Online diabetic foot care advice often too complex and unreliable, study finds

Research shows that most online information for managing diabetic foot ulcers is difficult to read and varies in quality, potentially impacting self-care and leading to serious health outcomes.

People living with diabetes are expected to manage most of their own day-to-day foot care, yet much of the online advice they are likely to find is pitched above the reading level recommended for patient information and is uneven in quality. That was the central finding of a paper published in JMIR Diabetes on 11 January 2022 by David Michael Lee of the University of Toronto, Elysia Grose of the University of Ottawa and Karen Cross of St Michael’s Hospital in Toronto. (diabetes.jmir.org)

The researchers tried to mirror the way a patient might actually look for help online. On 1 October 2020, they searched Google for “diabetic foot ulcer care”, “diabetic foot care”, “diabetic wound care” and “foot care”, then reviewed the first 20 pages of results after switching to incognito mode, clearing browsing data and disabling location settings. From 80 pages retrieved, 41 met the study criteria. Nearly two-thirds of those pages came from the United States, with the rest from Canada. The sample included medical information sites, government pages, professional organisations, private clinics, a single academic institution and a small miscellaneous group, while scientific databases, professional-only pages, news items, videos and pages with too little patient information were excluded. (diabetes.jmir.org)

Measured by the Flesch-Kincaid grade level, the average page required reading skills around school year 8, at 7.85. On the Flesch Reading Ease scale, the overall mean was 63.43, which sits in the “standard” range, but the detail was less reassuring: the paper says 68% of the material scored below 60, placing it from “fairly difficult” to “very difficult” to read. That matters because the study notes that the US National Institutes of Health, the Canadian Medical Protective Association and the American Medical Association all recommend patient education material be written for about a year 6 audience. Among the sources reviewed, government websites were the easiest to read on average, while private clinics produced the highest grade-level scores. The paper also found that US pages tended to demand a higher reading level than Canadian ones. (diabetes.jmir.org)

Quality was not much stronger. Using the DISCERN instrument, which is intended to help patients and clinicians judge the reliability of written information on treatment choices, the study found a mean score of 45.66, placing the overall body of material in the fair range. More than a quarter of the pages, 11 out of 41, fell into the poor or very poor bands. Medical information websites scored significantly better than other types of source, while private clinics were among the weakest performers. Just as importantly, the researchers found no meaningful relationship between readability and quality: easier text was not automatically more trustworthy, and more reliable information was not necessarily easier to understand. (diabetes.jmir.org)

The stakes are not trivial. The full paper says diabetic foot ulcers affect between 15% and 25% of people with diabetes at some point in their lives and precede most lower-limb amputations. It also cites a 7% risk of amputation 10 years after diagnosis. Good foot-care advice, the authors note, includes inspecting and washing feet properly, drying them carefully, choosing suitable socks and footwear, using moisturiser on dry skin, cutting nails appropriately and seeking help quickly if a cut, blister or sore appears. Because patients and families carry out 95% of diabetes foot care themselves, weak online guidance can directly affect self-management rather than merely adding background noise. (diabetes.jmir.org)

The study also sits within a broader pattern in diabetes information. In their discussion, the authors pointed to earlier work by Lipari and colleagues which found that 77% of online patient education materials on diabetes were written above an eighth-grade reading level. Their own results suggested that institutional credibility did not guarantee plain language: material from professional organisations, and the lone academic source in the sample, also tended to sit above the recommended level. In other words, patients cannot safely assume that an established name will automatically mean clearer instructions. (sciencedirect.com)

Lee and colleagues were careful not to overclaim. They said readability formulae do not measure full comprehension, and DISCERN does not directly test whether every statement on a page is factually correct. Even so, the message was clear: authors of patient material should cut sentence length and avoid unnecessarily complex wording, while clinicians should think harder before sending patients to online resources without checking how usable they are. The paper’s reach extended beyond its original journal listing on PubMed and the JMIR platform, and it was later highlighted by Wound Care Weekly and indexed through a ScienceDirect landing page, suggesting the concern over understandable foot-care advice resonated well beyond a single specialist audience. (diabetes.jmir.org)