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A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema

Johnson, Anna Rose, MPH; Doval, Andres F., MD; Egeler, Sabine A., MD; Lin, Samuel J., MD, MBA; Lee, Bernard T., MD, MBA, MPH; Singhal, Dhruv, MD

doi: 10.1097/SAP.0000000000001762
Circumspectus Medicinae: Texts and Contexts

Background Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources.

Methods A web search using the Spanish term “linfedema” was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined.

Results Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters.

Conclusions Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.

From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.

Received March 8, 2018, and accepted for publication, after revision October 17, 2018.

Conflicts of interest and sources of funding: none declared.

A.R.J. and A.F.D. share first authorship.

Reprints: Dhruv Singhal, MD, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Suite 5A, Boston, MA 02215. E-mail:

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