Plastic Surgery Research Council

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Literacy Analysis of Spanish Online Resources for Breast Reconstruction
Andres F. Doval, MD1, Luis Riba, MD1, Anna Rose Johnson, MPH1, Bao Ngoc N. Tran2, Bernard T. Lee, MD, MBA, MPH1
1Division of Plastic & Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 2Division of Plastic & Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ

PURPOSE: Health literacy studies indicate that low literacy can prevent patients from actively participating in health discussion and decision-making process. In the U.S., those who speak English as a second language may be particularly vulnerable. There is a paucity of research examining the match or mismatch between Spanish speaking patients' literacy and the demand of existing health materials. The aim of this study is to evaluate breast reconstruction online resources available for the Spanish speaking population in the United States through metrics developed for readability, suitability and cultural sensitivity.
METHODS: A search for the term ‘Reconstrucción de seno' (Translation: Breast Reconstruction) was conducted using Google. The 10 most easily accessible institutional/academic websites (e.g., government entities, academic centers, nonprofit organizations), and media/private websites (e.g., blogs, news sites, private organizations) were identified. Each website was assessed for readability (SOL Readability Formula and Fry Readability Formula), understandability/actionability (PEMAT: the Patients Education Materials Assessment Tool), suitability (SAM: the Suitability Assessment of Materials tool), cultural sensitivity (CSAT: the Cultural Sensitivity Assessment Tool), numeracy (Matrix of Numerical Complexity and Comprehension Hierarchy), and for website content organization and navigation (Health Literacy Online Guide by the U.S. Department of Health and Human Services). Understandability/actionability, suitability and cultural sensitivity were evaluated by two independent raters and Fleiss-Kappa score as obtained to ensure inter-rater reliability.
RESULTS: Readability analysis revealed higher than recommended scores and no significant reading grade level difference between institutional/academic and media/private websites (SOL: 10.4 and 10.8, respectively; p=0.78. Fry Readability Formula: 9.1 and 9.7, respectively; p=0.21). Understandability scores for institutional/academic and media/private websites were 50.6% and 47.1%, respectively (p=0.53); actionability scores were 18% and 14%, respectively (p=0.67). Suitability was assessed as adequate and, similarly, no difference was found in suitability analysis between institutional/academic and media/private websites (50.2% vs. 49.7%, respectively; p=0.92). Cultural sensitivity evaluation yielded adequate score for both types of websites, with no statistically significant difference observed (p=0.31). In terms of numeracy analysis, the majority of websites fell into the less complex area of the hierarchy matrix.
CONCLUSION: Available breast reconstruction online resources for the Spanish-speaking population are rated too high for the general public on readability. The adequate level in terms of suitability, understandability and cultural sensitivity, along with the low actionability scores, indicate a need for improvement. In addition, there is limited availability of institutional/academic online resources in Spanish. These findings demonstrate a need for more comprehensible literature on breast reconstruction for the Spanish-speaking population of the United States.


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