Abstract
Tracheostomy is a surgical procedure to create an opening in the neck to insert a tube into the trachea to help a person breathe. Proper cleaning and care of the tracheostomy tube is vital to prevent infections. Patients frequently use the internet to learn about tracheostomy tube care before and after the procedure. To assess the readability and reliability of 50 websites providing patient information on tracheostomy tube care. The websites were evaluated using the Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Gunning Fog score (GF), DISCERN score, and JAMA benchmark criteria. The mean FKGL was 6.2, FRES was 61.9 and GF score was 7.2, indicating moderate overall readability. The reliability scores were average, too, with mean DISCERN and JAMA scores being 3.2 and 1.8, respectively. There is immense scope for improvement in the readability and reliability of online resources on tracheostomy tube care for patients to comprehend the information quickly.
Keywords: Tracheostomy, Trachea, Comprehension, Internet, Digital health
Introduction
Tracheostomy is a surgical procedure to create an opening through the neck into the trachea [1]. It involves placing a tube into this opening, called a tracheostomy tube, to help the person breathe. Tracheostomy is one of the most common operations carried out on severely ill patients requiring protracted mechanical ventilation. More than 100,000 tracheostomies are estimated to be performed annually in the United States [2]. Upper airway blockage, the requirement for airway protection in patients with neurological impairment, severe obstructive sleep apnea not responding to conservative treatment, and as an adjuvant in patients undergoing major head and neck surgery are some typical indications for tracheostomy [3].
Polyvinyl chloride (PVC), silicon, and metal are the materials used to make tracheostomy tubes. The most commonly used are disposable PVC tracheostomy tubes, which must be periodically changed or cleaned to prevent infection and blockage [4]. Maintaining the patency of the tracheostomy tube is vital for adequate oxygenation and ventilation. Tracheostomy tube dysfunction can occur due to thick secretions, mucus plugging, tube dislodgement, or kinking [5]. To prevent complications such as infection, bleeding, pneumonia, subglottic stenosis, and tracheo-innominate fistula, meticulous cleaning and maintenance of the tracheostomy tube and stoma site is crucial [6].
Patients and caregivers must be educated regarding appropriate techniques for tracheostomy tube care before and after the procedure. This covers directions for suctioning, changing clothes, cleaning the inner cannula, and changing the tracheostomy ties [7]. Increased internet availability worldwide has resulted in patients frequently using online resources to learn about various medical ailments and their management. It allows them to conveniently find information at their own pace when making healthcare decisions.
However, online information must be easily understandable, accurate, unbiased, and consistent to empower patients [8]. The usefulness of web-based patient education materials is highly influenced by their health literacy level, readability, reliability, and quality [9]. Patients who obtain their information from subpar online sources are more likely to have poor health outcomes [10].
Objective assessment of the readability and reliability of online health information can help identify areas for improvement. Readability refers to the ease with which written material can be read and understood. It depends on word length, sentence structure, grammar, and writing style [11]. Reliability evaluates the presented information’s trustworthiness, correctness, and consistency [12].
Various validated tools have been developed to appraise the readability and reliability of health websites, such as the Flesch Reading Ease Score, Flesch-Kincaid Grade Level, Gunning Fog Index, DISCERN, and JAMA benchmark criteria [13–15]. However, there needs to be more literature on analysing web-based resources on tracheostomy tube care using such assessment tools. This study evaluates the readability and reliability of online patient information regarding tracheostomy tube care.
Methodology
A cross-sectional study was conducted evaluating patient information websites on tracheostomy tube care. The search engine Google was used to find relevant websites. Google occupies over 90% of the global search engine market share [16]. The search term used was “tracheostomy tube care.” Two specialists were involved in the study to ensure a precise and comprehensive evaluation process - one specialized in Otorhinolaryngology and the other in Community Medicine. They meticulously analysed the first 50 results individually, considering all the potential factors that could influence the scoring. After a thorough review, the specialists discussed and reached a final consensus on the scoring, ensuring the most accurate and reliable results.
The inclusion criteria were:
1) Websites providing information on cleaning and caring for a tracheostomy tube.
2) Websites having tracheostomy tube care as a primary focus.
3) Websites accessible without registration or paid subscription.
The exclusion criteria were:
1) Websites not in the English language.
2) Video-based resources without transcribed text.
3) Social media links like Facebook, Twitter, and LinkedIn.
4) Shopping websites mainly advertising products.
5) Websites requiring subscription or payment to access content.
6) Websites with technical errors restricting access.
7) Sponsored links.
After applying these criteria, 41 websites were selected by consensus between the two reviewers for final analysis. The chosen websites were categorized based on the source of information as done in several studies in the past [14, 17]:
1) Academic sources which includes articles published in journals and scientific literature.
2) Discussion websites which are written in a discussion like format by experts in the domain and updated regularly.
3) Hospital generated sources which includes information provided by hospitals and healthcare providers.
The reliability and readability of the chosen websites were evaluated using the JAMA benchmark criteria, DISCERN score, Flesch-Kincaid Grade Level (FKG), Flesch Reading Ease Score (FRE) and Gunning Fog score (GF). These tools have been extensively utilized in prior studies to assess the quality of online health information [14, 17].
Assessment of Readability
First, we used the FRE, FKG and GF tools to determine the readability scores for each individual site in the top 50 search results. Higher values indicate simpler readability when calculating the FRE score, while the FKG score determines the grade level needed to comprehend the content. One-way ANOVA was the statistical test that was utilized.
Readability was evaluated using a readability calculator tool available online [18]. For FKG, the acceptable score was set at ≤ 6th grade level. For FRE, the satisfactory score was fixed at ≥ 80. These cutoffs were based on similar studies conducted in the past [13, 19]. The minimal education level necessary to comprehend the written material is determined by FKG. Lower values indicate more straightforward readability. FRE rates reading ease on a scale of 0-100. Higher scores mean easier reading comprehension [14, 19].
Assessment of Reliability
Using the JAMA criteria and the DISCERN tool, we evaluated the reliability of the data in the selected sources. The JAMA criteria assess whether specific crucial characteristics including authorship, references and declaration of conflicts of interest are present. On the other hand, the DISCERN tool explicitly evaluates the quality and reliability of health information.
Reliability was appraised using the DISCERN instrument and JAMA benchmark criteria. The 16-question DISCERN questionnaire assesses the reliability and accuracy of health information about available treatments. Each question is scored between 1 and 5, with higher scores indicating higher quality. The overall DISCERN score ranges from 16 to 80 [12, 20].
The JAMA benchmarks assess websites’ authorship, attribution, disclosure, and currency. If adequately met, one point is given for each parameter, giving a total score ranging from 0 to 4 [15]. A JAMA score > 2 was considered acceptable, similar to previous studies [21].
Statistical Analysis
With the help of IBM SPSS version 26, statistical analysis was carried out. For the scores of the FKG, FRE, GF, DISCERN, and JAMA, descriptive statistics were computed. The Shapiro-Wilk test was used to determine whether the data distribution was normal. For parametric data between various website categories, one-way ANOVA was used. It was used to test non-parametric data using the Kruskal-Wallis H test. Statistical significance was defined as a p-value of 0.05.
Results
The hospital and discussion categories accounted for the most website information, with 19 (46%) and 14 (34%) respectively while the remaining 8 websites (20%) were from academic sources. The readability analysis revealed mean FRE, FKG and GF scores of 61.9, 6.2 and 7.2 with standard deviations of 17.1, 2.6 and 3.2 respectively and the reliability analysis revealed mean Discern and JAMA scores of 3.2 and 1.8 with standard deviations of 0.7 and 1.1 respectively. The mean scores for websites belonging to each category are given in Table 1.
Table 1.
Mean scores for various categories depicting the website quality
| Sl No | Categories | Mean scores (SD) | ||||
|---|---|---|---|---|---|---|
| FRE | FKG | GF | DISCERN | JAMA | ||
| 1 | Academic sources (n = 8) | 56.8 (18.5) | 7.4 (2.9) | 9.2 (3.4) | 3.6 (0.7) | 2.8 (0.6) |
| 2 | Discussion (n = 14) | 69.3 (17.2) | 5.1 (2.7) | 6.1 (3.2) | 3.2 (0.8) | 1.8 (1.1) |
| 3 | Hospital generated (n = 19) | 58.5 (15.4) | 6.5 (2.3) | 7.1 (2.8) | 3.0 (0.7) | 1.5 (1.1) |
SD = Standard Deviation, FRE = Flesch reading ease score, FKG = Flesch-Kincaid Grade level, GF = Gunning Fog score
On assessing readability, there was no statistically significant difference detected in FRE scores between the categories (p-value = 0.129). There was no statistically significant difference detected in FKG and GF scores between the categories (p-value = 0.052 and p-value = 0.081 respectively). The mean FRE, median FKG and GF scores for the various categories are given in Table 2 with p values of 0.13, 0.05 and 0.08 respectively. The readability scores vary across the sources, suggesting a range of comprehension levels required for understanding the tracheostomy tube care patient information found on Google.
Table 2.
Mean FRE scores, median FKG scores and median gunning scores
| Sl No | Categories | Mean FRE scores (SD) p = 0.13 |
Median FKG scores (IQR) p = 0.05 |
Median Gunning scores (IQR) P = 0.08 |
|---|---|---|---|---|
| 1 | Academic sources (n = 8) | 56.8 (18.5) | 8.4 (6.3, 9.1) | 10.0 (7.4, 11.8) |
| 2 | Discussion (n = 14) | 69.3 (17.2) | 5.5 (3.1, 6.8) | 6.4 (2.8, 9.1) |
| 3 | Hospital generated (n = 19) | 58.5 (15.4) | 7.2 (5.4, 8.3) | 6.5 (5.4, 9.3) |
SD = Standard Deviation, FRE = Flesch reading ease score, FKG = Flesch-Kincaid Grade level, IQR = InterQuartile Range
Reliability assessment showed that there was no statistical significance detected in the Discern score between the groups (p = 0.244) while there was a statistically significant difference detected in the JAMA score between the groups (p = 0.009). The median DISCERN and JAMA scores for the analysed websites are given in Table 3 with p values of 0.24 and 0.009 respectively.
Table 3.
Median DISCERN scores and median JAMA scores
| Sl No | Categories | Median Discern scores (IQR) p = 0.24 |
Median JAMA scores (IQR) p = 0.009 |
|---|---|---|---|
| 1 | Academic sources (n = 8) | 3.5 (3.0, 4.0) | 3.0 (2.5, 3.0) |
| 2 | Discussion (n = 14) | 3.0 (3.0, 4.0) | 1.5 (1.0, 2.0) |
| 3 | Hospital generated (n = 19) | 3.0 (3.0, 4.0) | 1.0 (1.0, 2.0) |
IQR = InterQuartile Range
Post-hoc analysis by the Dunn test revealed that there was a statistically significant difference between the scores from Academic sources and discussion (p-value = 0.010) and between the scores from Academic sources and hospital-generated sources for tracheostomy (p-value = 0.001).
A total of 41 websites were analysed for information on tracheostomy tube care after excluding 2 inaccessible websites, 5 duplicates, 1 sponsored website and a veterinary tracheostomy care website. The categories identified were academic (20%), hospital generated (34%) and discussion (46%).
The mean FKGL score was 6.2 ± 2.6, depicting the need for reading skills equivalent to 6th grade education for comprehension. Ten websites (24.3%) had FKGL score < 5th grade level. On the other hand, the average FRES was 61.9 ± 17.1, signifying difficult readability. Merely six websites (14.6%) met the target FRES score ≥ 80.
The reliability of the websites based on DISCERN and JAMA scores was moderate. The mean DISCERN score was 3.2 ± 0.7. The highest DISCERN score was 5, seen on two websites. The average JAMA score was 1.8 ± 1.1. Twelve websites (29.2%) met the minimum acceptable JAMA score > 2. The highest individual JAMA score was 4, seen on four websites.
Discussion
Our study found that the overall readability and reliability of online patient education materials on tracheostomy tube care were modest based on recommended criteria. The mean FKGL grade level was 6.2, indicating the need for reading proficiency higher than 6th grade to understand the content properly. This is in accordance with the National Institutes of Health and American Medical Association’s target of 3rd to 6th-grade reading level for patient resources, while the average FRES score was 61.9, lower than the satisfactory target of ≥ 80, signifying difficult readability [22, 23]. The discrepancy between the FKGL and FRES scores for the same set of websites can be explained by the fact that both these scoring systems take into account different methodologies and underlying principles such as average sentence length, number of words per sentence(FKGL) and vocabulary richness, sentence length variation, grammatical complexity(FRES). In this case, the high FKGL score of 6.2 suggests that the websites use relatively simple sentences in terms of length and number of words per sentence. However, the lower FRES score of 61.9 indicates that the websites may contain complex terminology, convoluted sentence structure or a lack of clear organisation making them more challenging to read despite having an acceptable FKGL score.
These results highlight that most websites contain complex text requiring high school or college-level education to comprehend tracheostomy tube care instructions. However, health literacy studies reveal that nearly half of the adult population in the United States possesses only basic or below basic literacy skills [24]. About a quarter of U.S. adults have rudimentary reading and numerical skills [25]. Online information written in complex language can impair understanding and retention, especially among poor readers. Limited health literacy is associated with reduced medication compliance, hospitalizations, increased mortality, and poorer health outcomes [26]. Presenting health information in plain language using short sentences, everyday words, and illustrations improves accessibility for patients with lower literacy [27]. Efforts must be taken to improve the readability of tracheostomy tube care education materials to the 6th-grade level or lower. Also, previous studies focused only on readability or used just DISCERN scoring along with readability scores to evaluate websites on tracheostomy tube care which put forth the need for conducting this study, hence providing a more comprehensive assessment of the same [28, 29].
The reliability of online information on caring for a tracheostomy tube was average in our assessment. The average DISCERN score was just 3.2 out of a maximum of 5. The mean JAMA score was 1.8 against an acceptable score of > 2. Only 29% of websites displayed adequate authorship, references, currency, and disclosure per JAMA benchmarks. This demonstrates that most online resources lack key indicators of content reliability like author credentials, information references, dates, ownership disclosure, and potential conflicts of interest. Unreliable information can lead to patient harm by promoting inappropriate techniques for tracheostomy care and complications. Identifying trustworthy resources is challenging for patients without medical training.
Patients should be guided toward academically affiliated websites or resources endorsed by reputed health organizations for education on tracheostomy care. Examples of recommended websites as per the readability and reliability recommendations as mentioned in this study are given in Table 4. Content creators must adhere to standardized quality criteria and health literacy principles when designing online tracheostomy tube care materials for public use [30].
Table 4.
Examples of recommended websites for Tracheostomy Tube Care Information
| Sl No | Organization | Website |
|---|---|---|
| 1 | BC campus Open Publishing | https://opentextbc.ca/clinicalskills/chapter/10-6-tracheostomies/ |
| 2 | National Library of Medicine | https://www.ncbi.nlm.nih.gov/books/NBK555919/ |
| 3 | National Tracheostomy Safety Project | https://www.ficm.ac.uk/sites/ficm/files/documents/2021-11/2020-08%20Tracheostomy_care_guidance_Final.pdf |
| 4 | Royal Children’s Hospital Melbourne | https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/tracheostomy_management/ |
| 5 | Johns Hopkins Medicine | https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma |
Limitations
Our study does have limitations. We exclusively used Google as our search engine. Different websites may come up in other search engines. With only 50 websites analysed, the sample size was limited. The analysis of additional websites may impact the results of the quality assessment. There may be language bias present because only English-language websites were considered. The tools used for readability and reliability also have inherent limitations. However, this study offers valuable insights regarding the inadequate quality of online tracheostomy tube care instruction materials.
Conclusions
Online tools are essential for patient education and medical decision-making in an era where health technology is on the rise. Most websites that provide advice on tracheostomy tube care need to be more readable. Based on approved assessment methodologies, the reliability of online content is also modest. Patients with low literacy would require assistance interpreting the dense text on most web pages.
The educational materials on the internet for tracheostomy care have a great deal of room for quality enhancement. To improve readability, guidelines for streamlined health communication must be followed. Academic institutions and professional organizations should spearhead the development of patient-focused online tracheostomy care information. Clinicians must also direct patients to trustworthy internet sources rather than just disregarding information found online. To establish unequivocal guidelines for producing comprehensible and dependable online patient education resources across healthcare domains, a significant number of high-quality studies must be conducted.
Author Contributions
VMS, AKS, and AR were the major contributors to writing the manuscript. RR and KR participated in editing and data interpretation along with VMS. All authors have approved the manuscript.
Funding
There was no funding required to take up the study.
Data Availability
The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics Approval and Consent to Participate
The study didn’t require ethics approval as it is analyzing data freely available in internet.
Competing Interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.