Review articleUnderstanding online health information: Evaluation, tools, and strategies
Introduction
As Internet-based digital media have become more integrated into everyday life, popular information consumption behavior and strategies have shifted from a traditional model to a digital model [1]. In contrast to the traditional model in which information was obtained through direct contact with reliable information sources, such as teachers, professionals, or printed material, information retrieval in the online era is characterized by indirect connections, multiplicity of sources, and low levels of reliability [1], [2], [3], [4].
While this shift has occurred in every domain of human knowledge, it has particular implications for the dissemination of health-related information. Online sources of health-related information require particular oversight to ensure that they provide accurate, appropriate and understandable content that meets the unique needs of various populations of patients. In other words, the publication of online materials is not useful if they are not beneficial for patients. Furthermore, in the context of online resources such as forums and blogs − and despite the involvement of the community of users and moderators − information can be uncontrolled and sometimes poorly moderated, leading to the risk of spreading potentially harmful information [5].
Health literacy can be defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions [6]. This concept of health literacy not only implies the ability of patients to seek and understand health information, but also involves the capacity to evaluate and to use the information in order to make sound decisions about health-related issues [6], [7]. While essential in the context of traditional media, health literacy is obviously also central to the construction of Internet-based health resources and interventions [8]. Of particular concern is evidence suggesting that health literacy is relatively low in the general population [9], [10], [11], which is associated with poorer use of health care services and poorer health outcomes [12], [13]. This also contributes in part to health disparities [14]. Not surprisingly, the majority of patient health education materials, including those found online, surpass the recommended readability level suggested by the US National Institutes of Health [5], [15], [16], [17], [18], [19]. When confronted with non-adapted materials, patients might shift to sources which they would consider understandable, without these sources being necessarily endorsed by public health authorities. For instance, numerous patients consider websites such as Wikipedia as a primary source of information regarding their medical status or the different treatment options [20].
Although the health literacy of a given population can be measured, evaluating the appropriateness and understandability of online health-related material poses a challenge. Online material is composed of multiple elements that need to be considered. Some of these elements are shared with offline material, such as the validity and reliability of the information itself, the characteristics of the text (e.g., readability), the semantic complexity, and the way the content is organized and presented. In contrast, other elements are specific to online communication modes, such as the emotional tone (which is considerably more salient in user-generated content) and the use of multimedia materials. All of these elements contribute to the overall understandability and potential usability of the content. The need for evaluation of the appropriateness of online content has been recognized early on and a number of tools to evaluate online informational materials have been developed over the past two decades. However, given the complexity of the online material, there is currently no single tool that can be used to evaluate all of the various elements of health-related online content. Therefore, evaluation of online health material requires a combination of various methodologies, ranging from classical readability tools to more experimental medical content assessment questionnaires. This paper describes the available tools for assessment of online content and proposes that combined (quantitative and qualitative) approaches could be successfully used to evaluate online health information based on several complementary dimensions including readability, emotional tone, understandability and usability, connectivity and multimodality of content.
Section snippets
Readability: the ease of reading of online health information
When attempting to assess any form of text-based information, the first and obvious parameter to evaluate is whether the text is linguistically understandable − in other words, its readability. Quantifying readability is not a novel issue: over the last half-century, numerous tools have been developed and are available to assess the level of readability of text [21]. These tools have been used abundantly in order to evaluate professionally generated online medical materials [5], [15], [16], [17]
Emotional tone: potential emotional impact of online health information
In contrast to conventional media in which the degree of interaction between users and the content is limited, online applications where users have a more active role, such as social media, permit the introduction of additional informational elements into the content. In particular, interactions between users in online discussions of health-related information can introduce emotional elements that may impact the subsequent interpretation of the content by the users [28]. Furthermore, as
Understandability and usability: empowering the reader
While linguistic and semantic issues are obviously crucial when it comes to comprehending text-based content, they are however insufficient to fully define the understandability of given material. This is particularly true in the context of health-related information, in which characteristics such as suitability and reliability of the information are of central importance in properly conveying the desired message and ultimately leading to usability of the presented information. Therefore, in
Combined approaches and innovative research directions
Despite the multiplicity of available instruments, several critical problems remain unaddressed. First, most if not all evaluation tools − whether readability, sentiment analysis, or understandability and usability assessment tools − have been used on online materials covering a limited number of health issues, which prevents large-scale generalization of the utility of these tools. Second, critical studies directly comparing the results of analyses using different tools are needed. The few
Conclusion
Online resources offer a wide range of possibilities for health professionals to enhance patients’ health literacy. The numerous tools that we have discussed demonstrate that assessing online health information is possible. However, to be done effectively, several elements need to be considered. First, a thorough evaluation of online content requires the exploration of several dimensions (among which are readability, emotional tone, understandability and usability), Second, the characteristics
Acknowledgements
MJG holds a Career Grant from the “Fonds de Recherche du Québec − Santé” (FRQS). This work was supported by the Oto-Rhino-Laryngology − Head and Neck Surgery Research Fund of the “Fondation de l'Université Laval”.
References (77)
Dynamics of social roles in a knowledge management community
Comput. Hum. Behav.
(2010)- et al.
Interacting with bots online: users’ reactions to actions of automated programs in Wikipedia
Comput. Hum. Behav.
(2015) - et al.
Web Wisdom: an essay on how Web 2.0 and Semantic Web can foster a global knowledge society
Comput. Hum. Behav.
(2011) - et al.
Information quality and dynamics of patients' interactions on tonsillectomy web resources
Internet Interv.
(2016) - et al.
Suitability of prostate cancer education materials: applying a standardized assessment tool to currently available materials
Patient Educ. Couns.
(2004) - et al.
Seeking health information online: does Wikipedia matter?
J Am Med. Inform. Assn.
(2009) - et al.
Readability formulas: cautions and criteria
Patient Educ. Couns.
(1991) - et al.
Assessing readability formula differences with written health information materials: application, results, and recommendations
Res. Soc. Adm. Pharm.
(2013) - et al.
Readability assessment of online patient education materials from academic otolaryngology − head and neck surgery departments
Am. J. Otolaryngol.
(2013) Swimming with mermaids: communication and social density in the second life merfolk community
Comput. Hum. Behav.
(2015)