Readability Assessment of Internet-based Patient Education Materials Related to Mammography for Breast Cancer Screening Rend AlKhalili, MD, Pratik A. Shukla, MD, Ronak H. Patel, MD, Saurin Sanghvi, MD, Basil Hubbi, MD Rationale and Objectives: The US Department of Health and Human Services (USDHHS) recommends that Internet-based patient education materials (IPEMs) be written below the sixth-grade reading level to target the average American adult. This study was designed to determine the readability of IPEMs regarding mammography for breast cancer screening. Materials and Methods: Three-hundred mammography-related Web sites were reviewed for IPEMs. Forty-two IPEMs that met the Health on the Net Foundation Code of Conduct were assessed for readability level with four readability indices that use existing algorithms based on word and sentence length to quantitatively analyze Internet sources for language intricacy including the following: Flesch–Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (Gunning FOG; GFOG). Results were compared to national recommendations, and intergroup analysis was performed. Results: No IPEMs (0%) regarding mammography were written at or below the sixth-grade reading level, based on FKGL. The mean readability scores were as follows: FRES, 49.04 10.62; FKGL, 10.71 2.01; SMOG, 13.33 1.67; and Gunning FOG, 14.32 2.18. These scores indicate that the readability of mammography IPEMs is written at a ‘‘difficult’’ level, significantly above the recommended sixthgrade reading level (P < .05) determined by the USDHHS. Conclusions: IPEMs related to mammography are written well above the recommended sixth-grade level and likely reflect other IPEMs in diagnostic radiology. Key Words: Mammography; readability; Internet-based patient education materials (IPEMs); Flesch–Kincaid grade level; Flesch reading Ease score; Gobbledygook. ªAUR, 2015
T
he availability of Internet resources has allowed >113 million Americans (of various ethnic backgrounds, socioeconomic status, and so forth) to access the Internet for health care–related information (1,2). A majority of people who access Internet-based education materials (IPEMs) state that they influence medical treatment decision making (1). Health care professionals must keep the poor rates of health literacy—the ‘‘degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions’’ (3)—in the United States in mind when authoring
Acad Radiol 2015; 22:290–295 From the Department of Radiology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 150 Bergen St. UH CC-318, Newark, NJ 07101 (R.A., P.A.S., R.H.P., S.S., B.H.). Received August 1, 2014; accepted October 31, 2014. Financial Disclosures: None. Conflict of interest: None of the authors have a conflict of interest. Address correspondence to: B.H. e-mail: [email protected] ªAUR, 2015 http://dx.doi.org/10.1016/j.acra.2014.10.009
290
the IPEMs. Furthermore, health literacy is a ‘‘measure of patients’ ability to read, comprehend, and act on medical instructions’’ (4). It is a direct prognostic measurement of a patient’s health (5). Unfortunately, the average American adult reads only at a seventh–eighth grade level (6–8). Direct consequences of poor health literacy include increase risk of being admitted to the hospital and poorer self health maintenance, both of which lead to poorer patient outcomes and increased cost of health care (9). Tackling the epidemic of poor health literacy may be a long and difficult process; however, health care physicians may be able to improve patient comprehension of IPEMs by improving readability—the level of comprehension a person must have to understand written materials (7). The US Department of Health and Human Services (USDHHS), American Medical Association, and the National Institutes of Health recommend that IPEMs be written at or below the sixth-grade level (6). Readability analyses have been established to evaluate IPEMs available to patients (1,6). Readability assessments have been used by the various fields
Academic Radiology, Vol 22, No 3, March 2015
of medicine to calculate readability of IPEMs available to their patient population (10–12). Readability assessments have recently been published in the radiology literature (13,14). Within radiology, mammography has been established as an effective tool for breast cancer screening. There are guidelines that exist, which provide physicians (and thus their patients) with recommendations for breast cancer screening. Thus, patients are inevitably exposed to mammography and may turn to IPEMs for medical information. In this study, we assess the readability of IPEMs from US hospitals and universities, professional societies, clinical practices, and miscellaneous health care–associated Web sites related to mammography. MATERIALS AND METHODS Experimental Design
This study qualifies as exempt status as per the ‘‘non-human subject research’’ protocol set by the Institutional Review Board at our institution. Internet-based patient education material, IPEM was defined as any mammography-related material on the Internet targeted toward the general public (ie, not health care personnel). Inclusion criteria required the IPEMs to be authored or critically reviewed by at least one Doctor of Medicine (MD degree) and/or the meeting criteria set by Health on the Net Foundation Code of Conduct (HONcode) standards for reliable information regarding mammography. The HON Foundation is a nonprofit organization that aims to improve health care–related information on the Internet (15). Search Procedure. From May 14th to May 16th, 2012, the term ‘‘mammogram’’ or ‘‘mammography’’ was searched using the Google search engine (www.google.com) to find IPEMs to be included in our study. The first individual 300 Web sites from the resulting search were evaluated for readability. A database was created with Web sites from the following sources: US hospitals and universities, professional societies, clinical practices, and miscellaneous health care– associated Web sites regarding mammography meeting the HONcode criteria. Among the US hospitals and universities were sources such as the Johns Hopkins Hospital, Massachusetts General Hospital, and Mayo Clinic. Examples of professional societies include National Cancer Institute, Radiological Society of North America/American College of Radiology, and American Cancer Society. Miscellaneous health care–associated Web sites included popular sources such as WebMD, Drugs.com, and MEDLINE. Web sites that were written in non-English languages, predominantly in graphic or pictorial forms, predominantly in table or list format, or Web sites with .05, two-tailed Student t test). There was no statistically significant difference in FRES readability score between professional societies and miscellaneous health care–associated Web sites (P > .05, Student two-tailed t test). The same patterns of significance were noted for other readability scales between all the subcategories as illustrated in Figure 1b.
DISCUSSION With the increase in access to the Internet, IPEMs steer a majority of patients when inquiring about health care topics or making health care–related decisions (1,3). Patients may turn to IPEMs with questions or clarifications of medical information. For example, in radiology (specifically mammography), guidelines for breast cancer screening
Figure 1. Comparison of readability scores among subcategories for Internet-based patient education materials related to mammography calculated using (a) Flesch Reading Ease Score scale (b) other readability scales (Simple Measure of Gobbledygook scale, Gunning Frequency of Gobbledygook, and Flesch–Kincaid Grade Level). * (blue asterix) indicates significance at the P < .05 level; * (orange asterix) trending toward significance. FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; GFOG, Gunning Frequency of Gobbledygook; IPEMs, Internet-based patient education materials; SMOG, Simple Measure of Gobbledygook. (Color version of figure is available online.)
created by the US Preventative Services Task Force have confused women (patients) regarding mammography screening for breast cancer, especially in the 40–49 years age group, rather than properly providing a timeline to follow for breast cancer screening (21). Women in this age group tend to overestimate breast cancer risk and are confused by these new guidelines (22). The confusion among the patient population may drive them to refer to the Internet for more information. The societies that create guidelines are also responsible for or a play a role in authoring many IPEMs available to patients, some of which met the inclusion criteria (ie, American College of Radiology) and were thus included in this study. Patients report difficulty in understanding the health care– related IPEMs (23). Our results indicate that 76.2% IPEMs pertaining to mammography are higher than a tenth-grade reading level on the FKGL readability scales, which is higher than the reading level of the average American adult. 293
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Furthermore, 100% of the IPEMs are above the recommended sixth-grade level on all four readability scales. Interestingly, we applied the readability analysis to a news article (did not meet the HONcod criteria for an IPEM) that appeared within the first 300 Web sites. The readability of the article was also greater than the sixth-grade level (FKGL > tenth-grade level). Subgroup analyses revealed that readability scores were high in all different subcategories of IPEMs. Hospitals/universities and clinical practices had worse readability compared to professional societies and miscellaneous health care–associated Web sites. Poorer readability in these groups may reflect the fact that physicians authoring IPEMs from hospitals/universities and clinical practices overuse medical jargon when creating or critically analyzing IPEMs, possibly overestimating patient literacy rates (6). Miscellaneous health care–associated Web sites may be more targeted toward the average American population and thus may have better readability than its counterparts (although not meeting the standards provided by the USDHHS). It is thus imperative that IPEMs be written at or lower than the reading level of the average American adult. Many patients may first be introduced to breast cancer screening in the hospital/university or clinical practice setting. They may access the IPEMs supplied by these institutions (or any IPEMs the find by searching the Internet), thus highlighting the importance of lowering readability scores for these reading materials. However, a limitation of our study is that we cannot assess which persons (and their literacy level) in the population access these materials. Additional limitations to the study are inherent to the established algorithms for readability assessments. For example, the algorithms use factors such as number of syllables per word, which may result in the data being skewed by words such as ‘‘mammography.’’ The content of words is not evaluated in the readability analyses. Nonetheless, information in IPEMs regarding any guidelines should be accurate and targeted toward a specific audience keeping the patient, in mind (21,24). Many IPEMs are written well above this recommended level, with more than half being at college level (1). These IPEMs should be written at the average American adult’s reading level in hopes of improving patient comprehension (25). Our findings are congruent with readability assessments in the literature. IPEMs across various sources are written above the recommended sixth-grade reading level (10–14). For example, Tian et al. (26) demonstrated similar results with IPEMs pertaining to colon cancer screening. Improving IPEMs
Guidelines have been created for physician practices that improve the readability of IPEMs. For example, shortening sentence length (words per sentence) as well as shortening the words themselves (number of syllables per sentence) can increase the comprehensibility of IPEMs (25,27). Other methods of increasing comprehensibility not studied here 294
Academic Radiology, Vol 22, No 3, March 2015
include use of active voice (25), corresponding higher numerical values to better outcomes (28), creating easy-tounderstand web-page layouts (ie, font) (7), and as well as using adjunct illustrations (29). An inherent limitation to this study is that any visual aids were excluded from the analysis. A critical part of understanding IPEMs is the physician’s role in integrating the IPEMs available to patients into discussions of diagnosis and treatment planning with respect to patients’ signs, symptoms, and disease processes (30,31). The easy access to IPEMs has now shifted the patient–physician relationship into a ‘‘patient–web–physician’’ triangle (31) Patients may be able to understand of written materials published in the Internet better if physicians review IPEMs with their patients. In addition to difficulty with reading and understanding written materials, the patients with low literacy levels may also have difficulty with verbal information (4). It is important that physicians avoid medical jargon presented in these IPEMs when engaging with patients to ensure that they are adequately supplementing the IPEMs. This restructuring of the patient–physician interaction paradigm necessitates that the IPEMs readily available be targeted toward the appropriate audience (32).
CONCLUSION Mammography has been established as an effective tool to screen for breast malignancy. This study was performed in lieu of low health literacy rates in the United States with efforts to increase the awareness of the poor readability of IPEMs regarding mammography in hopes to increase patients’ understanding of the indications, benefits, and risks of mammography screening. These IPEMs should be evaluated and rewritten at the readability level of the average American patient. Breast imagers (radiologists) must take an active role in patients’ shaping knowledge provided by IPEMs to help increase the understanding of the IPEMs as well as use them as a catalyst for discussion.
REFERENCES 1. Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA 2001; 285(20):2612–2621. 2. Fox S. Online health search 2006. Available at: http://www.pewinternet. org/pdfs/PIP_Online_Health_2006.pdf. Accessed May 24, 2008. 3. Committee On Health Literacy. Health literacy: prescription to end confusion. The National Academies Press, 2004. 4. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA 2002; 288(4):475–482. 5. Weiss BD, Hart G, McGee DL, et al. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1992; 5(3):257–264. 6. Walsh TM, Volsko TA. Readability assessment of internet-based consumer health information. Respir Care 2008; 53(10):1310–1315. 7. Albright J, de Guzman C, Acebo P, et al. Readability of patient education materials: implications for clinical practice. Appl Nurs Res 1996; 9(3): 139–143. 8. Goldstein AKA, Sikali E, White SE. National assessment of adult literacy (NAAL). National Center for Education Statistics. Available at: http:// nces.ed.gov/naal; 2003.
Academic Radiology, Vol 22, No 3, March 2015
9. Dewalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004; 19(12): 1228–1239. 10. D’Alessandro DM, Kingsley P, Johnson-West J. The readability of pediatric patient education materials on the World Wide Web. Arch Pediatr Adolesc Med 2001; 155(7):807–812. 11. Heilman CB, Schmitt PJ, Prestigiacomo CJ. Readability of neurosurgeryrelated patient education materials provided by the American Association of Neurological Surgeons, and the National Library of Medicine and National Institutes of Health. World Neurosurg 2013; 80(5):e33–e39. 12. Sanghvi S, Cherla DV, Shukla PA, et al. Readability assessment of internetbased patient education materials related to facial fractures. Laryngoscope 2012; 122(9):1943–1948. 13. Hansberry DR, John A, John E, et al. A critical review of the readability of online patient education resources from RadiologyInfo.org. AJR Am J Roentgenol 2014; 202(3):566–575. 14. Shukla P, Sanghvi SP, Lelkes VM, et al. Readability assessment of internet-based patient education materials related to uterine artery embolization. J Vasc Interv Radiol 2013; 24(4):469–474. 15. HONcode. Health On the Net Foundation. Available at: http://www.hon.ch/ HONcode/Conduct.html. 16. Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav 2006; 33(3):352–373. 17. McLaughlin G. SMOG grading—a new readability formula. J Reading 1969; 12:639–946. 18. Flesch R. A new readability yardstick. J Appl Psychol 1948; 32(3):221–233. 19. Kincaid J, Fishburne R, Rogers R, et al. Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Forumula) for Navy enlisted personnel. National Technical Information Service, 1975. Research B. 20. Gunning R. Technique of clear writing. McGraw-Hill, 1968; 329.
MAMMOGRAPHY IPEM READABILITY
21. Squiers LB, Holden DJ, Dolina SE, et al. The public’s response to the U.S. Preventive Services Task Force’s 2009 recommendations on mammography screening. Am J Prev Med 2011; 40(5):497–504. 22. Davidson AS, Liao X, Magee BD. Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011; 205(1):30.e1. 30.e7. 23. Aslam N, Bowyer D, Wainwright A, et al. Evaluation of Internet use by paediatric orthopaedic outpatients and the quality of information available. J Pediatr Orthop B 2005; 14(2):129–133. 24. Petitti DB, Calonge N. Media coverage of U.S. preventive services task force recommendations: a commentary. Am J Prev Med 2011; 40(5): 579–580. 25. Hill-Briggs F, Schumann KP, Dike O. Five-step methodology for evaluation and adaptation of print patient health information to meet the
T
he availability of Internet resources has allowed >113 million Americans (of various ethnic backgrounds, socioeconomic status, and so forth) to access the Internet for health care–related information (1,2). A majority of people who access Internet-based education materials (IPEMs) state that they influence medical treatment decision making (1). Health care professionals must keep the poor rates of health literacy—the ‘‘degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions’’ (3)—in the United States in mind when authoring
Acad Radiol 2015; 22:290–295 From the Department of Radiology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 150 Bergen St. UH CC-318, Newark, NJ 07101 (R.A., P.A.S., R.H.P., S.S., B.H.). Received August 1, 2014; accepted October 31, 2014. Financial Disclosures: None. Conflict of interest: None of the authors have a conflict of interest. Address correspondence to: B.H. e-mail: [email protected] ªAUR, 2015 http://dx.doi.org/10.1016/j.acra.2014.10.009
290
the IPEMs. Furthermore, health literacy is a ‘‘measure of patients’ ability to read, comprehend, and act on medical instructions’’ (4). It is a direct prognostic measurement of a patient’s health (5). Unfortunately, the average American adult reads only at a seventh–eighth grade level (6–8). Direct consequences of poor health literacy include increase risk of being admitted to the hospital and poorer self health maintenance, both of which lead to poorer patient outcomes and increased cost of health care (9). Tackling the epidemic of poor health literacy may be a long and difficult process; however, health care physicians may be able to improve patient comprehension of IPEMs by improving readability—the level of comprehension a person must have to understand written materials (7). The US Department of Health and Human Services (USDHHS), American Medical Association, and the National Institutes of Health recommend that IPEMs be written at or below the sixth-grade level (6). Readability analyses have been established to evaluate IPEMs available to patients (1,6). Readability assessments have been used by the various fields
Academic Radiology, Vol 22, No 3, March 2015
of medicine to calculate readability of IPEMs available to their patient population (10–12). Readability assessments have recently been published in the radiology literature (13,14). Within radiology, mammography has been established as an effective tool for breast cancer screening. There are guidelines that exist, which provide physicians (and thus their patients) with recommendations for breast cancer screening. Thus, patients are inevitably exposed to mammography and may turn to IPEMs for medical information. In this study, we assess the readability of IPEMs from US hospitals and universities, professional societies, clinical practices, and miscellaneous health care–associated Web sites related to mammography. MATERIALS AND METHODS Experimental Design
This study qualifies as exempt status as per the ‘‘non-human subject research’’ protocol set by the Institutional Review Board at our institution. Internet-based patient education material, IPEM was defined as any mammography-related material on the Internet targeted toward the general public (ie, not health care personnel). Inclusion criteria required the IPEMs to be authored or critically reviewed by at least one Doctor of Medicine (MD degree) and/or the meeting criteria set by Health on the Net Foundation Code of Conduct (HONcode) standards for reliable information regarding mammography. The HON Foundation is a nonprofit organization that aims to improve health care–related information on the Internet (15). Search Procedure. From May 14th to May 16th, 2012, the term ‘‘mammogram’’ or ‘‘mammography’’ was searched using the Google search engine (www.google.com) to find IPEMs to be included in our study. The first individual 300 Web sites from the resulting search were evaluated for readability. A database was created with Web sites from the following sources: US hospitals and universities, professional societies, clinical practices, and miscellaneous health care– associated Web sites regarding mammography meeting the HONcode criteria. Among the US hospitals and universities were sources such as the Johns Hopkins Hospital, Massachusetts General Hospital, and Mayo Clinic. Examples of professional societies include National Cancer Institute, Radiological Society of North America/American College of Radiology, and American Cancer Society. Miscellaneous health care–associated Web sites included popular sources such as WebMD, Drugs.com, and MEDLINE. Web sites that were written in non-English languages, predominantly in graphic or pictorial forms, predominantly in table or list format, or Web sites with .05, two-tailed Student t test). There was no statistically significant difference in FRES readability score between professional societies and miscellaneous health care–associated Web sites (P > .05, Student two-tailed t test). The same patterns of significance were noted for other readability scales between all the subcategories as illustrated in Figure 1b.
DISCUSSION With the increase in access to the Internet, IPEMs steer a majority of patients when inquiring about health care topics or making health care–related decisions (1,3). Patients may turn to IPEMs with questions or clarifications of medical information. For example, in radiology (specifically mammography), guidelines for breast cancer screening
Figure 1. Comparison of readability scores among subcategories for Internet-based patient education materials related to mammography calculated using (a) Flesch Reading Ease Score scale (b) other readability scales (Simple Measure of Gobbledygook scale, Gunning Frequency of Gobbledygook, and Flesch–Kincaid Grade Level). * (blue asterix) indicates significance at the P < .05 level; * (orange asterix) trending toward significance. FKGL, Flesch–Kincaid Grade Level; FRES, Flesch Reading Ease Score; GFOG, Gunning Frequency of Gobbledygook; IPEMs, Internet-based patient education materials; SMOG, Simple Measure of Gobbledygook. (Color version of figure is available online.)
created by the US Preventative Services Task Force have confused women (patients) regarding mammography screening for breast cancer, especially in the 40–49 years age group, rather than properly providing a timeline to follow for breast cancer screening (21). Women in this age group tend to overestimate breast cancer risk and are confused by these new guidelines (22). The confusion among the patient population may drive them to refer to the Internet for more information. The societies that create guidelines are also responsible for or a play a role in authoring many IPEMs available to patients, some of which met the inclusion criteria (ie, American College of Radiology) and were thus included in this study. Patients report difficulty in understanding the health care– related IPEMs (23). Our results indicate that 76.2% IPEMs pertaining to mammography are higher than a tenth-grade reading level on the FKGL readability scales, which is higher than the reading level of the average American adult. 293
ALKHALILI ET AL
Furthermore, 100% of the IPEMs are above the recommended sixth-grade level on all four readability scales. Interestingly, we applied the readability analysis to a news article (did not meet the HONcod criteria for an IPEM) that appeared within the first 300 Web sites. The readability of the article was also greater than the sixth-grade level (FKGL > tenth-grade level). Subgroup analyses revealed that readability scores were high in all different subcategories of IPEMs. Hospitals/universities and clinical practices had worse readability compared to professional societies and miscellaneous health care–associated Web sites. Poorer readability in these groups may reflect the fact that physicians authoring IPEMs from hospitals/universities and clinical practices overuse medical jargon when creating or critically analyzing IPEMs, possibly overestimating patient literacy rates (6). Miscellaneous health care–associated Web sites may be more targeted toward the average American population and thus may have better readability than its counterparts (although not meeting the standards provided by the USDHHS). It is thus imperative that IPEMs be written at or lower than the reading level of the average American adult. Many patients may first be introduced to breast cancer screening in the hospital/university or clinical practice setting. They may access the IPEMs supplied by these institutions (or any IPEMs the find by searching the Internet), thus highlighting the importance of lowering readability scores for these reading materials. However, a limitation of our study is that we cannot assess which persons (and their literacy level) in the population access these materials. Additional limitations to the study are inherent to the established algorithms for readability assessments. For example, the algorithms use factors such as number of syllables per word, which may result in the data being skewed by words such as ‘‘mammography.’’ The content of words is not evaluated in the readability analyses. Nonetheless, information in IPEMs regarding any guidelines should be accurate and targeted toward a specific audience keeping the patient, in mind (21,24). Many IPEMs are written well above this recommended level, with more than half being at college level (1). These IPEMs should be written at the average American adult’s reading level in hopes of improving patient comprehension (25). Our findings are congruent with readability assessments in the literature. IPEMs across various sources are written above the recommended sixth-grade reading level (10–14). For example, Tian et al. (26) demonstrated similar results with IPEMs pertaining to colon cancer screening. Improving IPEMs
Guidelines have been created for physician practices that improve the readability of IPEMs. For example, shortening sentence length (words per sentence) as well as shortening the words themselves (number of syllables per sentence) can increase the comprehensibility of IPEMs (25,27). Other methods of increasing comprehensibility not studied here 294
Academic Radiology, Vol 22, No 3, March 2015
include use of active voice (25), corresponding higher numerical values to better outcomes (28), creating easy-tounderstand web-page layouts (ie, font) (7), and as well as using adjunct illustrations (29). An inherent limitation to this study is that any visual aids were excluded from the analysis. A critical part of understanding IPEMs is the physician’s role in integrating the IPEMs available to patients into discussions of diagnosis and treatment planning with respect to patients’ signs, symptoms, and disease processes (30,31). The easy access to IPEMs has now shifted the patient–physician relationship into a ‘‘patient–web–physician’’ triangle (31) Patients may be able to understand of written materials published in the Internet better if physicians review IPEMs with their patients. In addition to difficulty with reading and understanding written materials, the patients with low literacy levels may also have difficulty with verbal information (4). It is important that physicians avoid medical jargon presented in these IPEMs when engaging with patients to ensure that they are adequately supplementing the IPEMs. This restructuring of the patient–physician interaction paradigm necessitates that the IPEMs readily available be targeted toward the appropriate audience (32).
CONCLUSION Mammography has been established as an effective tool to screen for breast malignancy. This study was performed in lieu of low health literacy rates in the United States with efforts to increase the awareness of the poor readability of IPEMs regarding mammography in hopes to increase patients’ understanding of the indications, benefits, and risks of mammography screening. These IPEMs should be evaluated and rewritten at the readability level of the average American patient. Breast imagers (radiologists) must take an active role in patients’ shaping knowledge provided by IPEMs to help increase the understanding of the IPEMs as well as use them as a catalyst for discussion.
REFERENCES 1. Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA 2001; 285(20):2612–2621. 2. Fox S. Online health search 2006. Available at: http://www.pewinternet. org/pdfs/PIP_Online_Health_2006.pdf. Accessed May 24, 2008. 3. Committee On Health Literacy. Health literacy: prescription to end confusion. The National Academies Press, 2004. 4. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA 2002; 288(4):475–482. 5. Weiss BD, Hart G, McGee DL, et al. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract 1992; 5(3):257–264. 6. Walsh TM, Volsko TA. Readability assessment of internet-based consumer health information. Respir Care 2008; 53(10):1310–1315. 7. Albright J, de Guzman C, Acebo P, et al. Readability of patient education materials: implications for clinical practice. Appl Nurs Res 1996; 9(3): 139–143. 8. Goldstein AKA, Sikali E, White SE. National assessment of adult literacy (NAAL). National Center for Education Statistics. Available at: http:// nces.ed.gov/naal; 2003.
Academic Radiology, Vol 22, No 3, March 2015
9. Dewalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004; 19(12): 1228–1239. 10. D’Alessandro DM, Kingsley P, Johnson-West J. The readability of pediatric patient education materials on the World Wide Web. Arch Pediatr Adolesc Med 2001; 155(7):807–812. 11. Heilman CB, Schmitt PJ, Prestigiacomo CJ. Readability of neurosurgeryrelated patient education materials provided by the American Association of Neurological Surgeons, and the National Library of Medicine and National Institutes of Health. World Neurosurg 2013; 80(5):e33–e39. 12. Sanghvi S, Cherla DV, Shukla PA, et al. Readability assessment of internetbased patient education materials related to facial fractures. Laryngoscope 2012; 122(9):1943–1948. 13. Hansberry DR, John A, John E, et al. A critical review of the readability of online patient education resources from RadiologyInfo.org. AJR Am J Roentgenol 2014; 202(3):566–575. 14. Shukla P, Sanghvi SP, Lelkes VM, et al. Readability assessment of internet-based patient education materials related to uterine artery embolization. J Vasc Interv Radiol 2013; 24(4):469–474. 15. HONcode. Health On the Net Foundation. Available at: http://www.hon.ch/ HONcode/Conduct.html. 16. Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav 2006; 33(3):352–373. 17. McLaughlin G. SMOG grading—a new readability formula. J Reading 1969; 12:639–946. 18. Flesch R. A new readability yardstick. J Appl Psychol 1948; 32(3):221–233. 19. Kincaid J, Fishburne R, Rogers R, et al. Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Forumula) for Navy enlisted personnel. National Technical Information Service, 1975. Research B. 20. Gunning R. Technique of clear writing. McGraw-Hill, 1968; 329.
MAMMOGRAPHY IPEM READABILITY
21. Squiers LB, Holden DJ, Dolina SE, et al. The public’s response to the U.S. Preventive Services Task Force’s 2009 recommendations on mammography screening. Am J Prev Med 2011; 40(5):497–504. 22. Davidson AS, Liao X, Magee BD. Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011; 205(1):30.e1. 30.e7. 23. Aslam N, Bowyer D, Wainwright A, et al. Evaluation of Internet use by paediatric orthopaedic outpatients and the quality of information available. J Pediatr Orthop B 2005; 14(2):129–133. 24. Petitti DB, Calonge N. Media coverage of U.S. preventive services task force recommendations: a commentary. Am J Prev Med 2011; 40(5): 579–580. 25. Hill-Briggs F, Schumann KP, Dike O. Five-step methodology for evaluation and adaptation of print patient health information to meet the
