Usability of Health Websites: What Have We Learned

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Usability of Health Websites What Have We
Learned?
Presented by Christine Paulsen, Kristen Leclerc
Deborah Goff1 Human Factors Research and
Design Group American Institutes for
Research June 10, 2004
1The authors wish to thank Kelly GordonVaughn,
formerly of AIR, for her contributions to this
paper.
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Our presentation

• Provides an overview of the quality of Health
  Websites and the characteristics of health
  information users.
• Summarizes key findings and lessons learned from
  recent studies conducted by American Institutes
  for Research (AIR).

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Your experiences

• Health Website developers?
• Health Website evaluators?
• Health Website users?

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The popularity of health Websites

• Use of health Websites is exploding
• Roughly 100M people go online to find health
  information (Harris Poll)
• 70 of people report having made a health care
  decision based on information discovered online
  (Pew)

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The 8 most popular health Websites
Percent of patients accessing health information
online
(Poll conducted by Harris Interactive, 2002)
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The potential of health Websites

• Health Websites have the potential to reach
  audiences who normally do not have access to a
  health care professional.
• Health Websites offer access to important
  information 24 hours a day, 7 days a week.
• Unlike other types of Websites, health sites have
  the potential to lead to adverse health
  consequences, serious injury or even death for
  users who misunderstand information or are misled
  by poor quality information.

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User literacy

• The ability to read is a stronger indication of
  health status than other variables, including
  race, age, employment status, income and
  education level.
• One in five adults reads at or below the 5th
  grade reading level.
• Two out of five Americans who are over age 65, or
  minority, read at or below the 5th grade reading
  level.
• The average American adult reads between the 8th
  and 9th grade reading levels.
• (AIR developed the National Assessment of Adult
  Literacy 2003)

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Health literacy

• Health literacy is defined as the ability to
  obtain, interpret and understand basic health
  information, as well as the ability to apply
  skills to health situations at home, at work and
  in the community.
• Half of all adult Americans (approximately 90
  million people) are challenged by low health
  literacy.
• Low health literacy is present at all income
  levels, among all races and across all ages.
• Even individuals who can read and understand
  basic information can struggle with health
  literacy.

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Health website quality

• Recent studies have concluded
• The information online is generally accurate, but
  most health Websites are not comprehensive and
  are missing key information.
• Most health materials (online and paper
  documentation) are written at or above the 10th
  grade reading level.
• Rand found that 100 of the websites surveyed
  (n18) presented health information written at a
  9th grade reading level or higher.

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Why should we care?

• Excess health care costs due to low literacy
  amount to 70 to 100 billion per year.
• People with marginal literacy skills
• make more medication errors
• are less able to comply with treatments
• fail to seek preventative care and
• experience difficulty getting treatment.
• People with low literacy skills are at a 50
  higher risk for hospitalization.
• Annual health care costs for people with low
  literacy skills are 4 times higher than those
  with higher literacy skills

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Our research synthesis

• Based on eight separate studies
• Caveat Not an exhaustive meta-analysis of the
  universe of studies on health Websites

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Study A

• Usability evaluation of MedlinePlus and
  MedlinePlus en español, sponsored by the National
  Library of Medicine (NIH) www.medlineplus.gov
• 32 participants (16 health consumers and 16
  health professionals) in the Washington, DC area
• Half the sessions conducted in English, half in
  Spanish

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Study B

• Usability evaluation of prototype Go Local
  Website, sponsored by the National Library of
  Medicine (NLM)
• 16 participants (8 health consumers and 8 health
  professionals) in the Boston, MA area

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Study C

• Heuristic review by four usability experts of
  five health Websites
• CDC Division of Healthcare Quality Promotion
  (DHQP) http//www.cdc.gov/ncidod/hip/default.htm
• National Institutes of Health (NIH)
• http//www.nih.gov
• WebMD
• http//www.webmd.com
• World Health Organization (WHO)
• http//www.who.int/en
• Yahoo! Health
• http//health.yahoo.com

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Study D

• Iterative usability testing of National Heart,
  Lung,and Blood Institute (NHLBI at NIH) Website
• 24 participants (health consumers, health
  professionals, and health researchers) in the
  Washington, DC area
• Online survey of over 700 Website users

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Study E

• Part 1 Usability testing of an interactive
  software tool for health consumers
• 12 usability test participants in the Boston area
• Part 2 Study to compare learning effects of
  using the software tool
• 31 health consumers with low health literacy
• 30 health consumers with moderate to high health
  literacy

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Study F

• Study designed to determine the effects of five
  different text formats on the experience of
  reading health content on-screen
• 44 study participants in the Boston, MA area

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Study G

• Usability study of a Website targeted toward
  children with learning differences/disabilities
  www.schwablearning.org
• Test participants included 12 parents and 13
  students from the Palo Alto, CA area

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Study H

• Remote usability test of online health education
  materials designed for Latino health consumers
  http//www.nhlbi.nih.gov/health/prof/heart/latino/
  salud.htm
• Test participants included 6 participants from
  the Southwest region of the United States

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Lesson learned Credibility is key

• Credibility was key to health consumers and
  health professionals looking for accurate
  information online.
• Users looked for indicators of the quality of the
  content.
• Indication of who published the information
• and when it was last updated
• Users were especially trusting of information
  provided by federal agencies, such as the Centers
  for Disease Control, National Institutes of
  Health, National Cancer Institute and the
  Department of Health and Human Services.

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Lesson learned Lively look and feel

• While users wanted credibility, health Website
  users also expected online health information to
  have a lively, cheerful look and feel.
• Users searching for health information on a
  serious medical condition did not want to sift
  through Websites with drab, depressing colors and
  images.
• Spanish-speaking users expected Spanish Websites
  to contain colors and images that appeal to their
  community, rather than using the English site as
  a template and simply translating the content.

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Lesson learned Information density

• Most health Websites provided access to numerous
  pages of health content. As such, these sites
  were too information-dense.
• Most Websites could do a better job of organizing
  the massive amounts of content they contain.
• Users did not want to scroll through pages and
  pages of information to find what they need.

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Lesson learned Topic searches

• Health Websites can provide their own content, or
  they can act as portals to the information
  contained in a number of other health Websites.
• When users were searching portal sites, they
  expected to search for information by topic,
  rather than by the source of the content.

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Lesson learned Multiple pathways

• In our studies, users preferred to have the
  ability to access content through multiple
  targeted pathways.
• For example, providers wanted to enter a pathway
  on the homepage that would contain more technical
  information than if they had chosen the consumer
  pathway.
• Across our studies, health consumers both wanted
  and expected this type of option.

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Lesson learned Topic screens

• Some health sites we studied presented a
  homepage, or topic screen, that compiled all of
  the links, articles and information relevant to a
  particular topic on one screen. Other sites
  organized topics into health centers.
• These centers provided consistent types of
  summary information, facts, news and articles
  across the different topics.
• Compiling information into one area unifies the
  site and may serve to reassure users that they
  successfully located all of the relevant content.

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Lesson learned Right side of screen

• Users did not pay attention to navigational
  features or content contained on the right-hand
  sides of Web pages.
• Users have become conditioned to expect
  advertising on the right-hand side, and
  indicated, in our studies, that they ignore the
  content contained on the right.
• Users were drawn to the text and navigational
  features located in the body and left-side of the
  screen, rather than the right side.

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Lesson learned Interactive tools

• Consumers enjoyed using interactive tools but
  some had concerns about entering personal data.
• Consumers liked using interactive dosage
  calendars and interactive tutorials.
• However, some consumers expressed privacy
  concerns about entering any personal information
  and preferred the option of seeking information
  from charts as well e.g., BMI (Body Mass Index)
  charts versus an interactive BMI calculator.

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Lesson learned Columns

• Most health Websites provided the actual health
  content in a typical one column, HTML fashion.
• In one study, we found that users preferred a
  two-column presentation of dense health
  information when they were reading it on-screen,
  as opposed to the traditional one-column format.
• In fact, the two-column format helped users read
  the information significantly faster, but did not
  appreciably enhance comprehension of the
  material.

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Lesson learned Reading level is key

• The actual reading-level of the health content is
  a crucial indicator of Website quality.
• Most of the health Websites we reviewed contained
  terminology and jargon that made the content
  difficult to comprehend.
• For example, using acronyms like OCD rather than
  obsessive compulsive disorder or using the phrase
  cardiovascular disease rather than heart
  disease
• We found that it is possible to simplify content
  without losing meaning.

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Lesson learned Accessibility

• Many health Websites we evaluated had usability
  problems that prevented users with disabilities
  from fully accessing their content.
• This is a major problem, considering that
  individuals with existing health problems may be
  even more inclined to seek out health information
  online than other individuals.

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Lesson learned Information retrieval

• Most users in our studies preferred to be able to
  print, download or email information so that
  they, or someone they were helping (e.g.,
  parents, friends, family), could use the
  information at a later date.
• In most of our studies, we found that many
  Websites could improve the ways in which they
  facilitate the process of printing or emailing
  health information.
• Users had difficulty understanding whether print
  functions would produce text-only versions or
  would include graphics and images.
• In addition, some print and email features were
  difficult to locate.

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Discussion

• What have been your own experiences with health
  Websites?
• Do our experiences mirror your experiences?
• If not, what factors account for differences?
• What have we learned?

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Other resources

• There are several organizations and associations
  that have established guidelines and ethics for
  health Websites
• Health on the Net (HON) Code of Conduct,
• American Medical Association,
• Health Internet Ethics (Hi-Ethics), and
• the eHealth Ethics Initiative.

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Contact information
Christine Paulsen, Ph.D. cpaulsen_at_air.org Copies
of our paper and slides may be downloaded
at http//www.air.org/usability/publications/
Thank you!