https://orcid.org/0000-0003-4155-1741
Figures
Abstract
Introduction
Fibroadenomas are benign lesions found in the breast tissue. Widespread access to and use of the internet has resulted in more individuals using online resources to better understand health conditions, their prognosis and treatment. The aim of this study was to investigate the readability and visual appearance of online patient resources for fibroadenoma.
Methods
We searched GoogleTM, BingTM and YahooTM on 6 July 2022 using the search terms “fibroadenoma”, “breast lumps”, “non-cancerous breast lumps”, “benign breast lumps” and “benign breast lesions” to identify the top ten websites that appeared on each of the search engines. We excluded advertised websites, links to individual pdf documents and links to blogs/chats. We compiled a complete list of websites identified using the three search engines and the search terms and analysed the content. We only selected pages that were relevant to fibroadenoma. We excluded pages which only contained contact details and no narrative information relating to the condition. We did not assess information where links were directed to alternative websites. We undertook a qualitative visual assessment of each of the websites using a framework of pre-determined key criteria based on the Centers for Medicare and Medicaid Services toolkit. This involved assessing characteristics such as overall design, page layout, font size and colour. Each criterion was scored as: +1- criterion achieved; -1- criterion not achieved; and 0- no evidence, unclear or not applicable (maximum total score 43). We then assessed the readability of each website to determine the UK and US reading age using five different readability tests: Flesch Kincaid, Gunning Fog, Coleman Liau, SMOG, and the Automated Readability Index. We compared the readability scores to determine if there were any significant differences across the websites identified. We also generated scores for the Flesh Reading Ease as well as information about sentence structure (number of syllables per sentence and proportion of words with a high number of syllables) and proportion of people the text was readable to.
Results
We identified 39 websites for readability and visual assessment. The visual assessment scores for the 39 websites identified ranged from -19 to 31 points out of a possible score of 43. The median readability score for the identified websites was 8.58 (age 14–15), with a range of 6.69–12.22 (age 12–13 to university level). There was a statistically significant difference between the readability scores obtained across websites (p<0.001). Almost half of the websites (18/39; 46.2%) were classified as very difficult by the Flesch Reading Ease score, with only 13/39 (33.33%) classified as being fairly easy or plain English.
Conclusion
We found wide differences in the general appearance, layout and focus of the fibroadenoma websites identified. The readability of most of the websites was also much higher than the recommended level for the public to understand. Fibroadenoma website information needs to be simplified to reduce the use of jargon and specificity to the condition for individuals to better comprehend it. In addition, their visual appearance could be improved by changing the layout and including images and diagrams.
Citation: Hutchings HA, Remesh A (2022) An evaluation of the readability and visual appearance of online patient resources for fibroadenoma. PLoS ONE 17(11): e0277823. https://doi.org/10.1371/journal.pone.0277823
Editor: Miquel Vall-llosera Camps, PLOS ONE, UNITED KINGDOM
Received: November 26, 2021; Accepted: November 4, 2022; Published: November 18, 2022
Copyright: © 2022 Hutchings, Remesh. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data are available from https://zenodo.org/record/6992835#.Yv_Bji7MI2x.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Fibroadenomas are benign breast lesions which are found in the breast tissue. They generally affect premenopausal women and are one of the most common benign tumours of the breast in women under 35 years of age [1–3]. The incidence rate in the adolescent population is 2.2% [4]. These lesions are said to occur in one in four women [5] and account for two-thirds of breast lesions in young women [6].
Generally, there is no need to treat fibroadenomas as they are harmless and rarely lead to malignancy [7]. The options are either to observe the growth or to excise it. Although the latter is uncommon, it is generally based on the lesion size and the healthcare professional’s recommendation [8, 9].
There has been a huge increase in the number of people in the last two decades with access to a computer and the ability to search the internet. The development of the world wide web and increased utilisation of the internet has provided an opportunity for individuals to search for health information online whereas previously they would have accessed medical staff [10].
In 2019, it was estimated that 96% of the UK population had access to the internet, giving people access to a vast array of information in the comfort of their own homes [11]. More people than ever are said to be searching the internet for health information for themselves, family and friends [12]. The internet has become the first port of call for many regarding their health [13]. It has been estimated that 37% of internet traffic involves searching for information relating to health conditions [14]. It has been suggested that as people have improved access to online-based health information it is likely that they will become more engaged and involved in decision making [15]. Given the scale of internet searching, it is therefore important that the information provided is accessible, readable and up to date for those accessing it.
The Centers for Disease Control and Prevention (CDC) define Personal Health Literacy as ‘the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others’ [16]. Individuals with low literacy levels may not be able to read a book or newspaper, understand road signs or price labels, make sense of a bus or train timetable, fill out a form, read instructions on medicines, or use the internet [17]. A high proportion of individuals in the UK and US have been documented as having below average levels of general literacy. The National Literacy Trust has estimated that between 1 in 8 and 1 in 4 adults have a general literacy level below the expected of a UK year 6 student (age 11) [17]. Similar figures have been documented in the US, with 52% of the population having only basic (US 4th or 5th grade, age 10–11) or below levels of literacy [18]. Table 1 illustrates the readability grades and the corresponding school grades in the UK and US [19].
Fibroadenoma has a relatively high incidence particularly in younger people but has a positive outcome in a high proportion of cases. It is important that the online information available for fibroadenoma is therefore informative and understandable such that individuals can understand the nature of the condition and make informed decisions regarding their treatment choices. In terms of breast care, previous research regarding the readability of online patient resources for breast augmentation and breast cancer have illustrated that online material was above the recommended reading age and more needed to be done to improve the quality and readability of such information [20, 21]. The Ricci et al. study also suggested that high readability could be a barrier to individuals seeking surgery [20].
To our knowledge there has been no previous research undertaken to assess online information for fibroadenoma. The aim of this study was therefore to assess the readability of online information for fibroadenoma and evaluate their visual appearance.
Materials and methods
We aimed to identify and evaluate websites that contained relevant information about fibroadenoma. We did this in three stages: 1) identification of relevant online websites; 2) qualitative visual assessment of each website; and 3) readability assessment of each website. HAH and AR both did each step, compared the results, and resolved the conflicting results by conversation.
Identification of online websites
The first stage of the study involved searching and identifying the top websites for fibroadenoma information resources. To establish this, we used the terms “fibroadenoma”, “breast lumps”, “non-cancerous breast lumps”, “benign breast lumps” and “benign breast lesions” and searched GoogleTM, BingTM and YahooTM on 6 July 2022 to identify the top ten websites that appeared on each of the search engines. We chose these three search engines as they are currently the top three used [22].
We excluded advertised websites, links to individual pdf documents and links to blogs/chats. We identified the top 10 sites listed on each of the search engines. We decided to exclude paid advertisements as they receive under 10% of search traffic [23]. We decided to keep Wikipedia in the final list. Although controversial in terms of content quality, Wikipedia is commonly used by the public as a resource, and we therefore considered that it was important to include it.
We compiled a complete list of websites identified using the three search engines. We then analysed the content of each of the identified sites. We aimed to assess up to 10 pages for each of the identified websites. Where fewer pages were available, we analysed the maximum number of relevant pages that were available for that site. We only selected pages that were relevant to fibroadenoma. We excluded pages which only contained contact details and no narrative information relating to the condition. We did not assess information where links were directed to alternative websites. We recorded screenshots and dated them to ensure that we had a permanent record of them on the day the searches were undertaken.
Qualitative assessment of the identified websites
For the second stage of the study, we undertook a qualitative visual assessment of the identified websites using a pre-determined framework. This was based on an adaption of the guidance provided in the Centers for Medicare and Medicaid Services toolkit (https://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit) [24, 25].
The CMS government tool kit aims to “provides a detailed and comprehensive set of tools to help you make written material in printed formats easier for people to read, understand, and use”[25]. We considered 43 different variables including the use of different fonts, the distribution of headings and subheading and if the site had a clear path for the eye to follow, to name a few aspects. We scored each of the 43 variables to provide an overall qualitative assessment of the visual aesthetic of the resource. We assigned a score of +1 point if the statement was achieved for each of the 43 variables; 0 if there was no evidence, evidence was unclear or the criterion was not applicable; and -1 point if the statement was not achieved.
Readability assessment of each website
We assessed readability of the information from each of the identified websites through the Readable website (https://readable.com). Readable is a website which allows for a chosen piece of text to be entered into a website allowing a range of readability formulae to be applied to the text. We entered the information from each page into Readable. We utilised a number of readability formulae to assess the readability of the written content. We used the various readability formulae to directly compare the readability of the text from the identified websites.
We used five of the available readability formulae from Readable to broaden our evaluation of the readability of the websites. Each of these formulae assesses different aspects of the text, and some are specifically used for medical purposes (see Table 2).
For this study we used the following readability formulae: Flesch-Kincaid [26], Gunning Fog [27], Coleman-Liau Index [28], Simple Measure of Gobbledygook Index (SMOG) [29] and the Automated Readability Index [30].
A good readability score should be as low as possible as this classifies that the text is comprehensible for a greater proportion of the public. Readable says that a score of 8 or below indicates 85% of the population are able to comprehend the text in question [31]. This would translate to the reading age of 13–14 years of age.
We standardised the text format prior to calculating the readability score to avoid bias between different formulae. This included removing images, advertisements, and side panels, such as navigation panels, seen on the first page of each website. We left in sub-headings, and bulleted lists as they were in the original website layout.
We calculated five readability scores for each website using each of the five formulae. We calculated a median (and range) readability score for each website. We used the Kruskal-Wallis test to compare the median readability grades across each of the websites identified. We ran a post hoc analysis to determine where these significances were, if applicable. A p value of less than 0.05 was regarded as statistically significant.
In addition to calculating the readability scores, we also generated scores for the Flesh Reading Ease [32] as well as information about sentence structure (number of syllables per sentence and proportion of words with a high number of syllables) and proportion of people the text was readable to.
Results
Identification of online websites
We identified 39 websites using the search terms ‘fibroadenoma’, ‘breast lumps’, ‘non-cancerous breast lumps’, ‘benign breast lumps’ and ‘benign breast lesions’ using GoogleTM YahooTM and BingTM search engines. The websites normally occurred across one or two pages of the search engine. There was substantial repetition of sites beyond the top 10, hence we deemed that exploring sites beyond this offered limited additional value. S1 Table in S1 File illustrates the websites identified using the different search terms across the three search engines.
Table 3 illustrates the websites identified (excluding advertisements) along with brief initial appearance assessment and content information.
Qualitative assessment of the identified websites
The visual assessment undertaken based on the CMS toolkit [25] is shown in S2 Table in S1 File. We identified a large score range indicating high variability between the websites in terms of their visual aesthetics. The highest scores were achieved by the Breast Cancer Now website with a score of 31 and the Bupa UK site with a score of 30. The lowest scoring websites were iheartpathology with a score of -19 and Medanta with a score of -6.
Both Breast Cancer Now and Bupa UK were simple and visually appealing (see Table 3). They were well-spaced-out with a good amount of white space. There were no advertisements distracting the reader from the information. The text was well spaced out with bold headings and sub-headings. This helped to break up the text, making the layout of information more digestible for the reader. The font was consistent throughout both websites, and this reflects positively in the scoring system used for the visual assessment. They both included images which were useful for the target audience.
The lowest scoring website (iheartpathology) appeared engaging initially due to the bright colours and images, but the information contained within the images and text was very scientific and difficult to interpret for a lay person. There was only a single page of information with no links and limited explanation. The website was also very cluttered with limited white space. Medanta had a low visual assessment score due to the inclusion of distracting adverts, limited information, and the unwieldy nature of the website.
Readability assessment of each website
There was a range in the number of pages on each website providing information regarding fibroadenoma. Some websites contained only a single page, some contained 10 or more pages, whilst others provided somewhere in between. We assessed each of the relevant pages for readability for each website and generated a median score (where possible) for the readability statistics.
We obtained five readability scores for each of the 39 identified websites using Readable (see Table 4). The median readability score for the identified websites was 8.58 (age 14–15), with a range of 6.69–12.22 (age 12–13 to university level). This illustrates the large range of readability scores across the 39 websites.
The websites with the lowest median readability scores were the WebMD Cancer Center and Medanta, which both had a median readability score of 6.69, which equates to a reading age of 12–13 years. The Nathan T Thomas MD and Specialist Breast Cancer Surgery websites had high median readability scores of 12.22 and 12.10 respectively. This equates to a reading age of between 17 years of age to university level.
The Kruskal-Wallis test identified a p value of 0.001 indicating that there was a statistically significant difference in the readability scores across the 39 websites. A post-hoc analysis identified that there were significant differences between the median readability scores of many of the websites (see S3 Table in S1 File).
Additional readability assessment further identified differences between the 39 websites (see Table 4). The Flesh Reading Ease score ranged between 22.14 (Very difficult) for the Gp notebook website to 70.43 (Easy) for the National Health Service website. Almost half of the websites (18/39; 46.2%) were classified as very difficult by the Flesch Reading Ease score, with only 13/39 (33.33%) classified as being fairly easy or plain English.
The proportion each website was readable to ranged between 64% to 85%. Exploration of the number of sentences and words with large numbers of syllables and letters did not reveal any consistent pattern or major differences across the websites.
Fig 1 illustrates both the readability and visual assessment for each of the 39 websites. There was a large amount of variation between the websites for both categories. Some websites performed well in the readability assessment but badly in the visual assessment and vice versa. A low readability score and a high visual assessment score is most desirable.
Discussion
In general, we found that online resources for fibroadenoma were at a level too high for the public both in terms of their readability and visual appearance. This was seen across all the 39 websites analysed. This highlights that patient resources are not being creating at an accessible and informative level. This may result in miscommunication or misunderstanding of the content currently provided to patients, which may have detrimental effects on physician associated trust or compliance with physician advice.
Readable states that readability scores of 8 or below indicate that the written material is comprehensible for 85% of the population [31]. This score was only achieved by eight of the 39 websites. This suggests that the fibroadenoma resources are not catering and educating the public as we would hope. Similarly a Flesh Reading Ease score lower than 60 is classed as fairly difficult [32], yet only 13/39 (33.33%) identified were classified as being fairly easy or plain English.
These finding correlate with the findings from other readability research based on online patient resources for Phenylketonuria and Skin Cancer treatments [19, 33]. These online resources were also pitched at a level too high for members of the public to understand. Similar findings were also seen for online resources for breast cancer and breast augmentation [20, 21].
The findings suggest that website developers need to consider the content they post to ensure that it is clear and accessible to their target audience. Our findings point to a number of ways in which the websites could be improved. Word and sentence length is important as shorter words and sentences are thought to be more comprehensible. The use of simpler vocabulary and less subject specific jargon and clear information written in a concise manner are also preferable. Defining new or complex words and making them stand out may also help readers [34]. By ensuring text is comprehensible to a larger proportion of the public, this will enable better public health education. Secondary and community healthcare providers could help support patients by developing their own resources that have a low readability score and that are visually engaging [35]. They should also consider directing patients to websites that are trusted, provide understandable information and that are engaging to patients. If these were hosted on healthcare providers websites, this would reassure patients about their credibility.
In terms of visual assessment, there are various ways in which websites can be improved to achieve a higher score. The Centers for Medicare and Medicaid Services toolkit [25] is a useful resource to inform website development. The visual image of the first page of the website is important as this is the first interaction the user will have with it, even before reading the written content. It is therefore important to make sure there is a clear and obvious path for the eye to follow. This includes the removal of advertisements and unnecessary images and creating a clean and uncluttered layout. Ensuring that the page is appealing at first glance also includes the use of colour sparingly. When considering colour usage, it is important to maintain that the text is still easy to read. The best way to achieve this is by using a dark coloured font on a light-coloured background. It is also important to consider if the colour scheme chosen also works if printed.
The layout of the text is also an important consideration which can improve the visual assessment score. Text size should be large enough to be easily read without changing the view of the page and an easy-to-read font should be used [24, 36]. The UK Government suggests that public resources should be written in Arial or Helvetica font [37]. Ways of improving the visual appearance also include: the use of bold or highlighted key words, bullet pointed lists, spacing between lines of text and paragraphs, and the use of headings and subheadings. This assists with breaking up large blocks of text which may not entice the reader to work their way through the text.
Utilisation of audio-visual materials within websites may also improve accessibility. Our findings illustrated that websites that used simple figures were visually much better than those without. Visual materials can be an effective way to convey and present information in a clear, organized way. In the health setting, the use of audio-visual materials alongside written materials has been shown to be beneficial [38].
There are some limitations of this study. Firstly, the identified websites were only analysed for readability and visual appearance. The readability formulae examine the readability of the text only and are based primarily on information such as the sentence length, number of words per sentence and the complexity of some of the words. Additional website resources such as tables, diagrams and videos may aid the understanding of the information presented on the websites [39] and these were not specifically examined. The readability grades found in our study therefore only give an insight into the overall website readability. We did however visually assess the overall visual appearance of each website which will also play a part in engaging with the patient and similarly found that many of the websites identified performed poorly in terms of visual aesthetics. There are other aspects that could be evaluated to assess the resources. This could include the usefulness of the written content with specific focuses on the scientific knowledge or the quality of the information provided.
By assessing up to a maximum of ten pages on each website it is likely that the median readability score is truly representative of the website. However, some websites only had limited information or a small number of pages and this may have resulted in an overly high readability score. It is important to ensure that home or landing pages are visually engaging and have a low readability score as 90% of users do not progress beyond the first page of an internet search [23]. The first page of each website should be informative enough to provide some basic understanding for a patient with little to no understanding of the condition.
This study only looked at the top ten webpages using GoogleTM, YahooTM and BingTM search engines utilising specific search terms. Although these search engines are the top three most popular and widely used [22], they may not necessarily be the only source of information for patients. Further exploration utilising different search engines, and varying assessment criteria and exploring links to other online resources such as videos and pdf leaflets is necessary.
Conclusion
Following the introduction of the Internet, more and more people are using it to access information regarding their health. Given the low average literacy levels in the UK and US, it is important that the information presented within websites is accessible and comprehensible. We found that available resources for fibroadenoma are above the recommended reading age and that for most the visual appearance of these resources was poor. This may mean that the fibroadenoma resources are not accessible and educating the public as we would hope.
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