Discussion
In this study, we evaluated the quality of YouTube videos on HoLEP that has gained popularity as a frequently preferred surgical method for BPH. Across the world, there are approximately 3 billion internet users that can share information through virtual communication and interaction via the internet in contrast to the more traditional method (16). The huge video archive on YouTube naturally consists of a large number of video contents that examine each subject or topic from different perspectives. However, available evidence has shown that patients can be exposed to low-quality, biased, and/or commercial videos, which can lead to dangerous consequences (7,17) Therefore, it is important to evaluate the reliability and quality of YouTube videos providing health information. Platforms such as YouTube allow patients to easily obtain information about the issues in which they are interested. However, based on the information presented here, patients can also make poor decisions or resort to expensive treatments. Nevertheless, the literature shows the increasing viewing of videos about the health field among patients or healthcare professionals (18).
Depending on the upload source of surgical videos on YouTube, the message conveyed to the viewer and its reliability may vary. In a study conducted by Huang et al., it was found that the videos that did not contain accurate information were viewed more and received more comments (19). In another study, it was proven that fake news or inaccurate content spread faster in the internet environment and created more interaction (20). Other researchers similarly emphasized that training videos for skill development might mislead patients due to the presence of unreliable information (21). In our study, regardless of the upload source, we observed that 16.2% had extreme- or high-degree misinformation while commercial bias was present in 55.7%. In addition, it was observed that complications and alternative treatments were not mentioned in most of the videos. In previous studies, it was shown that the majority of videos uploaded to YouTube were not reliable (22,23). In a review, it was emphasized that most of the health-related YouTube videos presented inaccurate and unreliable information (24). The literature indicates that this misinformation is not necessarily caused by a source being inappropriate or having insufficient expertise, and it could actually be intentional (25). Therefore, we consider that surgical videos on YouTube may pose more of a threat than guidance for patients seeking information to make a treatment decision.
There is no study evaluating the information sources of patients with BPH; therefore, it is not precisely known how the videos posted on video-sharing sites reflect on or affect patients. In previous studies, it was emphasized that the videos uploaded by universities or healthcare institutions provided more comprehensive information and had higher quality (26,27). In a study by Gul et al., the videos were classified as those containing reliable and unreliable information, and the GQS and reliability scores were found to be statistically higher in the former. In addition, the authors showed that the majority of videos containing reliable information had been uploaded by for-profit companies (28). In our study, 23.0% of the total videos had been uploaded by Group 2. In the literature, it has been reported that the vast majority of educational videos without any financial gain such as those on breast self-examination had been uploaded by universities or physicians, but most on oral leukoplakia had been uploaded by commercial companies for advertisement purposes (23,29). We attribute these differences to the variations of the subjects discussed in videos. In our study, no significant difference was observed in DISCERN, GQS and JAMA scores ​​between the upload source groups. There was also no difference between the two groups in relation to the total number of views, likes and dislikes. A previous study compared videos as useful and misleading, and in contrast to our findings, the authors reported the comprehensiveness score of GQS to be statistically significantly higher in useful videos (21). In the same study, when the data were compared according to the upload source, the GQS, misleading information and comprehensiveness scores were found to be statistically higher for the videos that had been uploaded by for-profit companies (21). In contrast, in our study, we also evaluated the videos using JAMA, PEMAT and Likert scales and found that the PEMAT and misinformation scores were higher in the videos uploaded by Group 2. In a study conducted by Fode et al. to evaluate videos containing medical information, the median PEMAT understandability score was found to be 100% (range 50-100) and the median PEMAT actionability score was 100% (range 33-100). It was observed that 28% of 92 videos containing medical information contained misinformation. The results of their multivariate regression analysis revealed that all the parameters of videos uploaded by medical institutions had a statistically significant effect on DISCERN rating (30). In our study, the PEMAT score differed according to the upload source of the videos. The understandability and actionability scores of the videos uploaded by Group 2 were statistically significantly higher compared to Group 1. Furthermore, although there was misinformation in both groups, the number of videos with high-degree misinformation was significantly higher in Group 2. We consider that the videos uploaded by Group 2 aim to encourage or direct patients to undergo HoLEP surgery, which is a new and expensive treatment. In addition, in the study conducted by Fode et al., it was emphasized that there was no barrier and/or restriction when uploading content to websites, especially in the field of health. In the same study, the authors observed that the majority of the videos had a DISCERN score of 3 or less (30). In a study by Huang et al., there was no difference in the median number of viewers and viewer interaction according to low or high DISCERN scores. However, the authors observed that if a video had been uploaded by an academic hospital, it had a higher DISCERN score (19). Similarly, in our study, there was no difference between the DISCERN groups in terms of video viewing parameters. This shows that people watch these videos without distinguishing between poor and good content or they may even not know how to make such a distinction. Thus, the videos they watch can direct them to a wrong treatment or misinformation. The PEMAT score also showed that these videos were easy to understand. Although the easy understandability of a video is a favorable characteristic, misinformation contained in some of the videos can have further negative effects on viewers. The subject of misinformation has been previously investigated and findings similar to our study have been presented by many studies. However, in the literature, the rating of the extent of misinformation as part of video analysis is usually undertaken in a subjective manner, and the rating options are self-designed (e.g., very little, moderate, high and extreme level of misinformation) (25). In our study, all the videos were evaluated independently by two authors. In the evaluation of misinformation, a Likert-type scale was used to minimize possible bias. Inconsistencies were rare, but if any, they were resolved through the evaluation of the third author.
Another cause of concern is the frequent mention of unreliable information and sources of information in viewers’ comments related to videos since it can mislead viewers. As emphasized earlier, false information spreads faster on the internet than accurate information. Doctors and healthcare institutions and associations have great responsibility in preventing the spread of such misinformation. Moreover, there are currently no measures to prevent the spread of false information in the comment sections of high-quality videos. Therefore, physicians should direct patients to videos that have been reviewed and proven to be reliable, not only during face-to-face meetings but also through digital interactions, including social media posts, online communications, and telehealth visits. Our findings highlight the importance of high-quality videos that objectively cover all spectrums of a treatment modality and are able to explain it in a way that patients can understand. High-quality information platforms are available (31). In addition, urology associations should be encouraged to upload high-quality and easy-to-understand videos to websites such as YouTube, where patients can research theirs diseases and treatment options.
Videos from a single video-sharing platform (YouTube) were viewed; however, since YouTube is an ever-evolving website, the evaluation of videos at a single time point may not accurately reflect what patients view after this initial search. By excluding non-English language videos, we may have further reduced the generalizability of our findings. Our study did not include videos available on other online video platforms such as Vimeo or those posted on academic department websites that may not be available on YouTube due to license agreements. Another limitation of the study can be considered as the inability to obtain the demographic characteristics of video viewers. There is still no complete consensus on how to fully evaluate health-related online videos.