Health Literacy Online

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1 Heath Literacy Onine A guide to writing and designing easy-to-use heath Web sites Strategies Actions Testing Methods Resources HEALTH OF & HUMAN SERVICES USA U.S. Department of Heath and Human Services Office of Disease Prevention and Heath Promotion DEPARTMENT

2 Suggested citation: U.S. Department of Heath and Human Services, Office of Disease Prevention and Heath Promotion. (2010). Heath iteracy onine: A guide to writing and designing easy-to-use heath Web sites. Washington, DC: Author. ii Heath Literacy Onine

3 Contents About This Guide...1 Why Design Easy-to-Use Web Sites?...2 Buiding On the Principes of Usabiity...3 Terminoogy: Literacy and Heath Literacy...3 A Note on the Research...4 What We Know About Web Users With Limited Literacy Skis...5 A Brief Introduction to User-Centered Design...9 Summary of Iterative Design and Testing Methods...9 Individua Interviews...9 Focus Groups...10 Task Anaysis...10 Personas and Scenarios...10 Card Sorting Prototypes Usabiity Testing Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites Learn About Your Users and Their Goas...13 The Basics...13 Actions Identify your users. Who are they? Understand their motivations. Why are they here? Understand their goas. What are they trying to do?...15 Iterative Design Methods and Tips...16 iii Heath Literacy Onine

4 Contents 2. Write Actionabe Content...17 The Basics...17 Actions Put the most important information first Describe the heath behavior just the basics Stay positive and reaistic. Incude the benefits of taking action Provide specific action steps Write in pain anguage Check content for accuracy...27 Iterative Design Methods and Tips Dispay Content Ceary on the Page...30 The Basics...30 Actions Limit paragraph size. Use buets and short ists Use meaningfu headings Use a famiiar font in at east 12-point type Use white space and avoid cutter Keep content in the center of the screen and above the fod Labe inks ceary Use images that faciitate earning Use bod coors with contrast. Avoid dark backgrounds Make your site accessibe to peope with disabiities...40 Iterative Design Methods and Tips Organize Content and Simpify Navigation...42 The Basics...42 Actions Create a simpe and engaging home page Use abes that refect words your users know Enabe easy access to home and menu pages Make sure the Back button works Use inear information paths Incude simpe search and browse options...49 Iterative Design Methods and Tips...52 iv Heath Literacy Onine

5 Contents 5. Engage Users With Interactive Content...53 The Basics...53 Actions Incude printer-friendy toos and resources Simpify screen-based contros and enarge buttons Incude interactive content that users can taior but not too much Incorporate audio and visua features Expore new media such as Twitter or text messaging...61 Iterative Design Methods and Tips Evauate and Revise Your Site...64 The Basics...64 Actions Recruit users with imited iteracy and imited heath iteracy skis Choose experienced moderators Test comprehension in mutipe ways Consider user engagement and sef-efficacy Create pain anguage testing documents...67 Iterative Design Methods and Tips...68 References...69 Appendixes...75 Appendix A: Reviewers...76 Appendix B: Sampe Measures...78 Appendix C: Sampe Testing Documents...80 Appendix D: Overview of ODPHP Origina Research...83 Appendix E: Resources for Creating Easy-to-Use Web Sites...91 Appendix F: Annotated Bibiography...95 v Heath Literacy Onine

6 About This Guide More Americans are going onine than ever before. According to a 2006 survey, 80 percent of Internet users have ooked for heath information on the Web. 1 As a resut, both pubic and private institutions are using the Internet to streamine the deivery of heath information and connect peope and services in exciting new ways. Yet the transition to onine heath information and services poses a unique set of chaenges for Web users with imited iteracy skis or imited experience on the Internet. For many of these users, the Web is stressfu and overwheming even inaccessibe. Much of this stress is the resut of compex heath content and poory designed Web sites. The U.S. Department of Heath and Human Services Office of Disease Prevention and Heath Promotion (ODPHP) has written a research-based how-to guide for creating heath Web sites and Web content for the miions of Americans with imited iteracy skis and imited experience using the Web. The strategies in this guide compement accepted principes of good Web design and thus have the potentia to improve the onine experience for a users, regardess of iteracy skis. This guide is written for Web designers, Web content speciaists, and other pubic heath communication professionas. We offer an overview of how to: Deiver onine heath information that is actionabe and engaging. Create a heath Web site that s easy to use, particuary for peope with imited iteracy skis and imited experience using the Web. Evauate and improve your heath Web site with user-centered design. 1 Heath Literacy Onine

7 Why Design Easy-to-Use Web Sites? Athough the probem remains argey invisibe, miions of Americans have a hard time reading. As many as haf of U.S. aduts have imited iteracy skis. 2 Even more Americans as many as 9 out of 10 have imited heath iteracy skis. This means they have troube understanding compex heath information. 2 As more heath information and services move onine, Web deveopers and professionas must find new and better ways to communicate heath information to the pubic. The number of oder aduts using the Internet continues to grow. A significant number of oder Web users are searching for heath information. However, age-reated changes in vision, hearing, and cognition affect oder aduts use of the Internet. 3 Taken individuay, each of these factors presents a chaenge for Web deveopers and heath professionas. Taken together, they represent an urgent need for innovative design and redesign of heath content on the Web. Severa factors affect how we users can find, understand, and use information on the Web, incuding: Access to computers and experience onine Abiity to read and understand printed text Compexity of information on the Web Usabiity of the Web in genera and Web sites specificay 4,5 Ceary written content, uncuttered Web sites, and simpe navigation dramaticay improve the performance and experience of Web users, incuding those with imited iteracy skis. Studies show that simpifying your Web site improves the experience of a users, not just those with imited iteracy skis. 4,6 Cean ayouts and famiiar anguage are more usabe for everyone. 7 2 Heath Literacy Onine

8 Why Design Easy-to-Use Web Sites? Buiding On the Principes of Usabiity The atest research in Web design supports creating easy-to-use Web sites. This guide buids on the principes of Web usabiity and adds to existing best practices by providing research-based strategies for writing and designing heath Web sites that are accessibe to users with imited iteracy and imited heath iteracy skis. Drawing on experience with heathfinder.gov, this guide synthesizes essons earned from ODPHP s origina research with more than 700 Web users and the sma but growing body of iterature on the Web experiences of users with imited iteracy skis. The strategies outined in this guide are supported by the Research-Based Web Design and Usabiity Guideines, 2nd edition (Usabiity Guideines), 8 deveoped by the U.S. Department of Heath and Human Services in partnership with the Genera Services Administration. The reevant chapters of the Usabiity Guideines are isted at the end of each section. Terminoogy: Literacy and Heath Literacy Literacy is a person s abiity to read, write, speak, and sove probems at eves needed to function in society. 9 Heath iteracy is a person s capacity to find, understand, and use basic heath information and services needed to make appropriate heath decisions. 10 Athough iteracy and heath iteracy are distinct constructs, they are cosey reated. Literacy has been found to be a predictor of heath iteracy. 11 Roughy 1 in 3 aduts has imited iteracy skis; however, a far greater number of aduts (as many as 9 in 10) strugge with compex heath information. 2,11 In other words, a person may be extremey iterate and sti have difficuty interpreting and acting on heath information whether it s onine or in print. The aim of creating easy-to-use heath Web sites is to reach as many Web users as possibe, especiay those aduts who are overwhemed by everyday iteracy tasks. For this reason, this guide refers to Web users with imited iteracy skis; it s assumed that these Web users, and miions more, ikey have imited heath iteracy skis as we. 3 Heath Literacy Onine

9 Why Design Easy-to-Use Web Sites? A Note on the Research Most of the recommendations in this guide are based on origina research studies conducted on behaf of ODPHP (detaied in Appendix D). ODPHP used proxy measures to identify a sampe of aduts with imited iteracy and imited heath iteracy skis based on statistics from the heath iteracy component of the 2003 Nationa Assessment of Adut Literacy. Individuas incuded in many of the studies referenced in this guide met the foowing criteria: High schoo education or beow Beow the poverty threshod Have not searched for heath information onine in the past year Participants were recruited from community settings ikey to serve peope with imited iteracy and heath iteracy skis, incuding federay funded community heath centers. ODPHP s studies pertain specificay to the deivery of onine heath promotion and disease prevention content. Much of the research focused on communicating actionabe information and motivating users to adopt heathy behaviors. The communication and usabiity strategies outined in this guide aso appy more generay to the deivery of heath information on the Web. Throughout the guide, we incorporate quotes from Web users with imited iteracy skis who participated in our usabiity studies. These quotes speak to the vauabe roe Web users pay in writing and designing effective Web sites. 4 Heath Literacy Onine

10 What We Know About Web Users With Limited Literacy Skis Many aduts with imited iteracy skis have had itte training and experience searching the Web. They strugge not ony with reading the content on the page, but aso with retaining and managing new information as they move through a Web site. 4,5,12 Severa key characteristics and common behaviors of users with imited iteracy skis affect how they perform on a Web site. Many of the foowing characteristics are common to a Web users; however, the degree to which they occur is greater for users with imited iteracy skis. Wiing and Abe Most importanty, we know that users with imited iteracy skis are generay: Wiing to use the Web to access heath information Successfu in accompishing their tasks when Web sites are designed we 4 6 More often than not, poory designed Web sites more than imited iteracy skis contribute to users chaenges onine. Simpe navigation and cear content can hep aduts with imited iteracy skis find, understand, and use heath information on a Web site. 5 Heath Literacy Onine

11 What We Know About Web Users With Limited Literacy Skis Skipping Instead of Scanning Most Web users skim and scan a Web page before they read. 7,13 They may read the first few words or sentences on a page and then scan the rest of the headings and bueted ists on the page unti they find what they re ooking for. Users with imited iteracy skis have a hard time scanning headings and subheadings to grasp and manage the information on a Web page. Instead, these users have a tendency to do one of the foowing: Read every word on the page. Skip over entire chunks of dense text. Start cicking on inks instead of reading the content. 4,5,14 17 Instead of jumping from one heading to the next, users with imited iteracy skis may skip and and in the midde of a page, or even the midde of a paragraph. 4 Web sites with short, stand-aone sections of text written in pain anguage can make it easier for aduts with imited iteracy skis to find information and absorb and retain what they read. 4,12,14,15,18 In fact, one study found that users with imited iteracy skis skip over a paragraph when it contains more than three ines of text. 15 Use short chunks of text and bueted ists. Difficuty Searching Users with imited iteracy skis avoid searching. Instead, users prefer to browse topics using an aphabetica ist (even if the ist is ong). 4,16,19 When they do use the search function, they may have difficuty speing the search term. 4,5,16,19 When designing your site, incude both a search function and another way to browse the content, such as an A to Z ist. Be sure to compensate for misspeings in the search box and to imit the number of resuts on a page. 6 Heath Literacy Onine

12 What We Know About Web Users With Limited Literacy Skis Focusing on the Center of the Screen Research with users with imited iteracy skis indicates that they tend to have a narrow fied of view. 4,5,12,15,18,20 As these users read through a page, they are ess ikey to notice content above, beow, or to the sides of their focus of attention. Links and content in the right margin are often mistaken for advertisements or ignored. 12,20 Moreover, many users with imited iteracy skis don t scro. 4,5,18,20 This means they are ony seeing the content in the center of their screen. It s important to keep key text above the fod when possibe. Above the fod means that the text fits on the screen and can be read without scroing. Use ony eft and center navigation eements. Easiy Overwhemed Dense text, sma font size, content in the margins, compex sentences, and too many inks can overwhem users with imited iteracy skis. As a resut, users may skip over key content or give up their search prematurey, often setting for incompete or vague information. 4,7,12 Even content written in pain anguage can be overwheming if too much text is together in one paragraph or there is not enough white space on the page. Dispay content ceary on the page and avoid cutter. 7 Heath Literacy Onine

13 What We Know About Web Users With Limited Literacy Skis Limited Working Memory Users with imited iteracy skis, incuding many oder aduts, reach information overoad more quicky than users with stronger iteracy skis. Those with imited iteracy skis are ess ikey to remember content from previous pages, and they rarey ook ahead or back on a page. 4,15,16,18 As a resut, you can t rey on context to orient users or to add meaning to the text on the screen. In one study, users with imited iteracy skis were prompted to enter their age and sex into a Web-based too. When they viewed the resuts, many users had difficuty making the connection between the resuts page and the data they entered on the previous screen. 15 To compensate for users imited working memory, use cear, stand-aone headings and sections that function independenty. Incude penty of visua cues to orient users on the site. Simpe Navigation Users with imited iteracy skis are often ess experienced using the Web. They may be unfamiiar with and often may ignore common navigationa eements such as drop-down menus, cicking buttons and inks, or breadcrumbs. 5,12,15,18,20,21 Breadcrumbs are found near the top of the page and ook ike this: Home > Quick Guide to Heathy Living > Nutrition and Fitness In one study, even after being shown how to return to a home page, users with imited iteracy skis had difficuty repeating the task from a different page on the site Studies with users with imited iteracy skis found that they had success with simpe tabbed navigation with inear (numbered) pages. 16,17 Use obvious step-by-step navigation, such as numbered pages and previous and next buttons, whenever possibe. 8 Heath Literacy Onine

14 A Brief Introduction to User-Centered Design Question: How do I know whether my Web site meets the needs of users with imited iteracy skis? Answer: By invoving users with imited iteracy skis throughout a stages of Web site deveopment. This is caed user-centered design. User-centered design is accompished through an iterative process. The iterative process can be summed up in three words: Test. Revise. Repeat. Imagine spending money and time designing a Web site from start to finish, ony to discover that your users are unhappy with the site or unabe to find what they are ooking for (or both). Instead, invove users as codesigners. Have users try out your Web site eary on, and continue to test different sections of your site as you deveop them. Fine-tune as you go to avoid a major overhau. This is iterative design. 22 The key to iterative design is to continuay appy what you earn from users to improve your site. 8 Summary of Iterative Design and Testing Methods Common iterative design methods are briefy described here. At the end of each chapter, we suggest specific methods and tips you can use to test and improve your Web site. Individua Interviews Individua interviews invove taking to users one on one, either in person or over the phone. Unike a usabiity test, you aren t watching the participant work. You are finding out background information about their information preferences, habits, and experiences. 8,23 9 Heath Literacy Onine

15 A Brief Introduction to User-Centered Design Focus Groups Focus groups are simiar to individua interviews, except that you are interviewing severa participants (typicay 5 to 10) at once. A moderator faciitates the focus group and uses a script to ead the discussion. Focus groups are used to earn about users beiefs, attitudes, or reactions to a design or prototype. 8 Task Anaysis Conduct a task anaysis to find out what users are trying to accompish on your Web site and how they currenty accompish those tasks. 8,13,23,24 What steps do they take? What toos do they use? A task anaysis can be done through observation or interviews. A task anaysis can hep you unpack the requirements or demands put on users to accompish a task on your site. Often we make fase assumptions about Web users knowedge or skis. For exampe, we may assume users know what BMI (body mass index) stands for or that users wi correcty interpret the meaning of an icon or symbo. Personas and Scenarios A persona is a made-up individua who embodies the characteristics of the rea users you may have interviewed and the data you gathered. When creating a persona, incude demographics, vaues, access to technoogy, and quotes. 7,8,13,25 27 It heps to give your persona a name and a picture. Keep your personas in mind as you design your site. Ask yoursef: Woud Susan use this? How woud Joe approach this task? Once you ve deveoped personas for your site users, you are ready to deveop scenarios. Scenarios are short stories that describe the goas and tasks of your users. 7,8,24 They can hep paint a reaistic picture of how personas use your Web site. 10 Heath Literacy Onine

16 A Brief Introduction to User-Centered Design Card Sorting Card sorting can hep you group or organize information on your Web site. Many peope use card sorting to hep with information architecture. The topics and information featured on your site are isted on index cards. Participants are asked to sort or organize the cards into categories that make sense to them. You aso can use card sorting to prioritize information by importance. 23 Prototypes A prototype is a mockup of your Web site, simiar to a rough draft. Start with a paper prototype or wireframe. (A wireframe is an iustration of the ayout of a Web page.) Each piece of paper represents a page of your Web site. Users te you which information or ink they woud cick on, and you show them the new piece of paper (or screen ). 8,22,24,28,29 As you get further aong in the deveopment process, consider buiding a cickabe prototype. This HTML (hypertext markup anguage) she ets users cick through severa screens of content. Usabiity Testing In usabiity testing, a moderator observes a user performing tasks on your Web site. Have participants think out oud as they use the site to hep you understand their approach and process. Note where users have probems or get ost. 22,30,31 11 Heath Literacy Onine

17 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites In the six chapters that foow, this guide presents specific strategies with exampes for writing and designing heath Web sites that are accessibe to users with imited iteracy skis. 1. Learn about your users and their goas. 2. Write actionabe content. 3. Dispay content ceary on the page. 4. Organize content and simpify navigation. 5. Engage users with interactive content. 6. Evauate and revise your site. Each strategy incudes: Actions Exampes Iterative design methods and tips 12 Heath Literacy Onine

18 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 1. Learn About Your Users and Their Goas The Basics The key to creating good Web content is to understand your intended users and to design information based on their specific wants and needs. The goas are to: Write heath content your users need in words they understand. 7 Organize the content so that it s easy to find. Before you design your site, think about the content you wi provide and how it wi be used. Research shows that targeted heath information gets users attention and promotes earning. 32 For exampe, information can be targeted to users age, sex, cuture, heath status, motivation, or readiness to change. Actions at a Gance 1.1. Identify your users. Who are they? 1.2. Understand their motivations. Why are they here? 1.3. Understand their goas. What are they trying to do? 13 Heath Literacy Onine

19 1. Learn About Your Users and Their Goas Actions 1.1. Identify your users. Who are they? Are they ooking for heath information for themseves or someone ese? Many users with imited iteracy skis are searching for heath information for a famiy member or friend. As a resut, they often prefer to print or e-mai the information they find onine. 16,33,34 Consider incuding heath content targeted to caregivers and famiy members. What are the socia and cutura characteristics of your intended users that might infuence how they perform on the site? 13 (Consider age, education, economic status, and experience with the Internet.) What are the technoogica characteristics that infuence how users perform on the site? (Do they have broadband access? Do they have a home computer?) If Web users don t have broadband access, graphics and other features wi take a ong time to oad. Many users with imited iteracy skis access the Internet at the house of a friend or famiy member. Some go onine at a pubic ibrary or community center. This may affect the type of heath information they search for, the ength of time they spend searching, and the degree of persona heath information they provide. 5, Understand their motivations. Why are they here? Motivation drives the search for heath information and infuences users performance on a Web site. 32,33 Understanding users motivations wi hep you target heath promotion content to meet their information needs and expectations. 14 Heath Literacy Onine

20 1. Learn About Your Users and Their Goas Exampe ODPHP s research identified the foowing motivations for onine heath information seeking: Those seeking information about a heath probem affecting them or someone they know Those seeking to find out whether they have a heath probem or reason to be concerned Those seeking information on how to prevent the onset of heath probems 32,33 Studies found that users motivations tend to shift, often frequenty. 7 In response, target content to mutipe motivations for seeking heath information. The formua beow was deveoped based on the motivations identified in the previous exampe. It s designed to move users from I want some information about a topic to I want to do something about it. Try it! Foow this proven formua for presenting heath promotion information: Describe the heath behavior. Describe the benefits of taking action. Provide specific action steps. (For more information, see Section 2.) 1.3. Understand their goas. What are they trying to do? Most Web users have a specific goa in mind. Typicay, they are trying to answer a question. 4,7,12 Ask your users what they want to know. Then decide how to give them that information. 15 Heath Literacy Onine

21 1. Learn About Your Users and Their Goas Iterative Design Methods and Tips Methods Individua interviews Focus groups A task anaysis Personas and scenarios Tips for designing and testing your Web site with users In this eary phase of iterative design, use focus groups and interviews to tak to peope who might use your Web site. Consider interviewing intermediaries who work with Web users with imited iteracy skis. These coud incude pubic ibrarians, heath care providers, and adut educators. Find out how your Web site coud hep them serve their cients better. Once you ve observed and interviewed potentia users, create user personas and scenarios. Use these to guide you through the next phase of content deveopment. If you are revising an existing Web site, start with a usabiity test. Coect benchmark data on how ong it takes peope to find the information they need. After you revise the site, repeat the test to see whether you have successfuy improved usabiity. UG Refer to Research-Based Web Design & Usabiity Guideines sections: 1:2, 1:3, 1:4, 1:6, 1:7, 1:11 16 Heath Literacy Onine

22 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 2. Write Actionabe Content The Basics Writing for the Web is different than writing for print. Most Web users are ooking for specific information or an answer to a question. 7 They typicay don t stay very ong on one page (the average time on a home page is about 27 seconds). 7,35 When it comes to heath information, users want to quicky and easiy: Understand the heath probem or behavior Find out how to take action 14,16,36 Content is the most important eement of your Web site. 7,13 Aim for heath content that is: Brief and to the point Actionabe and engaging Actionabe means you are focusing on heath behavior. Te users what you want them to do and how to do it. Engagement is the process of invoving users in heath content in a way that motivates them to take action. Interactive toos and checkists are exampes of engaging content. When appied to onine heath information, high eves of engagement can ead to heath behavior change. 37 Take note: Pain anguage is not enough. If you want your users to adopt heathy behaviors, you must write actionabe heath content. Pain anguage aone wi not get you to your desired outcome. Actions at a Gance 2.1. Put the most important information first Describe the heath behavior just the basics Stay positive and reaistic. Incude the benefits of taking action Provide specific action steps Write in pain anguage Check content for accuracy. 17 Heath Literacy Onine

23 2. Write Actionabe Content Actions 2.1. Put the most important information first. 13 Many users with imited iteracy read ony the first few words on a page or paragraph. If they think the content wi be easy to get through, they may keep reading. If they think it might be too difficut, they wi skip to a different spot on the page. 4,5,14,16,18,20,38 Exhibit 1 Most important information Source: This NHLBI Diseases and Conditions Index Web page puts the most important information about this ung disease just the basics first. Additiona information about ung function comes ater. 18 Heath Literacy Onine

24 2. Write Actionabe Content In card-sorting exercises, Web users with imited iteracy skis prioritized the foowing types of heath information as most usefu: Basics I need to know (Understanding) I woud ike to earn more (Assessment) I can do this (Overcoming Barriers) How wi this hep me? (Motivators) Ways I can take action (Strategies) Where can I go for hep? (Community Resources) Common comments from users incuded: Just te me what I need to know. Get my attention. Then get to the point. 19 Heath Literacy Onine

25 2. Write Actionabe Content 2.2. Describe the heath behavior just the basics. Start by introducing the prevention behavior. Users want specific behaviora guidance. 16,17,19,21,34 In other words, te users what to do and how to do it. Focus on behavior rather than background information and statistics. Heath information does not need to be comprehensive. Instead, usabiity research has shown that many users prefer to earn just the basics about a heath topic. 36 What do your users need to know to take action? Keep your information direct and to the point. Make your information actionabe and specific. Exampe Instead of: Bood pressure is the force of bood against the was of your arteries. Bood pressure shoud be checked often. Start with: Check your bood pressure every 2 years, especiay if you are age 40 or oder. 20 Heath Literacy Onine

26 2. Write Actionabe Content Exhibit 2 Start with the behavior. Source: The first sentence on this page from heathfinder.gov incudes the behaviora recommendation (reguar screenings after age 50). I ike this Web site because it gives you the information you want right away. It gives you the basics, not too much to read. 21 Heath Literacy Onine

27 2. Write Actionabe Content 2.3. Stay positive and reaistic. Incude the benefits of taking action. Users overwhemingy prefer a positive tone. During card-sorting exercises, in addition to basic heath information, users prioritized information on motivators and overcoming barriers to behavior change over information on risks and barriers. 12,14,19,21,23,25,36,39 Te users what they can gain from adopting the desired behavior. Exhibit 3 Source: 1&TopicContentID=409 This heathfinder.gov Web page ceary ists the socia, physica, and financia benefits of quitting smoking, instead of focusing on the risks and consequences of continuing to smoke. 22 Heath Literacy Onine

28 2. Write Actionabe Content Be positive. Instead of teing peope what not to do, give them positive reasons to change their behavior. Losing just 10 pounds can hep ower my bood pressure? I didn t know that. Limit the use of the foowing words when writing heath recommendations: Don t Uness Not Shoud Peope must overcome many perceived and actua barriers on the road to heath behavior change. It s important to acknowedge these barriers and offer encouragement and motivation. 40 Focus on tips and toos for overcoming barriers rather than on the barriers themseves. Be reaistic. Exampe If you don t have time to exercise for 30 minutes at once, try to get moving for shorter 10-minute periods throughout the day. Remember: It s not a or nothing. Ten minutes of exercise is better than none! 23 Heath Literacy Onine

29 2. Write Actionabe Content My favorite part [about the Web site] is that the suggestions appied to me Provide specific action steps. Give users the toos they need to get started. Users gravitate toward action steps, especiay things they can do immediatey. 16,17,19,21,34 Instead of teing users what to do, te them how to do it. Breaking behaviors down into smaer steps improves users sef-efficacy. 16,17,19,21,34 Sef-efficacy is an individua s judgment of his or her abiity to succeed in reaching a specific goa. Sef-efficacy is an important predictor of heath behavior. 40,41 Breaking behaviors into smaer steps gives users choices about which steps fee reaistic and doabe. Incude steps users can take immediatey. 24 Heath Literacy Onine

30 2. Write Actionabe Content Exhibit 4 Source: This heathfinder.gov Web page uses a Start Today box with specific action steps. These steps are concrete and easy to achieve. As part of your action steps, engage users with interactive content such as menu panners, printabe checkists, and questions to ask a doctor (see Strategy 5). This is good information because a ot of times, I take information to the doctor and ask questions about diet issues, what to avoid, and medications. 25 Heath Literacy Onine

31 2. Write Actionabe Content 2.5. Write in pain anguage. Keep paragraphs and sentences short and simpe. Use anguage that is famiiar to your users. 4,7,12 15,18 Use famiiar anguage and an active voice. Writing in an active voice means that the subject of your sentence performs the action. An active sentence is easier to understand and generay requires fewer words. 3,7,13,38 Active: Check your bood pressure every 2 years. Passive: Bood pressure shoud be checked every 2 years. Use everyday exampes to expain medica or technica concepts, and write in a conversationa tone. Use words and images that users can reate to. Exampe When you get a mammogram, the nurse wi pace your breasts between two pastic pates and take a picture of each breast. When introducing a medica term, ceary define the term the first time you use it. Define the word in context rather than use a gossary or scro-over definition. Exampe If you have high bood pressure, you may need treatment. High bood pressure is 140/90 miimeters of mercury (mmhg) or higher. The medica term for high bood pressure is hypertension. I ike [this Web site] because it s easy for everyday peope ike me to read. No big words or medica terms. 26 Heath Literacy Onine

32 2. Write Actionabe Content 2.6. Check content for accuracy. Have a subject matter expert or pane periodicay review your heath content for accuracy. Indicate the date the content was ast reviewed and the reviewer s name and contact information. This gives your content more credibiity with Web users. Exhibit 5 Source: The date the content was ast reviewed, as we as the name and contact information of the reviewer, is ceary dispayed on this Web page from the Office on Women s Heath. 27 Heath Literacy Onine

33 2. Write Actionabe Content Use a stye guide to keep your content consistent. A stye guide is a document that ays out the rues for writing content for a specific Web site. A stye guide can hep you keep track of grammar, speing, and writing preferences. (For exampe, is it Web site or website?) You aso can use a stye guide to keep track of headings and font size. A stye guide shoud be an evoving document. Writers and editors wi ikey add to it over time. Be sure to keep it easiy accessibe. Try it! Keep a stye guide onine as a wiki, a Web site that aows for the easy creation and editing of Web documents via a Web browser. 28 Heath Literacy Onine

34 2. Write Actionabe Content Iterative Design Methods and Tips Methods Card sorting Prototypes Usabiity testing Tips for designing and testing your Web site with users Use card sorting to find out how users rank content by most to east usefu or most to east ikey to do. Buid a paper prototype to find out what content users are most ikey to cick on. Test user comprehension using content in a paper prototype (see Section 6.3). UG Refer to Research-Based Web Design & Usabiity Guideines sections: 1:1; 2:5; 15:1 5; 15:7; 15: Heath Literacy Onine

35 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 3. Dispay Content Ceary on the Page The Basics Writing easy-to-read Web content is ony the first step. If you want peope to understand the content, the next step is to make it ook easy to read. Even heath content written in pain anguage can ook overwheming if too much text is together in one paragraph or if there is not enough space on the page. 4,7,15,18 Web design and content go hand in hand. Use white space (aso caed active or bank space), ayout, font, and coor to hep users understand the content on your Web site. Actions at a Gance 3.1. Limit paragraph size. Use buets and short ists Use meaningfu headings Use a famiiar font in at east 12-point type Use white space and avoid cutter Keep content in the center of the screen and above the fod Labe inks ceary Use images that faciitate earning Use bod coors with contrast. Avoid dark backgrounds Make your site accessibe to peope with disabiities. 30 Heath Literacy Onine

36 3. Dispay Content Ceary on the Page Actions 3.1. Limit paragraph size. Use buets and short ists. A of the foowing triggered Web users with imited iteracy skis to skip over content: Dense was of text Long sentences Paragraphs with mutipe numbers in the text Long words Paragraphs with more than three ines 4,7,11 Write for users imited working memory. Use cear, stand-aone sections or chunks of text. Use sma chunks of text with ots of headings. 7,13 Turn sentences into ists. 7,13 31 Heath Literacy Onine

37 3. Dispay Content Ceary on the Page Exhibit 6 Version 1 Version 2 Source: Compare these two Web pages from heathfinder.gov. Testing showed that users did not read Version 1, where information was presented in paragraphs of text. However, Web users did read Version 2, where information was presented in bueted ists and smaer chunks of text. 32 Heath Literacy Onine

38 3. Dispay Content Ceary on the Page 3.2. Use meaningfu headings. As peope scan your Web page, they often wi read ony the headings to determine whether the heath content is reevant to them. It is important to make your headings as specific as possibe. 7,13 Create a subheading, or teaser text, underneath each heading to give the user additiona cues. Exampe Main heading: Subheading: Get Active Aim for 2 hours and 30 minutes of activity a week. In the exampe above, both the heading and the subheading start with verbs. This is a good practice to foow when you are writing actionabe content. Try it! When appropriate, try using questions as headings.7 Use I and me to refect the voice of the user. For exampe, when discussing mammograms, common questions incude: How wi this benefit me? How much does it cost? What happens if the doctor finds something wrong? How often do I need to get tested? Does it hurt? Are there any risks associated with the test? What if I don t have time? Make sure your headings don t foat on the page. There shoud be more space above a heading than between the heading and the text that foows. 7 The goa is to create discrete chunks of content that comprise a heading and reated text or buets. 33 Heath Literacy Onine

39 3. Dispay Content Ceary on the Page Exhibit 7 Source: 1&TopicContentID=299 On this heathfinder.gov Web page, information about osteoporosis is organized using questions as headings. There is more space before the heading than after, creating cear chunks of text Use a famiiar font in at east 12-point type. There are two categories of fonts: serif (with arms and feet ) and sans serif (without arms and feet ). Exampe Aria is a sans serif font. Times New Roman is a serif font. There has been much debate about whether serif or sans serif fonts are easier to read onine. Most usabiity and iteracy experts recommend using sans serif fonts such as Aria or Tahoma. 3,7 Because sans serif fonts are commony used on the Web, they are more famiiar to users. 34 Heath Literacy Onine

40 3. Dispay Content Ceary on the Page Pay attention to font size. A sma font size is more difficut to read, especiay for users with imited iteracy skis and oder aduts. Use at east a 12-point font. If many of your users are oder aduts, consider using a 14-point font. 3,7,8 I coud read the words without my reading gasses. Let users adjust the size of the text on the page. 7 Web designers can enabe this feature by using reative type size. However, it s important to test out your Web page with different font sizes to make sure it s sti easy to read and navigate. Exhibit 8 Source: NIH SeniorHeath incudes a toobar on every page that ets users change the text size, adjust coor contrast (coored text on a back background), and activate a screen reader that reads aoud the text on the page. 35 Heath Literacy Onine

41 3. Dispay Content Ceary on the Page 3.4. Use white space and avoid cutter. Cean, crisp Web pages are easier to read. 7,13 They are aso ess distracting and ess overwheming for peope with imited iteracy skis. Use white space inside your main content area to break pieces of information into chunks. Leave space between sections of text and around images and buttons. Exhibit 9 Source: 01.htm#skip2 This page from NIH SeniorHeath incudes space around the image and Next Page button, which heps the site ook cean and uncuttered. 36 Heath Literacy Onine

42 3. Dispay Content Ceary on the Page 3.5. Keep content in the center of the screen and above the fod. 6,7,13 Many users with imited iteracy skis don t scro. This means they are ony seeing the content in the center of their screen. 4,5,15,18,20 Make an effort to keep text above the fod. Above the fod means that the text can be read without scroing down. If you need to continue text beow the fod, provide strong visua cues to prompt users to scro down the page for more information. Try it! View your Web site using different monitors and browsers to see how your content dispays on the screen. Caution: Horizonta ines or arge sections of white space at the bottom of the screen are sometimes mistaken for fase bottoms and stop peope from reading further Labe inks ceary. Users with imited iteracy skis tend to cick on inks rather than read the content on a page; this is sometimes caed ink hopping. 4 Link directy to toos and resources that suppement and support your text. 16,34 Avoid inking to pages with redundant content. Instead, aow users to dri down for more detaied information. 12,16,34 Limit the number of inks on a page. 37 Heath Literacy Onine

43 3. Dispay Content Ceary on the Page Here are four rues to foow when incuding inks on a Web page: 1. Make inks obvious by underining them. 3,13 2. Make inks ong enough to grab easiy. 3,7 3. Use descriptive ink abes so there are no surprises. 7,13 4. Use action verbs in ink tites. 3,7 Exampe Instead of: Try: Visit this Web site to search for heart-heathy recipes. Find heart-heathy recipes your whoe famiy wi enjoy. Exhibit 10 Source: ContentID=359 Links on this heathfinder.gov Web page foow a four rues for ink abeing. For each ink, readers have a good idea of what to expect. Avoid these ink abes: Cick here Print Learn more 38 Heath Literacy Onine

44 3. Dispay Content Ceary on the Page 3.7. Use images that faciitate earning. Incuding pictures aong with written text can hep users with imited iteracy skis find, understand, communicate, and use heath information. 16,17,42 44 Exhibit 11 Source: This simpe ine drawing and caption from CDC.gov expain the ocation of the coon and rectum. Use simpe, reaistic pictures to iustrate heath behaviors and medica concepts. Web users prefer photographs of rea peope rather than iustrations or peope who ook ike modes. 15 However, when iustrating an anatomica or medica concept, simpe ine drawings are often most effective. 42 Incude a descriptive caption that expains the picture Heath Literacy Onine

45 3. Dispay Content Ceary on the Page Be sure your graphics support your text rather than detract from it. Busy, bright, or animated graphics are distracting and often mistaken for advertisements. 21 Use aternative text (caed an at tag or at text ) to describe graphics for peope using screen readers Use bod coors with contrast. Avoid dark backgrounds. Back text on a white or very ight background is the easiest to read. 7,13 Keep the background cear (avoid patterns and images) Make your site accessibe to peope with disabiities. A Federa Government Web sites must be accessibe to peope with disabiities. This is often caed Section 508 compiance (referring to Section 508 of the Rehabiitation Act). 45 Design a Web site that works for everyone. Here are a few of the important considerations addressed under Section 508: Make sure screen readers and other software can read your site. Choose strong coor contrast, especiay for buttons. Test pug-ins and other software for accessibiity. 13 To earn more about accessibiity, visit or 40 Heath Literacy Onine

46 3. Dispay Content Ceary on the Page Iterative Design Methods and Tips Methods Prototypes Usabiity testing Tips for designing and testing your Web site with users Conduct user testing with paper or cickabe prototypes. If you buid a cickabe prototype, gauge how much content can fit on a screen. Experiment with heading sizes, space, and coor contrast. If you are using a cickabe prototype or deveopmenta Web site for usabiity testing, be on the ookout for dense chunks of text that trigger skipping. UG Refer to Research-Based Web Design & Usabiity Guideines sections: 3:1; 3:5; 6:1; 6:3; 6:5; 6:10; 6:11; 9:1; 9:2; 9:3; 9:4; 10:1; 10:3; 10:6; 10:9; 10:14; 11:1 8; 11:10; 11:11; 12:4; 14:8; 14:15; 14:16; 15:6; 16:2; 16:4; 16:6 41 Heath Literacy Onine

47 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 4. Organize Content and Simpify Navigation The Basics This section discusses two important concepts: Content Organization (aso caed Information Architecture) Information architecture is the way information is categorized on a Web site. It typicay invoves a category structure (taxonomy) and abes. For exampe, think of browsing through a bookstore. Ceary abeed sections (Mystery, Nonfiction, Teen, Business) hep you find what you re ooking for. Good content organization heps users find information quicky. Navigation Navigation refers to how users move through the pages of your Web site. Eements of navigation incude menus, tabs, headings, breadcrumbs, site maps, and back or next buttons. Keep content organization and navigation simpe and consistent. Users are typicay topic-focused. 7,13 Organize and abe your content according to your users needs, and use terms that are famiiar to them. Actions at a Gance 4.1. Create a simpe and engaging home page Use abes that refect words your users know Enabe easy access to home and menu pages Make sure the Back button works Use inear information paths Incude simpe search and browse options. 42 Heath Literacy Onine

48 4. Organize Content and Simpify Navigation Actions 4.1. Create a simpe and engaging home page. The home page shoud be an easy entry point to the content on your Web site. Research indicates that Web users with imited iteracy skis have difficuty processing mutipe concepts at the same time. 3 5 Incude as few eements as possibe on the home page. Exhibit 12 Source: White space and short inks create a cean home page on heathfinder.gov. 43 Heath Literacy Onine

49 4. Organize Content and Simpify Navigation A usefu home page is mosty inks and short descriptions. 7,13 Use white space and arge buttons. Limit the amount of text on the home page. 13 If you incude information in more than one anguage, ink to the non-engish sections right from the home page Use abes that refect words your users know. Use the words of your Web users, rather than technica or catchy terms. 7 This enabes users to find content more quicky. Peope have different menta modes (methods) for grouping heath information. 20,34 To hep different users find what they need, repeat topics under mutipe categories. For exampe, based on card sorting, content on mammograms appears under three categories on heathfinder.gov: Cancer, Women, and Screening. Exhibit 13 Source: This Web page from the Office on Women s Heath incudes a navigation bar with audience-appropriate category abes (the site is for girs aged 10 to 16). For exampe, the menta heath section is abeed your feeings. 44 Heath Literacy Onine

50 4. Organize Content and Simpify Navigation 4.3. Enabe easy access to home and menu pages. Incude arge buttons that take users back to the home page or the main menu pages on the site. 13,18,19 Web users with imited iteracy skis typicay don t use breadcrumbs. 13,18 Avoid drop-down menus, especiay those that require interna scroing. Use a cear efthand navigation menu. Indicate where users are in reation to the rest of the site. 13,18 20 Exhibit 14 Source: NIH SeniorHeath uses a strong efthand navigation menu. The current section is highighted with a different coor in the navigation bar so users can easiy see where they are in the site. 45 Heath Literacy Onine

51 4. Organize Content and Simpify Navigation 4.4. Make sure the Back button works. Web users with imited iteracy skis often depend on the Back button to navigate a Web site. 21 Make sure this button works predictaby and consistenty. If users are entering data into a registration page or form, ensure that the information does not get deeted when users seect the Back button Use inear information paths. Using inear navigation (numbered pages) heps Web users with imited iteracy skis move through the content on your Web site. 12,16,17 Linear navigation can be combined with tabs (typicay running horizontay across the top of the page) to organize content and simpify navigation. Exhibit 15 Source: 1&TopicContentID=469 The heathfinder.gov Quick Guide to Heathy Living uses tabs to organize content (Overview, The Basics, Take Action). Within each tabbed section, pages are numbered so users can move easiy through the content. 46 Heath Literacy Onine

52 4. Organize Content and Simpify Navigation Linear information paths move users through a topic using a series of pages or screens. Each topic on the site has its own inear path. The content progresses from genera to more specific. I ike that you can cick on the page numbers at the bottom and go directy to other pages. Aow users to move easiy from page to page by providing Next and Back buttons as we as cickabe page numbers at the top or bottom of each screen. 3,13,15,16,18,20 Exhibit 16 Source: On this Web page from NIH SeniorHeath, the Next Page button is arge and ceary abeed. 47 Heath Literacy Onine

53 4. Organize Content and Simpify Navigation On the first page of each topic, give the user a short overview of the content. Provide a ink to each subsection for users who wish to skip directy to a specific section. Exhibit 17 Source: The Overview tab on this heathfinder.gov Web page gives a brief summary of the content and inks users directy to the section that interests them. 48 Heath Literacy Onine

54 4. Organize Content and Simpify Navigation 4.6. Incude simpe search and browse options. Many users with imited iteracy skis wi browse through categories of content rather than use a search box. 4,5,16,19 This may be because these users: Don t see the search box (many users with imited experience on the Web don t know where to ook for a search box) Are worried about speing mistakes Are overwhemed by search resuts Incude mutipe ways to browse for topics (for exampe, by topic category and using an A to Z ist). Exhibit 18 Source: The NIH SeniorHeath Web site aows users to search for heath information by topic categories or an A to Z ist. Note that some etters (in back) aren t inked to anything; they are sti incuded so that users see a famiiar aphabet. 49 Heath Literacy Onine

55 4. Organize Content and Simpify Navigation During usabiity testing, some users with imited iteracy skis cicked a search button without entering any terms in the search box. 15 Consider using the search abe together with a get started or go button. This wi hep signa to users that they must first enter a term(s) and then submit or go. When designing a search function, use a arge text box with obvious buttons. Exhibit 19 Source: The Food and Drug Administration (FDA) Web site s Search box is ceary abeed and has an obvious go button to submit the search request. Here are three rues to foow when designing a search function: 1. Aow for common misspeings. 4,13 2. When dispaying search resuts, imit the number of resuts dispayed on a page. Use numbered pages to avoid scroing. 4,13 Use white space and a arge font. 3. Use cear page tites and incude a brief pain-anguage description of each resut. 4,13 Avoid using ong URLs in search resuts, if possibe. 50 Heath Literacy Onine

56 4. Organize Content and Simpify Navigation Exhibit 20 Short URLs Source: medinepus&query=stroke&x=0&y=0 This search resuts Web page from MedinePus dispays cear tites and short URLs for the inked resuts. A brief description written in pain anguage appears above the top resuts. Ony 10 resuts show per page. 51 Heath Literacy Onine

57 4. Organize Content and Simpify Navigation Iterative Design Methods and Tips Methods Card sorting Prototypes Usabiity testing Tips for designing and testing your Web site with users Use card sorting to group the content on your Web site into categories. Once you have initia categories estabished (sometimes caed a seed structure ), conduct another round of user testing to confirm the structure. Have participants suggest abes for the categories. If resources are tight, buid a imited prototype of the home page and a few secondary navigation pages. This shoud be enough to test with users to determine whether the content is organized we. UG Refer to Research-Based Web Design & Usabiity Guideines sections: 2:13; 5:1; 5:2; 5:4; 5:5; 5:7; 7:1; 7:4; 7:12; 8:1; 8:4; 13:11; 16:4; 16:5; 17:1; 17:4; 17:5; 17:6 52 Heath Literacy Onine

58 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 5. Engage Users With Interactive Content The Basics Invite Web users to customize content to their interests and provide feedback about their experiences. Exampes incude: Printing information out or e-maiing it to a friend Taking a po or rating the quaity of information on the site Entering persona data such as age or weight to get taiored information Using caorie or body mass index (BMI) cacuators, activity ogs, recipe finders, persona assessments, and quizzes Interactive toos increase user engagement. 32 Section 2 introduced the idea of engagement. Engagement is the process of invoving users in heath content in a way that motivates them to take action. 37 Interactive toos that provide personaized heath content can engage users and promote earning. Actions at a Gance 5.1. Incude printer-friendy toos and resources Simpify screen-based contros and enarge buttons Incude interactive content that users can taior but not too much Incorporate audio and visua features Expore new media such as Twitter or text messaging. 53 Heath Literacy Onine

59 5. Engage Users With Interactive Content Actions 5.1. Incude printer-friendy toos and resources. Many Web users with imited iteracy skis prefer to print pages from a Web site rather than read text on a computer screen. 6,13,16,34 Aso, they may want to share heath information with famiy members or friends who don t have access to a computer or post it on their refrigerator. Provide a ink to printabe pages. Make the ink or icon ceary visibe. If possibe, give users the option to print a singe page, a compete section, or just a portion of the text. Exhibit 21 Source: whatiskidneydisease Users of NIH SeniorHeath s Web site can print an entire topic or seect specific pages. They aso can choose whether to incude images in the printout. 54 Heath Literacy Onine

60 5. Engage Users With Interactive Content I woud ike to print this page and show it to famiy members who need this information Simpify screen-based contros and enarge buttons. Design buttons that are easy to find and cick on by making them: Large Bright Contrasting coor from the surrounding text and background Obviousy cickabe 3,13,18,20 Keep in mind that widgets and toos that are too fashy are often interpreted as advertisements. 21 Some users with imited iteracy skis did not understand the term submit. Use an aternative abe such as go or get started for buttons. 55 Heath Literacy Onine

61 5. Engage Users With Interactive Content 5.3. Incude interactive content that users can taior but not too much. Users want personaized heath information, but they don t want to enter a ot of persona data. 14,15,19 Exhibit 22 Source: This interactive Ovuation and Due Date Cacuator from the Web site for the Office on Women s Heath asks for the date of the user s ast menstrua period and the number of days in her menstrua cyce. 56 Heath Literacy Onine

62 5. Engage Users With Interactive Content Exhibit 23 Source: The myheathfinder too on heathfinder.gov prompts users to enter their age, sex, and pregnancy status to get personaized recommendations. Users can specify whether they are searching for information for themseves, a chid, or someone ese. Create a ink between the information entered by users and their resuts. 15 This can hep compensate for users imited working memory. I m very comfortabe [entering my age]. That way, I get exact information for me, not different age groups. 57 Heath Literacy Onine

63 5. Engage Users With Interactive Content Exhibit 24 Source: The myheathfinder resuts page from heathfinder.gov incudes a summary of the user s persona information entered on the previous screen. Keep required information to a minimum, and avoid creating accounts or sign-in pages. If your content requires a registration page, ask for the minimum amount of information. Be sure to: Distinguish between ogging in and registering. Make the username an e-mai address. Keep registration to no more than three screens, and provide cues (for exampe, page 1 of 3 ). Dispay input fieds as a vertica ist. Incude a fina resuts page with questions and responses. Dispay fieds that need corrections on a new page. Incude instructions for correcting information Heath Literacy Onine

64 5. Engage Users With Interactive Content Exhibit 25 Source: This registration form for the MyPyramid Tracker Web site dispays fieds as a vertica ist. 59 Heath Literacy Onine

65 5. Engage Users With Interactive Content 5.4. Incorporate audio and visua features. Whenever possibe, provide heath information in mutipe formats, such as audio cips, video cips, or side shows. Be sure to incude a text aternative or transcript. There is some evidence that audio and video can enhance comprehension and retention of onine information; however, more research is needed Exhibit 26 Source: NIH SeniorHeath offers short video cips on popuar heath topics. Each video incudes a transcript and a hep too. 60 Heath Literacy Onine

66 5. Engage Users With Interactive Content 5.5. Expore new media such as Twitter or text messaging. Text messaging, bogs, Twitter, and Webcasting are exampes of new media. To date, there has been itte testing of new media with users with imited iteracy. We expect this wi change in the near future. What we know about new media eads us to beieve it hods potentia for reaching peope with imited iteracy skis for severa reasons: Communications are shorter (a message on Twitter is 140 characters or ess). The tone is conversationa. Most messages are user-generated. Exhibit 27 Source: heathfinder.gov inks to news reeases through Twitter updates. 61 Heath Literacy Onine

67 5. Engage Users With Interactive Content Text messages, aso known as SMS (short-message services), are increasingy being used to reach the pubic with heath messages. 52,53 Text messages can be used for one-way messaging (tips and reminders) or two-way communication. Many of the groups receptive to the use of text messaging for heath, such as aduts beow the poverty threshod and immigrants and refugees, are aso ikey to have imited iteracy skis. 2,52,54 Exhibit 28 Source: Instructions appear on AIDS.gov for mobie phone users to send a text message with their ZIP code to KNOWIT (566948). Within seconds, they wi receive a text message identifying an HIV testing site near them. 62 Heath Literacy Onine

All Aspects. of a...business...industry...company. Planning. Management. Finance. An Information. Technical Skills. Technology.

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