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Health Literacy in Shoulder Labral Repair: A Quantitative Assessment of the Understandability and Readability of Online Patient Education Material

Health Literacy in Shoulder Labral Repair: A Quantitative Assessment of the Understandability and Readability of Online Patient Education Material

Olivia O'Reilly, MD, UNITED STATES Mary Kate Skalitzky, BA, UNITED STATES Alan Shamrock, MD, UNITED STATES Burke Gao, MD, UNITED STATES Trevor Gulbrandsen, MD, UNITED STATES Brendan Patterson, MD, UNITED STATES

University of Iowa Hospitals and Clinics, Iowa City, Iowa, UNITED STATES

2021 Congress   ePoster Presentation     Not yet rated


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Summary: Online shoulder procedure patient educational materials scored poorly with respect to readability, understandability, and actionability.


The American Medical Association (AMA) and National Institutes of Health (NIH) recommend online health information to be written at a 6th grade or lower reading level to be understood by the average adult in the United States. Syntax reading grade-level analyses do not measure if text is written such that readers can manage vital information (understandability) or recognize actions (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a valid and reliable method to measure understandability and actionability of online patient education materials (PEM). The study aim was to evaluate online resources regarding shoulder labrum repair utilizing measures of readability, understandability, and actionability. It was hypothesized that current online resources score poorly on these objective measures. Additionally, it was hypothesized that these measures would not correlate with the order of the listed search results (rank).


The commonly searched terms “shoulder labrum repair” were evaluated utilizing two independent online searches ( Websites were selected from the top 50 search results if directed at educating patients. News articles, non-text material (video), articles (new/research/industry), and unrelated websites were excluded. 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 (CLI), and Gunning-Fog Index (GFI). The PEMAT-P form was used to assess actionability and understandability and measured against a threshold of 70%, of which below is considered poorly understandable or poorly actionable. The relationship between a website’s average search rank and its readability, understandability, and actionability was calculated.


Two independent Google searches identified 58 unique websites were identified and 55 websites (94.83%) met inclusion criteria. The mean FKGL was 10.58, corresponding with a high school reading level. with only one website reading at a 6th grade level. No readability scale had a mean score of a 6th grade level. Mean understandability and actionability scores were 65.79% and 24.72%. A total of 20 PEMs met the PEMAT score threshold for understandability, while no website met the PEMAT threshold for actionability. Amongst institutions (private practice, academia, commercial health publishers), no institution has a mean understandability or actionability score that meets the PEMAT threshold or readability scores that meet a 6th grade reading level. No readability, understandability, nor actionability score was significantly associated with search result rank.


Overall, online shoulder procedure PEMs scored poorly with respect to readability, understandability, and actionability. Only one PEM scored at the AMA and NIH recommended reading level. Twenty websites scored above the 70% PEMAT score on understandability and, none met the PEMAT threshold for actionability. If online resources are misunderstood due to poor readability, understandability, or actionability, these resources may lead to poor decision making by patients. Future efforts should be made to improve online resources in order to optimize patient knowledge and facilitate informed decision-making.

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