Readability of English and Spanish patient-directed educational materials on gynecologic malignancies

Objectives: Patients frequently use the Internet as a resource to learn about gynecologic cancers. Online materials are increasingly relevant in the context of the COVID-19 pandemic as patients weigh risk of clinic visits against risk of inaction. Internet resources can promote patient agency in shared decision-making. However this requires resources to be accessible, and disparities exist for non-native English speakers. The National Institutes of Health recommends that patient educational materials be written at a reading level between sixth and eighth grade. The purpose of this study was to evaluate the readability of patient educational materials for gynecologic malignancies. Methods: Commonly searched keywords related to gynecologic oncology were sorted by primary malignancy. Location-agnostic searches were performed by cancer diagnosis using public internet search engines to identify the top ten websites for endometrial, ovarian, cervical, vaginal, and vulvar cancers with English and Spanish material. Readability was assessed using five validated methods. One-way ANOVA with post-hoc Tukey's tests were performed as appropriate to detect differences by publisher. Results: Over 80% of patient educational materials on gynecologic cancers were written at a tenth grade reading level or higher. Articles written below tenth grade reading level tended to discuss simpler topics such as risk factors, symptoms, and staging; articles on treatment or complications tended to be at university freshman reading level or above. Materials from governmental and non-governmental non-profit organizations were significantly more difficult than materials from the Society for Gynecologic Oncology but were similar in level to those from academic medical centers. Primarily only governmental and non-governmental non-profit organizations had Spanish patient-directed resources easily searchable on their websites, whereas fewer than seven academic medical centers did in the first four levels of their websites. The average for Spanish resources was thirteenth grade level whereas the average for English resources was eleventh grade level with a wider range. Conclusions: Patient educational materials about gynecologic cancers exceed recommended reading levels. This discrepancy is evident in Spanish-language resources, which may relate to suboptimal translation of English materials. While variation in readability allows physicians to direct patients to appropriate English-language sources, there remains a paucity of accessible Spanish-language materials for patients with low health literacy. This is particularly challenging given many Spanish-speaking communities have only sparse or intermittent internet access with limited time for complex searches. Modification to existing materials and creation of new materials is an urgent public health priority.