Health Literacy Demands Research Articles

Consulting “Dr. YouTube”: an objective evaluation of hypospadias videos on a popular video-sharing website

Parents who make decisions about hypospadias repair for their child may seek information from online platforms such as YouTube. The purpose of this study is to evaluate the health literacy demand of hypospadias videos on YouTube using the Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V). We performed a YouTube search using the term "hypospadias," limiting results to the first 100 videos. We excluded videos that were <1min or >20min and videos that were not in English or did not include subtitles. Two evaluators independently examined videos and determined PEMAT-A/V scores for understandability and actionability (i.e., ability to identify actions the viewer can take). Videos with scores >70% are understandable or actionable. The inter-rater reliability (kappa) and intraclass correlation coefficient (ICC) of PEMAT scores were calculated. Bivariate and multivariable linear regression models assessed the association of video characteristics with respective scores. Of the 100 videos that were identified on YouTube, 47 (47%) were excluded leaving 53 for analysis: 14 were >20min, 14 were <1min, 9 had no audio or subtitles, 7 were not in English, 1 was a duplicate, 1 was unrelated to hypospadias, and 1 was deleted at the time of data analysis. Three (5.6%) were understandable (mean score 54.5%, standard deviation (SD) 14.9) and eight (15.1%) were actionable (mean score 21.8%, SD 16.6) (Extended Summary Figure). Kappa values ranged from 0.4 to 1. The ICC's were 0.55 and 0.33 for understandability and actionability, respectively. In the bivariate analysis, mean understandability scores were significantly higher for English language videos (p=0.04), videos with animation (p=0.002), and those produced by industry (p=0.02). In the multivariable analysis, mean understandability scores were significantly higher for "expert testimonial" or "other" video types after adjusting for graphics type and overall tone (p=0.04). Mean understandability scores were also significantly higher for videos with animation after adjusting for video type and overall tone (p=0.01). Mean actionability scores were significantly higher for videos with a negative tone (p=0.01). The vast majority of hypospadias-related YouTube content is not appropriate for users with low health literacy although certain types of videos, such those with animation and expert testimonials, scored higher on understandability than other types. Due to the lack of sufficient online informational content regarding hypospadias, we plan to engage parents of sons with hypospadias in the development of high-quality patient educational materials about hypospadias.

Evaluation of the scope, quality, and health literacy demand of Internet-based anal cancer information.

ObjectivesAs there is a dearth of information about anal cancer available at cancer centers, patients often use the Internet to search for information. This is problematic, however, because the quality of information on the Internet is variable, and the health literacy demanded is higher than the average patrons’ capacity. The purposes of this study were to (1) determine the most common websites with anal cancer consumer health information, (2) identify the supportive care needs that each website addresses, and (3) evaluate the websites’ quality and health literacy demand.MethodsMedical Subject Headings (MeSH) entry terms for “Anus Neoplasms” were used in Google Canada to identify websites. Seven domains of supportive care needs were defined using Fitch’s Supportive Care Framework for Cancer Care. Website quality was evaluated using the DISCERN tool. Health literacy demand was assessed using readability calculators, where best practice dictates a grade 6 or lower, and the Patient Education Material Assessment Tool (PEMAT) that computes a percentage score in 2 domains, understandability and actionability, with 80% being an acceptable score.ResultsEighteen unique websites were evaluated. One website met health literacy best practices and had a “good” quality rating. Most websites addressed only 1 supportive care domain (61%), were of “fair” quality (67%), had readability scores higher than grade 6 (89%), and had PEMAT scores ranging from 41%–92% for understandability and 0–70% for actionability.ConclusionThe information gaps on anal cancer websites warrant a need for more health literate anal cancer health information on the Internet.

Assessing the information quality and usability of My Health Record within a health literacy framework: What's changed since 2016?

Background:This study examined the health literacy demands of My Health Record (MyHR) in the context of preparing for a government-announced opt-out system by repeating two studies of health information and usability conducted in 2016.Objective:To examine whether Australia’s MyHR meets the information and usability needs of people at risk of low health literacy and changes since 2016.Method: Content analysis: Informed by the 2016 methods and findings, measures of information quality, themes and target audiences were recorded and reported for each online consumer-facing health information resource. Heuristic evaluation: An evaluation of the MyHR and supporting information website was conducted using a predetermined checklist of usability criteria. A list of usability violations for both websites was identified.Results:Total number of resources grew from 80 in 2016 to 233 in 2018. There was little change since 2016 to average readability levels, target audiences, presentation style, links between resources and usability of MyHR. Compared to 2016, this study demonstrated increases in resources from non-government organisations; video resources; translated resources; and resources with themes of privacy, security and post-registration use.Conclusion:This study identified some improvements in information quality since 2016, but gaps remain in information quality and usability which may negatively impact the ability for people with low health literacy to access and use MyHR.Implications:This study provides a framework for ongoing monitoring and evaluation of the suitability of MyHR for people at risk of low health literacy.

Identifying the Preferred Method to Educate Low Income Caregivers About Common Childhood Illnesses: A Step Toward Health Literacy Through a Focus Group Study

PurposeThe purpose of this focus group was to identify the preferred method of education for low-income caregivers to learn about common childhood illnesses in an effort to meet their health literacy needs. MethodsFocus group participants were recruited from two sources; caregivers who qualified for Women, Infants, and Children (WIC) Food and Nutrition Services and those attending a monthly prenatal health education program for low-income pregnant women. Participants were asked to rank in order of preference five educational options. The five options included a commonly used diagnosis-specific handout, a booklet of the most common childhood illnesses and symptoms, a comprehensive book of common childhood illness and symptoms, a 24-hour nurse call line, and a mobile application developed by the American Academy of Pediatrics. All options provided accurate information from professional sources. ResultsThe ranking of the five educational options identified the mobile application developed by the American Academy of Pediatrics, KidsDoc, to be the preferred method with the commonly used diagnosis-specific handout as the least favorite option. Conclusion/practice implicationsThe United States Department of Health and Human Services (USDHHS) has identified a need to change the way health information is designed and delivered. Identifying that materials should be redesigned using best practices to reduce health literacy demands and match consumer preferences, the USDHHS calls for periodic testing of materials with the intended consumers. This focus group provides valuable information and a step toward future research to address health literacy using materials identified by low-income consumers.

The Association Between Health Literacy and Breast and Cervical Cancer Screening Behaviors: Findings From the Behavioral Risk Factor Surveillance System.

Health literacy has been linked to breast and cervical cancer screening, with inconsistent findings, which may result from the use of nonprobability sampling and a health literacy instrument that measures a subset of health literacy. The aim of this study was to examine the association between health literacy and breast and cervical cancer screening using data from the Behavioral Risk Factor Surveillance System (BRFSS) that uses a nationally representative U.S. probability sample. This cross-sectional, correlational study used national-level data from the 2016 BRFSS for women eligible for breast (N = 44,241) and cervical (N = 38,956) cancer screening per the American Cancer Society guidelines. A health literacy survey consisted of three items: oral (asking for medical advice), listening (understanding information that providers offer), and written (understanding printed health information) literacy. We extracted data regarding age, race/ethnicity, income, marital status, education, employment, insurance, and access to providers. Analyses were weighted using the complex survey design and multiple logistic regressions were used to test for the associations between health literacy and cancer screening after controlling for sociodemographic and healthcare system factors. Oral and listening literacies were contributing factors to up-to-date breast cancer screening (p = .002, p < .001, respectively). The association ceased to be significant in the presence of all three literacy items in one model. Oral and listening literacies were also associated with cervical cancer screening (p < .001, p = .005, respectively), but only oral literacy maintained significance in the presence of listening and written literacy items. Oral and listening literacies are contributing factors to lifetime breast cancer screening and up-to-date cervical cancer screening. Providers should create an atmosphere of effective patient-provider communication and informed decision-making by reducing health literacy demands in the medical encounter.

Utilization of Mobile Nutrition Applications by Patients With Chronic Kidney Disease

Utilization of Mobile Nutrition Applications by Patients With Chronic Kidney Disease

Patient counseling materials: The effect of patient health literacy on the comprehension of printed prescription drug information

Counseling patients with written materials relies equally on patients' health literacy to understand their disease and its treatment, and the written materials' effectiveness communicating clearly in accessible and actionable ways. Only about 12% of the US population is adequately health literate. To explore the impact of reducing the health literacy demands of written patient health information. 805 patients were screened for health literacy, and recruited for balanced cohorts of adequate and low literacy, and high and normal blood pressure. Half of each patient cohort received either standard or "health literacy-friendly" drug summaries (i.e. Patient Package Inserts, or PPIs or "leaflets") along with a standardized health literacy assessment scale. The literacy-friendly drug summary improved comprehension of drug-related information overall from 50% to 71% correct responses. Adequate literacy patients improved from 58% correct to 90%, while lower literacy patients improved from 42% to 52% correct in response to the health literacy-friendly PPIs. Health literacy demands require special attention in developing and using written drug summary materials. Additionally, pharmacists should be provided additional information and counseling support materials to facilitate communications with low health literacy level patients.

The Developmental Check-In: Development and initial testing of an autism screening tool targeting young children from underserved communities.

Children with autism spectrum disorder from low-income, minority families or those with limited English proficiency are diagnosed at a later age, or not at all, compared with their more advantaged peers. The Developmental Check-In is a new tool that could potentially be used to screen for autism that uses pictures to illustrate target behaviors. It was developed to enhance early identification of autism spectrum disorder in low literacy groups. The Developmental Check-In was tested in a sample of 376 children between the ages of 24 and 60 months, from underserved communities. It showed good ability to discriminate autism spectrum disorder from non-autism spectrum disorder (area-under-the-curve = 0.75) across the full age range represented in the sample. Twenty-six of the 28 Developmental Check-In items predicted the presence of autism spectrum disorder. Findings suggest that this pictorial tool may reduce linguistic and health literacy demands when screening for autism among vulnerable populations.

Health Literacy Demands of Patient-Reported Evaluation Tools in Orthopedics: A Mixed-Methods Case Study.

In response to an assessment of organizational health literacy practices at a major academic health center, this case study evaluated the health literacy demands of patient-reported outcome measures commonly used in orthopedic surgery practices to identify areas for improvement. A mixed-methods approach was used to analyze the readability and patient feedback of orthopedic patient-reported outcome materials. Qualitative results were derived from focus group notes, observations, recordings, and consensus documents. Results were combined to formulate recommendations for quality improvement. Readability results indicated that narrative portions of sample patient outcome tools were written within or below the recommended eighth-grade reading level (= 5.9). However, document literacy results were higher than the recommended reading level (= 9.8). Focus group results revealed that participants had consensus on 8 of 12 plain language best practices, including use of bullet lists and jargon or technical words in both instruments. Although the typical readability of both instruments was not exceedingly high, appropriate readability formula and assessment methods gave a more comprehensive assessment of true readability. In addition, participant feedback revealed the need to reduce jargon and improve formatting to lessen the health literacy demands on patients. As clinicians turn more toward patient-reported measures to assess health care quality, it is important to consider the health literacy demands that are inherent in the instruments they are given in our health systems.

Health Literacy, Health Disparities, and Sources of Health Information in U.S. Older Adults.

Low health literacy in older adults has been associated with poor health outcomes (i.e., mortality, decreased physical and cognitive functioning, and less preventive care utilization). Many factors associated with low health literacy are also associated with health disparities. Interaction with healthcare providers and sources of health information are influenced by an individual's health literacy and can impact health outcomes. This study examined the relationships between health literacy, sources of health information, and demographic/background characteristics in older adults (aged 65 years and older) related to health literacy and disparities. This descriptive, correlational study is a secondary analysis of the 2003 National Assessment of Adult Literacy, a large-scale national assessment. Older adults with lower health literacy have less income and education, rate their health as poor or fair, have visual or auditory difficulties, need help filling out forms, reading newspaper, or writing notes, and use each source of health information less (print and nonprint). Many of these characteristics and skills are predictive of health literacy and associated with health disparities. The results expand our knowledge of characteristics associated with health literacy and sources of health information used by older adults. Interventions to improve health outcomes including health disparities can focus on recognizing and meeting the health literacy demands of older adults.

A Linguistic Analysis of Health Literacy Demands of Chronic Kidney Disease Patient Education Materials.

Background:Instruments to assess the quality and comprehensibility of printed patient education materials may lack proper consideration of how readers derive meaning from text. The Evaluative Linguistic Framework (ELF) considers how factors that influence readers' expectations about health care texts also affect their ability to understand them. The ELF has demonstrated value in improving the quality of patient materials about medication, consent, and self-reported questionnaires, but has not yet been used to evaluate a corpus of patient education materials about chronic disease self-management.Objective:This study sought to apply the ELF to examine specific elements of printed self-management patient education materials for chronic kidney disease (CKD) not captured by other tools.Methods:From a previously published systematic review, we identified 14 patient education materials (eight self-management, six diet and nutrition) for people with CKD. We used the ELF to identify the different ways the text could be structured, its intended purpose, the relationship established between reader and writer, presence of signposting, its complexity and technicality of language, and factual content.Key Results:Our analysis identified nine possible structural units, of which “introducing the problem” and “instructing the reader to self-manage” were common to all materials. However, there was no consistency or common sequence to these units of text. The intended readership and aims of the author(s) were not always clear; many materials made assumptions about what the reader knew, the language was often complex and dense, and the meta-discourse was sometimes distracting.Conclusions:Our analysis suggests CKD document developers can benefit from a theoretically grounded linguistic tool that focuses on the intended audience and their specific needs. The ELF identified structural units of text, aligned with rhetorical elements that can be uniformly applied for developing self-management education materials for CKD, and provided checks for language complexity. Further work can determine its usefulness for other (e.g., electronic) formats and other chronic diseases. [HLRP: Health Literacy Research and Practice. 2018;2(1):e1–e14.]Plain Language Summary:Helping patients make meaning from information about their condition is a key goal of health care organizations. We analyzed chronic kidney disease patient education materials on self-management using the Evaluative Linguistic Framework. The purpose and intended audience were frequently unclear. We identified nine structural units of text that may assist information providers to plan and structure content.

Literacy analysis of National Comprehensive Cancer Network patient guidelines for the most common malignancies in the United States.

Cancer information is of critical interest to the public. The National Comprehensive Cancer Network (NCCN) offers a series of comprehensive patient guidelines on the management of the most common cancer diagnoses. This study was aimed at assessing the health literacy demands of NCCN patient guidelines for the most common malignancies in the United States. The American Cancer Society's most common malignancies by annual incidence in the United States and their corresponding NCCN patient guidelines were identified. Four validated tools were used to evaluate literacy levels: 1) the Simple Measure of Gobbledygook, 2) the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH), 3) the Patient Education Materials Assessment Tool (PEMAT), and 4) the Clear Communication Index from the Centers for Disease Control and Prevention (CDC). The average reading grade level was 10.3, which was higher than the recommended 6th-grade level. The average PMOSE/IKIRSCH score was 11; this corresponded to moderate complexity and required some college-level education for interpretation. Only 1 tool, the PEMAT, yielded scores above the benchmarks for high-quality materials. The PEMAT's understandability, actionability, and overall scores were 94%, 83%, and 91%, respectively. The average CDC index was 85%, which was below the recommended 90% for an appropriate health literacy demand. Overall, the assessment indicates high demand scores for the readability and complexity of the NCCN patient guidelines and thus that the materials are not quite suitable for the general US adult population. Further input from patient focus groups to address appropriateness and usefulness is critical. Cancer 2018;124:769-74. © 2017 American Cancer Society.

Should We Recommend Renal Diet–Related Apps to Our Patients? An Evaluation of the Quality and Health Literacy Demand of Renal Diet–Related Mobile Applications

Mobile phone applications (apps) are increasingly being used by patients with chronic kidney disease (CKD). We sought to describe the main purpose of commonly available renal diet apps and to quantify the accuracy of information, technical quality, and health literacy demand of renal diet apps. The design was content analysis. All eligible renal diet apps in the Australian Apple App Store, Google Play, Windows Phone, and Blackberry App World were evaluated. Eligible apps were in English and were related to kidney disease in humans (of any type or stage). Exclusion criteria included apps which were prohibited because of password protection. Renal diet information in the apps was compared with evidence-based guidelines for the management of kidney disease to quantify information accuracy. App information was evaluated using the Silberg Scale. Technical quality and health literacy demand were evaluated using the Mobile Application Rating Scale. A total of 21 apps were eligible for evaluation. The main purpose of these apps was to provide food and nutrition information (57.1%) or for educative purposes for CKD patients (38.1%). Only 47.6% (10/21) of apps contained accurate evidence-based information. Overall, app technical quality was considered acceptable (mean Mobile Application Rating Scale score 3.19±0.35 out of 5), with 80.9% of apps scoring acceptable or greater for app technical quality. Scores for health literacy demand also indicated that most apps (15/21, 71.4%) were acceptable. A range of apps currently exist that may provide individuals with CKD with useful food and nutrition information or increase their knowledge of the renal diet. These apps are also mainly of acceptable technical quality and health literacy demand. However, caution is required when using renal diet apps because more than half of the apps evaluated were not accurate and evidence based.

Assessing the Plain Language Planner for Communication About Common Palliative Care Medications

Using plain language to communicate about oncology and palliative care medications and symptoms is recommended as a communication strategy to address patient/family health literacy demands. This study tested the Plain Language Planner©, a provider tool for communicating about medication and symptoms using plain language. Prior to and immediately following an oncology and palliative care nurse educational session, participants (n = 87) role-played about a symptom and medication. Common symptoms (nausea, constipation, and anxiety) and medications were selected. Self-evaluation and peer evaluation addressing the extent of plain language used during the role-play were rated. Plain language characteristics improved post educational role-play sessions for nurses. The largest improvement in plain language was the inclusion of the brand and generic names of medication in relating the drug to the symptom. The pocket guide provided during the educational session was consulted by 86% of nurses during the postsession role-play. Brief training with the Plain Language Planner may improve provider communication and meet patient/family health literacy needs. This resource may be a valuable asset to other health-care disciplines working in oncology and palliative care contexts.

Health Literacy and Informed Consent Materials: Designed for Documentation, Not Comprehension of Health Research

Minority populations with health disparities are underrepresented in research designed to address those disparities. One way to improve minority representation is to use community-based participatory methods to overcome barriers to research participation, beginning with the informed consent process. Relevant barriers to participation include lack of individual or community awareness or acceptance of research processes and purposes. These barriers are associated with limited health literacy. To inform recommendations for an improved consent process, we examined 97 consent documents and 10 associated Institutional Review Board websites to determine their health literacy demands and degree of adherence to principles of community-based research. We assessed the reading level of consent documents and obtained global measures of their health literacy demand by using the Suitability and Comprehensibility Assessment of Materials instrument. Although these documents were deemed suitable as medical forms, their readability levels were inappropriate, and they were unsuitable for educating potential participants about research purposes. We also assessed consent forms and Institutional Review Board policies for endorsement of community-based participatory principles, finding that very few acknowledged or adhered to such principles. To improve comprehension of consent documents, we recommend restructuring them as educational materials that adhere to current health literacy guidelines.

Evaluation of the quality and health literacy demand of online renal diet information.

Dietary modification is critical in the self-management of chronic kidney disease. The present study describes the accuracy, quality and health literacy demand of renal diet information for adults with kidney disease obtained from the Internet and YouTube (www.youtube.com). A comprehensive content analysis was undertaken in April and July 2015 of 254 eligible websites and 161 YouTube videos. The accuracy of the renal diet information was evaluated by comparing the key messages with relevant evidence-based guidelines for the dietary management of people with kidney disease. The DISCERN tool (www.discern.org.uk) was used to evaluate the quality of the material. Health literacy demand was evaluated using the Patient Education Material Assessment Tool (www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/pemat/index.html) and seven validated readability calculators. The most frequent renal diet topic found online was generic dietary information for people with chronic kidney disease. The proportion of renal diet information obtained from websites that was accurate was 73%. However, this information was mostly of poor quality with extensive shortcomings, difficult to action and written with a high health literacy demand. By contrast, renal diet information available from YouTube was highly understandable and actionable, although only 18% of the videos were accurate, and a large proportion were of poor quality with extensive shortcomings. The most frequent authors of accurate, good quality, understandable, material were government bodies, dietitians, academic institutions and medical organisations. Renal diet information found online that is written by government bodies, dietitians, academic institutions and medical organisations is recommended. Further work is required to improve the quality and, most importantly, the actionability of renal diet information found online.

Health Literacy Demand of Printed Lifestyle Patient Information Materials Aimed at People With Chronic Kidney Disease: Are Materials Easy to Understand and Act On and Do They Use Meaningful Visual Aids?

People with chronic kidney disease (CKD) need usable information on how to live well and slow disease progression. This information is complex, difficult to communicate, and changes during the course of the disease. We examined lifestyle-related printed CKD patient education materials focusing on actionability and visual aids. From a previous systematic review assessing readability of CKD patient information, we identified materials targeting nutrition, exercise, and self-management. We applied the Suitability Assessment of Materials (SAM) and Patient Education Materials Assessment Tool (PEMAT) to evaluate how easy materials were to understand (understandability) and act on (actionability). We created the 5C image checklist and systematically examined all visual aids for clarity, contribution, contradiction, and caption. Of the 26 materials included, one fifth (n = 5, 19%) were rated “not suitable” on SAM and fewer than half (n = 11, 42%) were rated “superior.” PEMAT mean subdomain scores were suboptimal for actionability (52) and visuals (37). Overall, more than half of all 223 graphics (n = 127, 57%) contributed no meaning to the text. Images in three documents (12%) directly contradicted messaging in the text. CKD lifestyle information materials require focused improvements in both actionability of advice given and use of visual aids to support people with CKD to self-manage their condition. The fifth C is culture and is best evaluated by user-testing.

Application of the Health Literacy INDEX on the development of a manual for prevention of falls for older adults

ObjectiveThe Health Literacy INDEX tool has been developed for creating accessible and readable health information materials for people of all literacy levels. To increase knowledge of falls risk factors and actively engage older adults, we developed an improved manual for prevention of falls for low-health literacy older people entitled “Preventing falls-I can do it”,with the aid of INDEX. MethodsFirst time application of the INDEX tool for assessing the health literacy demands of available manuals for prevention of falls for older adults and subsequent development of an improved manual using the INDEX tool as a checklist, supported by a pretest phase involving sixteen adults ≥65, living in the community, with literacy ≤4th grade and limited functional health literacy. ResultsThe engagement of older adults from the target audience and their feedback obtained during the validation process contributed to the development of an improved health literacy- and age-friendly manual for prevention of falls. ConclusionBy offering effective health information materials, older adults can play a more active role in their health care. Practice implicationsThe manual developed to be health literacy- and age-friendly is available to be included in any multifactorial program for the prevention of falls in older adults.

A Mismatch Between Patient Education Materials About Sickle Cell Disease and the Literacy Level of Their Intended Audience.

IntroductionDespite the first goal of the 2010 National Action Plan to Improve Health Literacy, the literacy demands of much health information exceeds the reading skills of most US adults. The objective of this study was to assess the health literacy level of publicly available patient education materials for people with sickle cell disease (SCD).MethodsWe used 5 validated tools to evaluate 9 print and 4 online patient education materials: the simple measure of gobbledygook (SMOG) to assess reading grade level, the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH) to assess structure and density, the Patient Education Materials Assessment Tool (PEMAT) to assess actionability (how well readers will know what to do after reading the material) and understandability, the Centers for Disease Control and Prevention’s (CDC’s) Clear Communication Index (Index) to obtain a comprehensive literacy demand score, and the Printed Cancer Education Materials for African Americans Cultural Sensitivity Assessment Tool.ResultsMaterials’ scores reflected high reading levels ranging from 8th grade to 12th grade, appropriate (low) structural demand, and low actionability relative to understandability. CDC suggests that an appropriate Index score should fall in or above the 90th percentile. The scores yielded by materials evaluated in this assessment ranged from the 44th to the 76th percentiles. Eight of the 13 materials scored within the acceptable range for cultural sensitivity.ConclusionReading levels of available patient education materials exceed the documented average literacy level of the US adult population. Health literacy demands should be a key consideration in the revision and development of patient education materials for people with SCD.

Quality and Health Literacy Demand of Online Heart Failure Information.

The ubiquity of the Internet is changing the way people obtain their health information. Although there is an abundance of heart failure information online, the quality and health literacy demand of these information are still unknown. The purpose of this study is to evaluate the quality and health literacy demand (readability, understandability, and actionability) of the heart failure information found online. Google, Yahoo, Bing, Ask.com, and DuckDuckGo were searched for relevant heart failure Web sites. Two independent raters then assessed the quality and health literacy demand of the included Web sites. The quality of the heart failure information was assessed using the DISCERN instrument. Readability was assessed using 7 established readability tests. Finally, understandability and actionability were assessed using the Patient Education Materials Assessment Tool for Print Materials. A total of 46 Web sites were included in this analysis. The overall mean quality rating was 46.0 ± 8.9 and the mean readability score was 12.6 grade reading level. The overall mean understandability score was 56.3% ± 16.2%. Finally, the overall mean actionability score was 34.7% ± 28.7%. The heart failure information found online was of fair quality but required a relatively high health literacy level. Web content authors need to consider not just the quality but also the health literacy demand of the information found in their Web sites. This is especially important considering that low health literacy is likely prevalent among the usual audience.