|Ahead of print
Content analysis of patient material resources on the internet for oral cancer—An exploratory study
Shreya Bhatia1, Gururaghavendran Rajesh2, Almas Binnal3, S Shreya Sarkar2, Chirag Suhane2
1 Departments of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Submission||23-Jul-2019|
|Date of Decision||05-Jun-2019|
|Date of Acceptance||27-Feb-2020|
|Date of Web Publication||27-Jan-2021|
Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Oral cancer is one of the leading causes of mortality in the world over and is a major public health problem. There are numerous resources on the internet which provide information related to oral cancer. However, they may not be optimal and standardized. The present study was conducted to assess the quality, readability, and content of the online resources for oral cancer.
Methods: The content analysis approach was employed for the present study. Google search engine was employed to search for various online resources on oral cancer. The first 50 websites were evaluated for their quality and readability. Flesch–Kincaid readability tests were used to assess the readability of the internet material and consisted of Flesch reading ease and Flesch–Kincaid grade level. The quality of websites was assessed by Journal of American Medical Association (JAMA) benchmarks and HONcode (Health Over Net code).
Results: A total of 12 (32.43%) of the websites were fairly difficult to comprehend, while none of the websites were easy/very easy to comprehend. A total of 8 (21.62%) websites were readable by only college-level graduates. Overall, 21 (56.76%) of the websites did not have HONcode certification.
Conclusion: The present study revealed that a majority of the websites were fairly difficult to comprehend and readable by college-level graduates. There is a definite need to monitor the quality of the websites on oral cancer. The present study highlights the need for stringent norms and regulations regarding oral cancer made available to the common man on the internet.
Keywords: Internet, oral cancer, patient information, readabilityKey Message Internet-based resources on oral cancer need to address critical issues related to quality, readability and content. Appropriate norms and regulations have to be established and implemented to disseminate reliable and comprehensible information on the internet about oral cancer.
|How to cite this URL:|
Bhatia S, Rajesh G, Binnal A, Sarkar S S, Suhane C. Content analysis of patient material resources on the internet for oral cancer—An exploratory study. Indian J Cancer [Epub ahead of print] [cited 2021 Feb 25]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308042
| » Introduction|| |
Noncommunicable diseases are now widely prevalent due to changing lifestyles and are one of the leading causes of mortality and morbidity the world over. India contributes to 7.8% of the global cancer burden and 8.33% of global cancer deaths. The burden of these diseases is greater in developing and underdeveloped nations than in developed nations. Oral cancer is one such disease that affects a large number of individuals and has emerged as a major public health problem.,,,, This can be attributed to tobacco, alcohol, dietary and lifestyle factors.
We are currently witnessing numerous technological advancements that have influenced our lives. Technology use is increasing by the day as it is very easily available to the common man. Among these, the internet and mobile phone usage are observed to be a common phenomenon worldwide. One of the advantages offered by technology is its use by all sections of society, irrespective of age, gender, caste, and creed. There has been a rise in the percentage of population browsing the internet for information regarding health-related issues.,
There are numerous resources on the internet which provide information related to oral cancer. One of the major developments that coincide with the expansion of the internet is the emergence of evidence-based medicine and evidence-based health care. However, the quality and the contents of the online resources on oral cancer may not be considered to be optimal and standardized. Internet resources may contain information that is factually and scientifically wrong and inaccurate. It may also be obsolete and may be replaced by recent advancements. It may ultimately lead to more harm than good for the health of patients. One also has to consider the competency of the end-users in filtering out information that is not accurate. Internet-based information, thus, confers greater responsibility on patients for their health care decisions.
Information reaching the end-users should not only be of high quality and scientifically accurate but should also be readable. The use of jargon and highly technical language may be a confusing and exasperating experience for a layperson. It also has major implications for doctor-patient relationships and health care delivery systems.
Oral health professionals should be aware of the internet resources pertaining to oral cancer available to the common man. This will help them in guiding patients and allaying their fears and apprehensions. There are very few studies that explore the quality of information available on the internet about oral cancer. Such investigations might provide valuable information in tackling the growing health problem of oral cancer in developing countries like India with scarce resources. Spreading awareness will help in making proper standardized health care information available and easily accessible to all. The present study was thus carried out to assess the quality, content, and readability of the online resources for oral cancer.
| » Methods|| |
The present study was conceived to explore the websites related to oral cancer for readability, content, and quality. The study was conducted in Manipal College of Dental Sciences, Manipal University, Mangalore. Google search engine was used to search for various online resources on oral cancer. Out of all the resources, the first 50 websites were evaluated for their content, quality, and readability. The inclusion criteria used for the selection of websites were as follows: websites should be patient-focused and should not involve any form of payment. The exclusion criteria included websites containing only videos, websites that are password-protected, and all scientific articles and books.
Data collection was performed from March 2019 to April 2019. Website selection was conducted by two investigators (SB and SS) based on the aforementioned inclusion and exclusion criteria. When there was a lack of agreement between the two reviewers, the consensus was arrived at by discussing the same with the third investigator (GR).
After the selection of the websites, they were assessed for quality, contents, and readability. Flesch–Kincaid readability tests, were used to assess the readability of the internet material, which included Flesch reading ease and Flesch–Kincaid grade levels. The content of the selected websites was entered on the website, http://www.online-utility.org/english/readability_test_and_improve.jsp, and Flesch reading ease (FRE) and Flesch-Kincaid grade level (FK) scores were allotted to each text. FRE and FK grade level scores are inversely related, hence, a higher FRE score relates to a lower FK score.
The content analysis was done by making a checklist which was drafted on comparing the information available on the included websites, by an expert panel. The quality was assessed by using the Health Over Net code (HONcode) and Journal of American Medical Association (JAMA) benchmark. JAMA benchmark consists of four criteria (authorship, attribution, currency, disclosure). The quality of the content was assessed based on the presence or absence of each of the abovementioned criteria. The investigators evaluated the websites for the certification by HONcode.
Data were analyzed using Statistical Package for Social Sciences (SPSS), version 16.0 (SPSS Inc, Chicago IL). Descriptive statistics about the quality, content, and readability of the various websites were presented.
| » Results|| |
The present study was conducted to assess the websites related to oral cancer for readability, content, and quality. The first 50 websites were included for analysis. A total of 13 websites did not meet the inclusion criteria, due to which they were excluded. Therefore, a total of 37 websites were included in the final analysis.
The median Flesch–Kincaid Readability Ease Scores was 56.7 corresponding to fairly difficult (interquartile range: 17.60). A total of seven (18.92%) were fairly easy to read based on Flesch–Kincaid Readability Ease Scores. It was also observed that a total of nine (24.32%) were of standard readability ease. The number of websites that were difficult, fairly difficult, and very confusing to read was 5 (13.51%), 12 (32.43%) and 4 (10.81%), respectively. The median Flesch–Kincaid grade levels were 10, corresponding to the 10th grade level (interquartile range: 4.35). Results also indicated that a majority of 8 (21.62%) websites were college graduate level according to the Flesch–Kincaid grade levels. Only 3 (8.11%) and 7 (18.92%) belonged to the 7th and 8th-grade readability levels [Table 1].
A majority of 18 (48.65%) of websites fulfilled four criteria of JAMA benchmarks. It was also observed that 4 (10.81%) and 15 (40.54%) of the websites fulfilled two and three criteria of JAMA benchmarks. Disclosure and attribution were fulfilled by a maximum of 37 (100%) and 35 (94.59%), respectively [Table 2].
On the other hand, authorship and currency were fulfilled 29 (78.38%) and 24 (64.86%), respectively. A total of 21 (56.76%) websites displayed the HONcode certification, while 16 (43.24%) did not have the same [Table 3].
A majority of the 35 (94.59%) and 33 (89.19%) of the websites reported tobacco (smoking and smokeless) and alcohol consumption as the cause of oral cancer, respectively. The number of websites that had included family history, chronic irritation, and chronic inflammation as the cause of oral cancer was 9 (24.32%), 8 (21.62%) and 8 (21.62%), respectively [Table 4]. The symptoms of a lump in neck, persistent sores, and functional disability were reported in 30 (81.08%) of the websites. Ear pain and dramatic weight loss were reported in 10 (27.03%) and 14 (37.84%) of the websites included in the present study [Table 5].
The most common method of diagnosis reported by websites in the present study was by clinical examination, which was reported in 27 (72.97%) of the websites. A blood test as a method of detection of oral cancer was reported in 10 (27.03%) of the websites. Surgery and radiotherapy as a modality of treatment of oral cancer were reported in 28 (75.68%) of the websites, while chemotherapy was reported in 27 (72.97%) of the websites. Prognosis and survival rates of oral cancer were reported in 18 (48.65%) of the websites in the present study. Only 21 (56.76%) of the websites had reported that tobacco or alcohol cessation as one of the measures of preventing oral cancer. Limited exposure to sunlight was reported in 20 (54.05%) of the websites. A total of 20 (54.05%) of the websites had provided links, while a majority of 25 (67.57%) of the websites had pictures displayed [Table 6].
| » Discussion|| |
The present study was conducted to assess the readability, content, and quality of websites pertaining to oral cancer. The recent decades have witnessed a great surge in technological advancements in the field of information technology. The internet has now metamorphosed into a huge, sprawling phenomenon that is growing at breakneck speed. The present study systematically assesses the quality and content of the information available on the internet about oral cancer.
Flesch–Kincaid readability tests consisting of Flesch reading ease and Flesch–Kincaid grade level were chosen over other readability indices such as the Simple Measure of Gobbledygook (SMOG) index. SMOG index tends to predict readability two grades above the other estimates as it relies on the stringent criteria of 100% correct answers by respondents. Moreover, the review of the literature indicates that Flesch–Kincaid readability tests are more frequently employed for readability assessments. Results of the present study indicate that the readability ease score was fairly difficult for 12 (32.43%) websites. A total of 9 (24.32%) and 7 (18.92%) of the websites were of standard and fairly easy readability, respectively. The findings of the present study are in agreement with those reported by Wiriyakijja et al. for websites on oral leukoplakia and Diniz-Freitas et al. for websites on tobacco cessation by dentists.
A majority of the websites in the present study were readable only by college-level graduates. This is in contrast with that reported by Joury et al., for websites on chest pain. The recommended reading grades for health-related information for adults by the National Institutes of Health are between 7th and 8th grades. However, when the majority of the patient-centered websites are readable only by college-level graduates, it is a cause for concern. A layperson may not be able to comprehend the information presented.
A total of 18 (48.65%) of the websites met all the JAMA benchmarks in the present study. Wiriyakijja et al. observed that a total of 17% of websites on oral leukoplakia, and Ni Riordain et al. observed 45% of websites on head and neck cancer fulfilled all four JAMA benchmark. Diniz-Freitas et al. observed that none of the websites related to tobacco cessation services by dentists fulfilled all four JAMA benchmarks. A majority of the JAMA benchmarks fulfilled in the present study includes disclosure (76%) and attribution (72%). This is similar to the findings reported by Wiriyakijja et al. for websites on oral leukoplakia but contrasting with those reported by Diniz-Freitas et al. for websites on tobacco cessation services by dentists. Authorship and currency were the frequently fulfilled JAMA benchmark in websites on adult orthodontics assessed by McMorrow et al.
A majority of 42% of the websites in the present study did not have HONcode certification, which is similar to those reported by Wiriyakijja et al., for websites on oral leukoplakia; Diniz-Freitas et al., for websites related to tobacco cessation services by dentists; and Joury et al., for websites on chest pain. This is in contrast with the findings of McMorrow et al. for websites on adult orthodontics. Riordain et al. observed that 39% of websites on head and neck cancer revealed the HONcode seal. One has to bear in mind that HONcode is an indicator of reputation and ethical aspects rather than a quality indicator.
The results of the present study indicated that a majority of the websites report tobacco and alcohol consumption as the cause of oral cancer. It was also seen that the websites did not include family history, chronic irritation, and chronic inflammation as the cause of oral cancer; prognosis and survival rates; tobacco or alcohol cessation as one of the measures of preventing oral cancer. This indicates that the information provided on the internet may not be comprehensive.
The number of individuals surfing the internet to access information related to health has phenomenally increased in the past few years. This brings to light the crucial aspect of the content and readability of the information. The quality of information on oral cancer in different languages has also found to be far from satisfactory.,, Websites on dental care for patients with cancer are broad in content yet are limited in quality and are written at difficult reading levels.
It has been observed that high levels of unmet health information needs may be associated with high anxiety levels. Varela-Centelles et al. have reported that the overall quality rate of the information about screening for oral cancer in health care professionals (HCP) addressed websites were of good standards. High levels of anxiety may trigger other problems such as adverse health outcomes and poor compliance with medical therapy. Lack of information may, thus, lead to difficulties for the decision-making by the patients, which can, in turn, have adverse consequences on doctor-patient relationships. This highlights the importance of accurate, reliable information for individuals searching the internet on oral cancer.
The internet is often a source of much conflicting information. However, this does not imply that the internet should not be used as a source of information. Internet should, thus, be viewed as a delightful source of all information, and also a source of chaotic information overload and a source of spurious information. Health-related quality of life information gives patients and caregivers an indication of how they will be affected following treatment. Such knowledge can promote realistic expectations and help patients come to terms with their outcomes.
One of the reasons for such variability in the information on the internet is that the contents are prepared by a diverse group of individuals with different training backgrounds. The websites are also prepared for different objectives. One also has to keep in mind that the patients have different health literacy levels and different access to the internet.
The present study should be viewed in light of its inherent shortcomings. The present study was cross-sectional in nature and a limited number of websites were included. The ever-changing nature of the internet implies that the content on oral cancer on the internet is constantly undergoing changes. Further studies involving a larger number of websites should be conducted. The checklist to assess the content of the websites was specifically prepared for the present study. This may or may not fully represent the entire range of content related to oral cancer. Certain websites were excluded by the researchers in the present study, which might be used by a common man. Research articles were excluded from the present study, which may provide scientific information that is more accurate. The assessor in the present study was a trained and qualified dentist, who might have more knowledge about oral cancer than a common man. The assessor may also be more critical than a common man browsing the internet for information about oral cancer.
| » Conclusions|| |
Results of the present study indicated that the readability ease and readability grade levels of the websites pertaining to oral cancer were not compliant with the recommended guidelines. A majority of the websites were not compliant with JAMA benchmarks and HONcode certification. The present study highlights the need for stringent regulations for information displayed at websites pertaining to oral cancer. As the number of individuals browsing the internet for health-related information is phenomenally increasing by the day, there is a definite need to regulate the quality of information available on the internet on oral cancer. The present study highlights the need for stringent policies related to the information being displayed by various websites pertaining to oral cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71.
Boyer C, Baujard V, Geissbuhler A. Evolution of health web certification through the HONcode experience. Stud Health Technol Inform 2011;169:53-7.
Silberg WM. Assessing, controlling, and assuring the quality of medical information on the internet. JAMA 1997;277:1244-5.
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ 2005;83:661-9.
Kawashima N, Wadachi R, Suda H. Root canal medicaments. Int Dent J 2009;59:5-11.
Petersen PE. Global policy for improvement of oral health in the 21st
century-Implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dent Oral Epidemiol 2009;37:1-8.
Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014;64:9-29.
Simard EP, Torre LA, Jemal A. International trends in head and neck cancer incidence rates: Differences by country, sex and anatomic site. Oral Oncol 2014;15:387-403.
Naganandini S, Rao R, Kulkarni SB. Survey on the use of the Internet as a source of oral health information among dental patients in Bangalore City, India. Oral Health Prev Dent 2014;12:141-7.
Harris CE, Chestnutt IG. The use of the Internet to access oral health-related information by patients attending dental hygiene clinics. Int J Dent Hyg 2005;3:70-3.
Patton LL, George SF, Hollowell RP. Content, quality, and readability of website information on dental care for patients with cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:78-83.
Booth A. Netting the evidence: Finding pearls, not sewage. Singapore Med J 2006;47:1023-9.
Kaicker J, Debono VB, Dang W, Buckley N, Thabane L. Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument. BMC Med 2010;8:59.
Flesch R. A new readability yardstick. J Appl Psychol 1948;32:221-33.
McLaughlin GH. SMOG grading-a new readability formula. Journal of Reading 1969;12:639-46.
Wiriyakijja P, Fedele S, Porter S, Ni Riordain R. Web-based information on the treatment of oral leukoplakia-quality and readability. J Oral Pathol Med 2016;45:617-20.
Diniz-Freitas M, Insua A, Keat R, Fricain JC, Catros S, Monteiro L, et al
. Web-based information on the treatment of tobacco dependence for oral health professionals: Analysis of English-written websites. J Med Internet Res 2017;19:e349.
Joury AU, Alshathri M, Alkhunaizi M, Jaleesah N, Pines JM. Internet websites for chest pain symptoms demonstrate highly variable content and quality. Acad Emerg Med 2016;23:1146-52.
Ni Riordain R, McCreary C. Head and neck cancer information on the internet: Type, accuracy and content. Oral Oncol 2009;45:675-7.
McMorrow SM, Millett DT. Adult orthodontics: A quality assessment of Internet information. J Orthod 2016;43:186-92.
Kummervold PE, Chronaki CE, Lausen B, Prokosch HU, Rasmussen J, Santana S, et al
. eHealth trends in Europe 2005-2007: A population-based survey. J Med Internet Res 2008;10:1-16.
Vivien A, Kowalski V, Chatellier A, Babin E, Bénateau H, Veyssière A. [Information quality in general public French-speaking websites dedicated to oral cancer detection]. J Stomatol Oral Maxillofac Surg 2017;118:20-8.
Irwin JY, Wali T, Fernando S, Schleyer T. Quality assessment of English and Spanish oral cancer websites. Am Med Inf Assoc Annu Symp Proc 2007:987.
Irwin JY, Thyvalikakath T, Spallek H. English and Spanish oral cancer information on the Internet: A pilot surface quality and content evaluation of oral cancer Web sites. J Public Health Dent 2011;71:106-16.
Lin HY, Chen SC, Peng HL CM. Unmet information needs and clinical characteristics in patients with precancerous oral lesions. Eur J Cancer Care 2015;24:911-9.
Varela-Centelles P, Insua A, Seoane-Romero JM, Warnakulasuriya S, Rapidis A, Diz P, et al
. Available web-based teaching resources for health care professionals on screening for oral cancer. Med Oral Patol Oral Cir Bucal 2015;20:e144-9.
Kiley R. Quality of medical information on the internet. J R Soc Med 1998;91:369-70.
Rogers SN, Hogg ES, Cheung WKA, Lai LKL, Jassal P, Lowe D. The use of health related quality of life data to produce information sheets for patients with head and neck cancer. Ann R Coll Surg Engl 2015;97:359-63.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]