Quality and Health Literacy Demand of Online Heart Failure Information

Investigation of the quality and health literacy demand of online information on pelvic floor exercises to reduce stress urinary incontinence

BACKGROUND

Many women are embarrassed to discuss pelvic floor exercises with health professionals during pregnancy; instead they search the internet for information on pelvic floor exercises.

AIMS

This project investigated the quality and health literacy demand in terms of readability, understandability and actionability of information available on the internet relating to pelvic floor exercises.

MATERIALS AND METHODS

An analysis was conducted on 150 websites and 43 videos obtained from three consecutive Google searches relating to pelvic floor exercises. Websites were assessed for Health on the Net certification. Readability was assessed using a readability calculator, and understandability/actionability of website and video information was assessed using the Patient Education Materials Assessment Tool (PEMAT) for Print or Audiovisual Materials.

RESULTS

Less than one-third (24%) of the websites were certified for quality. The median readability score for the websites was grade 9 and the websites and videos both rated highly for understandability and actionability. The median understandability score for the website information was 87%, and the median actionability score was 71%. The median understandability score of the video information was 95.5% and the median actionability score was 100%. The understandability and actionability of video information was also significantly greater than that for website information (P < 0.01).

CONCLUSION

Clinicians could consider directing patients to video-based resources when advising online pelvic floor exercise resources for women during pregnancy, especially those with lower health literacy.

Assessing the understandability and actionability of online resources for patients undergoing hemodialysis

INTRODUCTION

This study quantitatively evaluated the understandability and actionability of webpages for patients undergoing hemodialysis (HD).

METHODS

In June 2022, we searched on Google and Yahoo Japan using the top five keywords associated with end-stage kidney disease and HD to identify relevant materials. Subsequently, we used the Japanese version of the Patient Education Materials Assessment Tool to assess the understandability and actionability of these materials, rating them on a scale from 0% to 100%. The threshold was set at 70%.

RESULTS

Among the included 194 materials, the overall understandability was 66.7%, and the actionability was 33.3%. Only 38.7% and 16.5% of the materials were deemed understandable and actionable, respectively. Challenges included the need for plain language and concise summaries to improve understandability, along with the use of effective visual aids for actionability.

CONCLUSION

This study suggests that existing webpages on HD are not presented in a manner that patients can utilize.

Readability Level of Spanish Language Online Health Information: A Systematic Review

Introduction: Because there is limited online health information in Spanish and it is critical to raise health literacy among Spanish-speaking people, it is essential to assess the readability level of Spanish material. Method: This systematic review included all articles published up to January 3, 2024, and used the CINAHL, MEDLINE, and PubMed databases. The objective was to include the body of knowledge on published articles on the readability levels of Spanish-language, web-based health information intended for lay audiences. Results: There were 27 articles in the final review. Within these articles, 11 tools were used in the Spanish language text. Of the tools, INFLESZ was the most frequently used and the FRY formula, Flesch-Szigriszt Index, and Flesch Formula Index were least used. Most materials (85.2%) reported readability levels of online Spanish information above the 8th grade reading level. Conclusions: The findings show the lack of internet-based Spanish language health information and materials at a recommended (e.g., 5th to 8th grade) reading level. More research is needed to determine which readability tests are more accurate for calculating the readability of Spanish web health information.

Quality Analysis of Online Resources for Patients Undergoing Coronary Artery Bypass Grafting

Background

Online resources are becoming the primary educational resource for patients. Quality and reliability of websites about coronary artery bypass graft (CABG) procedures are unknown.

Methods

We queried 4 search engines (Google, Bing, Yahoo!, and Dogpile) for the terms coronary artery bypass, coronary artery bypass graft, coronary artery bypass graft surgery, and CABG. The top 30 websites from each were aggregated. After exclusions, 85 websites were graded with the DISCERN instrument, patient-focused criteria, and readability calculators by a 2-reviewer system.

Results

Accessibility was low; 34.1% of websites disclosed authorship, and 23.5% were available in Spanish. Median total score was 55 of 95 (interquartile range [IQR], 44-68); this score varied by website type (P = .048). Professional medical society (median, 76; IQR, 76-76) and governmental agency (median, 69; IQR, 56.6-75.5) scored higher, whereas industry (median, 51.8; IQR, 47.1-56.4) and hospital/health care (median, 49; IQR, 40-61) scored lower. Readability was low, with median Flesch-Kincaid grade level score of 11.1 (IQR, 9.5-12.6) and 75.3% of websites written above eighth-grade reading level.

Conclusions

Accessibility of online patient educational resources for CABG procedures is limited by language and reading level despite being widely available. Quality and reliability of the information offered varied between website types. Improving readability to ensure patients' understanding and comprehensive decision-making should be prioritized.

Can Artificial Intelligence Improve the Readability of Patient Education Materials on Aortic Stenosis? A Pilot Study

INTRODUCTION

The advent of generative artificial intelligence (AI) dialogue platforms and large language models (LLMs) may help facilitate ongoing efforts to improve health literacy. Additionally, recent studies have highlighted inadequate health literacy among patients with cardiac disease. The aim of the present study was to ascertain whether two freely available generative AI dialogue platforms could rewrite online aortic stenosis (AS) patient education materials (PEMs) to meet recommended reading skill levels for the public.

METHODS

Online PEMs were gathered from a professional cardiothoracic surgical society and academic institutions in the USA. PEMs were then inputted into two AI-powered LLMs, ChatGPT-3.5 and Bard, with the prompt "translate to 5th-grade reading level". Readability of PEMs before and after AI conversion was measured using the validated Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook Index (SMOGI), and Gunning-Fog Index (GFI) scores.

RESULTS

Overall, 21 PEMs on AS were gathered. Original readability measures indicated difficult readability at the 10th-12th grade reading level. ChatGPT-3.5 successfully improved readability across all four measures (p < 0.001) to the approximately 6th-7th grade reading level. Bard successfully improved readability across all measures (p < 0.001) except for SMOGI (p = 0.729) to the approximately 8th-9th grade level. Neither platform generated PEMs written below the recommended 6th-grade reading level. ChatGPT-3.5 demonstrated significantly more favorable post-conversion readability scores, percentage change in readability scores, and conversion time compared to Bard (all p < 0.001).

CONCLUSION

AI dialogue platforms can enhance the readability of PEMs for patients with AS but may not fully meet recommended reading skill levels, highlighting potential tools to help strengthen cardiac health literacy in the future.

A Systematic Evaluation of the Quality of Health Information on Cleft Lip and Palate in the Arabic Language

Background

The internet serves as a vital health information resource, yet the quality of data on specific health conditions, especially in Arabic, is often overlooked. This research assesses the quality of Arabic online information about cleft lip and palate (CLP) and proposes avenues for enhancement.

Methods

From July to August 2022, a systematic evaluation of Arabic articles on CLP was performed using the DISCERN tool for quality assessment. Searches on Google and Bing resulted in 119 articles that met the study's criteria.

Results

The quality of available Arabic information on CLP displayed substantial gaps. Commercial sources dominated (49.6%), followed by private (32.8%) and nonprofit entities (17.6%). The average DISCERN score was 2.26 of 5 (SD = 1.06), indicating the need for enhanced content, particularly concerning treatment risks.

Conclusions

The study underscores the subpar quality of Arabic CLP information online, which might mislead patients and impede access to accurate advice. Nonprofit organizations should bolster their online footprint, offering refined health content. A deep dive into DISCERN scores reveals pinpointed improvement areas. Clinicians should direct patients and their families to reliable information sources. Addressing these gaps promises improved CLP knowledge in Arabic, fostering superior patient education and outcomes for those with this condition.

Evaluating the understandability and actionability of online CKD educational materials

BACKGROUND

Previous studies have not fully determined whether online education materials on chronic kidney disease (CKD) for Japanese patients are easy to understand and help change their behavior. Therefore, this study quantitatively assessed the understandability and actionability of online CKD education materials.

METHODS

In September 2021, we searched Google and Yahoo Japan using the keywords "kidney," "kidney disease," "CKD," "chronic kidney disease," and "renal failure" to identify 538 webpages. We used the Japanese version of the Patient Education Materials Assessment Tool (PEMAT), ranging from 0 to 100%, to evaluate the understandability and actionability of webpages. We set the cutoff point to 70%.

RESULTS

Of the 186 materials included, the overall understandability and actionability were 61.5% (± 16.3%) and 38.7% (± 30.6%), respectively. The materials were highly technical in their terminology and lacked clear and concise charts and illustrations to encourage action. Compared to lifestyle modification materials on CKD overview, symptoms/signs, examination, and treatment scored significantly lower on the PEMAT. In addition, the materials produced by medical institutions and academic organizations scored significantly lower than those produced by for-profit companies.

CONCLUSION

Medical institutions and academic organizations are encouraged to use plain language and to attach explanations of medical terms when preparing materials for patients. They are also expected to improve visual aids to promote healthy behaviors.

Website quality evaluation: a model for developing comprehensive assessment instruments based on key quality factors

Purpose

The field of website quality evaluation attracts the interest of a range of disciplines, each bringing its own particular perspective to bear. This study aims to identify the main characteristics – methods, techniques and tools – of the instruments of evaluation described in this literature, with a specific concern for the factors analysed, and based on these, a multipurpose model is proposed for the development of new comprehensive instruments.

Design/methodology/approach

Following a systematic bibliographic review, 305 publications on website quality are examined, the field's leading authors, their disciplines of origin and the sectors to which the websites being assessed belong are identified, and the methods they employ characterised.

Findings

Evaluations of website quality tend to be conducted with one of three primary focuses: strategic, functional or experiential. The technique of expert analysis predominates over user studies and most of the instruments examined classify the characteristics to be evaluated – for example, usability and content – into factors that operate at different levels, albeit that there is little agreement on the names used in referring to them.

Originality/value

Based on the factors detected in the 50 most cited works, a model is developed that classifies these factors into 13 dimensions and more than 120 general parameters. The resulting model provides a comprehensive evaluation framework and constitutes an initial step towards a shared conceptualization of the discipline of website quality.

Web-Based Nutrition and Physical Activity Education Intervention to Ameliorate Cardiometabolic Risks: A Single-Arm and Non-Randomized Feasibility Study

OBJECTIVE

This study aimed to evaluate the feasibility of the D-PATH website to improve dietary and physical activity management for patients with cardiometabolic risk.

METHODS

A website called D-PATH was developed, consisting of 6 learning units for managing hypertension. A 4-week program was implemented, and a pre- and post-intervention assessment was conducted to measure acceptability and changes in knowledge, attitude and practice, dietary intake, physical activity, and anthropometric status.

RESULTS

The D-PATH website was acceptable in terms of understandability, actionability and cognitive load. Knowledge, attitude and practice, and physical activity levels were improved, but no changes were noted for dietary intake and blood pressure level.

CONCLUSION

The D-PATH website was accepted and feasible for the intervention study. This study has shed light on using the website to promote behavioral change in patients with cardiometabolic risks.

Info-pollution: a word of caution for the neurosurgical community

The medical-patient relationship is facing pollution of information all over the internet, for physician and patients is becoming tougher to keep updated with the highest quality of information. During the last 20 years multiple evaluation tools have been developed trying to find the best tool to assess high-quality information, to date DISCERN tool represents the most widely spread. Information can be found on the surface internet and in the deep web, constituting the biggest chunk of the internet, informing and controlling the quality of information is a formidable task. PubMed and Google Scholar are the most important tools for a physician to find information, although multiple others are available; awareness must be raised over improving current strategies for data mining high-quality information for the patients and the healthcare community.

Evidence-based health information about pulmonary embolism: Assessing the quality, usability and readability of online and offline patient information

Objective

Pulmonary embolism (PE) is the third most common cardiovascular disease worldwide. However, public awareness is considerably lower than for myocardial infarction or stroke. Patients suffering from PE complain about the lack of (understandable) information and express high informational needs. To uncover if reliable information is indeed scarce, this study evaluates the quantity and quality of existing patient information for tertiary prevention using an evidence-based health information paradigm.

Methods

We conducted a quantitative content analysis (n = 21 patient information brochures; n = 67 websites) evaluating content categories addressed, methodical quality, usability, and readability.

Results

Results show that there is not enough patient information material focusing on PE as a main topic. Existing patient information material is mostly incomplete, difficult to understand, and low in actionability as well as readability.

Conclusion

Our systematic analysis reveals the need for more high-quality patient information on PE as part of effective tertiary prevention.

Innovation

This is the first review analyzing content, methodical quality, readability, and usability of patient information on PE. The findings of this analysis are guiding the development of an innovative, evidence-based patient information on PE aiming to support patients' informational needs and their self-care behavior.

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

Considering health literacy in cardiovascular disease management: a qualitative study on healthcare professionals' and patients' perspectives

Background

Implementing practices adapted to patient health literacy (HL) is a promising avenue for improving their outcomes in the context of cardiovascular diseases (CVD). The health communication skills of healthcare professionals (HCPs) and the quality of information provided are essential for low-HL patients. We aimed to explore HCP knowledge about HL, patients’ and HCPs’ views on current practices regarding low-HL patients, and facilitators and barriers to adapting communication to patients’ HL level, in order to prepare the implementation of a complex intervention dedicated to improve CVD management for low-HL patients.

Methods

We conducted face-to-face semi-structured interviews with HCPs practicing in cardiology units and patients hospitalized for CVD. The study design and analysis were based on the Theory of Planned Behavior for HCPs and on the framework of Health Literacy and Health Action for patients. Deductive and inductive thematic analysis were used. Barriers and facilitators were structured into an Ishikawa fishbone diagram and implementation strategies were selected to address resulting themes from the Expert Recommendations for Implementing Change (ERIC).

Results

Fifteen patients and 14 HCPs were interviewed. HCPs had partial knowledge of HL dimensions. Perceptions of HCPs and patients were not congruent regarding HCP-patient interactions and information provided by hospital and community HCPs. HCPs perceived they lacked validated tools and skills, and declared they adapted spontaneously their communication when interacting with low-HL patients. Patients expressed unmet needs regarding communication during hospital discharge and at return to home.

Conclusion

To implement HL-tailored practices in this setting, our results suggest that several implementation strategies will be valuable at individual (engaging patients and their family), interactional (educating and training of HCPs about HL), and organizational levels (creating a multidisciplinary HCP interest group dedicated to HL).

Trial registration

ClinicalTrials.gov, (NCT number) NCT03949309, May 10, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08455-8.

Assessment of patient education materials for age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a leading cause of vision loss. It is helpful for patients living with AMD to understand the prognosis, risk factors and management of their condition. Online education materials are a popular and promising channel for conveying this knowledge to patients with AMD. However, the quality of these materials—particularly with respect to qualities such as ‘understandability’ and ‘actionability’—is not yet known. This study assessed a collection of online materials about AMD based on these qualities of ‘understandability’ and ‘actionability’.

Methods

Online education materials about AMD were sourced through Google from six English‐speaking nations: Australia, New Zealand, USA, UK, Ireland and Canada. Three Australian/New Zealand trained and registered optometrists participated in the grading of the ‘understandability’ and ‘actionability’ of online education materials using the Patient Education Materials Assessment Tool (PEMAT).

Results

This study analysed a total of 75 online materials. The mean ‘understandability’ score was 74% (range: 38%–94%). The ‘understandability’ PEMAT criterion U11 (calling for a summary of the key points) scored most poorly across all materials. The mean ‘actionability’ score was 49% (range: 0%–83%). The ‘actionability’ PEMAT criterion A26 (using ‘visual aids’ to make instructions easier to act on) scored most poorly across all materials.

Conclusion

Most education materials about AMD are easy to understand, but difficult to act on, because of a lack of meaningful visual aids. We propose future enhancements to AMD education materials—including the use of summaries, visual aids and a habit tracker—to help patients with AMD improve their understanding of disease prognosis, risk factors and eye assessment schedule requirements.

Do anxiety websites have the answers people are looking for?

OBJECTIVES AND METHODS: A wealth of online anxiety information exists but much of it is not evidence-based or well-balanced. This study evaluated anxiety websites (N = 20) on readability, quality, usability, visual design, and content.

RESULTS

Overall, websites were of reasonable quality but only half were considered understandable according to the PEMAT usability scale (70% cutoff value). The average reading level across websites was 11.2 (SMOG), which is higher than NIH recommended grade 6-7 level. Websites had variable design features and a trending association suggested websites with better design come up earlier in search results. The number of topics covered varied across websites and most did not adequately cover all topics of interest. Most websites included information about psychological and self-help treatments, how treatment works, and what treatment entails. The Top 5 websites were: (1) Anxiety BC, (2) ADAA, (3) Mind, (4) Beyond Blue, and (5) Web MD.

CONCLUSIONS

This is the first study to evaluate existing anxiety information websites based on the dimensions described above and their relationship to Google search results.

PRACTICE IMPLICATIONS

This study highlights the importance of considering several dimensions in developing mental health resources and provides direction for strategies to improve existing websites and/or develop new resources.

The Retrospective Analysis of Google Queries Related to Cardiovascular Diseases Symptoms in the Years 2004-2019

The Internet enables immediate access to health-related information. We aimed to rank the complaints related to cardiovascular diseases among Google users globally and locally as well as investigate secular and seasonal trends in the years 2004 to 2019. We used Google Trends (GT) to identify and analyze course over time and regional interest of seven topics: "Chest pain," "Cyanosis," "Edema," "Orthopnea," "Palpitation," "Shortness of breath," and "Syncope." We analyzed secular trends using the seasonal Mann-Kendall test and seasonal variation using time series decomposition. We calculated the interest of all topics in proportion to the relative search volume (RSV) of "Chest Pain." Globally the most popular topics were: "Edema" (proportion to RSV of "Chest pain," 1.39), "Chest pain" (1.00), and Syncope (0.71). "Chest pain" was predominately searched in n  = 25 countries, while "Edema" in n  = 24, "Syncope" in n  = 9, and "Shortness of breath" in n  = 3. The RSV of all topics increases over time and the most dynamically for "Chest pain" (4.30 RSV/year), "Shortness of breath" (3.87 RSV/year), and "Palpitations" (3.69 RSV/year). Interest in "Chest pain," "Cyanosis," "Orthopnea," "Palpitations," and "Syncope" peaks in fall and winter, while interest in "Edema" in midsummer and "Shortness of breath" in April. Google users were particularly interested in "Edema," "Chest pain," and "Syncope." The interest in cardiovascular diseases-related symptoms increases over time and presents explicable seasonal variations. The Internet plays the acquisition of health-related information; thus, professionals should create and recommend evidence-based information sources for their patients.

Sources of Health Information, Technology Access, and Use Among Non-English-Speaking Immigrant Women: Descriptive Correlational Study

BACKGROUND

As the world is becoming increasingly connected by the World Wide Web, the internet is becoming the main source of health information. With the novel COVID-19 pandemic, ubiquitous use of the internet has changed the daily lives of individuals, from working from home to seeking and meeting with health care providers through web-based sites. Such heavy reliance on internet-based technologies raises concerns regarding the accessibility of the internet for minority populations who are likely to already face barriers when seeking health information.

OBJECTIVE

This study aims to examine the level of technology access and common modes of technology used by Korean American women and to investigate how key psychosocial determinants of health such as age, education, English proficiency, and health literacy are correlated with sources of health information used by Korean American women and by their use of the internet.

METHODS

We used data from a subsample of Korean American women (N=157) who participated in a community-based randomized trial designed to test a health literacy-focused cancer screening intervention. In addition to descriptive statistics to summarize Korean American women's internet access and common modes of technology use, we conducted backward stepwise logistic regression analyses to substantiate the association between the psychosocial determinants of health and internet use.

RESULTS

Approximately two-thirds (103/157, 65.6%) of the sample had access to the internet, and nearly all had access to a mobile phone. The internet was the most commonly used channel to obtain health information 63% (99/157), and 70% (110/157) of the sample used text messaging. Nevertheless, only approximately 38.8% (40/103) of the sample were very confident in using the internet, and only 29.9% (47/157) were very confident in using text messaging. Multivariate analyses revealed that older age (>50 years) was associated with 79% lower odds of using the internet to seek health information (adjusted odds ratio [AOR] 0.21, 95% CI 0.10-0.46). The higher health literacy group (19+ on Rapid Estimate of Adult Literacy in Medicine) had 56% lower odds of using the internet to acquire health information (AOR 0.44, 95% CI 1.13-11.18). Higher education (college+) was associated with both internet use (AOR 4.42, 95% CI 1.88-9.21) and text messaging (AOR 3.42, 95% CI 1.55-7.54). Finally, English proficiency was associated with text messaging (AOR 4.20, 95% CI 1.44-12.24).

CONCLUSIONS

The differences in modes of technology access, use, and confidence by some of the key psychosocial determinants, as observed in our study sample, have important implications when health care teams develop dissemination plans.

Development of a discharge education program using the teach-back method for heart failure patients

Background

Heart failure (HF) patients have difficulties in self-management after discharge. This study aimed to develop a discharge education program for HF patients using the teach-back method (TBM).

Methods

As a methodological study to develop a program, we applied the analysis, design, development, implementation, and evaluation (ADDIE) model comprised of (1) analysis using EMR data, systematic review, and focus group interviews, (2) design and development of a program draft, (3) tests of program validity using 15 experts, 10 nurses, and 10 patients, and (4) development of the final program. The content validity index (CVI), and understandability and actionability of the educational material were used.

Results

The discharge education program provides definitions and information about medication, symptom/weight/diet management, physical activity, and other precautions. The educational method uses TBM. The overall CVI for the program was 0.96, and all item CVIs were greater than 0.8. The understandability and actionability were 90.2 and 91.3 % in patients, and 94.6 and 86.8 % in nurses. The contents and methods of the program were appropriate for patients and providers.

Conclusions

We expect the discharge education program using TBM to enhance self-management among HF patients. The process we used to develop this program could guide researchers and clinical practice.

Evaluation of the quality and readability of online information about breast cancer in China

OBJECTIVE

This study aimed at evaluating the quality and readability of online information about breast cancer written in Chinese.

METHODS

An Internet search was conducted for "breast cancer" in Chinese using the Baidu search engine. Website quality was evaluated using the DISCERN instrument, and readability was evaluated using the Chinese Readability Index Explorer (CRIE). Higher DISCERN score indicated higher quality of websites, while higher CRIE score indicated lower readability of the content of the websites. We also investigated the effects of website producer category, and the associations of search engine ranking with DISCERN and CRIE scores.

RESULTS

A total of 49 websites were included. The mean overall DISCERN score was 50.27 ± 4.14, and the mean CRIE score was 6.78 ± 0.16. Websites produced by non-profit organizations had the highest overall DISCERN scores, while those produced by private individuals had the lowest CRIE scores. Search engine ranking had no significant correlation with website quality or readability.

CONCLUSIONS

The quality and readability of breast cancer websites in Chinese were not satisfactory, and they varied among different website producer categories.

PRACTICE IMPLICATIONS

Website producers should seek to provide more accurate, comprehensive, and easy-to-understand information to better meet the needs of breast cancer patients. In addition, search engines should revise algorithms to promote websites with higher quality and accessibility.

Evaluation of the Heart Failure in Internet Patient Information: Descriptive Survey Study

Patients with heart failure (HF) may not receive enough HF education from their clinicians throughout the course of the illness. Given that information is readily accessible on the Internet, patients with HF may seek HF information online. However, the relevance of online information for patients, the health literacy demand, and quality of the information is unknown. The purpose of this study was to compare the HF topics available online with topics HF patients perceived to be important and to evaluate the health literacy demand and quality of online HF information. The most popular search engines and a website that ranks the popularity of the websites were searched to identify websites with HF information. The health literacy demand and quality of the information were evaluated using the Patient Education Material Evaluation Tool for Print Materials and the DISCERN tool, respectively. First, the HF Patients' Learning Needs Inventory (HFPLNI) was used to determine whether the websites included the 46 topics identified in this inventory. Patients with HF (n = 126) then completed the HFPLNI to rate the perceived importance on each topic. A chi-square test was used to compare the differences between the topics on the websites and those patients perceived to be important. Of the 46 topics, 39 were less likely to be included on the websites even though patients perceived that they were important topics. Information on the websites (n = 99) was not written could not be easily understood by patients and did not meet the overall health literacy demands of 58.0% and 19.8% of the patients, respectively. Only one-fifth of the websites were rated as fair to good quality. Online HF information had high health literacy demand and was poor quality with mostly generic HF information, which did not meet patients' information needs. Websites need to be developed reflecting patients' learning needs with low health literacy demand and good quality.

Cardiologists' and patients' views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study

BACKGROUND

Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments.

AIM

To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits.

METHODS

Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres.

RESULTS

A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative.

CONCLUSIONS

The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

Implementation of an organisation-wide health literacy approach to improve the understandability and actionability of patient information and education materials: A pre-post effectiveness study

OBJECTIVE

Limited examples exist globally of coordinated, organisation-wide health literacy approaches to systematically improve the understandability and actionability of patient health information. Even fewer have been formally evaluated. The aim of this study was to use the Patient Education Materials Assessment Tool (PEMAT) to evaluate the effectiveness of an organisation-wide, evidence-based approach to improve the understandability and actionability of patient information materials in regional health service in New South Wales, Australia.

METHODS

Two independent raters (blinded to the document version) evaluated pre- and post-implementation versions of 50 randomly-selected patient information materials using the PEMAT, with differences in understandability and actionability analysed using paired samples tests.

RESULTS

Mean (±SD) overall scores for understandability increased significantly by 5% (95% CI 2-8; p = 0.002) up to 77%±10%, and mean actionability (±SD) increased significantly by 4% (95% CI 0-8; p = 0.046) up to 56%±22%.

CONCLUSION

These results demonstrate that organisation-wide approaches with standardised processes for staff to prepare, review and store written patient information and education materials can be successfully implemented to address the impacts and risks of low health literacy.

PRACTICE IMPLICATIONS

The success of this approach provides a framework for other health organisations to work in partnership with patients to make health information more understandable and actionable.

Online decision aids for primary cardiovascular disease prevention: systematic search, evaluation of quality and suitability for low health literacy patients

OBJECTIVES

Recent guideline changes for cardiovascular disease (CVD) prevention medication have resulted in calls to implement shared decision-making rather than arbitrary treatment thresholds. Less attention has been paid to existing tools that could facilitate this. Decision aids are well-established tools that enable shared decision-making and have been shown to improve CVD prevention adherence. However, it is unknown how many CVD decision aids are publicly available for patients online, what their quality is like and whether they are suitable for patients with lower health literacy, for whom the burden of CVD is greatest. This study aimed to identify and evaluate all English language, publicly available online CVD prevention decision aids.

DESIGN

Systematic review of public websites in August to November 2016 using an environmental scan methodology, with updated evaluation in April 2018. The decision aids were evaluated based on: (1) suitability for low health literacy populations (understandability, actionability and readability); and (2) International Patient Decision Aids Standards (IPDAS).

PRIMARY OUTCOME MEASURES

Understandability and actionability using the validated Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P scale), readability using Gunning-Fog and Flesch-Kincaid indices and quality using IPDAS V.3 and V.4.

RESULTS

A total of 25 unique decision aids were identified. On the PEMAT-P scale, the decision aids scored well on understandability (mean 87%) but not on actionability (mean 61%). Readability was also higher than recommended levels (mean Gunning-Fog index=10.1; suitable for grade 10 students). Four decision aids met criteria to be considered a decision aid (ie, met IPDAS qualifying criteria) and one sufficiently minimised major bias (ie, met IPDAS certification criteria).

CONCLUSIONS

Publicly available CVD prevention decision aids are not suitable for low literacy populations and only one met international standards for certification. Given that patients with lower health literacy are at increased risk of CVD, this urgently needs to be addressed.

Favourable understandability, but poor actionability: An evaluation of online type 2 diabetes risk calculators

OBJECTIVE

The study aim was to identify all freely available online diabetes risk calculators and to evaluate their suitability for patients with low health literacy.

METHODS

Online diabetes risk calculators were identified by an environmental scan. The Patient Education Material Assessment Tool for Printable Materials was used to determine understandability and actionability scores. A high-risk profile was used to compare the risk results obtained with each calculator.

RESULTS

Thirty-five risk calculators were identified; 51% had no described model, 23% reported absolute risk and 31% used visual aids. The estimated risk for the same profile ranged from low to very high. The mean understandability score was 79% (SD = 19%) and the mean actionability score was 42% (SD = 30%).

CONCLUSIONS

Online diabetes risk calculators are generally understandable, but not very actionable, and may not be completely suitable for use by patients with low health literacy. The estimated risk is highly variable depending on the underlying model used for the calculation.

PRACTICE IMPLICATIONS

Patients and healthcare providers need to exercise caution when selecting a diabetes risk calculator.

Online health information seeking by adults hospitalized for acute coronary syndromes: Who looks for information, and who discusses it with healthcare providers?

OBJECTIVE

To describe characteristics associated with online health information-seeking and discussing resulting information with healthcare providers among adults with acute coronary syndromes (ACS).

METHODS

Consecutive patients hospitalized with ACS in 6 hospitals in Massachusetts and Georgia who reported Internet use in the past 4 weeks (online patients) were asked about online health information-seeking and whether they discussed information with healthcare providers. Participants reported demographic and psychosocial characteristics; clinical characteristics were abstracted from medical records. Logistic regression models estimated associations with information-seeking and provider communication.

RESULTS

Online patients (N = 1142) were on average aged 58.8 (SD: 10.6) years, 30.3% female, and 82.8% non-Hispanic white; 56.7% reported online health information-seeking. Patients with higher education and difficulty accessing medical care were more likely to report information-seeking; patients hospitalized with myocardial infarction, and those with impaired health numeracy and limited social networks were less likely. Among information-seekers, 33.9% discussed information with healthcare providers. More education and more frequent online information-seeking were associated with provider discussions.

CONCLUSION

Over half of online patients with ACS seek health information online, but only 1 in 3 of these discuss information with healthcare providers.

PRACTICE IMPLICATIONS

Clinician awareness of patient information-seeking may enhance communication including referral to evidence-based online resources.

Tinnitus information online – does it ring true?

Objective

To assess, using standardised tools, the quality and readability of online tinnitus information that patients are likely to access.

Methods

A standardised review was conducted of websites relating to tinnitus and its management. Each website was scored using the DISCERN instrument and the Flesch Reading Ease scale.

Results

Twenty-seven unique websites were evaluated. The mean DISCERN score of the websites was 34.5 out of 80 (standard deviation = 11.2). This would be considered ‘fair’ in quality. Variability in DISCERN score between websites was high (range, 15–57: ‘poor’ to ‘very good’). Website readability was poor, with a mean Flesch Reading Ease score of 52.6 (standard deviation = 7.7); this would be considered ‘difficult’ to read.

Conclusion

In general, the quality of tinnitus websites is fair and the readability is poor, with substantial variability in quality between websites. The Action on Hearing Loss and the British Tinnitus Association websites were identified as providing the highest quality information.

Should We Recommend Renal Diet-Related Apps to Our Patients? An Evaluation of the Quality and Health Literacy Demand of Renal Diet-Related Mobile Applications

OBJECTIVE

Mobile phone applications (apps) are increasingly being used by patients with chronic kidney disease (CKD). We sought to describe the main purpose of commonly available renal diet apps and to quantify the accuracy of information, technical quality, and health literacy demand of renal diet apps.

DESIGN

The design was content analysis. All eligible renal diet apps in the Australian Apple App Store, Google Play, Windows Phone, and Blackberry App World were evaluated.

SUBJECTS

Eligible apps were in English and were related to kidney disease in humans (of any type or stage). Exclusion criteria included apps which were prohibited because of password protection.

MAIN OUTCOME MEASURE

Renal diet information in the apps was compared with evidence-based guidelines for the management of kidney disease to quantify information accuracy. App information was evaluated using the Silberg Scale. Technical quality and health literacy demand were evaluated using the Mobile Application Rating Scale.

RESULTS

A total of 21 apps were eligible for evaluation. The main purpose of these apps was to provide food and nutrition information (57.1%) or for educative purposes for CKD patients (38.1%). Only 47.6% (10/21) of apps contained accurate evidence-based information. Overall, app technical quality was considered acceptable (mean Mobile Application Rating Scale score 3.19 ± 0.35 out of 5), with 80.9% of apps scoring acceptable or greater for app technical quality. Scores for health literacy demand also indicated that most apps (15/21, 71.4%) were acceptable.

CONCLUSIONS

A range of apps currently exist that may provide individuals with CKD with useful food and nutrition information or increase their knowledge of the renal diet. These apps are also mainly of acceptable technical quality and health literacy demand. However, caution is required when using renal diet apps because more than half of the apps evaluated were not accurate and evidence based.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Effects of Contributor Experience on the Quality of Health-Related Wikipedia Articles

BACKGROUND

Consulting the Internet for health-related information is a common and widespread phenomenon, and Wikipedia is arguably one of the most important resources for health-related information. Therefore, it is relevant to identify factors that have an impact on the quality of health-related Wikipedia articles.

OBJECTIVE

In our study we have hypothesized a positive effect of contributor experience on the quality of health-related Wikipedia articles.

METHODS

We mined the edit history of all (as of February 2017) 18,805 articles that were listed in the categories on the portal health & fitness in the English language version of Wikipedia. We identified tags within the articles' edit histories, which indicated potential issues with regard to the respective article's quality or neutrality. Of all of the sampled articles, 99 (99/18,805, 0.53%) articles had at some point received at least one such tag. In our analysis we only considered those articles with a minimum of 10 edits (10,265 articles in total; 96 tagged articles, 0.94%). Additionally, to test our hypothesis, we constructed contributor profiles, where a profile consisted of all the articles edited by a contributor and the corresponding number of edits contributed. We did not differentiate between rollbacks and edits with novel content.

RESULTS

Nonparametric Mann-Whitney U-tests indicated a higher number of previously edited articles for editors of the nontagged articles (mean rank tagged 2348.23, mean rank nontagged 5159.29; U=9.25, P<.001). However, we did not find a significant difference for the contributors' total number of edits (mean rank tagged 4872.85, mean rank nontagged 5135.48; U=0.87, P=.39). Using logistic regression analysis with the respective article's number of edits and number of editors as covariates, only the number of edited articles yielded a significant effect on the article's status as tagged versus nontagged (dummy-coded; Nagelkerke R² for the full model=.17; B [SE B]=-0.001 [0.00]; Wald c² [1]=19.70; P<.001), whereas we again found no significant effect for the mere number of edits (Nagelkerke R² for the full model=.15; B [SE B]=0.000 [0.01]; Wald c² [1]=0.01; P=.94).

CONCLUSIONS

Our findings indicate an effect of contributor experience on the quality of health-related Wikipedia articles. However, only the number of previously edited articles was a predictor of the articles' quality but not the mere volume of edits. More research is needed to disentangle the different aspects of contributor experience. We have discussed the implications of our findings with respect to ensuring the quality of health-related information in collaborative knowledge-building platforms.

Clinical Validity, Understandability, and Actionability of Online Cardiovascular Disease Risk Calculators: Systematic Review

BACKGROUND

Online health information is particularly important for cardiovascular disease (CVD) prevention, where lifestyle changes are recommended until risk becomes high enough to warrant pharmacological intervention. Online information is abundant, but the quality is often poor and many people do not have adequate health literacy to access, understand, and use it effectively.

OBJECTIVE

This project aimed to review and evaluate the suitability of online CVD risk calculators for use by low health literate consumers in terms of clinical validity, understandability, and actionability.

METHODS

This systematic review of public websites from August to November 2016 used evaluation of clinical validity based on a high-risk patient profile and assessment of understandability and actionability using Patient Education Material Evaluation Tool for Print Materials.

RESULTS

A total of 67 unique webpages and 73 unique CVD risk calculators were identified. The same high-risk patient profile produced widely variable CVD risk estimates, ranging from as little as 3% to as high as a 43% risk of a CVD event over the next 10 years. One-quarter (25%) of risk calculators did not specify what model these estimates were based on. The most common clinical model was Framingham (44%), and most calculators (77%) provided a 10-year CVD risk estimate. The calculators scored moderately on understandability (mean score 64%) and poorly on actionability (mean score 19%). The absolute percentage risk was stated in most (but not all) calculators (79%), and only 18% included graphical formats consistent with recommended risk communication guidelines.

CONCLUSIONS

There is a plethora of online CVD risk calculators available, but they are not readily understandable and their actionability is poor. Entering the same clinical information produces widely varying results with little explanation. Developers need to address actionability as well as clinical validity and understandability to improve usefulness to consumers with low health literacy.