Health literacy in shoulder arthroplasty: a quantitative assessment of the understandability and readability of online patient education material

Abstract

The American Medical Association (AMA) and National Institutes of Health (NIH) recommend online health information to be written at sixth grade level or a lower reading level in order to be fully understood by the average adult. Reading grade level is commonly utilized to assess health information; however, these measures do not represent whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a valid and reliable method to measure the understandability and actionability of online patient education materials. The aim of this study was to evaluate online resources regarding shoulder replacement utilizing measures of readability, understandability, and actionability. Using the search term “shoulder replacement”, 2 independent online searches (Google.com) were performed and the top 50 websites were noted. Websites were included if directed at educating patients regarding shoulder replacement. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index, and Gunning-Fog Index (GFI). The PEMAT-P form was used to assess actionability and understandability. Fifty-seven websites met inclusion criteria and were analyzed. The mean FKGL was 8.31 ± 2.44, with only 5.26% (n = 3) websites scoring ≤6th grade reading level. Only 44.83% (n = 26) and 7.02% (n = 4) of websites met the >70% PEMAT threshold for understandability and actionability. Of the websites that met the understandability threshold, 50% were private practice, 34.6% were academic institutions, and 19.2% were from health information publishers. Coleman-Liau Index was the only readability score associated with higher (earlier) search rank (rho = 0.27, P = .045). Neither understandability scores (P = .65) nor actionability scores (P = .88) were associated with Google rank. Overall, shoulder arthroplasty online patient education material scored poorly with respect to readability, understandability, and actionability. Only 3 (5.2%) of the online resources scored at the AMA and NIH recommended reading level. Twenty-seven (47%) scored above the threshold for that is understandable to the general public and only 3 (5.2%) scored above a threshold which is actionable.