A health literacy analysis of online patient-directed educational materials about mycobacterium avium complex

Abstract

Introduction: Mycobacterium avium complex (MAC) is a complex lung infection requiring multi-disciplinary approach and management. Due to limited clinician-patient interactions, clinicians may refer patients to online resources to learn about the diagnosis, prognosis, and treatment of MAC. The American Medical Association (AMA) recommends educational materials be written at a sixth-grade reading level and the National Institutes of Health (NIH) recommends that patient education materials be written at an eighth-grade reading level; however, several evaluations found these materials inaccessible due to high literacy levels. To date, there has never been a health literacy assessment of MAC patient education materials. The study aims to assess the health literacy of online patient education materials about MAC.

Methods: The patient education materials were evaluated for readability, actionability, understandability and clarity. Readability was assessed through the Flesch-Kincaid Grade Level Scale (FkGL), SMOG Index, Coleman Liau Index (CLI), Gunning Fog Index (GFI), and Automated Readability Index (ARI). Actionability and understandability was evaluated using the Patient Education Materials Assessment Tool (PEMAT). The Centers for Disease Control (CDC) Clear Communication Index (CCI) was used to assess clarity.

Results: Ten patient education resources were evaluated: CDC, Cleveland Clinic, Mayo Clinic, JAMA, American Thoracic Society (ATS), National Jewish Health, UpToDate, CHEST, WebMD, and Medline. The mean readability scores were as follows: FkGL (9.76), SMOG index (9.82), CLI (13.54), GFI (11.66), ARI (9.15). Four patient education materials were written at a sixth-grade reading level and eight patient education materials were written at an eighth-grade reading level. The majority of the materials received a passing score for understandability but failed to achieve a passing score for actionability. Cleveland Clinic, JAMA, and ATS all received a passing clarity score, indicating that they are easy to read. No patient education materials were available on UpToDate.

Conclusion: Most patient education materials scored poorly for actionability and clarity while scoring highly for readability and understandability. This study should serve as a guide for clinicians interested in offering online education materials to their patients. Increasing access to readable MAC educational materials should be a priority for those working at the intersection of public health, clinical care, and communications.

Keywords: Health literacy; Infectious diseases; Mycobacterium avium complex; Patient education; Pulmonary disease.

Fig. 1

Mean Readability Grade Level Scores. Five formulas—the Flesch Kincaid, Coleman Liau Index, Automated Readability Index, SMOG Index, and Gunning Fog Index—were used to determine the average readability grade level. The solid line represents the NIH Recommendation for materials to be written at an 8th grade reading level. The dotted line represents the AMA recommendation for materials to be written at an 6th grade reading level. Readability The average reading grade level (mean ± standard deviations) of the five readability scales were as follows: Flesch Kincaid Grade Level 9.76 ± 2.23 [range: 6.15–13.58]; recommended score ≤ 8.0, SMOG index 9.82 ± 1.72 [7.3–12.42]; recommended score ≤ 8.0, Coleman Liau Index 13.54 ± 2.53 [range 10.27–20.7]; recommended score ≤ 8.0, Gunning Fog Index 11.66 ± 2.27 [range 7.78–15.29]; recommended score ≤ 8.0, Automated Readability Index 9.15 ± 2.21 [range 5.79–12.84]; recommended score: ≤ 8.0.

Fig. 2

Patient Education Materials Assessment Tool (PEMAT) Scores. Understandability and Actionability scores of patient education materials. According to the PEMAT tool, a score of 70% or higher is considered to be both understandable and actionable. This is shown by the solid line. Understandability and Accountability The patient education materials used were from CDC (1–3), Medline (4–6), Mayo Clinic (7), WebMD (8–12), Cleveland Clinic (13–15), JAMA (16), ATS (17), National Jewish Health (18) and CHEST (19). A total of 5 education materials (8, 9,12,14,19) met the acceptable threshold (>70%) for both understandability and actionability. The patient education resources that met that threshold were WebMD, Cleveland Clinic and CHEST. The majority: 16 out 19 or 84% of education material met the acceptable threshold for understandability.

Fig. 3

CDC Clear Communication Index (CCI) Scores. Clarity scores of the patient education materials. According to the CCI scale, scores above 90% is considered passing or “easy to read”. This is represented with the solid line. Clarity The Index-Full was applied to 18 materials and the Index-Mod was applied to 4 materials. The patient education materials used were from CDC (1–3), Medline (4–6), Mayo Clinic (7), WebMD (8–12), Cleveland Clinic (13–15), JAMA (16), ATS (17), National Jewish Health (18) and CHEST (19). Only 3 patient education resources specifically Index-Full material scored above 90 or easy to read. None of the Index-Mod sources were considered easy to read, the closest one was an online patient education material from Medline.