability of these Websites. Websites on pandemics and bioterrorism were the most difficult to read (F-K: p = 0.012; FRE: p = 0.014) and least suitable (SAM: p = 0.035) compared with other disasters and emergencies.

CONCLUSIONS

The results suggest the need for readily accessible preparedness resources on the Web that are easy-to-read and visually appropriate. Interdisciplinary collaborations between public health educators, risk communication specialists, and Web page creators and writers are recommended to ensure the development and dissemination of disaster and emergency resources that consider literacy abilities of the general public.

Tools for assessing readability and quality of health-related Web sites

With the Internet becoming a growing source of information on genetics, genetic counselors and other health-care providers may be called upon to guide their patients to appropriate material, which is written at a suitable reading level for the individual and contains quality information. Given that many health-related Web sites are written at a high school or higher reading level, without direction from a genetic counselor or health-care provider, many Internet users may currently be turning to health-related Web sites that they do not understand. Additionally, Internet users may not know how to evaluate the quality of information they find, which could lead to them access inaccurate or irrelevant information. To aid in the process of finding and designing Web sites that are appropriate for patients, the current article provides guidelines for assessing readability and quality of health-related content. Additionally, a demonstration of an assessment is provided. Finally, limitations of these assessments are discussed.

Computer and internet use in a community health clinic population

OBJECTIVE

To determine if patients from a community health clinic have access to computers and/or the Internet and if they believe a computer is useful in their medical care.

METHODS

A convenience sample of 100 subjects, aged 50 years and older, from a community health clinic in Nashville, Tennessee, completed a structured interview and a health literacy assessment.

RESULTS

Of the 100 participants, 40 did not have any computer access, 27 had computer but not Internet access, and 33 had Internet access. Participants with computer access (with or without Internet) had higher incomes, higher educational status, and higher literacy status than those without computer access. Of participants reporting current computer use (n = 54), 33% reported never using their computer to look up health and medical information. Of those who "never'' used their computer for this activity, 54% reported they did not have Internet connectivity, whereas 31% reported they did not know how to use the Internet. Although this group of individuals reported that they were comfortable using a computer (77%), they reported being uncomfortable with accessing the Internet (53%).

CONCLUSIONS

Not only does access to computers and the Internet need to be improved before widespread use by patients, but computer users will need to be instructed on how to navigate the Internet.

Online cancer communication: meeting the literacy, cultural and linguistic needs of diverse audiences

OBJECTIVE

This article provides an analysis of issues and empirical evidence related to literacy, cultural, and linguistic factors in online health and cancer communication, and recommendations to improve cancer communication for diverse audiences.

METHODS

We examined English-language online literature and selected books and policy documents related to literacy, cultural, and linguistic factors in health and cancer communication.

RESULTS

Studies about literacy, cultural, and linguistic factors in online cancer communication for diverse audiences are limited, but have increased during the past 15 years. Empirical evidence and theoretical guidance describe the critical importance of these factors, significant unmet needs among low-literate, multicultural and non-English-speaking populations, and strategies to improve communication.

CONCLUSION

Overall, online cancer communication has not met the literacy, cultural, and linguistic needs of diverse populations. The literature offers valuable recommendations about enhancing research, practice, and policy for better cancer communication.

PRACTICE IMPLICATIONS

Practitioners should understand the strengths and weaknesses of online cancer communication for vulnerable groups, guide patients to better Websites, and supplement that information with oral and tailored communication.

Internet information on colorectal cancer: commercialization and lack of quality control

OBJECTIVE

The objective of this study was to evaluate the effectiveness of the internet as a source of information for colorectal cancer (CRC).

METHOD

Six of the most common search engines (Yahoo, Google, MSN search, Alta Vista, Excite and Lycos) were used for the search of the generic term 'CRC'. First 300 links were analysed and classified by information type, provider, readership and commercial orientation.

RESULTS

The average time delay was 1.70 s before matches were located. A total of 3.2827 million matches on CRC were found using the six search engines ranging from 700 (Excite) to 1 417 000 (Lycos) websites. Approximately 50% of the links were based on information from textbooks or governmental websites. Commercial companies giving information about private hospitals and products provided over 50% of the websites on CRC. The distribution of target readers was uneven, although a majority of websites were delivering CRC information to public and patients. Readability of information was difficult to comprehend by the public.

CONCLUSION

The internet is becoming an essential tool for disseminating information about CRC to consumers. Half of the links on CRC are commercially oriented, containing information on goods or private health services. Less than 1% information is being provided by professional societies. To provide relevant CRC information, key consensus criteria for evaluating healthcare-related websites have to be established. There is an urgent need for CRC information on the internet to be regulated through the establishment of government-funded organizations (e.g. NHS) or professional societies (e.g. ACPGBI).

A new age for cancer information seeking: are we better off now?

A decade after the dawn of the Internet Age, are people who seek health information better off than they used to be? The current study by Arora and colleagues examines a small slice of the massive Health Information National Trends Survey dataset and attempts to understand the experiences of those US adults who have sought cancer information at any point in their lives from any source. One third reported that the information they encountered was hard to understand, and one half questioned the quality of the information they found. Several research questions regarding how individuals successfully find information on the Internet remain to be answered.

An analysis of cluster headache information provided on internet websites

OBJECTIVE

To evaluate the quality of websites providing cluster headache information for patients and healthcare providers.

BACKGROUND

The Internet has become an increasingly important source of healthcare information. However, limited data exist regarding the quality of websites providing headache information.

METHODS

This was a cross-sectional study conducted in February 2007. Websites providing cluster headache information were determined on the search engine MetaCrawler and classified as either patient oriented or healthcare provider oriented. The overall quality of each site was evaluated using a score system. Readability was evaluated using the Flesch-Kincaid Grade Level Readability Score (FKRS). Website quality was analyzed based on ownership, purpose, authorship, author qualifications, attribution, interactivity, and currency. The technical quality of the cluster headache information was analyzed based on content specific to cluster headache. The final ranking, based on the sum of the ranks of all 3 categories, was determined and then contrasted between the patient-oriented and healthcare professional-oriented websites using 2-sample t-tests.

RESULTS

Of the first 40 websites found on MetaCrawler, 72.5% were advertisements, unrelated to headache, or repeated websites. Although the standard US writing averages are at a seventh to eighth grade level, the mean FKRS of all sites was at a 12th grade level of difficulty, with no significant difference between the patient-oriented or healthcare provider-oriented websites (P = .54). Of a total possible 14 points, the overall mean quality component score was 9.9 for all sites; and of a total possible 23 points, the overall mean technical component score was 13.9. There was no significant difference for either the quality or technical component scores between patient-oriented or healthcare provider-oriented websites (P = .45 and P = .80, respectively).

CONCLUSION

There are numerous cluster headache websites that can be found on the Internet. The quality of most of the websites dedicated to cluster headache is mediocre, and although there are some excellent cluster headache websites, these sites may be challenging for many users to locate. There was no significant difference in the overall quality of websites oriented for patients or healthcare providers providing cluster headache information evaluated in this study. In addition, websites providing high-quality cluster headache information are written at an educational level too high for a significant portion of the general population to fully utilize. Physicians should strongly consider providing lists of quality websites on cluster headache for their patients.

Barriers and facilitators to home computer and internet use among urban novice computer users of low socioeconomic position

BACKGROUND

Despite the increasing penetration of the Internet and amount of online health information, there are significant barriers that limit its widespread adoption as a source of health information. One is the "digital divide," with people of higher socioeconomic position (SEP) demonstrating greater access and usage compared to those from lower SEP groups. However, as the access gap narrows over time and more people use the Internet, a shift in research needs to occur to explore how one might improve Internet use as well as website design for a range of audiences. This is particularly important in the case of novice users who may not have the technical skills, experience, or social connections that could help them search for health information using the Internet. The focus of our research is to investigate the challenges in the implementation of a project to improve health information seeking among low SEP groups. The goal of the project is not to promote health information seeking as much as to understand the barriers and facilitators to computer and Internet use, beyond access, among members of lower SEP groups in an urban setting.

OBJECTIVE

The purpose was to qualitatively describe participants' self-identified barriers and facilitators to computer and Internet use during a 1-year pilot study as well as the challenges encountered by the research team in the delivery of the intervention.

METHODS

Between August and November 2005, 12 low-SEP urban individuals with no or limited computer and Internet experience were recruited through a snowball sampling. Each participant received a free computer system, broadband Internet access, monthly computer training courses, and technical support for 1 year as the intervention condition. Upon completion of the study, participants were offered the opportunity to complete an in-depth semistructured interview. Interviews were approximately 1 hour in length and were conducted by the project director. The interviews were held in the participants' homes and were tape recorded for accuracy. Nine of the 12 study participants completed the semistructured interviews. Members of the research team conducted a qualitative analysis based on the transcripts from the nine interviews using the crystallization/immersion method.

RESULTS

Nine of the 12 participants completed the in-depth interview (75% overall response rate), with three men and six women agreeing to be interviewed. Major barriers to Internet use that were mentioned included time constraints and family conflict over computer usage. The monthly training classes and technical assistance components of the intervention surfaced as the most important facilitators to computer and Internet use. The concept of received social support from other study members, such as assistance with computer-related questions, also emerged as an important facilitator to overall computer usage.

CONCLUSIONS

This pilot study offers important insights into the self-identified barriers and facilitators in computer and Internet use among urban low-SEP novice users as well as the challenges faced by the research team in implementing the intervention.

Information about cancer clinical trials: An analysis of Internet resources

PURPOSE

Clinical trials are critical to improving patient outcomes, but participation in cancer clinical trials is low. Patient understanding of clinical trial process is also limited. Patients are increasingly using the Internet as a source of information. It is critical that such Internet-based information is relevant, current, balanced, and easy to access and navigate. We critically reviewed seven international online resources that provide information for patients/consumers regarding cancer clinical trials.

METHODS

Seven international websites from North America, Europe and Australia were selected based on profile/usage. Sites were evaluated with respect to their content, readability and appropriateness using a suite of standard assessment tools.

RESULTS

No sites performed well in terms of all assessment criteria. There was substantial variation between sites regarding information provided, content, design and readability. All sites required high literacy levels and assessment using the Standard Assessment of Means tool showed consistent deficiencies.

CONCLUSION

Although there are numerous websites providing information about cancer clinical trials to patients/consumers, all evaluated sites have several shortcomings. Attention to the content of information, its presentation and the design of Internet resources has an ethical imperative, and is likely to lead to improved patient satisfaction.

Cluster headache: a review of online resources for patients and clinicians

Technology has revolutionized the ability of both patients and physicians to find and retrieve medical information. In particular, the Internet has become an increasingly important source of information for patients and physicians in all medical fields, including headache. Although these resources may be readily available, it is not certain that those who would benefit most from these websites are aware of their existence or how to differentiate if the website is reputable. This article briefly reviews how patients and physicians can differentiate which sites provide legitimate and reputable information and then focuses on where to find online information on cluster headache.

eHealth research from the user's perspective

The application of information technology (IT) to issues of healthcare delivery has had a long and tortuous history in the United States. Within the field of eHealth, vanguard applications of advanced computing techniques, such as applications in artificial intelligence or expert systems, have languished in spite of a track record of scholarly publication and decisional accuracy. The problem is one of purpose, of asking the right questions for the science to solve. Historically, many computer science pioneers have been tempted to ask "what can the computer do?" New advances in eHealth are prompting developers to ask "what can people do?" How can eHealth take part in national goals for healthcare reform to empower relationships between healthcare professionals and patients, healthcare teams and families, and hospitals and communities to improve health equitably throughout the population? To do this, eHealth researchers must combine best evidence from the user sciences (human factors engineering, human-computer interaction, psychology, and usability) with best evidence in medicine to create transformational improvements in the quality of care that medicine offers. These improvements should follow recommendations from the Institute of Medicine to create a healthcare system that is (1) safe, (2) effective (evidence based), (3) patient centered, and (4) timely. Relying on the eHealth researcher's intuitive grasp of systems issues, improvements should be made with considerations of users and beneficiaries at the individual (patient-physician), group (family-staff), community, and broad environmental levels.

Plain language: a strategic response to the health literacy challenge

Low health literacy is a major challenge confronting American and international health organizations. Research in the past decade has documented the prevalence of limited literacy and limited health literacy skills among adults worldwide. This creates a major policy challenge: how to create text-based health information - a common method of health communication - that is accessible to the public. Plain language is a logical, flexible response. While touted by American, Canadian, and European health policy makers, adoption and promotion of plain language standards and skills in health-focused organizations have lagged. Most text-based health information continues to be too hard for most adults to read. Barriers to more rapid diffusion of plain language are reflected in a set of myths perpetuated by critics. These myths are identified and refuted. While plain language is only one of many broad-based solutions needed to address low health literacy, the benefits to everyone demand increased use by health organizations.

Impacting health disparities through community outreach: utilizing the CLEAN look (culture, literacy, education, assessment, and networking)

BACKGROUND

Community outreach programs are important vehicles for reducing the discovery-delivery disconnect by bringing cancer education and screening services directly to community members. Such programs are consistent with the priority areas of the Department of Health and Human Services' initiatives for reducing health disparities by 2010, and they support the use of culturally, linguistically, and literacy-specific approaches for eliminating cancer health disparities.

METHODS

This article reviews the important tenets of culture and literacy when developing community outreach programs for medically underserved populations, examines a health education empowerment model for community program planning, and describes the use of the CLEAN Look Checklist (in which CLEAN is an easy-to-remember mnemonic of culture, literacy, education, assessment, and networking) for identifying cues and strategies to achieve relevant outreach.

RESULTS

This article illustrates the application of this approach with an example of outreach strategies for reaching at-risk Haitian American women in our community.

CONCLUSIONS

Meeting the challenge of a strong health disparities agenda requires integration of cultural and literacy considerations in outreach program, message, and intervention development. The use of a checklist may help clinicians, educators, and researchers create a sustainable model of community outreach guided by a paradigm that incorporates a multilevel approach to address cancer outcomes for disenfranchised populations.

A critical review of FDA-approved Medication Guides

OBJECTIVE

To investigate whether consumer-directed, FDA-approved Medication Guides issued for potentially harmful medications are likely to be useful to patients with limited literacy.

METHODS

Lexile analysis and the suitability assessment of materials (SAM) were conducted on the 40 currently issued Medication Guides to evaluate reading difficulty, content, and format. Structured interviews with a literacy assessment were also conducted among 251 primary care patients at a public hospital clinic in Louisiana to determine if patients directed attention to Medication Guides and other accompanying patient information materials.

RESULTS

The average Lexile score estimated an 11th-12th grade reading level for the guides (M=1223, S.D.=200). None of the 40 Medication Guides met federal recommendations (6th-8th grade level). Most Medication Guides were deemed unsuitable because they did not provide a summary of content (90.0%) or limit the scope of information (77.5%). Only 23.0% of patients reported having looked at Medication Guides or accompanying patient information materials; patients with low literacy were less likely to have looked at them (16.7% versus 32.9%, p=0.03).

CONCLUSION

Medication Guides in their current form are not likely to be useful to patients with limited literacy skills.

PRACTICE IMPLICATIONS

Reading level of text in Medication Guides should be reduced, summaries or "highlights" provided, and the scope of information limited to increase the likelihood of use among individuals with limited literacy. Consumers should be involved in their development.