Christina Cheng|Matthew Dunn
Health literacy and the Internet: a study on the readability of Australian online health information
Deakin University|Deakin University
australian new zealand journal public healthvolume 39 issue 4 p 309314 public healthfree access health literacy internet study readability australian online health information christina cheng christina cheng school health social development faculty health deakin university victoriasearch papers authormatthew dunn corresponding author matthew dunn school health social development faculty health deakin university victoriacorrespondence dr matthew dunn school health social development faculty health deakin university 221 burwood highway burwood victoria 3125 email mdunndeakineduausearch papers author christina cheng christina cheng school health social development faculty health deakin university victoriasearch papers authormatthew dunn corresponding author matthew dunn school health social development faculty health deakin university victoriacorrespondence dr matthew dunn school health social development faculty health deakin university 221 burwood highway burwood victoria 3125 email mdunndeakineduausearch papers author first published 25 february 2015 httpsdoiorg1011111753640512341citations 61 authors stated conflict interest aboutsectionspdf toolsrequest permissionexport citationadd favoritestrack citation shareshare give accessshare full text accessshare fulltext accessplease review terms conditions use check box share fulltext version articlei read accept wiley online library terms conditions useshareable linkuse link share fulltext version article friends colleagues learn morecopy url share linkshare onfacebooktwitterlinked inredditwechat abstract objective almost 80 australian internet users seek health information online readability information important study aimed evaluate readability australian online health information determine matches average reading level australians methods two hundred fiftyone web pages information 12 common health conditions identified across sectors readability assessed fleschkincaid fk simple measure gobbledygook smog flesch reading ease fre formulas grade 8 adopted average australian reading level results average reading grade measured fk smog 1054 1212 respectively mean fre 4754 difficulttoread score 04 web pages written grade 8 according smog information dementia difficult read overall obesity difficult among government websites conclusions implications findings suggest readability australian health websites average australian levels reading quantifiable guideline needed ensure online health information accommodates reading needs general public effectively use internet enabler health literacy use internet well entrenched 16 million australians actively online1 2 almost 80 seeking health information internet3 advance communication technology transformed ways consumers access health information understand conditions make healthcare decisions4 studies shown internet effective medium deliver health information wider population including people lower income less education well minority groups5 however internet hailed useful tool increase health literacy6 studies us europe continue find readability online health information written average reading ability adults7 8 health literacy defined cognitive social skills obtain understand utilise information promote health9 indicates attainment skills knowledge confidence10 critical personal empowerment9 kickbusch colleagues11 describe health literacy ability make healthcare decisions involve knowledge motivation competences access understand appraise apply health information11p4 maintain improve quality life ageing population increasing demand selfmanagement chronic diseases minimise health costs combined diversified health services treatment choices health literacy considered essential life skill 21st century12 providing health information fundamental task health education health literacy major outcome9 purported health literacy linked general literacy skills13 involve individuals capacity read write speak solve everyday problems14 hence good comprehensible health information integral part developing health literacy10 15 one elements comprehension readability refers well passage text read understood individual16 health information may impractical ineffectual beyond reading ability reader17 20112012 programme international assessment adult competencies indicates 44 australians low literacy skills18 paramount health information presented readability level accommodates wide range literacy skills among general population19 based assessment reading ability adult americans us department health human services recommends health information written sixthgrade level level 11 12yearold child six years us education20 institute medicine recommends reading level sixth eighthgrade below21 however studies us europe continue find readability online health information average reading ability adults7 8 mcinnes haglund22 reviewed 352 health websites worldwide reported average reading grade level 123 found none websites met recommended level grade 6 review cancer information global websites indicated minimum average grade 10723 internet users ability read health information online may also affected internet behaviours vice versa instance web users spend 10 seconds two minutes web page deciding read on24 25 consumers find health information difficult understand particularly opening paragraphs may abandon web page australia studies assess readability local online health information lacking current study aimed determine readability australian online health information determine matches reading level general population specifically study aimed address following research questions average readability australian online health information average readability first 10 sentences australian health web pages differences readability health information different health conditions differences readability health information government notforprofit commercial websites methods data collection crosssectional design convenience sampling employed evaluate readability online health information posted government notforprofit commercial sectors twelve common health conditions selected based national health priority areas nhpas26 google 2013 searched list27 searched terms google trend assumed 12 conditions would represent health topics commonly searched australians simulate search average australian simple english terms instead medical terminology used 12 search terms identified bowel cancer breast cancer prostate cancer heart disease anxiety depression diabetes asthma arthritis back pain obesity dementia sample web pages identified search engines found consumers generally use search engines look health information28 29 15 february 2014 google australia used search engine representing 7077 searches google second used accounting 1237 searches bing third 65330 since focus study australian online health information google australia bing selected web page identification studies searchengineusing behaviour found 50 users reviewed first page results28 10 would go beyond third page results31 therefore first three pages results two search engines included study resulting web pages would represent 90 online health information 12 common conditions australian consumers accessed search conducted within one day 20 march 2014 minimise changes among websites32 33 description causes treatment symptoms searched information health condition4 5 first web page search result said information included analysis addition web pages needed english least 10 sentences accurate readability assessment34 written consumers freely available general public exclusion criteria web pages included broken links irrelevant information news advertisements medical journals search enginegenerated results definition blogs forums video audio links also excluded links pdf outside resources addition websites relevant health information five clicks away search result included considered difficult access average consumer unlikely read22 23 case multiple links website top ranking link included data analysis readability selected web pages determined use readability formula multiple regression equation used predict reading difficulty based linguistic characteristics texts35 costeffective objective alternative costly timeconsuming evaluation users experts16 increase reliability results fleschkincaid fk grade level simple measure gobbledygook smog flesch reading ease fre formulas used17 22 three formulas validated mccallcrabbs standard test lessons reading34 results fk smog form grade level equivalent years western formal education required understand passage fre produces reading score 0 100 0 hardesttoread 100 easiesttoread score fk standard readability measure us department defense23 together fre commonly used instruments readability studies online health information smog considered gold standard evaluating health materials predicts 100 comprehension complete understanding health information essential selfmanagement healthcare decisions20 36 recommended readability measurement cancer information us national cancer institute36 fk smog positively correlated r 095 assessing health information36 fk generally underestimating grade level 165 grades comparing smog37 two online calculation tools onlineutility wordscount chosen calculate readability verify reliability online tools five random samples health information calculated hand compared two tools average measures intraclass correlation coefficients iccs manual calculation onlineutility wordscount 0996 95ci 08371000 0998 95ci 09161000 respectively indicating almost perfect agreement confirmed online tool quick reliable way assess readability2 determine readability assessed information matches reading level australian population grade 8 used benchmark based recommendation sa health38 quantifiable readability guideline assessment reading ability australian adult population cannot identified government resources recommendation sa health provided guide also reported average reading level among stroke patients carers grade 7 8 australian study39 since grade 12 us equivalent year 12 australia40 projected grade 8 corresponds australian educational level year 8 representing reading ability 13 16yearold child eight years australian education41 42 procedures web pages met inclusion criteria downloaded saved html files urls recorded contents extracted saved microsoft word files33 samples edited minimise errors assessment removing irrelevant information confusing punctuations20 22 23 32 sample web pages also grouped according health conditions sectors gain insights comprehension three additional features recorded first whether web page required scrolling presents cognitive challenges lowliteracy older users recall information displayed earlier screen43 another feature video audio clips promote comprehension44 websites included languages english assist comprehension ethnic minorities45 also documented statistical analysis statistical analysis iccs calculated two online calculation tools spearmans correlation employed determine agreement readability formulas consistent reporting readability results similar studies20 22 23 means standard deviation 95 ci calculated three formulas whole page first 10 sentences producing total six readability results normality tests performed two six readability results indicated nonparametric distribution thus nonparametric tests kruskalwallis wilcoxon ranksum tests used check differences readability among health conditions three sectors statistical package social sciences spss 22 used conduct analysis pvalues 005 set statistical tests results three pages search results 12 health conditions google australia bing generated total 720 links based selection criteria 263 meet inclusion criteria 206 duplicates multiple links resulting final sample 251 web pages representing 137 websites depression highest number eligible results n28 dementia least number results n16 half web pages posted notforprofit organisations 5100 followed commercial 2749 government organisations 2151 21 84 pages nonscrolling web pages 17 677 web pages included video clips 21 837 contained audio features among 137 websites 251 web pages seven 511 provided health information languages one department health website others notforprofit websites average measures icc fk grade level smog fre two online calculation tools 0939 95ci 09160955 0935 95ci 07000 973 0975 95ci 09680981 respectively indicating high reliability results spearmans correlation showed strong positive correlation fk smog rho 093 strong negative correlations found fk fre rho 088 smog fre rho 083 supporting literatures discussion relationship various readability formulas22 readability australian health web pages mean grade level web pages calculated fk 1054 95ci 10301078 1211 calculated smog 95ci 11911234 differences result consistent reports fk tends underestimate grade level one two grades37 mean fre 4754 95ci 46174877 score considered difficult table 1 table 1 mean readability whole page first 10 sentences readability formula whole page mean sd first 10 sentences mean sd fk grade level 1054 195 1041 228 smog 1211 173 1196 206 fre 4754 1066 4925 1260 web page anxiety recovery centre victoria anxiety recorded highest grade fk 1703 smog 1915 difficult read score fre 1612 hand national asthma council australias web page asthma lowest grade fk 573 smog 800 arthritis victorias web page back pain easiest read fre score 7532 score considered fairly easy according fk 84 web pages grade 8 smog results indicated 04 grade 8 fre 24 web pages recorded scores higher 70 easytoread score information targeted general public recommended flesch creator formula46 readability first 10 sentences mean grade level first 10 sentences 1041 fk 95ci 10141070 1196 smog 95ci 1171 1222 mean fre 4925 95ci 47685079 difficult readability score table 1 first 10 sentences obesity web page health info net recorded highest grade fk 1842 smog 1859 anxiety web page better health channel hardest read fre score 1285 indicating difficult readability lowest grade easiest read results web pages whole page results national asthma council australia recording fk 447 smog 545 arthritis victoria easy fre score 8383 based fk results 135 web pages grade 8 percentage fell smog results 16 grade 8 fre 32 recorded score 70 higher readability health condition kruskalwallis tests revealed significant differences 12 health conditions fk 2 3654 df11 n251 p000 smog 2 5783 df11 n251 p000 fre 2 6143 df11 n251 p000 dementia recorded highest median score fk md 1156 smog md 1309 lowest median fre score md 3696 observed median scores similar mean scores fk x 1190 smog x 1324 fre x 3689 wilcoxon sumrank test showed fk grade dementia significantly higher bowel cancer breast cancer prostate cancer heart disease depression asthma arthritis back pain smog grade dementia significantly higher bowel cancer breast cancer prostate cancer asthma back pain fre scores dementia significantly harder read conditions except anxiety obesity table 2 table 2 result wilcoxon sumrank test readability health condition health condition n w p dementia fk grade level 16 anxiety 26 51900 030 arthritis 19 26250 001 asthma 18 20650 000 back pain 18 21950 000 bowel cancer 22 32200 000 breast cancer 21 29150 000 depression 28 52600 001 diabetes 24 42850 008 heart disease 17 23150 004 obesity 17 25500 022 prostate cancer 25 41600 000 dementia smog 16 anxiety 26 55100 084 arthritis 19 28650 007 asthma 18 20600 000 back pain 18 21500 000 bowel cancer 22 30300 000 breast cancer 21 29600 000 depression 28 56700 012 diabetes 24 45600 032 heart disease 17 24200 009 obesity 17 25450 021 prostate cancer 25 39900 000 dementia fre 16 anxiety 26 55100 084 arthritis 19 28650 007 asthma 18 20600 000 back pain 18 21500 000 bowel cancer 22 30300 000 breast cancer 21 29600 000 depression 28 56700 012 diabetes 24 45600 032 heart disease 17 24200 009 obesity 17 25450 021 prostate cancer 25 39900 000 dementia fre 16 anxiety 26 29500 020 arthritis 19 20600 001 asthma 18 15900 000 back pain 18 14900 000 bowel cancer 22 16800 000 breast cancer 21 15200 000 depression 28 24000 000 diabetes 24 24200 002 heart disease 17 19300 000 obesity 17 22600 010 prostate cancer 25 18000 000 significantly higher harder readability sector significant difference found kruskalwallis test fre sectors 2 862 df2 n251 p001 fre scores government web pages significantly harder read notforprofit web pages w n1 54 n2 128 407700 p001 significant difference found government commercial web pages significant differences observed across sectors fk smog grades investigation health information provided sector revealed obesity information recorded highest grade among government web pages fk 1273 148 smog 1396 126 dementia fk 1194 226 smog 1319 225 anxiety fk 1314 189 smog 1451 196 highest among notforprofit commercial web pages respectively reading ease dementia government fre 3537 510 notforprofit fre 3517 993 web pages difficult read anxiety continued hardest among commercial web pages fre 3133 573 mean readability health condition sector shown table 3 table 3 mean readability health condition sector mean sd sector health condition fk grade level smog fre government back pain 899 123 1090 119 5412 430 breast cancer 948 083 1110 069 5254 265 asthma 970 098 1062 060 5054 331 bowel cancer 976 120 1072 116 5196 646 depression 1034 090 1282 052 4707 331 prostate cancer 1040 081 1143 075 4805 418 anxiety 1081 127 1255 139 4107 466 arthritis 1152 184 1303 147 3895 919 diabetes 1180 268 1369 256 3908 1316 heart disease 1220 283 1358 227 4002 948 dementia 1217 117 1342 116 3537 510 obesity 1273 148 1396 126 3717 770 total 1078 179 1224 173 4488 882 notforprofit back pain 900 208 1069 182 5915 1267 asthma 910 194 1052 177 5428 1004 arthritis 955 251 1185 196 5150 1328 breast cancer 971 187 1158 146 5496 903 depression 1007 163 1219 131 5009 914 prostate cancer 1038 186 1152 111 4999 527 bowel cancer 1061 184 1148 123 4937 735 diabetes 1065 178 1248 142 4589 1207 anxiety 1065 236 1271 199 4734 1261 heart disease 1097 210 1249 174 4762 1133 obesity 1151 316 1284 270 4372 1782 dementia 1194 226 1319 225 3517 993 total 1031 202 1197 172 4932 1113 commercial heart disease 943 084 1103 069 5384 612 back pain 948 215 1110 160 5727 1060 breast cancer 967 288 1108 236 5307 870 bowel cancer 985 104 1115 090 5311 638 obesity 1010 085 1150 074 4510 712 asthma 1018 088 1168 103 5084 543 arthritis 1047 105 1249 091 4692 437 prostate cancer 1081 105 1186 105 4727 402 diabetes 1153 139 1311 074 4458 600 dementia 1159 169 1312 136 4050 791 depression 1222 219 1384 171 3722 1155 anxiety 1314 187 1451 196 3133 573 total 1077 192 1229 174 4633 1063 discussion noncommunicable diseases represent major disease burden australia ageing population increasing demand selfmanagement chronic diseases minimise health costs combined diversified health services treatment choices12 47 health literacy deemed currency success improve health individuals populations21 providing health information build health literacy essential improve population health however prevalence low health literacy serious implications health health care australia13 study investigated readability online health information australia found average australian online health information written two four grades higher benchmark grade 8 recommended sa health38 serious implications peoples understanding selfmanagement health conditions higher health literacy among population may help improve disease management efficient use health care12 people low health literacy estimated 15 3 times liable adverse health outcomes13 less knowledge conditions treatments higher rates chronic disease hospitalisation lower selfmanagement skills less participation preventive activities8 11 findings current study indicate limited amount online health information readable lowliteracy users 04 web pages grade 8 assessed smog gold standard evaluating health materials limited availability easytoread health materials suggests many australians may benefiting convenience internet low readability also raises concern many readers may misinterpret information lead inappropriate healthcare decisions48 internet unique environment reading habit web different reading printed written information web users tend skim web page deciding read browsing behaviour called screenandglean24 initial screening required web page viewed detail however initial screening brief evaluation opening paragraphs 16 first 10 sentences grade 8 evaluated smog 32 recorded easytoread score leading possibility web pages may survive brief initial screening period important health information may left unread cyberspace weinreich colleagues25 reported 10 web page visits longer two minutes 52 visits shorter 10 seconds suggesting consumers find health information useful difficult understand may abandon web page may real concern web pages included current study study found none mean grade levels 12 health conditions matched benchmark grade 8 according three formulas information dementia difficult read search dementia information also produced least amount web pages findings indicate dementia information limited difficult comprehend cause concern people risk dementia older adults tend poorer literacy skills low readability unacceptable even information aimed carers relatives22 ageing population estimated around 900000 australians dementia 205026 prevalence condition means easytoread health information required meet needs mostatrisk group 12 million australians overweight obese 34 million cardiovascular disease 200726 however 17 web pages formal discussion obesity identified also one hardertoread health topics concern government websites written high grade level perceived reliable trustworthy29 furthermore education found negatively correlated obesity49 implying mostatrisk group obesity may also lower literacy skills backholer colleagues50 estimated 44 less educated australian adults would obese 2025 predicted education disparities eliminated inequalities prevalence obesity higher educated less educated would reduced half hence vital obesity information presented appropriate literacy level meet needs vulnerable population order address social inequalities obesity limitations limi