Vocal Tremor: Assessing the Effectiveness of Online Patient Education Materials

Bethany Ho, BA | Hackensack Meridian School of Medicine

Bethany Ho is a recipient of the 2023 Dysphonia International Research Travel Award in partnership with The Voice Foundation. Bethany participated in the 2023 Voice Foundation Conference and presented research entitled, “Vocal Tremor: Assessing the Effectiveness of Online Patient Education Materials.”

When asked to describe how her work will help patients, Bethany stated “In an age where most people seek information on the Internet, we demonstrate that professional organizations and societies can promote public health literacy and improve health outcomes by creating effective online patient materials and may use the Health Literacy Online tool as a guide.”

Below is an abstract of Bethany’s podium presentation.


Additional Authors: Ellen M. Hong BA, Brian E. Benson MD

Introduction Health literacy, a strong indicator of health outcomes, is an important aspect of good patient care. With an increasing reliance on the Internet for health information, online patient materials must be easily understood by the average reader. The AMA and NIH recommend that patient education materials be written at a sixth-grade level. Creating effective digital information requires careful consideration of not only word choice, but also many other factors including actionability, comprehensiveness, evidence, and visual organization. To support the creation of valuable online health content, the Office of Disease Prevention and Health Promotion (ODPHP) published Health Literacy Online, a research-based guide that discusses why and how to design digital health information tools.   This study aims to assess the effectiveness of online patient education materials regarding vocal tremor, assess the effectiveness of patient education materials published by the American Laryngological Association, and to evaluate the usefulness of the Health Literacy Online guide in creating effective online patient education materials on laryngological diseases.   

Methods The first 50 unsponsored search results for the terms “vocal tremor” and “essential vocal tremor” were evaluated. Each website was analyzed using the Flesch Reading Ease Score (FERS) and Flesch-Kincaid Grade Level (FKGL) readability tests, the DISCERN instrument, and the Patient Education Materials Assessment Tool (PEMAT). The resources published by the American Laryngological Association were also evaluated in this manner. 

Results Of the 100 websites identified from the initial queries, 14 websites were included in this analysis. The average FRES and FKGL scores were 47.21+/-10.47 and 10.96+/-2.46, respectively, indicating that readers need a 11th grade education to comprehend the materials. The average DISCERN score was 22.50+/-9.76, indicating ‘very poor’ quality with serious shortcomings and not appropriate sources of information about treatment choices. The average PEMAT understandability score was 68.43%+/-9.80% with an actionability score of 20.00%+/-23.53%, indicating the information was fairly difficult to process and do not help identify next steps. For the materials published by the ALA, the average FRES and FKGL scores were 38.33 ± 12.81 and 12.56 ± 2.15, respectively, indicating a 12th-grade reading level. A DISCERN score of 27 was consistent across each item, indicating ‘very poor’ quality. A PEMAT understandability score was 45% with an actionability score of 0%, indicating they are difficult to process and do not help identify next steps. After writing a revised sample of the information provided by the ALA based on the ODPHP’s Health Literacy Online tool, the new FRES and FKGL score was 75.6 and 5.9, respectively. The new DISCERN score of 35. The new PEMAT understandability scores was 79% with actionability scores of 80%.  

Conclusion This study found that most publicly available online patient education materials on essential vocal tremor and other laryngological diseases do not use plain language and require reading levels too advanced for the average reader to comprehend. In addition, most websites were of very poor quality readability, and were therefore less likely to benefit individuals in their decision-making. In an age where most people seek information on the Internet, the lack of easily understood online patient resources reduces the usefulness of these resources for many individuals. Professional organizations and societies like the American Laryngological Association may consider the use of the Health Literacy Online tool as a resource to provide both accurate and easily understandable patient education resources.

Contact Information: Email: bethany.ho@hmhn.org

Sponsoring Organizations

The Fall Voice Conference is designed to encourage and educate professionals on a multi-disciplinary approach to the management of vocal disorders. The focus of this conference is the clinical care of patients with voice-related difficulties and how clinical and basic science research guide clinical care. For more information: fallvoice.org.

Dysphonia International is dedicated to improving the lives of people with spasmodic dysphonia and related voice conditions through research, education, awareness, and research.