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Accessibility, Quality, and Readability in English and Spanish

Gretchen K. Berland, MD; Marc N. Elliott, PhD; Leo S. Morales, MD, PhD; Jeffrey I. Algazy, MD, MPH; Richard L. Kravitz, MD, MSPH; Michael S. Broder, MD; David E. Kanouse, PhD; Jorge A. Muñoz, MS, MPhil; Juan-Antonio Puyol; Marielena Lara, MD, MPH; Katherine E. Watkins, MD, MSHS; Hannah Yang; Elizabeth A. McGlynn, PhD

JAMA. 2001;285:2612-2621.

Context  Despite the substantial amount of health-related information available on the Internet, little is known about the accessibility, quality, and reading grade level of that health information.

Objective  To evaluate health information on breast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites.

Design and Setting  Three unique studies were performed from July 2000 through December 2000. Accessibility of 14 search engines was assessed using a structured search experiment. Quality of 25 health Web sites and content provided by 1 search engine was evaluated by 34 physicians using structured implicit review (interrater reliability >0.90). The reading grade level of text selected for structured implicit review was established using the Fry Readability Graph method.

Main Outcome Measures  For the accessibility study, proportion of links leading to relevant content; for quality, coverage and accuracy of key clinical elements; and grade level reading formulas.

Results  Less than one quarter of the search engine's first pages of links led to relevant content (20% of English and 12% of Spanish). On average, 45% of the clinical elements on English- and 22% on Spanish-language Web sites were more than minimally covered and completely accurate and 24% of the clinical elements on English- and 53% on Spanish-language Web sites were not covered at all. All English and 86% of Spanish Web sites required high school level or greater reading ability.

Conclusion  Accessing health information using search engines and simple search terms is not efficient. Coverage of key information on English- and Spanish-language Web sites is poor and inconsistent, although the accuracy of the information provided is generally good. High reading levels are required to comprehend Web-based health information.

Author Affiliations: RAND Health (Drs Berland, Elliott, Morales, Algazy, Broder, Kanouse, Lara, Watkins, and McGlynn, Mr Puyol, and Ms Yang) and RAND Graduate School (Mr Muñoz), Santa Monica, Calif; Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles (Drs Berland and Algazy); University of California, Los Angeles School of Medicine (Drs Morales, Broder, and Lara); and University of California, Davis School of Medicine (Dr Kravitz).

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