Introduction
Epistaxis, commonly referred to as a ‘nosebleed’, has an incidence of approximately 60 per cent amongst the general population.Reference Petruson1 Most cases are self-limiting and managed in the community, with only 10 per cent requiring emergency care.Reference Smith, Hanson, Chowdhury and Bungard2 Therefore, a robust understanding of first-aid management is required for patients, community healthcare staff and emergency physicians. However, research has shown that many healthcare providers and patients cannot identify the correct first-aid steps for managing acute epistaxis.Reference McGarry and Moulton3,Reference Sowerby, Rajakumar, Davis and Rotenberg4
YouTube, a renowned internet platform, has become a popular resource for patients seeking healthcare advice.Reference Culha, Culha and Acaroglu5 An American national health survey reported that approximately one-third of the population accessed YouTube for health-related information.Reference Wu, Lee, Vescan and Lee6 However, content is uploaded without a peer-review process, and by authors with unknown credentials and intentions.Reference Memioglu and Ozyasar7 As a result, the quality and reliability of health-related videos can vary significantly.Reference Osman, Mohamed, Elhassan and Shoufan8
A key aspect of audio-visual patient material is the understandability of the content; this is particularly important for educating patients with lower literacy levels.Reference Dewalt, Berkman, Sheridan, Lohr and Pignone9 The US Agency for Healthcare Research and Quality created a checklist for evaluating the desirable characteristics of patient educational videos, coined the Patient Education Materials Assessment Tool (‘PEMAT’).Reference Shoemaker, Wolf and Brach10 This systematic tool was devised by experts in health literacy, content creation and patient education, and provides a structure for healthcare staff creating high-quality patient videos. Rigorous testing has shown the Patient Education Materials Assessment Tool to be a reliable and valid instrument for assessing the understandability and actionability of audio-visual material.Reference Shoemaker, Wolf and Brach10 Within otolaryngology, the tool has been employed to assess online audio-visual patient material for sinusitis and laryngectomy.Reference Rubel, Alwani, Nwosu, Bandali, Shipchandler and Illing11,Reference Wong, Gilad, Cohen, Kirke and Jalisi12
In 2016, Haymes and Harries evaluated the quality of YouTube videos on epistaxis first-aid management using the search query ‘how to stop a nosebleed’.Reference Haymes and Harries13 The objective accuracy of each video was evaluated using a curated checklist based on the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries guidelines for epistaxis.14 An untested, custom-made scoring system was used to form a subjective evaluation of each video. The quality of YouTube videos was shown to be highly variable, with a poor adherence to NICE Clinical Knowledge Summaries guidelines.
In light of the increased burden on healthcare services since the coronavirus disease 2019 pandemic, and the rise in patients seeking online health information, a reassessment of online audio-visual material portraying epistaxis management is required.Reference Wu, Lee, Vescan and Lee6,Reference Geyman15 This study aimed to use validated scoring systems to assess the accuracy, understandability and actionability of YouTube videos depicting epistaxis first-aid management, and to assess the differences in trends compared with the previous study by Haymes and Harries.Reference Haymes and Harries13
Materials and methods
Video selection
The YouTube video sharing platform (https://www.youtube.com) was searched on 13 August 2022, using the phrase: ‘How to stop a nosebleed’. The results were sorted based on ‘relevance’, and the first 50 eligible videos were selected and screened for duplicates. The exclusion criteria for included videos were: first-aid management not shown, video targeted towards secondary care, no audio or narration, and not presented in English language. This process is depicted in Figure 1.
Flow chart outlining the video selection pathway and review process. PEMAT-A/V = Patient Education Materials Assessment Tool for Audiovisual Materials
Video evaluation
The following characteristics were extracted from the included videos: title, uniform resource locator (‘URL’), view count, country, upload date, video length, number of comments and number of ‘likes’.
The videos were compared to a standardised checklist on first-aid management for epistaxis developed by Haymes and Harries, which is a reflection of current best practice from NICE Clinical Knowledge Summaries guidelines and Patient UK websites.Reference Haymes and Harries13,14,Reference Patient16 The eight criteria are: lean forwards, apply pressure to the appropriate part of the nose, apply pressure for at least 10 minutes, use ice packs or a cold compress, spit out (and avoid swallowing) blood, breathe through the mouth, seek medical attention if it does not resolve after 15 minutes of pressure, and provision of aftercare advice. Each criterion was marked as either absent or present in the video (score of 0 or 1, respectively), giving a total maximum epistaxis ‘advice’ score of 8.
A subjective evaluation of the videos was performed using the Patient Education Materials Assessment Tool for Audiovisual Materials (‘PEMAT-A/V’), which contains 17 questions addressing the understandability and actionability of patient education materials. Understandability was measured using a 13-item scale that focuses on video content, word choice, use of visual aids and organisational format, whilst actionability was determined using a 4-item scale. Understandability and actionability scores were reported as a percentage of fulfilled items out of 13 and 4 items, respectively. This process was performed independently by two otolaryngology trainees, both members of the Royal College of Surgeons of England (HD and BVT), with disagreements resolved through discussion before a consensus was reached.
Statistical analysis
Summary statistics were calculated for descriptive video characteristics, total advice score, and actionability and understandability (Patient Education Materials Assessment Tool for Audiovisual Materials) scores. Correlations between video characteristics (view count, video age, video length, number of comments and number of ‘likes’), objective advice score, understandability score and actionability score were calculated using Spearman's rank correlation co-efficients. P-values of less than 0.05 were considered statistically significant. Statistical analyses were performed using Microsoft™ Excel® for Mac software (version 16.65).
Results
The first 50 videos, sorted based on ‘relevance’, were screened for suitability. Twelve videos were aimed at medical professionals in a hospital setting; these depicted cauterisation, anterior nasal packing or other use of medical equipment. Another six videos were excluded because they: lacked audio narration, promoted alternative medicine or did not focus on first-aid management. A total of 32 videos were deemed eligible for inclusion in the study.
Table 1 summarises the characteristics of the 32 selected videos. Overall, 19 videos (59 per cent) were produced in the USA and 6 (19 per cent) in the UK. The remaining videos were produced in: Canada (n = 2), the Netherlands (n = 1), India (n = 1), Italy (n = 1), Australia (n = 1) and Singapore (n = 1). Across all videos, the mean view count was 159 562 (standard deviation (SD) = 304 557), with a range of 119 to 1 622 877 views. Videos were uploaded between 2008 and 2020, with a mean age of 6.73 years (SD = 3.65). The mean video length was 2.5 minutes (SD = 1.5). The mean number of comments was 132 (SD = 233) and the mean number of ‘likes’ was 882 (SD = 1199). Six videos (19 per cent) were from an accredited institution.
Video characteristics, advice score and PEMAT-A/V score of the 32 selected videos
PEMAT-A/V = Patient Education Materials Assessment Tool for Audiovisual Materials; hr:min:sec = hours:minutes:seconds; SD = standard deviation
Correlation analysis of video characteristic data revealed a series of statistically significant associations (Table 2). There were strong positive correlations between the number of views and the age of the video (ρ = 0.568; p < 0.001), the number of likes (ρ = 0.908; p < 0.001) and the number of comments (ρ = 0.845; p < 0.001). Moderately strong negative correlations were observed between video rank and the number of views (ρ = −0.502; p = 0.004), the number of likes (ρ = −0.548; p = 0.001) and the number of comments (ρ = −0.456; p = 0.009).
Summary of correlation analysis
*Indicates significant correlations
Our objective evaluation revealed that 29 videos (91 per cent) advised patients to lean forward as soon as a nosebleed commenced. Only 15 videos (47 per cent) advised avoiding swallowing blood and only 9 videos (28 per cent) provided aftercare advice. Even fewer videos suggested breathing through the mouth (n = 5, 16 per cent) or using ice packs (n = 9, 28 per cent). Thirty videos (94 per cent) demonstrated the appropriate part of the nose to apply pressure, but only 19 videos (59 per cent) advised sustaining pressure for at least 10 minutes, as recommended by NICE Clinical Knowledge Summaries guidelines (Table 3). Six videos (19 per cent) did not mention how long to sustain nasal pressure, whilst 7 videos (22 per cent) suggested less than 10 minutes. Ten videos (31 per cent) advised seeking medical attention if the epistaxis episode did not resolve after 15 minutes of conservative management, and 18 videos (56 per cent) did not specify a time period. The mean advice score for the videos was 4.1 out of 8 (SD = 1.9).
Content appraisal of the 32 selected videos based on the advice score
The subjective evaluation is summarised in Figure 2, which depicts the mean scores for each criterion of the Patient Education Materials Assessment Tool for Audiovisual Materials. The mean understandability score was 76 per cent (SD = 17 per cent). Notably, 94 per cent of videos successfully applied common language and used an active voice. More than 80 per cent of videos used medical language only for familiarisation, and presented the information in a logical sequence. However, only 39 per cent of videos utilised informative headers and only 14 per cent provided a summary. The mean actionability score was 89 per cent (SD = 18 per cent). Two categories scored over 90 per cent (addressing the user directly and identifying an action to stop epistaxis), whilst 75 per cent of videos were able to break down actions into manageable steps. There was a strong positive correlation between the actionability scores and the advice scores (ρ = 0.634; p < 0.001), and between the actionability scores and the understandability scores (ρ = 0.519; p = 0.002) (Table 2).
Summary of understandability and actionability scores.
Discussion
YouTube provides a large depository for audio-visual information on managing epistaxis. The platform is easily accessible, with more than two billion users and the potential to reach 95 per cent of the world.Reference Tackett, Slinn, Marshall, Gaglani, Waldman and Desai17,18 In recent years, there has been a rise in the number of people searching YouTube for health-related information.Reference Desai, Shariff, Dhingra, Minhas, Eure and Kats19 However, authors with unknown qualifications can freely upload videos, making the information imparted unreliable. The exact search algorithm used by YouTube is unknown, but it is likely to prioritise entertainment value over informational accuracy. This makes it harder to direct users towards videos of greater educational significance using the search parameters available.Reference Eysenbach and Köhler20 This is demonstrated within our study, whereby the video with the highest objective and subjective score was ranked 25 on ‘relevance’. The video had 1162 views, which is far fewer than the mean view count of all 32 selected videos (i.e. 159 562 views). YouTube has sought to address this dissonance by creating an ‘accredited’ banner for health-related videos authored by verified healthcare resources. The online platform adopted principles set by the National Academy of Medicine to identify credible healthcare resources, starting with pre-vetted public health and government organisations.21 From our assessment, 6 videos (19 per cent) were from an accredited institution, but only 2 of these videos were ranked within the first 10.
• Online video websites, such as YouTube, are being increasingly used to search for healthcare information
• Videos uploaded to social media platforms are not peer-reviewed and can vary in patient understandability
• A 2016 evaluation of YouTube videos on epistaxis first-aid management showed the quality to be highly variable, with poor adherence to guidelines
• This study evaluated the 50 highest-ranking videos upon searching ‘how to stop a nosebleed’ using an objective first-aid management checklist and a subjective assessment tool
• Analysis showed YouTube videos are providing more pertinent and precise advice on epistaxis first-aid management, compared to the 2016 study
• It is proposed that YouTube can be a useful medium for teaching epistaxis first-aid management to patients and community practitioners when carefully navigated
We compared our results with those of Haymes and Harries, who searched ‘How to stop a nosebleed’ on YouTube in 2016.Reference Haymes and Harries13 Their study produced a mean advice score of 2.0, whilst our study yielded a mean advice score of 4.1. This is a positive outcome, suggesting an overall improvement in informational accuracy over recent years. However, one area that scored low in both studies was the duration of nasal compression advised. This may be explained by the discordance between national guidelines for epistaxis management in America (American Academy of Otolaryngology – Head and Neck Surgery) and the UK (NICE Clinical Knowledge Summaries).14,Reference Tunkel, Anne, Payne, Ishman, Rosenfeld and Abramson22 There is no general consensus over the optimum period for nasal compression as there is insufficient evidence available.Reference Tunkel, Anne, Payne, Ishman, Rosenfeld and Abramson22 The American guideline states that nasal compression should be provided for a minimum of 5 minutes, whilst the UK recommends 10 minutes. This has a marked effect on the study, wherein 59 per cent of the videos originated from America. Furthermore, both studies found that a significant portion of videos failed to correctly specify the length of time one should wait before seeking medical attention. One population study found that 10 per cent of epistaxis patients will seek medical attention, but most epistaxis cases respond to simple first-aid measures and only 0.16 per cent of patients require admission.Reference Tunkel, Anne, Payne, Ishman, Rosenfeld and Abramson22 Therefore, better education of epistaxis first-aid management may help in reducing the workload of overstretched emergency services. This is supported by Neshewat et al., who found that the implementation of an epistaxis educational programme for patients on warfarin led to a reduction in emergency department visits.Reference Neshewat, Wasserman, Alexandris-Souphis, Haymart, Feldeisen and Kong23
As patients are increasingly looking towards online material for knowledge regarding their condition, the understandability of health information is vital.Reference Rössler, Lahner, Schebesta, Chiari and Plöchl24 A health survey found that over 50 per cent of patients changed their perspective of a disease after performing research online.Reference Iverson, Howard and Penny25 The Patient Education Materials Assessment Tool for Audiovisual Materials is a method for evaluating online audio-visual patient material, and has been applied to videos relating to otolaryngology issues and conditions such as hearing aid quality, endoscopic sinus surgery and sinusitis.Reference Rubel, Alwani, Nwosu, Bandali, Shipchandler and Illing11,Reference Gill, Biggs, Hagwood, Beliveau, Shahlaie and Strong26,Reference Chen, Zhou, Zhao and Tang27 However, such studies reported a poor Patient Education Materials Assessment Tool score that fell well below the recommended threshold of 70 per cent.Reference Shoemaker, Wolf and Brach10 In comparison, our study demonstrated that the Patient Education Materials Assessment Tool score for epistaxis first-aid management videos on YouTube surpassed the minimum standard threshold, with mean understandability and actionability scores of 76 per cent and 89 per cent, respectively. In contrast, Haymes and Harries reported a low standard of production quality among selected videos, with a mean score of 1.6 out of 3.Reference Haymes and Harries13 High-quality patient educational material is important for teaching low health literacy populations, who are more susceptible to misunderstanding instructional information.Reference Doak, Doak, Friedell and Meade28
This is the first study to evaluate online audio-visual patient material on epistaxis first-aid management using the Patient Education Materials Assessment Tool for Audiovisual Materials criteria. Whilst there is an element of subjectivity towards the interpretation and application of the scoring criteria, this was minimised by appointing two independent reviewers to provide responses.
Another limitation is the cross-sectional manner of our search, which does not reflect the dynamic nature of uploading online videos and changes in popularity. Moreover, this study only analysed one online platform, YouTube. There are other mainstream video sharing platforms, which may contain relevant epistaxis patient advice but are likely less popular than YouTube. Cross-platform comparison could be the focus of a future study. Finally, this study only included videos narrated in English; therefore, our findings can only be relevant to the English-speaking world.
Conclusion
Our appraisal of the highest-ranking videos on YouTube pertaining to epistaxis first-aid management showed that the content is becoming more accurate and more understandable. With more patients seeking online materials for medical advice, simple and easily applicable content carries high value. YouTube has taken steps to identify credible authors, although it remains unclear if this is preferentially weighted within the search ranking algorithm. We propose that YouTube can be a useful medium for teaching epistaxis first-aid management to patients and community practitioners, when carefully navigated.
Competing interests
None declared
