An evaluation of the readability and visual appearance of online patient resources for fibroadenoma
Authors: Hutchings Hayley Anne , Remesh Anagha 
Published: November 2022

Introduction
Fibroadenomas are benign lesions found in the breast tissue. Widespread access to and use of the internet has resulted in more individuals using online resources to better understand health conditions, their prognosis and treatment. The aim of this study was to investigate the readability and visual appearance of online patient resources for fibroadenoma.

Methods
We searched GoogleTM, BingTM and YahooTM on 6 July 2022 using the search terms “fibroadenoma”, “breast lumps”, “non-cancerous breast lumps”, “benign breast lumps” and “benign breast lesions” to identify the top ten websites that appeared on each of the search engines. We excluded advertised websites, links to individual pdf documents and links to blogs/chats. We compiled a complete list of websites identified using the three search engines and the search terms and analysed the content. We only selected pages that were relevant to fibroadenoma. We excluded pages which only contained contact details and no narrative information relating to the condition. We did not assess information where links were directed to alternative websites. We undertook a qualitative visual assessment of each of the websites using a framework of pre-determined key criteria based on the Centers for Medicare and Medicaid Services toolkit. This involved assessing characteristics such as overall design, page layout, font size and colour. Each criterion was scored as: +1- criterion achieved; -1- criterion not achieved; and 0- no evidence, unclear or not applicable (maximum total score 43). We then assessed the readability of each website to determine the UK and US reading age using five different readability tests: Flesch Kincaid, Gunning Fog, Coleman Liau, SMOG, and the Automated Readability Index. We compared the readability scores to determine if there were any significant differences across the websites identified. We also generated scores for the Flesh Reading Ease as well as information about sentence structure (number of syllables per sentence and proportion of words with a high number of syllables) and proportion of people the text was readable to.

Results
We identified 39 websites for readability and visual assessment. The visual assessment scores for the 39 websites identified ranged from -19 to 31 points out of a possible score of 43. The median readability score for the identified websites was 8.58 (age 14–15), with a range of 6.69–12.22 (age 12–13 to university level). There was a statistically significant difference between the readability scores obtained across websites (p<0.001). Almost half of the websites (18/39; 46.2%) were classified as very difficult by the Flesch Reading Ease score, with only 13/39 (33.33%) classified as being fairly easy or plain English.

Conclusion
We found wide differences in the general appearance, layout and focus of the fibroadenoma websites identified. The readability of most of the websites was also much higher than the recommended level for the public to understand. Fibroadenoma website information needs to be simplified to reduce the use of jargon and specificity to the condition for individuals to better comprehend it. In addition, their visual appearance could be improved by changing the layout and including images and diagrams.