The Internet vs kidney stones: What is the state of online kidney stone prevention information?

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Bassel Salka, Nadir El-Saidi, Dawan Naqshabandi, Belgin Kazkaz, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3079168/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION: The incidence of kidney stones continues to increase despite strong evidence of medical prevention of stone formation. With many patients seeking health information online, little is known regarding the quality of kidney stone prevention information available today. The purpose of this study was to evaluate the quality of kidney stone prevention information online. METHODS: We analyzed the first 50 results of the search term “kidney stone prevention” on the most popular search engine (Google), long-form media player (YouTube), short-form media player (TikTok) and social media platform (Instagram). Only content in English, related to the topic, and with greater than 1,000 views (when available) were included. Video quality was assessed utilizing DISCERN, a tool used to appraise consumer health information and the proportion of content that accurately represents AUA medical management guidelines. RESULTS: The average DISCERN score was statistically greatest on Google (60.1) followed by Youtube (40.4), TikTok (26.6) and Instagram (28.8). The most common type of content creator was Health Systems on Google (72%), physician personal creator on YouTube (56%), and non-physician personal creator on TikTok (84%) and Instagram (56%). TikTok is the only platform that shows a significantly different DISCERN score between healthcare/physician creators and non-physician creators. CONCLUSION: Kidney stone prevention content on the Internet is strongest on Google. The majority of videos on TikTok and Instagram are of low quality and fail to address AUA guidelines. Increased engagement on these platforms by urologists can improve education. kidney stone prevention online patient education social media Figures Figure 1 Introduction The prevalence of kidney stones in the United States continues to increase despite strongly supported kidney stone prevention practices 1 , 2 . As a result, many urologists have focused on improving patient education on medical management to prevent stone formation. With many patients resorting to online resources for healthcare information, the quality of patient education information on the internet has become a point of interest. Specifically, the value and reach of search engines and social media have become an increasingly studied topic in urology 3 , 4 . A systematic review published in 2018 explored studies pertaining to the accuracy and usefulness of search engines and social media for education of kidney stone formers 5 . The study identified ten papers exploring the popularity and content of Twitter, YouTube, smartphone apps and Google search engine and concluded that social media and search engines provide valuable yet non-comprehensive information to patients with stone disease. None of the studies included in this review or published since have evaluated and compared various online platforms with one standardized evaluation metric. Additionally, little has been written on the quality of information on TikTok and Instagram, two of the most popular social media platforms in the United States 6 , 7 . The purpose of this study was to assess the quality and reach of kidney stone prevention information on the Internet by evaluating some of the most popular online platforms (search engine, long-form media player, short-form media player, and social media app). The study consisted of three objectives: 1) to report kidney stone prevention content characteristics on each platform including popularity, creator type, and content themes, 2) to assess and compare the quality of kidney stone prevention content on each platform using the DISCERN media evaluation criteria and concordance with American Urologic Association (AUA) recommendations, and 3) to identify factors that influence content quality on each platform. This study can illuminate gaps in stone prevention information online and ultimately provide a target for intervention that can increase the quality and distribution of kidney stone prevention education. Methods Content Selection We conducted a cross-sectional analysis of renal stone prevention content in the United States’ most popular search engine (Google 8 ), most popular long-form media player (YouTube 8 ), most popular short-form media app (TikTok 7 ) and most popular social media app (Instagram 6 ). Only content in English, related to the topic, and with greater than 1,000 views (when available) were included. We utilized the search term “kidney stone prevention” for Google and YouTube and “#kidneystoneprevention” for TikTok and Instagram. YouTube content was limited to standard long-form videos and did not include YouTube Shorts, a short form video less than 60 seconds similar to TikTok. Before conducting any search, we created a new account, deleted all Cookies, and turned on private browsing to eliminate any user-specific responses. We then evaluated all results in order of appearance until 50 pieces of content fit our inclusion criteria. Data collection Two reviewers separately recorded information on each platform’s content creator, popularity (when available), DISCERN score, and video content. When the two reviewers disagreed on a particular piece of data, a third reviewer reviewed the video and settled the difference. Inter-reliability was ensured by confirming a minimum of 95% agreement across all reviewers. Information about each video’s creator was collected through the website’s “About” section (google) and the creator’s homepage (YouTube, TikTok, and Instagram). Whenever this information was not provided, the creator was designated as “Unknown”. The popularity of a piece of content was measured as the number of views, number of likes, and number of comments for each post when available. Google Search does not provide public information on the number of clicks a certain page receives and does not have an option for likes and comments. Instagram does not report views but does report likes and comments. Quality of content was ascertained through two systems. First, the DISCERN evaluation system, a 15 question survey that takes the sum of all questions answered with the Likert scale (“5” a strong yes and “1” a strong no), was used to assess the quality of each video 9 . Second, the proportion of content that mentions specific AUA stone prevention recommendations was found by reporting the exact stone prevention recommendations each piece of content describes and comparing to the AUA stone prevention medical management guidelines 10 . Data analysis A Wilcoxon Rank-Sum test was used to evaluate significant differences in the views, likes, and comments between the platforms given a non-parametric distribution of the data. A one-way variance analysis (ANOVA) was used to determine statistically significant differences in DISCERN scores between the platforms given a parametric distribution of the data. The proportion of videos that mention each AUA recommendation was determined by calculating the proportion of posts that mentioned particular AUA guidelines for medical management of stone prevention. All analysis was completed with PRISM (Graphpad Software, San Diego, CA). Results Content Selection A total of 50 Google, 59 YouTube, 64 TikTok, and 63 Instagram results were examined to find 50 that fit the inclusion criteria. All of the first 50 results on Google fit the inclusion criteria. The most common reason for exclusion on YouTube and TikTok was media containing less than 1,000 views. The most common cause for exclusion on Instagram was “Unrelated content”. These findings are summarized in Fig. 1. Content characteristics For the platforms that recorded the number of views (YouTube and TikTok), YouTube was the most popular with a median of 20,995 views per video as shown in Table 1 . Of the platforms that recorded likes and comments (YouTube, TikTok, and Instagram), Instagram was the least popular with a median of 55 likes and 8 comments per post. The most common type of content creator was Health Systems on Google (72%), physician personal creator on YouTube (56%), and non-physician personal creator on TikTok (84%) and Instagram (56%). Over 94% of the videos created across all platforms were made to be educational (as opposed to promotional or anecdotal). Table 1 Platform characteristics Google YouTube TikTok Instagram Popularity Median Views (2nd quartile, 3rd quartile) N/A 20,995.5 (3,951, 82,183) 11,300.0 (28,989, 53,400) N/A Median Likes (2nd quartile, 3rd quartile) N/A 216 (49, 759) 257 (84, 1680) 55 (10, 154) Median Comments (2nd quartile, 3rd quartile) N/A 19 (5, 120) 12 (2, 42) 8 (4, 14) Content Creator Health System 72% 22% 2% 26% Business 2% 2% 0% 0% Non-physician personal/creator 6% 18% 84% 56% Physician personal/creator 18% 50% 14% 18% Other 2% 8% 0% 0% Content Quality The average DISCERN score across all platforms was 40.59. The platform with the statistically highest discern score using ANOVA was Google (60.1 ± 8.1) followed by YouTube (44.9 ± 12.7), Instagram (30.5 ± 3.3) and TikTok (26.8 ± 11.8). The platform with the most AUA recommendations mentioned on average was Google (85.3% ± 10.6%) while the least was TikTok (19.0% ± 11.6%) and Instagram (22.7 ± 6.8%). No significant differences existed between the average proportion for each type of recommendation was mentioned across the four platforms as shown in Table 2 . Table 2 Content Quality AUA Recommendation Proportion of posts Google YouTube TikTok Instagram Increase fluid 98% 78% 36% 32% Limit sodium 96% 62% 20% 22% Control calcium 78% 54% 28% 18% Limit Oxalate 86% 14% 14% 16% Increase fruits and vegetables 70% 34% 4% 30% Limit non-dairy protein 84% 38% 12% 18% Average 85.3% ± 10.6% 46.7% ± 22.7% 19.0% ± 11.6% 22.7 ± 6.8% Factors affecting quality For the platforms that report the total number of views (YouTube and TikTok), the DISCERN score did not have a significant difference in the bottom 20% and top 20% most viewed content creations on YouTube but did have statistical difference on TikTok as shown in Table 3 . No statistical difference was observed for platforms that reported likes and comments (YouTube, TikTok and Instagram) DISCERN scores between the most liked/commented content and least liked/commented videos within a single platform. Table 3 DISCERN score stratified by creator/content characteristics Platform Google YouTube TikTok Instagram Popularity Bottom 20% views N/A 44.1 ± 11.2 21.4 ± 4.7 N/A Top 20% views N/A 38.4 ± 15.0 36.0 ± 11.6 N/A Bottom 20% Likes N/A 39.8 ± 10.7 21.0 ± 4.7 29.9 ± 3.0 Top 20% Likes N/A 36.6 ± 13.7 28.5 ± 11.4 31.2 ± 4.2 Bottom 20% Comments N/A 44.2 ± 13.9 20.3 ± 6.0 30.4 ± 3.1 Top 20% Comments N/A 34.1 ± 11.1 31.4 ± 14.0 30.0 ± 2.9 Content Creator Health System 59.3 ± 7.9 40.8 ± 9.4 22.0 ± 0.0 32.1 ± 4.1 Business 69.0 ± 0.0 23.0 ± 0.0 N/A N/A Physician personal/creator 62.1 ± 7.6 48.2 ± 13.8 41.0 ± 7.3 30.2 ± 2.9 Non-physician personal/creator 54.3 ± 3.5 44.5 ± 12.3 24.6 ± 10.9 29.9 ± 2.9 Other 73.0 ± 0.0 45.8 ± 13.3 N/A N/A Physician and health system content creators had a statistically different DISCERN score on TikTok compared to non-physician personal creators. However, no differences existed in DISCERN score between various creators on Google, YouTube, and Instagram. Discussion We evaluated 50 posts of online content from Google, YouTube, TikTok, and Instagram that were related to kidney stone prevention. Google had the most relevant pieces of content after initial query while Instagram had the lowest amount of pertinent content. YouTube was the most popular platform amongst those that collect views, likes or comments and Instagram was the least popular. The most common type of content creator was Health Systems on Google, physician personal creator on YouTube, and non-physician personal creator on TikTok and Instagram. The average DISCERN score was statistically greatest on Google followed by YouTube, TikTok and Instagram. No difference exists in the proportion of videos that represent each AUA medical kidney stone prevention guideline. TikTok is the only platform that shows a significantly different DISCERN score between healthcare/physician creators and non-physician creators. Our finding that millions of people are consuming kidney stone prevention across many different platforms has been confirmed by many other studies. The systematic review from 2018 reported an increase in social media and search engine usage over the last decade and that more videos, apps and search engine results are being created regarding management and prevention of stone disease. An analysis of kidney stone search trends on Google revealed a statistically significant increase over the last ten years in both developed and undeveloped nations 11 . Another study published in 2021 7 found that kidney stone prevention information on YouTube has doubled between 2015 and 2019. Similar findings have been conducted on Instagram and TikTok 3 . Our study further demonstrates the enlarging corpus of kidney stone prevention information online, both on Google and social media platforms. Although to our knowledge, no definitive classification of DISCERN score has been formally agreed upon and published, the scores we calculated for kidney stone prevention information online is generally lower than published studies in other fields of medicine 12 – 14 . Although the DISCERN system was developed as a standardized system for assessing content quality, it may still be subject to reviewer bias. Therefore, the best way of assessing quality between platforms is through intra study comparisons. Many studies have completed similar analyses to ours in the field of urology and have found similar findings. A study comparing modified DISCERN scores of erectile dysfunction content on YouTube and Tiktok 15 also found that YouTube had significantly higher quality information. These findings were paralleled in a study evaluating pelvic organ prolapse content on YouTube, Pinterest, and Instagram which found that YouTube had the highest content quality as well as the most creators associated with healthcare 16 . Lastly, an assessment of varicocele information on TikTok found that content produced by healthcare professionals/urologists was significantly higher than non-healthcare workers despite urologists only making up around 5.5% of all content creators 17 . Notably, all these studies, as well as others evaluating urological information on just YouTube or Google concluded that the overall quality of online information in their respective focus was unsatisfactory 18 – 20 . Our evaluation of kidney stone prevention content is similar to other fields of urology in which the overall DISCERN score across platforms is low and between platforms, Google and YouTube generally have higher quality than TikTok and Instagram. Our study found that physician created content on TikTok was significantly better quality than TikTok content created by non-physicians. This was noteworthy given the majority of creators on Google and YouTube, platforms with relatively high-quality content, were made up almost entirely by physicians or healthcare systems. This pattern was documented in the 2018 systematic review on online kidney stone prevention that concluded that the most accurate information was ascertained from physician and healthcare related websites and that content from non-physicians generally was of lower quality than physician created content. The improvement in quality of content when created by physicians/health professionals when compared to non-physicians has been observed in other urological areas as well 3 . As a result, our findings of lower information quality on TikTok and Instagram in conjunction with decreased non-physician content quality on TikTok and low physician involvement in Instagram reveals potential mediums that physicians should direct efforts towards in improving patient education. Although this is the first study to evaluate kidney stone prevention content on multiple online platforms using standardized assessment criteria, some limitations must be addressed. First, our study only looked at four platforms and is not representative of other search engines, media players, or social media applications. However, all the platforms we selected represent a minimum of 50% market share within search engines, long form media players, short form media players, and social media platforms. Second, we only used one search term for the assessment of kidney stone prevention and the usage of a variant term may have yielded different results. This practice is in line with similar studies on online content evaluation 15 , 21 , 22 . Third, we only evaluated content in English using an internet network within the United States. Content from other countries and languages may yield different statistics. Fourth, we only evaluated a subset (first 50 results) of online content that may not be representative of all other content. However, this practice is consistent with other published studies 15 and is controlled by creating a new account, clearing cookies, and using private browsing when conducting the search. Lastly, a cross-sectional study based upon the most popular videos and posts at a single point in time. Content is continuously produced and can change, especially with disrupting technologies like the possible advent of a new search engine or social media platform. Limitations notwithstanding, this is the first study to evaluate kidney stone prevention content on multiple online platforms using standardized assessment criteria. Our study affirmed the wide reach of online content regarding kidney stones and identified social media platforms like TikTok and Instagram have lower quality on average than Google and YouTube. Our findings of decreased content quality by non-physician creators on Tiktok, in parallel with low overall kidney stone content on Instagram, suggests that increasing physician engagement with these social media platforms can improve overall quality and reach. As a result, the general population can become better informed about evidence-based kidney stone prevention methods and potentially decrease the risk of kidney stone disease. Millions of people are already consuming kidney stone prevention information online and urologists have the opportunity to improve the information shared. Future directions of this study include a re-evaluation of online content after a suitable amount of time. The online environment evolves rapidly, as demonstrated by the recent growth of TikTok, and it is crucial to examine how new forms of online media will affect the content users consume. Further work is also needed to evaluate how consumers perceive health information online and if it has any effect on adherence to lifestyle modifications. The findings of a study of this kind will contextualize the potential impact of online information. Lastly, further analyses are needed to evaluate the amount of kidney stone prevention disinformation is online. Identification of where patients get erroneous information can further help guide efforts to improve stone prevention education online. CONCLUSIONS The reach and quality of kidney stone prevention information online is highly variable. While Google and YouTube have excellent quality content, TikTok and Instagram are not reliable places for education. Engagement on these platforms by healthcare providers can improve the quality of kidney stone prevention information and potentially increase adoption of evidence-based kidney stone prevention practices. Declarations Statements and declarations: No funds, grants, or other support was received. The authors have no relevant financial or non-financial interests to disclose. No IRB was required for this study. References Hill AJ, Basourakos SP, Lewicki P, et al. Incidence of Kidney Stones in the United States: The Continuous National Health and Nutrition Examination Survey. J Urol . 2022;207(4):851-856. doi:10.1097/JU.0000000000002331 Pearle MS, Roehrborn CG, Pak CY. Meta-analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. J Endourol . 1999;13(9):679-685. doi:10.1089/end.1999.13.679 Diaz P, Takele RA, Thaker S, et al. 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BJUI Compass . 2021;2(6):412-418. doi:10.1002/bco2.87 Mozafarpour S, Norris B, Borin J, Eisner BH. Assessment of readability, quality and popularity of online information on ureteral stents. World J Urol . 2018;36(6):985-992. doi:10.1007/s00345-018-2179-9 Di Bello F, Collà Ruvolo C, Cilio S, et al. Testicular cancer and YouTube: What do you expect from a social media platform? Int J Urol . 2022;29(7):685-691. doi:10.1111/iju.14871 Bai G, Pan X, Zhao T, Chen X, Liu G, Fu W. Quality Assessment of YouTube Videos as an Information Source for Testicular Torsion. Front Public Health . 2022;10:905609. doi:10.3389/fpubh.2022.905609 Huang MM, Winoker JS, Matlaga BR, Allaf ME, Koo K. Evidence-based analysis of online consumer information about prostate artery embolization for benign prostatic hyperplasia. Prostate Cancer Prostatic Dis . 2021;24(1):106-113. doi:10.1038/s41391-020-0242-2 Additional Declarations No competing interests reported. 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As a result, many urologists have focused on improving patient education on medical management to prevent stone formation. With many patients resorting to online resources for healthcare information, the quality of patient education information on the internet has become a point of interest. Specifically, the value and reach of search engines and social media have become an increasingly studied topic in urology\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA systematic review published in 2018 explored studies pertaining to the accuracy and usefulness of search engines and social media for education of kidney stone formers\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The study identified ten papers exploring the popularity and content of Twitter, YouTube, smartphone apps and Google search engine and concluded that social media and search engines provide valuable yet non-comprehensive information to patients with stone disease. None of the studies included in this review or published since have evaluated and compared various online platforms with one standardized evaluation metric. Additionally, little has been written on the quality of information on TikTok and Instagram, two of the most popular social media platforms in the United States\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to assess the quality and reach of kidney stone prevention information on the Internet by evaluating some of the most popular online platforms (search engine, long-form media player, short-form media player, and social media app). The study consisted of three objectives: 1) to report kidney stone prevention content characteristics on each platform including popularity, creator type, and content themes, 2) to assess and compare the quality of kidney stone prevention content on each platform using the DISCERN media evaluation criteria and concordance with American Urologic Association (AUA) recommendations, and 3) to identify factors that influence content quality on each platform. This study can illuminate gaps in stone prevention information online and ultimately provide a target for intervention that can increase the quality and distribution of kidney stone prevention education.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eContent Selection\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional analysis of renal stone prevention content in the United States\u0026rsquo; most popular search engine (Google\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e), most popular long-form media player (YouTube\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e), most popular short-form media app (TikTok\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e) and most popular social media app (Instagram\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e). Only content in English, related to the topic, and with greater than 1,000 views (when available) were included. We utilized the search term \u0026ldquo;kidney stone prevention\u0026rdquo; for Google and YouTube and \u0026ldquo;#kidneystoneprevention\u0026rdquo; for TikTok and Instagram. YouTube content was limited to standard long-form videos and did not include YouTube Shorts, a short form video less than 60 seconds similar to TikTok. Before conducting any search, we created a new account, deleted all Cookies, and turned on private browsing to eliminate any user-specific responses. We then evaluated all results in order of appearance until 50 pieces of content fit our inclusion criteria.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eTwo reviewers separately recorded information on each platform\u0026rsquo;s content creator, popularity (when available), DISCERN score, and video content. When the two reviewers disagreed on a particular piece of data, a third reviewer reviewed the video and settled the difference. Inter-reliability was ensured by confirming a minimum of 95% agreement across all reviewers.\u003c/p\u003e \u003cp\u003eInformation about each video\u0026rsquo;s creator was collected through the website\u0026rsquo;s \u0026ldquo;About\u0026rdquo; section (google) and the creator\u0026rsquo;s homepage (YouTube, TikTok, and Instagram). Whenever this information was not provided, the creator was designated as \u0026ldquo;Unknown\u0026rdquo;. The popularity of a piece of content was measured as the number of views, number of likes, and number of comments for each post when available. Google Search does not provide public information on the number of clicks a certain page receives and does not have an option for likes and comments. Instagram does not report views but does report likes and comments.\u003c/p\u003e \u003cp\u003eQuality of content was ascertained through two systems. First, the DISCERN evaluation system, a 15 question survey that takes the sum of all questions answered with the Likert scale (\u0026ldquo;5\u0026rdquo; a strong yes and \u0026ldquo;1\u0026rdquo; a strong no), was used to assess the quality of each video\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Second, the proportion of content that mentions specific AUA stone prevention recommendations was found by reporting the exact stone prevention recommendations each piece of content describes and comparing to the AUA stone prevention medical management guidelines\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eA Wilcoxon Rank-Sum test was used to evaluate significant differences in the views, likes, and comments between the platforms given a non-parametric distribution of the data. A one-way variance analysis (ANOVA) was used to determine statistically significant differences in DISCERN scores between the platforms given a parametric distribution of the data. The proportion of videos that mention each AUA recommendation was determined by calculating the proportion of posts that mentioned particular AUA guidelines for medical management of stone prevention. All analysis was completed with PRISM (Graphpad Software, San Diego, CA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eContent Selection\u003c/h2\u003e\n\u003cp\u003eA total of 50 Google, 59 YouTube, 64 TikTok, and 63 Instagram results were examined to find 50 that fit the inclusion criteria. All of the first 50 results on Google fit the inclusion criteria. The most common reason for exclusion on YouTube and TikTok was media containing less than 1,000 views. The most common cause for exclusion on Instagram was \u0026ldquo;Unrelated content\u0026rdquo;. These findings are summarized in Fig.\u0026nbsp;1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eContent characteristics\u003c/h2\u003e\n\u003cp\u003eFor the platforms that recorded the number of views (YouTube and TikTok), YouTube was the most popular with a median of 20,995 views per video as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the platforms that recorded likes and comments (YouTube, TikTok, and Instagram), Instagram was the least popular with a median of 55 likes and 8 comments per post. The most common type of content creator was Health Systems on Google (72%), physician personal creator on YouTube (56%), and non-physician personal creator on TikTok (84%) and Instagram (56%). Over 94% of the videos created across all platforms were made to be educational (as opposed to promotional or anecdotal).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePlatform characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGoogle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eYouTube\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTikTok\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInstagram\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003ePopularity\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian Views (2nd quartile, 3rd quartile)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20,995.5\u003c/p\u003e\n\u003cp\u003e(3,951, 82,183)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11,300.0\u003c/p\u003e\n\u003cp\u003e(28,989, 53,400)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian Likes (2nd quartile, 3rd quartile)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216\u003c/p\u003e\n\u003cp\u003e(49, 759)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e257\u003c/p\u003e\n\u003cp\u003e(84, 1680)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55 (10, 154)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian Comments (2nd quartile, 3rd quartile)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003cp\u003e(5, 120)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003cp\u003e(2, 42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003cp\u003e(4, 14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eContent Creator\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth System\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBusiness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-physician personal/creator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysician\u003c/p\u003e\n\u003cp\u003epersonal/creator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eContent Quality\u003c/h2\u003e\n\u003cp\u003eThe average DISCERN score across all platforms was 40.59. The platform with the statistically highest discern score using ANOVA was Google (60.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1) followed by YouTube (44.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7), Instagram (30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3) and TikTok (26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8). The platform with the most AUA recommendations mentioned on average was Google (85.3% \u0026plusmn; 10.6%) while the least was TikTok (19.0% \u0026plusmn; 11.6%) and Instagram (22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8%). No significant differences existed between the average proportion for each type of recommendation was mentioned across the four platforms as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eContent Quality\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAUA Recommendation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eProportion of posts\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGoogle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eYouTube\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTikTok\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInstagram\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIncrease fluid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimit sodium\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eControl calcium\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimit Oxalate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIncrease fruits and vegetables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimit non-dairy protein\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAverage\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85.3% \u0026plusmn; 10.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.7% \u0026plusmn; 22.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19.0% \u0026plusmn; 11.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eFactors affecting quality\u003c/h2\u003e\n\u003cp\u003eFor the platforms that report the total number of views (YouTube and TikTok), the DISCERN score did not have a significant difference in the bottom 20% and top 20% most viewed content creations on YouTube but did have statistical difference on TikTok as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. No statistical difference was observed for platforms that reported likes and comments (YouTube, TikTok and Instagram) DISCERN scores between the most liked/commented content and least liked/commented videos within a single platform.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDISCERN score stratified by creator/content characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003ePlatform\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGoogle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eYouTube\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTikTok\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInstagram\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003ePopularity\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBottom 20% views\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTop 20% views\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBottom 20% Likes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTop 20% Likes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBottom 20% Comments\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTop 20% Comments\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eContent Creator\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth System\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBusiness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysician personal/creator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-physician personal/creator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003ePhysician and health system content creators had a statistically different DISCERN score on TikTok compared to non-physician personal creators. However, no differences existed in DISCERN score between various creators on Google, YouTube, and Instagram.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe evaluated 50 posts of online content from Google, YouTube, TikTok, and Instagram that were related to kidney stone prevention. Google had the most relevant pieces of content after initial query while Instagram had the lowest amount of pertinent content. YouTube was the most popular platform amongst those that collect views, likes or comments and Instagram was the least popular. The most common type of content creator was Health Systems on Google, physician personal creator on YouTube, and non-physician personal creator on TikTok and Instagram. The average DISCERN score was statistically greatest on Google followed by YouTube, TikTok and Instagram. No difference exists in the proportion of videos that represent each AUA medical kidney stone prevention guideline. TikTok is the only platform that shows a significantly different DISCERN score between healthcare/physician creators and non-physician creators.\u003c/p\u003e \u003cp\u003eOur finding that millions of people are consuming kidney stone prevention across many different platforms has been confirmed by many other studies. The systematic review from 2018 reported an increase in social media and search engine usage over the last decade and that more videos, apps and search engine results are being created regarding management and prevention of stone disease. An analysis of kidney stone search trends on Google revealed a statistically significant increase over the last ten years in both developed and undeveloped nations\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Another study published in 2021\u003csup\u003e7\u003c/sup\u003e found that kidney stone prevention information on YouTube has doubled between 2015 and 2019. Similar findings have been conducted on Instagram and TikTok\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Our study further demonstrates the enlarging corpus of kidney stone prevention information online, both on Google and social media platforms.\u003c/p\u003e \u003cp\u003eAlthough to our knowledge, no definitive classification of DISCERN score has been formally agreed upon and published, the scores we calculated for kidney stone prevention information online is generally lower than published studies in other fields of medicine\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Although the DISCERN system was developed as a standardized system for assessing content quality, it may still be subject to reviewer bias. Therefore, the best way of assessing quality between platforms is through intra study comparisons. Many studies have completed similar analyses to ours in the field of urology and have found similar findings. A study comparing modified DISCERN scores of erectile dysfunction content on YouTube and Tiktok\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e also found that YouTube had significantly higher quality information. These findings were paralleled in a study evaluating pelvic organ prolapse content on YouTube, Pinterest, and Instagram which found that YouTube had the highest content quality as well as the most creators associated with healthcare\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Lastly, an assessment of varicocele information on TikTok found that content produced by healthcare professionals/urologists was significantly higher than non-healthcare workers despite urologists only making up around 5.5% of all content creators\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Notably, all these studies, as well as others evaluating urological information on just YouTube or Google concluded that the overall quality of online information in their respective focus was unsatisfactory\u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Our evaluation of kidney stone prevention content is similar to other fields of urology in which the overall DISCERN score across platforms is low and between platforms, Google and YouTube generally have higher quality than TikTok and Instagram.\u003c/p\u003e \u003cp\u003eOur study found that physician created content on TikTok was significantly better quality than TikTok content created by non-physicians. This was noteworthy given the majority of creators on Google and YouTube, platforms with relatively high-quality content, were made up almost entirely by physicians or healthcare systems. This pattern was documented in the 2018 systematic review on online kidney stone prevention that concluded that the most accurate information was ascertained from physician and healthcare related websites and that content from non-physicians generally was of lower quality than physician created content. The improvement in quality of content when created by physicians/health professionals when compared to non-physicians has been observed in other urological areas as well\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. As a result, our findings of lower information quality on TikTok and Instagram in conjunction with decreased non-physician content quality on TikTok and low physician involvement in Instagram reveals potential mediums that physicians should direct efforts towards in improving patient education.\u003c/p\u003e \u003cp\u003eAlthough this is the first study to evaluate kidney stone prevention content on multiple online platforms using standardized assessment criteria, some limitations must be addressed. First, our study only looked at four platforms and is not representative of other search engines, media players, or social media applications. However, all the platforms we selected represent a minimum of 50% market share within search engines, long form media players, short form media players, and social media platforms. Second, we only used one search term for the assessment of kidney stone prevention and the usage of a variant term may have yielded different results. This practice is in line with similar studies on online content evaluation\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Third, we only evaluated content in English using an internet network within the United States. Content from other countries and languages may yield different statistics. Fourth, we only evaluated a subset (first 50 results) of online content that may not be representative of all other content. However, this practice is consistent with other published studies\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e and is controlled by creating a new account, clearing cookies, and using private browsing when conducting the search. Lastly, a cross-sectional study based upon the most popular videos and posts at a single point in time. Content is continuously produced and can change, especially with disrupting technologies like the possible advent of a new search engine or social media platform.\u003c/p\u003e \u003cp\u003eLimitations notwithstanding, this is the first study to evaluate kidney stone prevention content on multiple online platforms using standardized assessment criteria. Our study affirmed the wide reach of online content regarding kidney stones and identified social media platforms like TikTok and Instagram have lower quality on average than Google and YouTube. Our findings of decreased content quality by non-physician creators on Tiktok, in parallel with low overall kidney stone content on Instagram, suggests that increasing physician engagement with these social media platforms can improve overall quality and reach. As a result, the general population can become better informed about evidence-based kidney stone prevention methods and potentially decrease the risk of kidney stone disease. Millions of people are already consuming kidney stone prevention information online and urologists have the opportunity to improve the information shared.\u003c/p\u003e \u003cp\u003eFuture directions of this study include a re-evaluation of online content after a suitable amount of time. The online environment evolves rapidly, as demonstrated by the recent growth of TikTok, and it is crucial to examine how new forms of online media will affect the content users consume. Further work is also needed to evaluate how consumers perceive health information online and if it has any effect on adherence to lifestyle modifications. The findings of a study of this kind will contextualize the potential impact of online information. Lastly, further analyses are needed to evaluate the amount of kidney stone prevention disinformation is online. Identification of where patients get erroneous information can further help guide efforts to improve stone prevention education online.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe reach and quality of kidney stone prevention information online is highly variable. While Google and YouTube have excellent quality content, TikTok and Instagram are not reliable places for education. Engagement on these platforms by healthcare providers can improve the quality of kidney stone prevention information and potentially increase adoption of evidence-based kidney stone prevention practices.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements and declarations:\u003c/strong\u003e No funds, grants, or other support was received. The authors have no relevant financial or non-financial interests to disclose. No IRB was required for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHill AJ, Basourakos SP, Lewicki P, et al. Incidence of Kidney Stones in the United States: The Continuous National Health and Nutrition Examination Survey. \u003cem\u003eJ Urol\u003c/em\u003e. 2022;207(4):851-856. doi:10.1097/JU.0000000000002331\u003c/li\u003e\n\u003cli\u003ePearle MS, Roehrborn CG, Pak CY. Meta-analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. \u003cem\u003eJ Endourol\u003c/em\u003e. 1999;13(9):679-685. doi:10.1089/end.1999.13.679\u003c/li\u003e\n\u003cli\u003eDiaz P, Takele RA, Thaker S, et al. Kidney Stone Surgery: Assessing Public Interest and Evaluating Social Media Content. \u003cem\u003eJ Endourol\u003c/em\u003e. 2022;36(7):954-960. doi:10.1089/end.2021.0902\u003c/li\u003e\n\u003cli\u003eLeelani NA, Barnett PA, Nguyen S, Hyatt DC. Patient Engagement With Urologists on Social Media in a Community Practice. \u003cem\u003eCureus\u003c/em\u003e. 2021;13(9):e18029. doi:10.7759/cureus.18029\u003c/li\u003e\n\u003cli\u003eJamnadass E, Aboumarzouk O, Kallidonis P, et al. 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Accessed May 6, 2023. http://www.discern.org.uk/discern_instrument.php\u003c/li\u003e\n\u003cli\u003eKidney Stones: Medical Mangement Guideline - American Urological Association. Accessed May 6, 2023. https://www.auanet.org/guidelines-and-quality/guidelines/kidney-stones-medical-mangement-guideline\u003c/li\u003e\n\u003cli\u003eMarchini GS, Faria KVM, L F, et al. Comparing public interest on stone disease between developed and underdeveloped nations: are search patterns on google trends similar? \u003cem\u003eInt Braz J Urol\u003c/em\u003e. 2021;47(5):989-996. doi:10.1590/S1677-5538.IBJU.2020.1076\u003c/li\u003e\n\u003cli\u003eRehman R, Hasan S, Akram H, Jahnke M. TikTok as a Source of Dermatologic Information on Atopic Dermatitis. \u003cem\u003eDermatitis\u003c/em\u003e. 2022;33(6S):S133-S134. doi:10.1097/DER.0000000000000830\u003c/li\u003e\n\u003cli\u003eOzsoy-Unubol T, Alanbay-Yagci E. 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Testicular cancer and YouTube: What do you expect from a social media platform? \u003cem\u003eInt J Urol\u003c/em\u003e. 2022;29(7):685-691. doi:10.1111/iju.14871\u003c/li\u003e\n\u003cli\u003eBai G, Pan X, Zhao T, Chen X, Liu G, Fu W. Quality Assessment of YouTube Videos as an Information Source for Testicular Torsion. \u003cem\u003eFront Public Health\u003c/em\u003e. 2022;10:905609. doi:10.3389/fpubh.2022.905609\u003c/li\u003e\n\u003cli\u003eHuang MM, Winoker JS, Matlaga BR, Allaf ME, Koo K. Evidence-based analysis of online consumer information about prostate artery embolization for benign prostatic hyperplasia. \u003cem\u003eProstate Cancer Prostatic Dis\u003c/em\u003e. 2021;24(1):106-113. doi:10.1038/s41391-020-0242-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"kidney stone, prevention, online, patient education, social media","lastPublishedDoi":"10.21203/rs.3.rs-3079168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3079168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eINTRODUCTION: The incidence of kidney stones continues to increase despite strong evidence of medical prevention of stone formation. With many patients seeking health information online, little is known regarding the quality of kidney stone prevention information available today. The purpose of this study was to evaluate the quality of kidney stone prevention information online.\u003c/p\u003e \u003cp\u003eMETHODS: We analyzed the first 50 results of the search term \u0026ldquo;kidney stone prevention\u0026rdquo; on the most popular search engine (Google), long-form media player (YouTube), short-form media player (TikTok) and social media platform (Instagram). Only content in English, related to the topic, and with greater than 1,000 views (when available) were included. Video quality was assessed utilizing DISCERN, a tool used to appraise consumer health information and the proportion of content that accurately represents AUA medical management guidelines.\u003c/p\u003e \u003cp\u003eRESULTS: The average DISCERN score was statistically greatest on Google (60.1) followed by Youtube (40.4), TikTok (26.6) and Instagram (28.8). The most common type of content creator was Health Systems on Google (72%), physician personal creator on YouTube (56%), and non-physician personal creator on TikTok (84%) and Instagram (56%). TikTok is the only platform that shows a significantly different DISCERN score between healthcare/physician creators and non-physician creators.\u003c/p\u003e \u003cp\u003eCONCLUSION: Kidney stone prevention content on the Internet is strongest on Google. The majority of videos on TikTok and Instagram are of low quality and fail to address AUA guidelines. Increased engagement on these platforms by urologists can improve education.\u003c/p\u003e","manuscriptTitle":"The Internet vs kidney stones: What is the state of online kidney stone prevention information?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-26 18:42:37","doi":"10.21203/rs.3.rs-3079168/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21848b9a-6fc3-4b49-9ac6-a1fbeb28f16c","owner":[],"postedDate":"June 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-08-16T13:59:14+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-26 18:42:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3079168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3079168","identity":"rs-3079168","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}