Health literacy and the World Wide Web: Assessing text readability and older adults' comprehension of cancer information on the Internet

Background. Cancer information on the Internet is written at or beyond high school reading levels, despite lower average literacy abilities of the general public. Functional health literacy, or the ability to comprehend health information, declines with age. It is important that older adults receive reliable cancer prevention information since age is a major risk factor for leading incident cancers. Older adults are the fastest growing user group of the Internet in North America and are turning to the Web for resources on disease conditions, medications, and lifestyle. This is the first study to evaluate systematically older adults' comprehension of Internet cancer content and to correlate text readability and end user comprehension.;Methods. Readability was assessed using SMOG, Flesch-Kincaid (FK), and Flesch Reading Ease (FRE) measures. Four Internet workshops were conducted at the Kitchener Public Library with 44 community-dwelling older adults aged 50 to 75. Older adults' comprehension of Web-based cancer information was assessed using the Cloze procedure and recall questions. Participants' comprehension scores were examined by SMOG readability level (< Grade 13 vs. Grade 13+).; Results. The mean readability score across cancer Web sites was Grade 12.9 (95% CI=12.4--13.3) using SMOG and Grade 10.7 (95% CI=10.4--11.0) according to FK. The mean FRE score was 45.3 (95% CI=42.7--48.0), a score considered 'difficult'. Colorectal cancer Web sites were the most difficult to read compared to breast and prostate cancer Web pages. Significantly higher SMOG reading levels (p=.02) were required for concluding paragraphs of Web articles (Grade 13.2, 95% CI=12.6--13.7) compared to introductory paragraphs (Grade 12.5, 95% CI=11.9--13.2). Overall, older adults' had satisfactory comprehension of Web-based cancer information as measured by Cloze (.86 +/- .01 SE) and recall (.71 +/- .02). However, for colorectal cancer Web pages written at or above a Grade 13 level, a significant negative correlation between readability and Cloze comprehension was found (rs=-.44, p=.019), indicating poorer participant comprehension at higher readability levels. Comprehension of breast and prostate cancer information did not vary by readability level. Results of post-workshop questionnaires showed that the library workshops were effective in teaching Internet search skills to older adults. Searching difficulty decreased significantly (p=.001) from 5.2 +/- .40 pre-workshop to 4.3 +/- .48 post-workshop (1=very easy; 10=very difficult). Self-rated understanding (1=poor; 5=excellent) of the Internet was also significantly higher (p=.001) post-workshop (3.9/5) compared to pre-workshop (2.4/5).;Conclusions. Findings suggest the need for more readable and tailored cancer information on the Web. Better collaboration between health educators, health informaticians, medical journalists, and Web page editors will be needed to ensure the use of plain and readable text to match the literacy skills of consumers. Though readability plays a role in older adults' understanding of cancer information, cancer type and content are also important factors that influence comprehension. Use of plain language is recommended for colorectal cancer.;Objectives. (1) To assess the readability level of 100 consumer-oriented Web pages on leading incident cancers (breast, prostate, and colorectal); (2) to teach older adults how to search the Internet effectively for cancer information; (3) to evaluate older adults' knowledge of and use of the Internet for cancer information after attending a library workshop; (4) to evaluate older adults' comprehension of breast, prostate, and colorectal cancer information on the Internet; and (5) to determine if comprehension of printed cancer information varies according to text readability.