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. 2021;41(1):61–67.

Health Literacy in Clubfoot: A Quantitative Assessment of the Readability, Understandability and Actionability of Online Patient Education Material

Mary Kate Skalitzky 1, Trevor R Gulbrandsen 2,✉, William Lorentzen 1, Burke Gao 2, Alan G Shamrock 2, Stuart L Weinstein 2, Jose A Morcuende 2
PMCID: PMC8259170  PMID: 34552405

Abstract

Background:

Parents often access online resources to educate themselves when a child is diagnosed with clubfoot and/ or prior to treatment initiation. In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding clubfoot would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). Additionally, it was hypothesized that the outcomes measured would not correlate with the order of listed search results.

Methods:

Patient education materials were identified utilizing two independent online searches (Google.com) of the term “Clubfoot”. From the top 50 search results, websites were included if directed at educating patients and their families regarding clubfoot. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to clubfoot were excluded. The readability of included resources was quantified using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG) Grade, Coleman-Liau Index (CLI), Gunning-Fog Index( GFI) and Automated Reading Index (ARI). The Patient Education Materials Assessment Tool (PEMAT) was used to assess actionability and understandability using a 0-100% scale for both measures of interest.

Results:

Of the 55 unique websites, 37 websites (65.2%) met inclusion criteria. The mean FKGL was 9.2 (+/- 2.1) with only three websites (7.32%) having a reading level ≤6. Mean understandability and actionability scores were 67.2±12.6 and 25.4±25.2, respectively. Thirteen (35%) websites met the understandability threshold of ≥70% but no websites met the actionability criteria. No readability statistics were statistically associated with Google™ search rank (p=0.07). There was no association between readability (p=0.94) nor actionability (p=0.18) scores and Google™ rank. However, understandability scores did correlate with Google™ rank (p=0.02).

Conclusion:

Overall, online clubfoot educational materials scored poorly with respect to readability, understandability, and actionability. There is an association with Google™ search rank for understandability of clubfoot materials. However, readability and actionability are not significantly associated with search rank. In the era of shared decision-making, efforts should be made by medical professionals to improve the readability, understandability, and actionability of online resources in order to optimize parent understanding and facilitate effective outcomes.

Level of Evidence:

Keywords: clubfoot, health literacy, readability

Introduction

Clubfoot, also known as congenital talipes equinovarus, is a relatively common congenital abnormality with a diagnosis being made in approximately 1 in 1,000 live births.1 Clubfoot occurs at a 2:1 ratio in male to female infants and is bilateral in approximately 50% of cases.2 The deformity consists of a combination of four specific foot abnormalities: forefoot adduction, midfoot cavus, hindfoot varus, and ankle equinus. The diagnosis of clubfoot can be distressing and overwhelming for parents, with previous studies reporting extreme stress at the moment of diagnosis related to the explanation of treatments, information about prognosis, and the lack of concrete details surrounding the condition.3,4 This emphasizes the need for accessible educational resources to help reduce parental anxiety associated with clubfoot deformity.4

Currently, the most widely accepted treatment for clubfoot is the Ponseti method.5 While this is a non-invasive procedure that consists of foot manipulation through sequential casting and often, percutaneous tenotomy, the Ponseti method is not simple and requires multiple clinic visits.3,4,6,7 Once the correction has been achieved, long term success is attained through the utilization of an abduction brace.6,8 However, the abduction brace requires significant commitment of the family and should be worn 23-24 hours each day for the first two to three months followed by 10-12 hours at night the subsequent three to four years.9 While the Ponseti method is successful at treating 95-97% of clubfoot cases, strict understanding and adherence to making follow up visits and correctly wearing the brace is essential for long term success. It has been previously reported that recurrence happens in 20-41% of cases treated with the Ponseti method, with brace non-compliance being the leading factor associated with relapse of the deformity.6,8-12

The quality of online educational materials regarding clubfoot is currently poorly understood. Previous orthopaedic and surgical literature have analyzed the readability of patient education materials to assess the reading grade level of materials.13-15 Readability measures, however, are based on syntax and are limited in the assessment of a resource’s ability to convey information such that readers can process and act on key messages. This limitation has been recognized and the Patient Educational Materials Assessment Tool (PEMAT) has become increasingly used to study patient education materials in surgical fields to evaluate the understandability (defined as the ability of readers to “process and explain key messages”) and actionability (defined as the ability of readers to “identify what they can do based on the information presented”) of educational materials.13,14,16-18 There is a paucity of literature evaluating whether online clubfoot patient resources are presented so that readers can efficiently understand the information and/ or identify available actions.19 The purpose of the current study was to utilize PEMAT and validated readability algorithms to quantify readability, understandability, and actionability of online clubfoot patient education resources.16,18,20

Methods

Collection of Patient Education Material

Using the trends analysis (trends.google.com21), the most common searched term “clubfoot” was determined for article identification. (Figure 1).

Figure 1.

Figure 1.

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Google Search Trends. Value ranked 0-100 based on GoogleTM algorithm. A value of 100 indicates peak popularity of the term. Studies demonstrate that “clubfoot” was 21.8 times more likely to be searched by the general public compared to “congenital talipes equinovarus.”

For internal validity, two Google™ searches were independently performed by two authors on 2/26/2020 (TRG and BG). The Google™ search engine was utilized because Google™ searches comprised 88-92% of online search market share at the time of this study.22,23 A target of the first 50 websites from each search were chosen for two reasons. First, analyses of click-through-rates suggest that approximately 70% or more of “clicks” come from the first 10 search results.24-26 Second, previous PEMAT studies have ranged from targeting the first 10 to 50 websites, so our search was made to be consistent with these prior analyses.17,27,28 The search results from both searches were identified and duplicates were removed. Exclusion criteria included: news articles; personal experiences; primarily audiovisual-based materials; written for reference by health care professionals; peer-review journal studies; focused primarily on the advertisement of a product or service without patient education; articles without patient-oriented tone; or unrelated to clubfoot or clubfoot related treatment. Audiovisual-based websites were excluded because these could not undergo readability analysis.

Content analysis

All included websites underwent qualitative review of their content including the following categories: discussion of operative management; discussion of nonoperative management; advertisement of a physician or group who offered the treatments described; discussion of general background information (anatomy, pathology, prognosis, and/ or risk factors); discussion of clubfoot prevention; discussion of clubfoot diagnosis and/ or preoperative management; discussion of postoperative management; and discussion of complications or risks of treatment. Online resources were categorized as including advertisements of a medical provider if it stated that a specific institution or group provided the treatments described on the website or a treatment related to clubfoot pathology within the main text of the educational material.

Statistical analysis

Readability

The following objective algorithms were utilized to determine the linguistic readability of the content: Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG) Grade, Coleman-Liau Index (CLI), Gunning-Fog Index( GFI) and Automated Reading Index (ARI). (Figure 2). These five algorithms have been reliably used to utilized in previous readability studies and were obtained using open-source readability software (https://www.webfx.com/tools/read-able/check.php).14-17,19,27 Text unrelated to patient education including copyright, references, and links outside of main text were excluded from readability analysis.

Figure 2.

Figure 2.

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Mean Readability scores. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend health information to be written at a 6th grade or lower reading level (orange line). All readability average scores exceed this recommended reading level.

Understandability and Actionability analyses

The PEMAT is a validated and reliable instrument utilized to assess the understandability and actionability of printed patient education materials. PEMAT analysis yields separate understandability and actionability scores. Scores are expressed as a percentage (0-100%) for each evaluated resource. A higher graded score represents a better level of understandability or actionability. A PEMAT score of 70% is considered the minimal standard for adequate results. Two reviewers (WL and MKS) individually conducted understandability and actionability analyses using the PEMAT-P form.20,29 Interrater reliability was calculated using Cohen’s Kappa. The magnitude of the kappa statistic was interpreted by the criteria established by Landis et al.,30 and was utilized by the PEMAT developers to measure the reliability of PEMAT scoring.18,31

Additional statistical analysis

Google™ search engine ranking was averaged from two independently conducted searches. Spearman’s rho was used to assess the correlation between variables in this study including search ranking, readability, understandability, and actionability. Statistical significance was defined as p<0.05.

Results

Following the two independent searches and the removal of duplicate websites, a total of 55 unique online materials were identified. Thirty-seven (67.3%) websites met inclusion criteria. Six websites were excluded due to being written for reference by health care professionals, four peer-review journal studies, four audiovisual-based materials; and two personal experiences. Additionally, four websites were excluded as not related to patient-and-family-directed medical education.

Of the 37 included online educational resources, 93% of websites included background information (anatomy, pathology, prognostic factors). 88% of websites described non-operative management of clubfoot, and 67% of websites that discussed operative management. The majority of websites (81%) discussed the workup and diagnosis of clubfoot, while only 45% discussed the postoperative course. Only 30% of websites included risks and complications of clubfoot management. Of the 37 included websites, around half (49%) included an advertisement for a physician or group who provided the described management.

Readability

The mean FRES was 57.5 (SD: 11.2) (Figure 2). Across all readability scores reporting grade-levels, average grade-levels ranged from 5.5 to 13.4. The mean FKGL, SMOG, CLI, GFI, and ARI were 9.24 (SD: 2.1), 8.69 (SD: 1.7), 12.29 (SD: 1.9), 11.57 (SD: 2.4), and 9.11 (SD: 2.3), respectively. Three (8.1%) websites scored ≤ 6th grade reading level. (Figure 2)

Understandability and Actionability

Mean understandability and actionability scores were 67.2% (SD: 12.6) and 25.4% (SD: 25.2), respectively (Figure 3). Overall, 13 (n=35%) met the understandability threshold of 70%. However, no websites met the threshold of actionability (≥70%). The most frequently missed understandability criteria included a lack of summaries and a lack of clear titles. Importantly, the included online resources were not written in common, everyday language. In regard to actionability criteria, the included resources frequently did not include at least one, specific action to be taken by the reader. Furthermore, if an action was provided, it was not broken down into manageable, explicit steps. Another commonly missed actionability criteria was a lack of visual aids to help facilitate the described actions.

Figure 3.

Figure 3.

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Acceptable understandability and actionability scores are ≥70% as established by the PEMAT tool. Only 13 (35%) websites met the 70% understandability threshold, while no (0%) websites scored above the 70% actionability threshold.

Search Rank

There was no association between readability (p=0.94) nor actionability (p=0.18) scores and Google™ rank. However, understandability scores did correlate with Google™ rank (p=0.02).

Discussion

This study investigated the readability, understandability, and actionability of online resources directed toward patients and family involved with clubfoot treatment. Our results Demonstrated that these commonly utilized resources scored poorly in regard to all variables that were measured.

Access of the internet is common in the United States. As of 2018, 90% of US adults had access to the internet,32 with at least 1 in 3 using the internet to diagnose or learn more about various health conditions.33 Amid increasing access and utilization of the internet, online resources play an increasing role in patient education. Interestingly, the internet has played a major role in the advancement of clubfoot education through available online patient resources. Morcuende et al. demonstrated the importance of internet resources in the decision making and support of patients and family members involved in the diagnosis and treatment of clubfoot. Through a retrospective review of websites, web based chat groups, and virtual hospital webpages on clubfoot, they discovered an average of 27,334 website visits (hits) per month and information requests from all 50 states as well as 72 countries.34

As access to internet resources continues to expand, there is an increased need to emphasize the importance of well-designed and patient centered online material to facilitate patient education and decision-making.35 The AMA and NIH currently recommend that public health literature be written at the 6th grade reading level or lower, in order to be understood by the average adult.36,37 Our readability analysis demonstrated that the mean grade level was well above these recommendations, at 9.2. This is troubling because it is estimated that 80-90 million Americans have limited health literacy.38-40 Additionally, parental education for those impacted by clubfoot has been demonstrated to increase parental understanding and compliance with bracing,41 a critical aspect of long-term success with the Ponseti method.5,8-10,41 Equally, studies have demonstrated that lower parental education level is associated with higher rates of relapse.9,10,42 A study by Dobbs et al. found that the risk of a clubfoot relapse is increased ten-fold when the parents have an education level of high school degree or less, as compared to parents who achieved education beyond high school.9 Interestingly, in the study by Dobbs et al., a subset of patients were referred to the authors’ care via clubfoot internet resources with the specific goal of pursuing the Ponseti method. All parents in this specific subset cohort reported full compliance with the bracing and none of the children in this cohort experienced a recurrence. While all parents in this group obtained higher education and may be more motivated to achieve success with the Ponseti method, this finding still does highlight the potential role of online education materials in the bigger context of education, compliance, and recurrence prevention for clubfoot.

In order to improve readability scores, materials should use fewer words per sentence and fewer syllables per word. These factors are the driving variables behind the readability algorithms (Figure 2). Although this may be difficult in the medical field, due to the complexity of medical vocabulary, every effort should be made to utilize common, non-medical language. It is also important to utilize short sentences toto avoid complex sentence structures that may exacerbate the level of difficulty.

However, readability is only a small factor in assessing the usefulness of patient educational resources as the effectiveness of educational material depends on more than just vocabulary, syllable count, and sentence structure. While the access to resources is valuable, producing patient education materials that the average adult in the United States can understand is crucial. Unfortunately, similar to other surgical subspecialties,16-19,27 the clubfoot patient education materials scored poorly on actionability and understandability. These previous studies have looked at the importance of understandability and actionability for educational efficacy. One such study was completed by Paulsen-Miller et al., who investigated the educational needs of parents of children being treated for clubfoot deformity.42 Of the thirty parents who were interviewed, approximately two-thirds reported initial confusion about the actual Ponseti method itself, despite utilizing their available resources. When asked about compliance with the treatment regimen, parents provided suggestions for ways that providers could enhance success. Parents requested that health care providers provide education on the treatment and risk of relapse, including access to educational materials online with the utilization of visual aids and videos. This demonstrates the need for leaders in the field to tailor website curriculum to be of maximum efficiency to patients and the general public in relation to clubfoot and its associated treatment.

Understandability and actionability are crucial components of effective education. In order to improve understandability and actionability for their audiences, authors of online educational materials should incorporate the components of the PEMAT criteria . For example, the authors should avoid medical vocabulary whenever possible and if the term is necessary, authors should explicitly define included medical terms. Authors should also consider limiting distracting information, simplifying presented data, and utilize the active tense. Visual aids should be non-cluttered, reinforce the written information, and contain informative, but clear captions. One of the most crucial components is to include actions for the reader within the resource. Furthermore, authors should break the action into “manageable, explicit steps” to facilitate action. Other important components of actionability include providing a tangible tool (such as a checklist) or providing a visual aid to accompany the explanation of the intended action. Overall, the PEMAT tool provides authors with numerous criteria that can be incorporated to improve patient education resources.

Limitations and future research

This study has several limitations. First, this study utilized the first 50 search results from a public online search engine. These top 50 results could be different at various times and search locations. In order to mitigate some of this variability, the authors cleared all cookies and cache prior to the search. Another limitation is the subjectivity of the PEMAT grading and implicit bias could not be fully eliminated. To limit this bias and subjectivity, two authors independently performed the grading, which demonstrated agreement with good inter-rater reliability (kappa = 0.52 +/- 0.04), consistent with prior studies.20

Prior to performing both Google™ searches, internet browsing histories and stored cookies were erased.

While previous studies have investigated the impact of education and compliance on clubfoot recurrence rates, we could find no literature that investigated the cost effectiveness of clubfoot education. Future studies looking into the effectiveness and cost benefits of clubfoot education are needed. Furthermore, future research should be conducted to investigate the accuracy of educational materials, which neither the readability scoring nor PEMAT scoring takes into account.

Conclusion

Overall, the online clubfoot patient educational materials scored poorly in readability, understandability, and actionability measures. There is an association with Google™ search rank for understandability of clubfoot materials. However, readability and actionability are not significantly associated with search rank. In the era of shared decision-making and readily available information, efforts should be made by medical professionals to improve the readability, understandability, and actionability of online patient resources in order to optimize parent understanding and facilitate effective decision-making.

References

  • 1.Balasankar G, Luximon A, Al-Jumaily A. Current conservative management and classification of club foot: A review. J Pediatr Rehabil Med. 2016;9(4):257–264. doi: 10.3233/PRM-160394. [DOI] [PubMed] [Google Scholar]
  • 2.Faldini C, Fenga D, Sanzarello I, Nanni M, Traina F, Rosa MAA. Prenatal Diagnosis of Clubfoot: A Review of Current Available Methodology. Folia Med (Plovdiv) 2017;59(3):247–253. doi: 10.1515/folmed-2017-0030. [DOI] [PubMed] [Google Scholar]
  • 3.Nogueira MP, Farcetta M, Fox MH, Miller KK, Pereira TS, Morcuende JA. Treatment of congenital clubfoot with the Ponseti method: the parents’ perspective. Journal of Pediatric Orthopaedics B. 2013;22(6):583–588. doi: 10.1097/BPB.0b013e328364eb3a. [DOI] [PubMed] [Google Scholar]
  • 4.Coppola G, Costantini A, Tedone R, et al. The Impact of the Baby’s Congenital Malformation on the Mother’s Psychological Well-Being: An Empirical Contribution on the Clubfoot. Journal of Pediatric Orthopaedics. 2012;32(5):521–526. doi: 10.1097/BPO.0b013e318257640c. [DOI] [PubMed] [Google Scholar]
  • 5.Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J. 2002;22:55–56. [PMC free article] [PubMed] [Google Scholar]
  • 6.Gibbons PGK. Update on Clubfoot. Journal of Paediatrics and Child Health. 2013;49(9):E434–437. doi: 10.1111/jpc.12167. [DOI] [PubMed] [Google Scholar]
  • 7.Zionts LE, Sangiorgio SN, Ebramzadeh E, Morcuende JA. The Current Management of Idiopathic Clubfoot Revisited: Results of a Survey of the POSNA Membership. Journal of Pediatric Orthopaedics. 2012;32(5) doi: 10.1097/BPO.0b013e318259ff79. [DOI] [PubMed] [Google Scholar]
  • 8.Dobbs MB, Gurnett CA. Update on clubfoot: etiology and treatment. Clinical orthopaedics and related research. 2009;467(5):1146–1153. doi: 10.1007/s11999-009-0734-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Dobbs M, Rudzki JR, Purcell D, Walton TIM, Porter K, Gurnett C. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. The Journal of Bone and Joint Surgery. 2004;86A:22–27. doi: 10.2106/00004623-200401000-00005. [DOI] [PubMed] [Google Scholar]
  • 10.Azarpira MR, Emami MJ, Vosoughi AR, Rahbari K. Factors associated with recurrence of clubfoot treated by the Ponseti method. World J Clin Cases. 2016;4(10):318–322. doi: 10.12998/wjcc.v4.i10.318. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Švehlík M, Floh U, Steinwender G, Sperl M, Novak M, Kraus T. Ponseti method is superior to surgical treatment in clubfoot – Long-term, randomized, prospective trial. Gait & Posture. 2017;58:346–351. doi: 10.1016/j.gaitpost.2017.08.010. [DOI] [PubMed] [Google Scholar]
  • 12.Brand RA. Clubfoot: Etiology and treatment. Clinical Orthopaedics and Related Research. 2009;467(5):1121–1123. doi: 10.1007/s11999-009-0719-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Wongworawat MD. Editor’s Spotlight/Take 5: Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate? Clin Orthop Relat Res. 2017;475(8):1932–1935. doi: 10.1007/s11999-017-5383-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Roberts H, Zhang D, Dyer GS. The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008. J Bone Joint Surg Am. 2016;98(17):e70. doi: 10.2106/JBJS.15.00658. [DOI] [PubMed] [Google Scholar]
  • 15.Wong K, Levi JR. Readability Trends of Online Information by the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Otolaryngol Head Neck Surg. 2017;156(1):96–102. doi: 10.1177/0194599816674711. [DOI] [PubMed] [Google Scholar]
  • 16.Wong K, Gilad A, Cohen MB, Kirke DN, Jalisi SM. Patient education materials assessment tool for laryngectomy health information. Head Neck. 2017;39(11):2256–2263. doi: 10.1002/hed.24891. [DOI] [PubMed] [Google Scholar]
  • 17.Balakrishnan V, Chandy Z, Verma SP. Are Online Zenker’s Diverticulum Materials Readable and Understandable? Otolaryngol Head Neck Surg. 2016;155(5):758–763. doi: 10.1177/0194599816655302. [DOI] [PubMed] [Google Scholar]
  • 18.Lopez Ramos C, Williams JE, Bababekov YJ, Chang DC, Carter BS, Jones PS. Assessing the Understandability and Actionability of Online Neurosurgical Patient Education Materials. World Neurosurg. 2019;130:e588–e597. doi: 10.1016/j.wneu.2019.06.166. [DOI] [PubMed] [Google Scholar]
  • 19.Maciolek KA, Jarrard DF, Abel EJ, Best SL. Systematic Assessment Reveals Lack of Understandability for Prostate Biopsy Online Patient Education Materials. Urology. 2017;109:101–106. doi: 10.1016/j.urology.2017.07.037. [DOI] [PubMed] [Google Scholar]
  • 20.Shoemaker SJ, Wolf MS, Brach C. Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Couns. 2014;96(3):395–403. doi: 10.1016/j.pec.2014.05.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Google LLC. Google Trends. https://trends.google.com/. Published 2019 Accessed.
  • 22.Statista. Worldwide desktop market share of leading search engines from January 2010 to July 2019. https://www.statista.com/statistics/216573/world-wide-market-share-of-search-engines/. Published 2019. Accessed 11/16/19.
  • 23.Statscounter GlobalStats. Search Engine Market Share Worldwide - October 2019. In: 2019.
  • 24.Advanced Web Ranking. GOOGLE ORGANIC CTR HISTORY: Fresh CTR averages pulled monthly from millions of keywords. 2019.
  • 25.Meyer C. The Top 5 Results in Google Get Almost 70% of All Clicks. https://www.amazeemetrics.com/en/blog/the-top-5-results-in-google-get-almost-70-of-all-clicks/. Published 2014 Accessed.
  • 26.Petrescu P. Google Organic Click-Through Rates in 2014. https://moz.com/blog/google-organic-click-through-rates-in-2014. Published 2014. Accessed 11/16/19.
  • 27.Balakrishnan V, Chandy Z, Hseih A, Bui TL, Verma SP. Readability and Understandability of Online Vocal Cord Paralysis Materials. Otolaryngol Head Neck Surg. 2016;154(3):460–464. doi: 10.1177/0194599815626146. [DOI] [PubMed] [Google Scholar]
  • 28.Doruk C, Enver N, Çaytemel B, Azezli E, Başaran B. Readibility, Understandability, and Quality of Online Education Materials for Vocal Fold Nodules. J Voice. 2020;34(2):302. doi: 10.1016/j.jvoice.2018.08.015. e315-302.e320. [DOI] [PubMed] [Google Scholar]
  • 29.Zuzelo PR. Understandability and Actionability: Using the PEMAT to Benefit Health Literacy. Holist Nurs Pract. 2019;33(3):191–193. doi: 10.1097/HNP.0000000000000327. [DOI] [PubMed] [Google Scholar]
  • 30.Landis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. Biometrics. 1977;33(1):159–174. [PubMed] [Google Scholar]
  • 31.Vishnevetsky J, Walters CB, Tan KS. Inter-rater reliability of the Patient Education Materials Assessment Tool (PEMAT). Patient Educ Couns. 2018;101(3):490–496. doi: 10.1016/j.pec.2017.09.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Internet/Broadband Fact Sheet. Pew Research Center. https://www.pewresearch.org/internet/fact-sheet/internet-broadband/. Published 2019 Updated June 12 2019. Accessed May 17, 2020.
  • 33.Jacobs W, Amuta AO, Jeon KC. Health information seeking in the digital age: An analysis of health information seeking behavior among US adults. Cogent Social Sciences. 2017;3(1):1302785. [Google Scholar]
  • 34.Morcuende JA, Egbert M, Ponseti IV. The effect of the internet in the treatment of congenital idiopathic clubfoot. Iowa Orthop J. 2003;23:83–86. [PMC free article] [PubMed] [Google Scholar]
  • 35.Tonsaker T, Bartlett G, Trpkov C. Health information on the Internet: gold mine or minefield? Can Fam Physician. 2014;60(5):407–408. [PMC free article] [PubMed] [Google Scholar]
  • 36.American Medical Association. CHAPTER 9: OPINIONS ON PROFESSIONAL SELF-REGULATION. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-9.pdf Published 2016 Accessed.
  • 37.Health NIo. MedlinePlus: How to write easy to read health materials. 2007.
  • 38.Miller TA. Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Educ Couns. 2016;99(7):1079–1086. doi: 10.1016/j.pec.2016.01.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Kilfoyle KA, Vitko M, O’Conor R, Bailey SC. Health Literacy and Women’s Reproductive Health: A Systematic Review. J Womens Health (Larchmt) 2016;25(12):1237–1255. doi: 10.1089/jwh.2016.5810. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228–1239. doi: 10.1111/j.1525-1497.2004.40153.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Zhao D, Liu J, Zhao L, Wu Z. Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis. Clin Orthop Surg. 2014;6(3):245–252. doi: 10.4055/cios.2014.6.3.245. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Paulsen-Miller M, Dolan L, Stineman A, Morcuende J. Understanding the Educational Needs for Parents of Children With Clubfoot. Orthopaedic nursing / National Association of Orthopaedic Nurses. 2011;30:273–278. doi: 10.1097/NOR.0b013e3182247c15. quiz 279. [DOI] [PubMed] [Google Scholar]

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