Are we failing to communicate? Internet-based patient education materials and radiation safety
Introduction
The Internet has become an important resource for patients and their families to help them better understand the diagnosis, the prognosis, and their treatment options of their diagnoses or disorders. Due to its ease, accessibility, and the extreme amount of information available, the Internet is frequently used both as an immediate reference and as a tool to assist with ongoing healthcare decisions. Two studies in 2011 found that 78% of Americans use the Internet and from 59% to 80% of Internet users will seek information regarding healthcare [1], [2]. Internet users who seek healthcare information deem it useful as evident in a 2006 study that found 55% of them thought it improved information accessibility, while 48% thought the information enhanced the management of their health, and 47% said the information they read influenced their healthcare decision making [3]. Another study found that half of those who use the Internet for medical information reported that the information they found had a significant effect on their subsequent decisions [4]. It is apparent that patients view the Internet as a valued form of education. Therefore it is imperative that the patient education materials available are comprehensible for the majority of patients.
However, seeking healthcare related information online isn’t necessarily commensurate with an ability to understand it. In fact a report from the National Center for Educational Statistics found that 75 million Americans had either a basic or below basic health literacy level, which means that they would find it difficult to understand instructions on the label of a medication [5]. Health literacy has been defined as someone's ability to read and understand healthcare information as well as their capability to make effective healthcare decisions [6]. Readability correlates with literacy and is a quantitative metric used to evaluate the ease of which text can be read and understood [7]. The effects of low health literacy are substantial with an estimated cost to the United States (US) economy of $106–$236 billion dollars annually [8]. Across the nation, the average American reads at a 7th to 8th grade level, which is typically 3–5 grade levels less than the highest grade level completed [6], [7]. As a result, the National Institutes of Health (NIH) and the American Medical Association (AMA) recommend that patient education materials be written between a third and seventh grade reading level to allow for patients to more fully benefit from the information [9], [10].
Nonetheless, despite the recommendations, a range of studies have revealed that the readability of patient education materials in several fields of medicine are written at a grade level that is much higher than the AMA and the NIH recommendations [11], [12], [13], [14], [15], [16], [17]. In fact, an article from 2013 in JAMA found that the readability of online patient education resources from 16 different medical disciplines were written well above the recommended grade level [18]. Another study analyzed 14 different major surgical subspecialty websites and found their patient education material was written between a 10th and 15th grade level [19]. Likewise a recent study that evaluated the readability of all patient education material from the American College of Radiology and Radiology Society of North America co-sponsored website, RadiologyInfo.org, found the overwhelming majority of the information to be pitched between the 10th and 14th grade level [20].
Patients routinely ask their healthcare providers to explain the risks and benefits of radiation associated with an imaging technique, and any health risks that may be associated with it [21]. The mainstream media has reported stories with headlines such as, “CT Scans in Children Linked to Cancer” in which patients are bluntly warned that of the 1.5 million children that received CT scans, “1500 of those will die later in life of radiation-induced cancer [22].” Another such article was published with the headline that “CT Scans in Kids Linked to Leukemia, Brain Cancer Risk [23].” Not surprisingly, articles and news reports like these will increase patients’ concern about radiation safety. It is therefore understandable that they will turn to trusted and easily accessible Internet resources for more information about the risks, benefits, and potential harm of radiation from imaging exams.
It is the goal of this study to determine the readability of online patient education materials regarding radiation safety provided from 8 different web resources encompassing the Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA), the European Society of Radiology (ESR), the Food and Drug Administration (FDA), the Mayo Clinic, MedlinePlus, the Nuclear Regulatory Commission (NRC), and the Society of Pediatric Radiology (SPR). Through the use of multiple quantitative readability metrics, we evaluate the reading level of the various Internet resources on radiation safety.
Section snippets
Methods
In 2013, online patient education resources were downloaded from 8 online resources, including the CDC, the EPA, the ESR, the FDA, the Mayo Clinic, MedlinePlus, the NRC, and the SPR. A total of 45 articles were copied and pasted individually into Microsoft Word (Microsoft Corp, Redmond, WA) files. Text not relevant to patient education, such as copyright notices, disclaimers, acknowledgements, text related to web page navigation, and references were removed. Each article was subsequently
Results
The 8 different online resources, compromising 45 individual patient education articles, were each written well above the NIH and the AMA recommendations that these resource be written no higher than a 7th grade level. The websites written at the lowest reading level were the Mayo Clinic and MedlinePlus, which demonstrated a grade level of 11.2 and 11.5, respectively, when averaged across the nine readability scales (Fig. 1 and Table 2). The NRC had text pitched at the most advanced level of
Discussion
As previous reports have demonstrated, there is discordance between the reading level of the general public and the online patient education materials available to them. For example, similar results have been noted in material related to the fields of radiology [20], surgical subspecialties [19], and other fields of medicine [18]. In this analysis we report analogous findings with material from multiple Internet resources concerning radiation safety to be written well above the NIH and the AMA
Financial disclosures
None.
Conflicts of interest
None.
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