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Rahmatizadeh S, Valizadeh-Haghi S, Ranjbar S, Motahari-Nezhad H, Khazaal Y, Kohzadi Z. Readability evaluation of online health information on COVID-19: a survey of Persian websites. jha 2025; 27 (4) :51-66
URL: http://jha.iums.ac.ir/article-1-4591-en.html
URL: http://jha.iums.ac.ir/article-1-4591-en.html
Shahabedin Rahmatizadeh1 
, Saeideh Valizadeh-Haghi2 , Sama Ranjbar2 , Hossein Motahari-Nezhad3 , Yasser Khazaal4 , Zeinab Kohzadi5
, Saeideh Valizadeh-Haghi2 , Sama Ranjbar2 , Hossein Motahari-Nezhad3 , Yasser Khazaal4 , Zeinab Kohzadi5
1- Department of Health Information Technology and Management, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. , shahab.rahmatizadeh@gmail.com
2- Department of Medical Library and Information Sciences, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3- Obuda University, Budapest, Hungary.
4- Department of Psychiatry, Lausanne University Hospitals and Lausanne University, Lausanne, Switzerland.
5- Department of Health Information Technology and Management, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Department of Medical Library and Information Sciences, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3- Obuda University, Budapest, Hungary.
4- Department of Psychiatry, Lausanne University Hospitals and Lausanne University, Lausanne, Switzerland.
5- Department of Health Information Technology and Management, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Figure 1. Google search flow diagram for website retrieval.
According to the formula, texts with shorter sentences, fewer words, and shorter syllables are more readable. A readability score between 60 and 70 is regarded "normal," while a score ≥70 is classified as "very easy" and "easy"[31] . Table 1 displays the readability scores based on the formula. The data were analyzed using SPSS version 17. Analysis of variance (ANOVA) was used to compare mean readability scores across websites based on the keywords searched and the number of pages retrieved from the Google. In addition, the Pearson correlation test was used to measure the correlation between the Google rank of the websites and their readability scores.
Table1. Flesch reading ease score interpretation with educational levels
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Introduction
The coronavirus disease (COVID-19) pandemic was declared on March 11, 2020, by the World Health Organization (WHO)[1] . Accurate information about COVID-19 is necessary to take preventative measures. In this regard, the Internet is considered as a key source of information about this disease. Information obtained from the Internet can impact disease prevention and decisions for seeking medical care [2,3] . In this context, research shows that many people not only follow their care providers’ advice, but also frequently use the Internet to obtain information about the diagnosis, treatment, and prevention of various diseases [4,5] . This information affects patient-physician interaction and medical consultations [6,7] .
Health literacy refers to the knowledge and skills required to address health-related problems[8] . People with lower literacy skills are less able to understand and process health information [9] . Low health literacy is associated with poor health outcomes and increased treatment costs [10,11] . Readability is an essential criterion for assessing a reader’s comprehension of written materials [12,13] and can help reduce the problems caused by limited health literacy [14] . Readability refers to the ease with which written material can be read and comprehended [15] . Reading, understanding written content, and comprehending and analyzing health information are crucial [16] . Readability rating scales examine the reader's ability to understand the information. The National Institutes of Health and the American Medical Association suggest that patient education materials be written at the sixth-grade level or lower (11 or 12 years old) [17] . However, numerous studies have demonstrated that health information is often written in a specialized and complex language, making it difficult for the public to understand [18–21] . In some cases, reading online health information is more challenging than reading traditional sources [22] . Poor readability leads to a lack of understanding of health information and have negative consequences, such as lower likelihood of disease prevention and health care utilization [23] .
Persian is the second most widely spoken language in the Middle East after Arabic and is the official language in Iran, Afghanistan, and Tajikistan. The total population of these countries is 132 million (1.72 % of the world's population), many of whom prefer to obtain health information online[24] . In addition, a substantial Persian-speaking population resides in Bahrain, the United Arab Emirates, and Iraq. Due to limited English proficiency, many individuals prefer to read educational materials in their native language [25]
The coronavirus disease (COVID-19) pandemic was declared on March 11, 2020, by the World Health Organization (WHO)
Health literacy refers to the knowledge and skills required to address health-related problems
Persian is the second most widely spoken language in the Middle East after Arabic and is the official language in Iran, Afghanistan, and Tajikistan. The total population of these countries is 132 million (1.72 % of the world's population), many of whom prefer to obtain health information online
. A 2020 study found that native Persian speakers are more likely to seek online health information about Ebola from website written in Persian. This implies a strong preference for Persian-language websites when seeking health-related information. Therefore, assessing the readability of Persian-language websites is critical, as it directly impacts the health of Persian-speaking populations. Although COVID-19 is no longer considered a global pandemic, assessing the readability of Persian-language health websites remains critical for future health crises and effective public health communication. This study evaluates the readability of Persian-language websites that provide information related to COVID-19.
Methods
To conduct this study, the terms “covid”, “coronavirus”, and “corona disease” were searched in Persian using Google search engine [26,27]. Because most users use the first three pages of search results [28], the first three pages of Google search results were retrieved. The search was performed on October 20, 2023, using the Google Chrome web browser. Before the search, the browser was set to private mode, and all browsing history and cookies were cleared; the first 30 results from Google search engine were selected for analysis. All URLs were evaluated, and irrelevant, inaccessible, non-Persian, duplicate, advertising, and non-textual sites (containg fewer than 100 words) were exluded. Finally, 46 websites containing information about Corona disease were selected as samples for this study (Figure 1).
Methods
To conduct this study, the terms “covid”, “coronavirus”, and “corona disease” were searched in Persian using Google search engine [26,27]. Because most users use the first three pages of search results [28], the first three pages of Google search results were retrieved. The search was performed on October 20, 2023, using the Google Chrome web browser. Before the search, the browser was set to private mode, and all browsing history and cookies were cleared; the first 30 results from Google search engine were selected for analysis. All URLs were evaluated, and irrelevant, inaccessible, non-Persian, duplicate, advertising, and non-textual sites (containg fewer than 100 words) were exluded. Finally, 46 websites containing information about Corona disease were selected as samples for this study (Figure 1).
Figure 1. Google search flow diagram for website retrieval.
The Flesch Reading Ease (FRE) formula is one of the most reliable methods for assessing text readability. In this study, website readability was evaluated and ranked using the Flesch-Dayani Reading Ease (FDRE) formula, which was developed by Dayani based on the original FRE for Persian language [29] . According to formula 1 [30] , this measurement scale is determined by calculating the sentence length (SL) and the word/syllable length (WL) per 100 words. The totla word count of Persian writings analuzed was 262,835. To determine readability, three random 100-word samples were taken from the beginning, middle, and end of each text. If s webpage contained more than 100 but less than 200 words, a single 100-word sample was selected; for texts under 300 words, two samples were chosen. Then, the values of SL and WL were added together and used in the Flesch Dayani method (Formula 1) for readability calculation. The mean readability score of the samples was calculated to uncover each web page's readability score.
Formula 1:
Formula 1:
According to the formula, texts with shorter sentences, fewer words, and shorter syllables are more readable. A readability score between 60 and 70 is regarded "normal," while a score ≥70 is classified as "very easy" and "easy"
Table1. Flesch reading ease score interpretation with educational levels
| Reading ease score | Description | predicting reading grade |
| 90-100 | Very easy | 5th grade |
| 80-90 | Easy | 6th grade |
| 70-80 | Fairly easy | 7th grade |
| 60-70 | Standard | 8th-9th grade |
| 50-60 | Fairly difficult | 10th-11th grade |
| 30-50 | Difficult | College grade |
| 0-30 | Very difficult | College graduate |
Results
A total of 46 websites were assessed. The mean and standard deviation of the readability scores of the analyzed websites were 80.56±11.22, indicating that, on average, Persian-language websites related to COVID-19 are easily comprehensible and written at a sixth-grade reading level. Eleven of these websites (23.9%) hade a “very easy” readability level. In comparison, only seven (15.2%) have a readability level below the standard score (Table 2).
Table 2. Frequency and percentage of websites based on readability score
A total of 46 websites were assessed. The mean and standard deviation of the readability scores of the analyzed websites were 80.56±11.22, indicating that, on average, Persian-language websites related to COVID-19 are easily comprehensible and written at a sixth-grade reading level. Eleven of these websites (23.9%) hade a “very easy” readability level. In comparison, only seven (15.2%) have a readability level below the standard score (Table 2).
Table 2. Frequency and percentage of websites based on readability score
| Readability Score | Frequency | Percent |
| 90-100 | 11 | 23.9 |
| 80-90 | 12 | 26.1 |
| 70-80 | 16 | 34.8 |
| <70 | 7 | 15.2 |
| Total | 46 | 100 |
Table 3 presents the mean and standard deviation of the websites’ readability scores based on the
searche keywords and the Google page rankings.
Table 3. Readability scores among webpages based on search keywords and Google page rankings
searche keywords and the Google page rankings.
Table 3. Readability scores among webpages based on search keywords and Google page rankings
| Variables | Readability score | F | P-value | ||
| Mean | SD | ||||
| Keywords | |||||
| Covid | 75.923 | 13.064 | 1.951 | 0.154 | |
| Coronavirus | 80.439 | 9.073 | |||
| Corona disease | 83.657 | 10.661 | |||
| Page ranking in google search results | |||||
| 1 | 77.551 | 10.661 | 2.566 | 0.089 | |
| 2 | 88.200 | 10.036 | |||
| 3 | 82.880 | 11.582 | |||
No statistically significant differences in readability scores were observed between webpages retrived by the term “corona disease” and the other two keywords (P = 0.154) based on one-way analysis of variance. A statistically non-significant difference was also found between the mean readability scores of results from Google’s second and first pages (P=0.089) (Table 3). Figure 2 illustrates websites' readability scores according to their rank position in Google search results. The Pearson correlation revealed no statistically significant relationship between readability scores and Google search ranking position (r= 0.245, P= 0.101).
Figure 2. Readability scores of websites based on Google search ranking position.
Figure 2. Readability scores of websites based on Google search ranking position.
Five of the analuzed websites were national or international. Table 4 presents the readability scores of these websites. With a score of 75.33, the WHO website ranked fourth among these five websites and was written slightly above the acceptable readability level.
Table 4. Readability score for Persian-language websites published by prominent international and national organizations
Table 4. Readability score for Persian-language websites published by prominent international and national organizations
| Organization | Reading score | Grade level | |
| canada.ca | Government of Canada's digital presence | 88.56 | 6th grade |
| chla.org | Children's Hospital Los Angeles | 63.84 | 8th-9th grade |
| iums.ac.ir | Iran University of Medical Sciences | 96.74 | 5th grade |
| ouh.dk | Odense University Hospital | 99.46 | 5th grade |
| who.int | World Health Organization | 75.33 | 7th grade |
Discussion
The COVID-19 pandemic has highlighted digital inequality[32,33] and the need for improved health literacy among the population [34] . Access to reliable, high-quality, and readable health information is an economic and social privilege [35] ; however, most health content, including resources from governments and public health sectors, fails to meet minimum readability standards [36] . Readability is crucial for understanding health information, and it must be carefully considered when preparing content [37] . The tendeny of many individuals to seek health information online before visiting a physician affects p attitudes and ther habits [38] . Every day, over 6.75 million people use Google to search for health-related information [39].
This research examined about the readability of COVID-19 content on commonly available websites. Despite recommendations from the American Medical Association and the National Institutes of Health, the average readability of the 46 websites suggests that some of them are appropriate for high school seniors or first year of college students[40,41] . The readability of most analyzed websites was much above the globally accepted minimum standards. This finding aligns with the study by Rahmatizadeh et al. [42,43] which evaluated the readability of websites realted to acupuncture and Middle East respiratory syndrome. There is a broad consensus that the universal reading level corresponds to that of a child aged 10 to 11 who has completed primary or junior school [44] .
Half of the web pages examined in this study have a readability level above internationally accepted standards, making them difficult for the general public to understand. Several previously published studies on vascular surgery[45] , pulmonary medicine [46] and genitourinary medicine [47] have also found the readability of English-language websites to be at a low level. A study assessing the readability of COVID-19 websites in four English-speaking countries (Ireland, the United Kingdom, Canada, and the United States) found that about 17% of the websites were universally readable [48] . A similar study examining the readability of Arabic health websites on COVID-19 reported an optimal readability level [49] . The results of another study suggest that the readability of online COVID-19-related health information significantly exceeds the recommended readability level. As health information is difficult to understand, fewer people follow hygiene, social distancing, and other medical advice [50] .
Websites that appear on the first page of search results are the most likely to be visited[51] , which is why website ranking is an important factor to consider [52] . Based on the website rankings in Google search results, this study found no statistically significant association between readability scores and Google rank, contrary to expectations that the more popular websites are more readable than others. Difficult and undesired readability levels may harm readers and result in misinformation, inappropriate treatment, and even health risks. One of these health risks is inappropriate self-medication, which may impair health outcomes and increase resource westage [53–55] . Moreover, websites designers and relevant managers must take action to improve their website rankings. By enhancing the design, they can position their sites within the top three pages of Google search results, attracting more public attention . Additionally, this study found only one website from the Iran University of Medical Sciences among Persian-language government websites, highlighting the deficiencies of academic websites in providing health information to the general public. The administrators of medical universities need to address this shortcoming.
The findings of this study, though centered on COVID-19, have broader implications for future pandemics and health crises. The inadequate readability of Persian health websites reveals a significant gap in public health communication, one that extends beyond COVID-19 to other diseases and epidemics. Regardless of the type of illness, access to comprehensible online health information is essential for effective prevention, treatment adherence, and the promotion of health literacy. These results highlight the need for health authorities and content developers to prioritize readability in all health communications, as complex language can impede public understanding and reduce compliance. Therefore, proactive steps such as adopting plain-language standards, training content developers, and conducting regular readability assessment should be institutionalized to strengthen communication during future health emergencies. Addressing these challenges can foster public trust, combat misinformation, and support better health outcomes across a wide range of health issues.
Limitations
Due to the dynamic nature of the Internet, repeating the study at a different time may yield different results. Additionally, since only Persian-language websites were evaluated, assessing the readability of websites in other languages may produce different results.
Conclusion
In this study, 46 Persian-language websites on COVID-19 were analyzed for readability. Overall, the analyzed websites had a readability score of 80.56, indicating a level of readability that may be inaccessible for the general public. Considering the importance of information accessibility during the COVID-19 and the general population’s tendency to obtain more health information online, it is crucial for developers of Persian-language COVID-19 materials to pay close attention to readability. In addition, the Ministry of Health and public health centers must regularly provide accessible and up-to-date information online to ensure that citizens can obtain accurate and timely health information. During a global pandemic, there is an urgent need to disseminate clear health information. It is essential for publishers of online and offline information to share readable information for individual with all levels of understanding, and enhance their health literacy and compliant health behavior.
Declerations
Ethical considerations: This study has been approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.RETECH.REC.1399.133).
Funding: The authors did not receive support from any organization for the submitted work.
Conflicts of interest: The authors declare that they have no competing interests.
Authors Contributions: Sh. R: Conceptualization, data curation, formal analysis, methodology, supervision, writing—original draft, writing—review and editing; S.VH: Conceptualization, data curation, formal analysis, methodology, resources, supervision, writing—original draft preparation, writing—review and editing; Sa. R: Data Curation, formal analysis, writing—original draft; H. MN: Resources, writing—original draft preparation; Y. Kh: conceptualization, methodology, writing—review and editing; Z. K: Formal analysis, writing—original draft preparation, writing—review and editing.
Consent for publication: None.
Data availability: The data supporting this study's findings are available from the corresponding author upon request.
The COVID-19 pandemic has highlighted digital inequality
This research examined about the readability of COVID-19 content on commonly available websites. Despite recommendations from the American Medical Association and the National Institutes of Health, the average readability of the 46 websites suggests that some of them are appropriate for high school seniors or first year of college students
Half of the web pages examined in this study have a readability level above internationally accepted standards, making them difficult for the general public to understand. Several previously published studies on vascular surgery
Websites that appear on the first page of search results are the most likely to be visited
The findings of this study, though centered on COVID-19, have broader implications for future pandemics and health crises. The inadequate readability of Persian health websites reveals a significant gap in public health communication, one that extends beyond COVID-19 to other diseases and epidemics. Regardless of the type of illness, access to comprehensible online health information is essential for effective prevention, treatment adherence, and the promotion of health literacy. These results highlight the need for health authorities and content developers to prioritize readability in all health communications, as complex language can impede public understanding and reduce compliance. Therefore, proactive steps such as adopting plain-language standards, training content developers, and conducting regular readability assessment should be institutionalized to strengthen communication during future health emergencies. Addressing these challenges can foster public trust, combat misinformation, and support better health outcomes across a wide range of health issues.
Limitations
Due to the dynamic nature of the Internet, repeating the study at a different time may yield different results. Additionally, since only Persian-language websites were evaluated, assessing the readability of websites in other languages may produce different results.
Conclusion
In this study, 46 Persian-language websites on COVID-19 were analyzed for readability. Overall, the analyzed websites had a readability score of 80.56, indicating a level of readability that may be inaccessible for the general public. Considering the importance of information accessibility during the COVID-19 and the general population’s tendency to obtain more health information online, it is crucial for developers of Persian-language COVID-19 materials to pay close attention to readability. In addition, the Ministry of Health and public health centers must regularly provide accessible and up-to-date information online to ensure that citizens can obtain accurate and timely health information. During a global pandemic, there is an urgent need to disseminate clear health information. It is essential for publishers of online and offline information to share readable information for individual with all levels of understanding, and enhance their health literacy and compliant health behavior.
Declerations
Ethical considerations: This study has been approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.RETECH.REC.1399.133).
Funding: The authors did not receive support from any organization for the submitted work.
Conflicts of interest: The authors declare that they have no competing interests.
Authors Contributions: Sh. R: Conceptualization, data curation, formal analysis, methodology, supervision, writing—original draft, writing—review and editing; S.VH: Conceptualization, data curation, formal analysis, methodology, resources, supervision, writing—original draft preparation, writing—review and editing; Sa. R: Data Curation, formal analysis, writing—original draft; H. MN: Resources, writing—original draft preparation; Y. Kh: conceptualization, methodology, writing—review and editing; Z. K: Formal analysis, writing—original draft preparation, writing—review and editing.
Consent for publication: None.
Data availability: The data supporting this study's findings are available from the corresponding author upon request.
AI declaration: Artificial intelligence (AI) tools were not used to write the article.
Acknowledgments: The authors thank everyone who collaborated in this research.
Acknowledgments: The authors thank everyone who collaborated in this research.
Type of Study: Research |
Subject:
Medical Librarianship and Information Science
Received: 2025/02/27 | Accepted: 2024/07/9 | Published: 2025/07/21
Received: 2025/02/27 | Accepted: 2024/07/9 | Published: 2025/07/21
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