Abstract
Aims & objectives
YouTube is a non-peer-reviewed platform with a large library of healthcare-related videos which attempt to provide educational content. The goal of this study is to analyze the quality, absorbability, and educational content of videos available to patients on YouTube regarding ankle fractures.
Materials & methods
On May 31, 2022, over 550 videos populated the initial search of “ankle fracture” within YouTube's platform. The first 100 videos were reviewed, and 62 videos were included in the final analysis. Video characteristics were recorded and evaluated. Videos were assessed using three objective scoring systems: (1) the Journal of American Medical Association (JAMA) benchmark criteria, (2) the Patient Education Materials Assessment Tool for audio and visual materials (PEMAT), and (3) the novel Ankle Fracture Content Score (AFCS).
Results
Each scoring system had high internal consistency and interrater reliability. The mean JAMA, PEMAT understandability, PEMAT actionability, and AFCS were 2.92, 61.85%, 16.38%, and 4.67, respectively. No association was seen between video popularity metrics and quality of information. The understandability of the patient-targeted videos was greater than those targeted at healthcare professionals (P = 0.049).
Conclusion
The information regarding ankle fractures available on YouTube for patient education is poor with no correlation between quality and popularity. This study illustrates the need for future collaboration between YouTube and trusted medical societies to provide patients with the highest quality information.
Keywords: Ankle injury, Ankle fracture education, Patient education, YouTube ankle fracture analysis, Video patient education
Abbreviations: JAMA, Journal of American Medical Association benchmark criteria; PEMAT, Patient Education Materials Assessment Tool for audio and visual materials; AFCS, Ankle Fracture Content Score; OTA, Orthopaedic Trauma Association; AAOS, America Academy of Orthopaedic Surgeons; APMA, American Podiatric Medical Association; AOFAS, American Orthopaedic Foot and Ankle Society; ACFA, American College of Foot and Ankle Surgeons
1. Introduction
YouTube is a non-peer-reviewed platform with a large library of healthcare-related videos uploaded by a variety of users including medical professionals, patients, and biomedical device companies. Prior literature suggests 75% of patients made medical decisions based on health information gathered online.1 With over 8 billion google searches daily, it has been shown that 7% of these are health-related.2 YouTube is a google enterprise and accumulates billions of views daily with over 2 billion active users per month and has been shown to be increasingly used for disseminating health information.1,3
Multiple in-depth analyses of various healthcare-related YouTube videos have recently been published.2,4, 5, 6, 7, 8, 9, 10, 11 These highlight the overall poor ability to accurately describe diagnoses and management of common medical illnesses and procedures.12 Few of these studies offer insight into the ease of patient understanding and absorbability when viewing such videos.13, 14, 15, 16, 17, 18, 19, 20 Together, an increase in the utilization of YouTube for healthcare information and an increase in inadequate and unreliable video content may cause confusion and frustration between healthcare providers and patients.21
Understanding the overall quality of information available to patients regarding ankle fractures is critical for physicians when discussing diagnosis and treatment options with patients, as quality patient education has been shown to decrease anxiety about procedures and promote better outcomes.22 While some studies analyze the educational content on YouTube for various orthopedic injuries and pathologies, no studies have investigated content available regarding ankle fractures.2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28 The incidence of ankle fractures in adult trauma has been reported to be 174 cases per 100,000 adults per year.29 Additionally, there are over 7000 search inquiries on YouTube per day in the United States related to ankle injuries.30 Given the high prevalence of these injuries amongst the general population and the increasing use of the internet as a source of health information, we sought to evaluate the quality of the educational materials available to patients. The purpose of our investigation is to analyze the quality, absorbability, and educational content of videos available to patients on YouTube regarding ankle fractures. We hypothesize that the information available to patients is of low quality and limited usefulness.
2. Methods
2.1. Study design
The keywords “ankle fracture” were searched on YouTube (https://www.youtube.com) within a private browser on the most updated version of Google Chrome. The first 100 videos from the two searches were compared and confirmed to be identical between each reviewer. The number of videos chosen from the initial search was based on previously published YouTube video analyses that suggest users rarely visit multiple pages of videos.22 Videos were accessed May 31, 2022 for analysis.
2.2. Study size
Videos containing information about ankle fractures were considered. Videos were excluded for: (1) lack of audio, (2) being less than 2 minutes, (3) spoken in a language other than English, (4) being focused on other fractures (for example, pilon fractures), (5) being duplicate videos, and (6) not accessible to all YouTube users regardless of account status (users may access videos without having an account). Videos less than 2 minutes were excluded to remove YouTube “short” videos and videos with inadequate content for analysis. Other criteria were based on similar studies assessing YouTube educational content.9 A total of 62 videos were included in the final analysis (Fig. 1).
Fig. 1.
Search methodology for videos regarding ankle fractures on YouTube.
2.3. Variables
For each video, multiple video characteristics were recorded including (1) title, (2) date uploaded, (3) video duration, (4) date viewed by authors, (5) days since upload, (6) views, (7) likes, (8) view ratio (the number of views divided by days since upload), (9) comments, (10) uploader/source, (11) subscriber number, and (12) YouTube verification status.
2.3.1. Video source demographics
Video sources were categorized as the following: (1) academic (source affiliated with academic institutions, research programs, or universities), (2) physician (including MD, DO, or Doctor of Podiatric Medicine), (3) non-physician health professional (including physical therapist, occupational therapist, physiotherapist, or physician assistant), (4) patient, or (5) device company. The intended audience, if specified during the video or in the video information tab, was recorded. Other video variables, including the presence of a medical disclaimer, patient testimonial, strict treatment/rehabilitation, or the presence of a YouTube designation were also recorded (Table 1).
Table 1.
Video characteristics.
| Characteristic | Average | Standard deviation | Min | Max |
|---|---|---|---|---|
| Video Duration, minutes | 9.82 | 13.12 | 2.05 | 68.35 |
| Days since upload, days | 1726.85 | 1076.20 | 43 | 4374 |
| Views | 141,513 | 323,322.41 | 548 | 1,682,373 |
| Likes | 1224.58 | 2679.33 | 4 | 16,000 |
| View ratio | 79.44 | 163.67 | 0.3 | 936.25 |
| Comments | 114.93 | 243.10 | 0 | 1328 |
| Source subscriber number | 464,596 | 1,201,664.48 | 295 | 5,710,000 |
| Characteristic | Number of Videos (%) |
|---|---|
| YouTube verification | |
| Yes | 8 (12.90) |
| No | 54 (87.10) |
| YouTube designation | |
| Yes | 2 (3.23) |
| No | 60 (96.77) |
| Patient testimonial | |
| Yes | 3 (4.84) |
| No | 59 (95.16) |
| Intended population | |
| Patients | 16 (25.81) |
| Healthcare professionals | 18 (29.03) |
| Both | 3 (4.84) |
| Unspecified | 25 (40.32) |
| Medical disclaimer provided | |
| Yes | 33 (53.23) |
| No | 29 (56.77) |
| Strictly treatment/rehabilitation | |
| Yes | 9 (14.52) |
| No | 53 (85.48) |
2.3.2. Video quality, reliability, absorbability, and educational content
Each video chosen for analysis was evaluated using three scoring systems: (1) the Journal of American Medical Association (JAMA) benchmark criteria, (2) the Patient Education Materials Assessment Tool for audio and visual materials (PEMAT), and (3) the novel Ankle Fracture Content Score (AFCS) created by the authors to evaluate each video's educational quality. Two of the authors evaluated and scored these videos together, and a third independent author viewed and scored the videos alone. Two sets of independent scores were created. Videos uploaded as part of a series were analyzed and scored as a single video, a similar methodology to Koller et al.25
2.3.3. Video source: reliability and quality
The JAMA benchmark scale is a validated tool used to measure the credibility and reliability of a source of information.31 It consists of a 4-point maximum score, with a point given for each category (authorship, attribution, disclosure, and currency) present in the video (Table 2). Higher scores indicate more reliable videos.
Table 2.
Journal of American Medical Association (JAMA) benchmark criteria.
| Authorship | Author and contributor credentials and their affiliations should be provided. |
| Attribution | References and sources for all content should be listed clearly, and all relevant copyright information noted. |
| Disclosure | Website “ownership” should be prominently and fully disclosed, as should any sponsorship, advertising, underwriting, commercial funding. |
| Currency | Dates that content was posted and updated should be indicated. |
2.3.4. Video content: understandability and actionability
The PEMAT is a validated tool that measures the understandability and actionability of information available to patients (Table 3).32 Understandability was measured using 13 criteria, while actionability was measured using 4 criteria. Total scores for understandability and actionability were calculated and divided by the number of items for each, which yielded a percentage. A higher percentage indicated a video that was more understandable or actionable.
Table 3.
Patient Education Materials Assessment Tool (PEMAT) For audio/visual materials.
| Understandability | ||
|---|---|---|
| Item # | Item | Response Option |
| TOPIC: CONTENT | ||
| 1. | The material makes its purpose completely evident. | Disagree = 0, Agree = 1 |
| TOPIC: WORD CHOICE & STYLE | ||
| 2. | The material uses common, everyday language. | Disagree = 0, Agree = 1 |
| 3. | Medical terms are used only to familiarize audience with the terms. When used, medical terms are defined. | Disagree = 0, Agree = 1 |
| 4. | The material uses the active voice. | Disagree = 0, Agree = 1 |
| TOPIC: ORGANIZATION | ||
| 5. | The material breaks or “chunks” information into short sections. | Disagree = 0, Agree = 1 |
| Very short materiala = NA | ||
| 6. | The material's sections have informative headers. | Disagree = 0, Agree = 1 |
| Very short materiala = NA | ||
| 7. | The material presents information in a logical sequence. | Disagree = 0, Agree = 1 |
| 8. | The material provides a summary. | Disagree = 0, Agree = 1 |
| Very short materiala = NA | ||
| TOPIC: LAYOUT & DESIGN | ||
| 9. | The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlighting) to draw attention to key points. | Disagree = 0, Agree = 1 |
| Video = NA | ||
| 10. | The material uses visual cues (e.g., arrows, boxes, bullets, bold, larger font, highlighting) to draw attention to key points. | Disagree = 0, Agree = 1 |
| No text or all text is narrated = NA | ||
| 11. | The material allows the user to hear the words clearly (e.g., not too fast, not garbled). | Disagree = 0, Agree = 1 |
| No narration = NA | ||
| TOPIC: USE OF VISUAL AIDS | ||
| 12. | The material uses illustrations and photographs that are clear and uncluttered. | Disagree = 0, Agree = 1 |
| No visual aids = NA | ||
| 13. |
The material uses simple tables with short and clear row and column headings. |
Disagree = 0, Agree = 1 |
| No tables = NA | ||
| Actionability | ||
| Item # |
Item |
Response option |
| 1. | The material clearly identifies at least one action the user can take. | Disagree = 0, Agree = 1 |
| 2. | The material addresses the user directly when describing actions | Disagree = 0, Agree = 1 |
| 3. | The material breaks down any action into manageable, explicit steps. | Disagree = 0, Agree = 1 |
| 4. | The material breaks down any action into manageable, explicit steps. | Disagree = 0, Agree = 1 |
| No charts, graphs, tables, diagrams = NA | ||
A very short audiovisual material is defined as a video or multimedia presentation that is under 1 min, or a multimedia material that has 6 or fewer slides or screenshots.
2.3.5. Video content: educational value
The AFCS is a novel scoring system used to assess the depth and amount of content covered to determine the educational value of videos for patients specifically. Videos intended for medical providers were also assessed with the scoring system since these also populate within patient searches. The standardized score received approval and verification from two fellowship-trained, practicing orthopedic trauma surgeons. This scoring system was based on readily available patient information regarding ankle fractures collected from the websites of the Orthopaedic Trauma Association (OTA), the America Academy of Orthopaedic Surgeons (AAOS), the American Podiatric Medical Association (APMA), the American Orthopaedic Foot & Ankle Society (AOFAS), and the American College of Foot and Ankle Surgeons (ACFAS). The system had two scoring criteria (major and minor) based on the importance of inclusion for patient education (Table 4). Major criteria were deemed as highly important for inclusion in basic patient education. Minor criteria were deemed as valuable for patient education but not critical for understanding. Major criteria received 2 value points while minor criteria received 1 for a total of 14 points. A higher score confers a higher educational value to patients. Novel scores have been included in previous studies as part of an effort to consolidate information pertaining to specific topics in medicine and provide authors with objective criteria for assessing videos.24, 25, 26
Table 4.
Ankle fracture content score (AFCS).
| Item # | Item | Points (Total 14) |
|---|---|---|
| Major Criteria | ||
| 1 | Basic explanation of ankle fracture | 2 |
| 2 | Signs/symptoms | 2 |
| 3 | Diagnosis | 2 |
| 4 | Treatment options | 2 |
| Minor Criteria | ||
| 5 | Anatomy of ankle fracture | 1 |
| 6 | Causes and risk factors | 1 |
| 7 | Specific types of ankle fractures | 1 |
| 8 | Delineation of treatment approaches | 1 |
| 9 | Outcomes and prognosis | 1 |
| 10 | Complications of treatment | 1 |
2.4. Bias
The use of a private browser was intended to eliminate bias from previously searched terms and saved “cookies” from each independent author's browser. Scoring systems completed by multiple reviewers were used to objectively score the videos and the inter-rater reliability was calculated to verify each system.
2.5. Statistical methods
To verify inter-rater reliability, Cronbach's alpha coefficient was assessed across the cumulative ratings of each scale. All numerical data compared across independent variables was analyzed using a Mann-Whitney U test for single numerical scale comparisons or Pearson's Correlation testing for dual numerical scale associations. Data was analyzed using R version 4.0.3.
3. Results
3.1. Descriptive data
A search for the keyword “ankle fractures” on YouTube's platform yielded a total of 554 videos. The first 100 videos from this search were evaluated. After initial screening, 62 videos met inclusion criteria and were analyzed. Videos that were excluded included videos under 2 minutes (n = 14), private videos (n = 15), videos lacking audio (n = 2), and duplicated videos (n = 7) (Fig. 1). Videos were uploaded between June 2010 and April 2022. The majority of videos were uploaded by medical professionals (n = 34, 54.84%), followed by academic centers or institutions (n = 11, 17.74%), non-physician healthcare professionals (n = 11, 17.74%), a device company or commercial (n = 4, 6.45%), and patients (n = 2, 3.23%).
Videos had a mean duration of 9.82 min ± 13.12 (range 2.05–68.35). Accumulated views, likes, and comments were 8773814, 75924, and 6896 respectively. On average, the videos received 79.44 views per day ±163.67. Two video uploaders disabled comments for their videos. No videos had the dislike feature activated. The mean number of days since upload was 1726.85 ± 1076.20 (range 43–4374). There were nine videos that only focused on the rehabilitation and physical therapy components of ankle fractures, such as providing exercises and stretches. A limited number of videos were patient testimonials (n = 3, 4.84%). A majority of videos provided medical disclaimers (n = 33, 53.23%). The intended audience of the videos was broadly unspecified, with 25 (40.32%) videos not specifying the target population. Population targets that were stated included patients (n = 16, 25.81%), healthcare professionals (n = 18, 29.03%), or both (n = 3, 4.84%) (Table 1).
3.2. Main results
3.2.1. JAMA score
The mean JAMA score was 2.92 ± 0.85. A majority of the videos analyzed had a score of 3 (n = 38, 61.29%), with many losing a point due to a lack of references or attributions. The mean JAMA score for videos targeted at patients (2.84 ± 0.68) was significantly lower than the mean score for videos targeted at healthcare professionals (3.53 ± 0.64) (P = 0.004).
3.2.2. PEMAT A/V score
The mean PEMAT understandability score was 61.86% ± 17.71% (range 22.50–96%) and the mean PEMAT actionability score was 16.38% ± 34.38% (range 0–100%). There was a significant negative correlation between average PEMAT understandability (P = 0.004) and actionability (P = 0.021) scores and number of days since upload. There was no correlation between video views, video likes, video views to days ratio, or subscriber count and average PEMAT understandability and actionability scores (P > 0.050). The understandability of the patient-targeted videos was greater than those targeted at healthcare professionals (P = 0.049). Additionally, the patient-targeted videos were more actionable than the videos targeted at healthcare professionals (P = 0.001).
3.2.3. Ankle Fracture Content Score
The mean AFCS across all videos was 4.67 ± 3.45 (range 0–14). A majority of the videos had a low AFCS indicating the overall poor educational value. Videos of longer duration were found to be positively correlated to the AFCS (P = 0.001). There was no correlation between number of days since video upload, video views, video likes, video views to days ratio, or subscriber count and the AFCS (P > 0.050). There was no statistically significant difference in AFCS in the videos targeted at patients compared to those targeted at healthcare professionals (P = 0.78).
3.3. Other analyses
3.3.1. Interrater reliability
For the JAMA, PEMAT understandability, PEMAT actionability, and the AFCS, the Cronbach's Alpha scores were 0.9702, 0.8597, 0.9674, and 0.9309, respectively. Scores greater than 0.8 indicate strong interrater reliability.
4. Presentation
All figures and tables are included in the submission as separate documents.
5. Discussion
5.1. Key results
While YouTube is a potentially useful platform for the distribution of patient information, the platform's open publication style offers information to patients that may be misleading or inaccurate.12 Our analysis supported the hypothesis that available video content for “ankle fracture” on YouTube is of low educational quality with low JAMA, PEMAT and Ankle Fracture Content Scores. To the authors' knowledge, no other studies have reviewed the educational content available on YouTube or other platforms regarding ankle fractures. Similar YouTube analyses of different pathologies have investigated the reliability and educational value of videos available and found similar results, but few assess the understandability and actionability of the information provided through a validated system like the PEMAT.2,4, 5, 6, 7, 8, 9, 10, 11, 12 While this study finds consistent results regarding the overall poor educational value of videos on YouTube, the analysis is further delineated by the role of the intended audience as well as discusses the recent implementation of YouTube designation and prioritization of health content shelves. This study serves to further expand awareness of educational gaps in current patient education as well as highlight the crucial factors needed when providing high-quality information.
A positive correlation was demonstrated between more recently published videos and PEMAT scores for understandability and actionability. This may be a result of the recent increased awareness of deficits in health literacy and the emphasis on increasing patient understanding seen in the literature.33 While this is encouraging because it shows improvement in some aspects of educational content on YouTube, this correlation was not seen between AFCS and the publication date of videos.
Additionally, the understandability (P = 0.037) and average AFCS (P = 0.001) were positively correlated to video length. This is expected as longer videos allow for more in-depth discussion and explanation of content. However, this does not suggest longer videos are necessarily better, as a study by Brame34 showed that the video length for optimal user engagement was less than 6 min. While creators should strive to publish highly educational videos, they should be wary of unnecessarily long videos as a majority of users will quickly become disengaged after 6 min, thus potentially losing educational value.34
Additionally, videos with more views were among the videos at the top of the page after our search. The study showed no association between popularity metrics such as the number of views, likes, subscribers, or views adjusted for time and any of our scoring systems, which highlights that more popular content creators are not providing higher quality healthcare information. This reinforces the notion that YouTube's algorithm for suggesting videos to users is not based on the educational value of the video, but rather on the platform's metric of video performance and preference based on user search history. Recently, this has been recognized by YouTube as a potential issue, and as part of an effort to offer credible health information, videos created by accredited institutions receive “designations” in the form of a blue text box. Videos meet this criterion through principles and definitions developed by a panel of experts convened by the National Academy of Medicine in the United States and reviewed by the American Public Health Association. A recently published paper by Kington et al.35 served as the source for YouTube's designation process. Some videos with designations are included in “content shelves” for health-related searches. These videos are given priority when searching related health topics and appear at the top of the page for users. While source credibility is an important factor when providing educational content, a video's credibility does not equate to its educational value.
When analyzing videos based on the intended audience of either patient or healthcare worker, we found that average PEMAT understandability and actionability scores were higher when creators specifically targeted patients (P = 0.049 and 0.001, respectively) while there was no difference in AFCS between groups. This shows that when creators are conscious of their audience, they are able to take the same amount of medical information and present it in a more absorbable format. While videos intended for healthcare professionals contained more detailed information, much of it was beyond the scope of basic patient education and thus did not result in higher scores in the AFCS. Future creators should be deliberate and intentional in their desired audience when making healthcare educational videos.
Additionally, JAMA reliability scores were found to be lower in videos created for patients (P = 0.004). This is understandable as the JAMA score assesses historically academic metrics of quality, which are prioritized by the medical community but not necessarily by patients. While patients may not place as high a value on publishers disclosing these metrics, creators should always provide appropriate credentials to validate their content across groups and allow for the vetting of information.
In the future, the authors propose that YouTube should work with trusted medical societies to ensure the most accurate and helpful information is recommended to users. In addition, medical societies should look to create or provide links to videos reviewed and endorsed by them on their education pages to allow patients an additional avenue of accessing health information. Finally, creators should not be discouraged from making their own videos due to small followings. We found no relationship between popularity metrics and the overall quality of videos. Creators should focus on using content from reliable sources, providing these sources for verification, and being intentional in their desired audiences.
6. Limitations & strengths
There were a number of limitations of this study. The initial video count was 554 when searching the key term, therefore some of the videos that were not included in the first 100 may be of higher quality. An analysis of 62 videos represents a relatively small population size, but is realistic when accounting for user video inclusion in search results.36 Videos available to patients on the platform are subject to change as new content is being created daily and video characteristics are constantly updated. Additionally, one video uploader, who was an independent physician, comprised 15 of the 62 videos, which may skew the statistical analysis. Nevertheless, these videos populate search results independently. To keep search criteria broad, the key term “ankle fracture” was used. A different search term may be used by patients. Finally, patients are likely exposed to videos based on previous searches on YouTube, as this is part of YouTube's algorithm of suggesting video content. This suggests the videos viewed by patients are likely different between users. Finally, while there are limitations in using a non-validated content score, the AFCS was devised from information for patients available on the websites of trusted orthopedic societies and endorsed by two fellowship-trained orthopedic trauma surgeons. The system allowed the authors to objectively quantify and compare the depth of educational content covered that was relevant to patients.
7. Conclusion
The information regarding ankle fractures available on YouTube for patient education is poor with no correlation between quality and popularity. This study illustrates the need for future collaboration between YouTube and trusted medical societies to provide patients with the highest quality information.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Institutional ethical committee approval
Institutional Review Board approval for this project was not required.
Author contributions
Tanner Stumpe: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing – original draft, supervision, project administration Austin Graf: conceptualization, methodology, formal analysis, investigation, data curation, writing – original draft Christopher Melton: formal analysis, investigation, data curation Aditya Devarakonda: methodology, software, validation, formal analysis, data curation, writing – original draft, Michael Steflik: conceptualization, methodology, Writing – review & editing James Blair: conceptualization, methodology, writing – review & editing, project administration Stephen Parada: conceptualization, methodology, writing – review & editing, project administration Jana Davis: conceptualization, methodology, validation, writing – review & editing, supervision, project administration
Conflict of interest
None
Acknowledgements
None
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