With the rapid expansion of the internet in recent decades, online educational material has become a readily accessible and widely used resource for patients.1,2 Despite the extensive use of these resources by patients, their comprehension of the material cannot be assumed. In the United States, the average reading level is eighth grade with an estimated 80 million Americans having limited health literacy.3,4 Because of limited health literacy, the American health system faces notable economic consequences amounting to more than 50 billion dollars annually.5 Inadequate health literacy has been associated with decreased medication adherence, poor comprehension of medical instructions, and higher risks of hospitalization.6,7 In addition, previous work has found a correlation between limited health literacy among parents and adverse consequences, including exacerbation of children's symptoms, increased trips to the emergency department, and poorer health outcomes.8–10

Previous studies have shown that online orthopaedic literature tends to exceed the average American reading level.11–13 This discrepancy is particularly important in pediatric orthopaedics where parents are responsible for making healthcare decisions for their children. In Peterlein et al,14 74% of parents completing a survey had researched their child's condition before consultation with the pediatric orthopaedic surgeon, and the most used research method was the internet. Therefore, the readability of online resources in pediatric orthopaedics is incredibly important in parent understanding of their child's health conditions.

In an effort to increase the comprehensibility of online patient resources, healthcare associations have put forth recommendations concerning the readability of these resources. The American Medical Association and Agency for Healthcare Research and Quality both recommend that patient education materials be written at a sixth grade reading level or below.5,15,16 However, online patient information often still exceeds the recommended level. In addition, the low-quality nature of online web pages has potential to misguide patients and parents in medical decisions.17,18 Previous literature has proposed the use of online resources from academic centers and hospitals because of higher quality web pages.19 However, the minimal research that has examined pediatric hospital web pages has found the availability of information to be limited, and the readability often exceeds the recommended reading level.20,21

Spondylolisthesis and spondylolysis are common causes of low back pain in the pediatric population, particularly in athletes.22 The prevalence of spondylolysis in the general pediatric population is estimated to be between 4 and 6%, with its prevalence in young athletes with back pain being reported as high as 47%.23,24 The presentation and management of these conditions can have a wide spectrum. Because these conditions can be both an incidental finding in radiographic imaging and a common cause of back pain in adolescents, the management can differ from patient to patient.25 Spondylolysis is a fracture through the pars interarticularis that may present as lower back pain.22,26 Isthmic spondylolisthesis is the forward slippage of a vertebra on the caudad vertebra because of a pars interarticularis defect.26 Although conservative measures are the initial and preferred method of management, patients who fail nonsurgical treatment or have radicular symptoms may require spinal surgery.23 The severity and possible complications of spinal surgery makes parental understanding even more important in the decision-making for their children.

Many studies have evaluated the online resources for a variety of medical conditions.12,20,24,27 However, there is a paucity of literature examining the availability and readability of online patient information among pediatric hospitals specifically for spondylolisthesis and spondylolysis.24 The objective of this study is to assess the availability and readability of online web pages related to spondylolisthesis or spondylolysis among pediatric hospitals across the United States. This study aims to determine whether the available pages are written below the recommended sixth grade reading level. We hypothesize that the online resources among United States-based pediatric hospitals for spondylolisthesis and spondylolysis will be limited in availability and above the recommended reading level as suggested by previous literature.20,28

Methods Identification of Institutions

The names of 219 United States pediatric hospitals that were affiliated with the Children's Hospital Association at the time of this study were adapted for the association's website.29 Of the 219 hospitals, 179 fulfilled the inclusion criteria, which involved having a medical website indicating they provide pediatric specialty care and being operational in the year 2023. This study excluded hospitals for two reasons: Sharing the same resource page with another hospital because of belonging to the same health system (39) and being closed in the year 2023 (1). A list of the top 25 pediatric hospitals for orthopaedics as ranked by US News and Reports in 2023 was also used.30

Website Search

Web pages were discovered by typing the name of the pediatric hospital followed by ‘spondylolisthesis’ or ‘spondylolysis’ between April 15, 2023, and May 01, 2023, into a Google search engine. Each hospital system's web pages were manually evaluated for applicability by a sole author. Initially, the evaluation process used web pages dedicated to both spondylolisthesis and spondylolysis. Subsequently, if no dual pages were available, web pages for spondylolisthesis were assessed, followed by an examination of spondylolysis pages. This sequential approach ensured the systematic identification and evaluation of web pages with relevant materials. Web pages with no information or < 100 words on these conditions had their availability recorded and then were discarded from the remaining analysis.

Availability Assessment

The availability of online education materials on web pages from the aforementioned search process was evaluated as follows: (1) No information pertaining to spondylolisthesis or spondylolysis on the hospital web page; (2) Mention of spondylolisthesis or spondylolysis under ‘conditions we treat’ or analogous phrase; (3) < 100 words dedicated to spondylolisthesis or spondylolysis; and (4) One standard web page dedicated to spondylolisthesis or spondylolysis with > 100 words.

Readability Assessment

The texts of standard web pages with > 100 words dedicated to spondylolisthesis, spondylolysis, or both were entered into the WebFX Online tool to evaluate their readability.31 The WebFX online tool uses a variety of readability metrics that provide a reading grade level score for each after analysis. The results from the Flesch Kincaid Grade Level, Gunning Fog Score, Simple Measure of Gobbledygook (Smog) Index, Coleman-Liau Index, and Automated Readability Index were recorded for each institution (Table 1). These indices produce scores that correlate to the academic grade level needed to read a piece of text, with higher scores specifying lower readability.32 In addition, the percentage of complex words, average words per sentence, and average syllables per word were recorded. Data were entered in Microsoft Excel 2022 (Version 16.69) for each institution. The average of all five scores was taken because of variability among the scores, and its value represented the related grade level for each institution's resources. The higher scores correspond to a greater degree in difficulty in reading comprehension. In addition, the words ‘spondylolisthesis’ and ‘spondylolysis’ were changed to ‘pars fracture’ and ‘vertebra slippage,’ respectively, among top institutions ranked to evaluate their influence on readability index scores.30

Table 1 - Five Formulae Used in the Calculation of Reading Difficulty and Grade Level, Adapted From the WebFX Tool.31 Grade Level Indicators Flesch-Kincaid Grade Level =

0.39(wordssentences)+11.8 (syllableswords)−15.9

Gunning Fog score

=0.4 [(wordssentences)+100(complexWordswords)]

SMOG Index =

1.0430√(30(complexWordssentences))+3.1291

Coleman-Liau Index =

5.89 (characterswords)−0.3(sentenceswords)−15.8

Automated Readability Index

=4.71(characterswords)+0.5(wordssentences)−21.43

Data Analysis

Data analysis was performed using Microsoft Excel 2022 (Version 16.69). Readability data were analyzed using Student t-tests. All statistical tests performed for this project were two-tailed. Significance was set at P < 0.05. Descriptive statistics were performed on each hospital system and readability metric category. Averages, percentages, and ranges were used to express the data.

Results Availability

A total of 179 hospitals web pages proving pediatric care were analyzed for online patient information pertaining to spondylolisthesis, spondylolysis, or both. A total of 40.2% (n = 72/179) had no information on these conditions on their web pages. A total of 20.1% (n = 36/179) mentioned treating these conditions on their website. A total of 7.8% (n = 14/179) had < 100 words dedicated to these conditions. A total of 31.8% (n = 57/179) has standard web pages with > 100 words dedicated to spondylolisthesis, spondylolysis, or both.

Readability

The 57 hospitals providing pediatric care with standard web pages dedicated to spondylolisthesis, spondylosis, or both had an average corresponding grade level of 12.0 (±2.2), requiring a high school education to comprehend. The lowest average corresponding grade level was 7.86, which requires a middle school education, and the highest was 17.02, requiring a college degree. The average number of words per sentence was 17.8 (±4.2). The average number of complex words per web page was 98.4 (±76.8), whereas the average percentage of complex words per page was 16.8 (±4.1). Last, the average number of syllables per word for each web page was 1.7 (±0.1).

None of the pediatric web pages had reading levels corresponding to below sixth grade. A total of 1.8% (n = 1/57) required a middle school education (sixth to eighth grade) to comprehend. A total of 57.9% (n = 33/57) required some form of high school education (> eighth grade to 12th grade). A total of 40.4% (n = 23/57) required some form of college education (> 12th grade). Hundred percentage (n = 57/57) of the corresponding grade levels for the pediatric hospitals were above the recommended sixth grade level. A total of 98.2% (n = 56/57) were above the average American reading level (eighth grade) (Figure 1).

Figure 1:

Box and whisker plot presenting the reading grade level for each readability assessment test. The horizontal line within the box indicates the median. The ‘X’ within each box represents the average. The four divisions represent interquartile range. Circles are representative of outliers.

Of the top 25 pediatric hospitals for orthopaedics, 60% (n = 15/25) had online webpages dedicated to spondylolisthesis, spondylolysis, or both. The average reading level among these hospitals was 12.0 (±0.8) (Table 2). The average among the other 42 remaining hospitals was 12.1 (±2.6). No significant difference existed between these two groups (P = 0.83). The top ranked institutions with changes to spondylolisthesis and spondylolysis subsequently had an average reading level of 11.2 (±0.9).

Table 2 - Readability index Scores Among Top 25 Ranked Pediatric Hospital as Reported by the US News and Reports in 2023.30 Hospital Rank Average Flesch-Kincaid Grade Level Gunning Fog Score SMOG Index Automated Readability Index Coleman-Liau Index Akron Children's Hospital 11.5 10.5 12.7 9.4 11.4 13.3 Boston Children's Hospital 12.6 11.4 14.4 10.6 12.3 14.2 Children's Healthcare of Atlanta 11.3 10.0 12.9 9.7 10.3 13.4 Children's Hospital Colorado 11.8 10.5 12.5 9.4 10.7 16.1 Children's Hospital of Orange County 11.3 10.1 10.9 8.3 10.5 16.8 The Children's Hospital of Philadelphia 13.9 12.8 15.9 12 13.6 15.1 Children's Medical Center Dallas-Scottish Rite for Children 11.3 9.7 13.2 9.6 9.9 14 Cincinnati Children's Hospital 11.8 10.4 12.6 9.6 11.9 14.4 Johns Hopkins Children's Center 11.5 10.5 12.7 9.5 11.5 13.1 Nationwide Children's Hospital 12.5 11.2 13.9 10.5 12.4 14.3 Nemours Children's Hospital Delaware 11.5 10.5 12.7 9.4 11.4 13.3 Rady Children's Hospital 11.8 11.0 14 10.4 9.8 13.6 St. Louis Children's Hospital 12.5 10.9 14.3 10.9 11.6 14.8 Texas Children's Hospital 11.9 10.9 12.5 9.9 11.3 14.7 UC Davis Children's Hospital/Shriners Children's 13.2 11.8 15 11 13 15.4
Discussion

There is currently a lack of literature examining the readability of online material from hospitals on pediatric spondylolisthesis or spondylolysis, a common source of back pain in children. This study sought to examine the accessibility and readability of material on these conditions from pediatric hospitals in the United States. Online patient information resources are widely used by parents to help learn about and aid in decision-making regarding their children's health, although limitations in health literacy may affect the comprehension of these resources.

Our study found limited availability for information related to spondylolisthesis and spondylolysis on pediatric hospital web pages. A total of 40.2% (n = 72/179) of pediatric hospitals had no information on spondylolisthesis, spondylolysis, or both, and only 31.8% (n = 57/179) had > 100 words dedicated to these conditions. Xie et al performed a similar study regarding the availability of information related to clubfoot on pediatric hospital web pages. A total of 30.5% (n = 29/95) of the hospitals they included did not provide any information regarding clubfoot, one of the most sought after online resources by parents.14,20 The lack of material for both conditions illustrates the need to examine the availability and the readability to provide better resources for patients.

Among the 57 hospital web pages examined, our analysis revealed an average reading level of 12.0 (±2.2). In addition, 100% (n = 57/57) of hospitals' web pages were above the recommended sixth grade reading level by the American Medical Association and Agency for Healthcare Research and Quality. A total of 98.2% (n = 56/57) were written above the average American reading level of eighth grade. Our analysis reports a higher average reading level than previous studies. Xie et al found the average reading level among pediatric hospital web pages on clubfoot to be 9.4, whereas Ó Doinn T et al found the average among pediatric orthopaedic resources to be 10.2.12,20 The higher average in our study may be because of the use of the words ‘spondylolisthesis’ and ‘spondylolysis,’ along with the medical language used relating to spinal conditions.33

Readability assessment methods usually consider the number of polysyllable words and sentence length in their calculation of grade level.34 Therefore, the frequent use of the word ‘spondylolisthesis’ and ‘spondylolysis,’ two multiple syllable words, could explain for the higher grade level in our study compared with other studies. Replacement of these words in our study changed the original grade level average of 12.0 (±2.6) to 11.2 (±0.9) among top ranked pediatric hospitals webpages. Although this change did lower the grade level of these resources, the average of the scores was still well above the recommended level of eighth grade. Michel et al24 found similar results when examining webpages for pediatric spinal conditions. The lower readability among webpages describing spinal conditions may be because of the complexity of spinal conditions and their treatment.24,33

Improving the availability and comprehensiveness of hospital web pages provides an opportunity to address limited patient health literacy and allows hospitals to be viewed more favorably by their consumers.35 Multiple studies have demonstrated that patients often consider the information they see online, including advertisements, into their healthcare decisions.36,37 To address the impact of health literacy barriers on patient outcomes and healthcare costs, it is important to examine the availability of resources provided to patients and their families. By providing readily available and readable educational materials on their web pages, pediatric hospitals could increase parents' trust and comfort in making informed decisions based on physician recommendations.38

Our study is not without limitations. First, readability assessment formulae are invaluable tools in assessing the difficulty of written material. However, these tools do not consider visual tools, such as images and diagrams, that can help in reader comprehension. Second, we did not assess the quality of the online patient education material that we assessed from the pediatric institutions which can influence patient understanding of their issue and the information accuracy. Last, readability formulae often base the reading difficulty off the number of syllables and length of sentences. These formulae do not account for medical jargon that may be shorter in length but difficult to understand.

Conclusion

In keeping with previous studies by Michel et al, Lock et al, and Ó Doinn et al examining the readability of online pediatric orthopaedic resources, our study examined the availability and readability of resources among pediatric hospital web pages for spondylolisthesis and spondylolysis. Spondylolisthesis and spondylolysis are two conditions that may lead to pain in pediatric patients, which can ultimately lead to parents seeking online patient information to understand the conditions better. In this study, the findings revealed the limited availability of information on these conditions, with only 31.8% of hospitals having dedicated web pages. In addition, the readability of the available resources was markedly higher than the recommended reading level, with an average grade level of 12.0. These results highlight the need for improved accessibility and readability of online patient information for common orthopaedic conditions among pediatric hospitals. Furthermore, limited health literacy and high reading levels may negatively affect parents' comprehension of information on their child's condition. Physicians should consider recommending reliable online resources with improved readability to support informed decision-making among parents and improve patient outcomes.

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