Health Literacy Online

Transcription

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

68 5. Engage Users With Interactive Content Iterative Design Methods and Tips Methods Prototypes Usabiity testing Tips for designing and testing your Web site with users During testing, observe participants using the input fieds for interactive or personaized toos. Give users a sampe task to perform with the too. Do users know how to use the too without prompting? UG Refer to Research-Based Web Design & Usabiity Guideines sections: 2:12; 2:15; 13:2; 14:4 63 Heath Literacy Onine

69 Six Strategies for Writing and Designing Easy-to-Use Heath Web Sites 6. Evauate and Revise Your Site The Basics These guideines have discussed severa methods to test your Web site with users. This section addresses some of the essons earned from conducting user testing with peope with imited iteracy skis. Refer to pages 9 11 for a brief overview of iterative design methods. Actions at a Gance 6.1. 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. 64 Heath Literacy Onine

70 6. Evauate and Revise Your Site Actions 6.1. Recruit users with imited iteracy and imited heath iteracy skis. Most screening toos designed to measure heath iteracy skis (such as the Test of Functiona Heath Literacy in Aduts and the Rapid Estimate of Adut Literacy in Medicine) must be administered in person and intended for patients in a cinica setting. 55 These options may not be practica or very usefu for Web and heath content deveopers, especiay those who are using a private company s recruitment database. Instead, a proxy for heath iteracy can be used based on commony coected demographic data. 55 ODPHP used the foowing proxy for identifying Web users with imited heath iteracy skis: High schoo education or beow Beow the poverty threshod (a househod income of $40,000 or beow) Have not searched for heath information onine in the past year Recruit from community contexts (e.g., adut earning centers, federay quaified community heath centers, senior centers) using trusted community recruiters. You re more ikey to get participants from your target popuations. Consider having the community recruiter or representative attend the focus group testing session in an informa capacity, such as a greeter. Try it! Pretest your protoco with at east one participant with imited iteracy skis to fine-tune tasks and timing. 65 Heath Literacy Onine

71 6. Evauate and Revise Your Site 6.2. Choose experienced moderators. Whenever possibe, use moderators who have experience working with peope with imited iteracy skis or with peope with imited experience on the Internet. Loca coeges and universities may be a good pace to find experienced and affordabe moderators. Expect testing sessions with users with imited iteracy skis to progress at a sow pace. It s strongy recommended that you pretest your protoco with participants with imited iteracy skis to fine-tune tasks and timing. During sessions, have the moderator both read tasks aoud and provide them in writing (one task per sheet). This wi remind users of the task you are asking them to accompish Test comprehension in mutipe ways. To evauate user comprehension: Have participants think out oud as they compete tasks. Ask participants to describe what they ve read in their own words. Ask participants to describe what action they woud take after reading the content. Participants with imited iteracy skis tend to focus on the specific task sometimes to a faut. Remind users that you re ess interested in the answer and more interested in where and how they woud ook to find the answer. 66 Heath Literacy Onine

72 6. Evauate and Revise Your Site 6.4. Consider user engagement and sef-efficacy. Utimatey, you want users to act on the important heath promotion messages in your content. User engagement and sef-efficacy are two important predictors of adopting heathy behaviors. Simiary, characteristics of the content itsef such as reevance, coherence, and tone may increase the ikeihood that users wi take action. 38 In addition to standard measures of usabiity and comprehension, consider using a mix of quantitative and quaitative measures (defined in Appendix B) designed to assess the foowing: User engagement User sef-efficacy Acceptabiity of the content Appicabiity of the content These measures can be adapted for onine heath promotion content Create pain-anguage testing documents. Write your screeners, consent forms, and moderator guides in pain anguage. See Appendix C for sampe testing documents. As a genera rue, imit the number of tasks and questions when conducting usabiity testing with users with imited iteracy skis. Be reaistic about what can be accompished in the time designated for each session. In addition to providing easy-to-read consent documents, consider using a consent process that does not rey on participants heath iteracy skis or Engish proficiency. See the AHRQ Informed Consent and Authorization Tookit for Minima Risk Research from the Agency for Heathcare Research and Quaity (AHRQ) for more information Heath Literacy Onine

73 6. Evauate and Revise Your Site Iterative Design Methods and Tips Methods Cickabe prototypes Usabiity testing Tips for designing and testing your Web site with users Pretest your protoco with at east one participant with imited iteracy skis to fine-tune tasks and timing. If participants get stuck on a task, redirect them by asking where and how they woud ook to find the answer. UG Refer to Research-Based Web Design & Usabiity Guideines sections: Chapter Heath Literacy Onine

74 References 1. Fox, S. (2006). Onine heath search Washington, DC: Pew Internet and American Life Project. Retrieved September 17, 2009, from Heath_2006.pdf.pdf 2. Kutner, M., Greenberg, E., Jin, Y., & Pausen, C. (2006). The heath iteracy of America s aduts: Resuts from the 2003 Nationa Assessment of Adut Literacy (NCES ). Washington, DC: U.S. Department of Education, Nationa Center for Education Statistics. Retrieved September 17, 2009, from pubsearch/pubsinfo.asp?pubid= Nationa Institute on Aging & Nationa Library of Medicine. (2009). Making your Website senior friendy. Bethesda, MD: Nationa Institute on Aging. Retrieved September 17, 2009, from HeathInformation/Pubications/website.htm 4. Summers, K., & Summers, M. (2004). Making the Web friendier for ower-iteracy users. Intercom, June, Retrieved September 18, 2009, from 5. Zarcadooas, C., Banco, M., Boyer, J. F., & Peasant, A. (2002). Unweaving the Web: An exporatory study of ow-iterate aduts navigation skis on the Word Wide Web. Journa of Heath Communication, 7(4), 1, Eichner, J., & Duabh, P. (2007). Accessibe heath information technoogy (IT) for popuations with imited iteracy: A guide for deveopers and purchasers of heath IT (AHRQ Pubication No EF). Rockvie, MD: Agency for Heathcare Research and Quaity. 7. Redish, J. (2007). Letting go of the words: Writing Web content that works. San Francisco: Esevier, Inc. 69 Heath Literacy Onine

75 References 8. Usabiity.gov. (n.d.). Washington, DC: U.S. Department of Heath and Human Services. Retrieved from 9. White, S., & McCoskey, M. (in press). Framework for the 2003 Nationa Assessment of Adut Literacy (NCES ). Washington, DC: U.S. Department of Education, Nationa Center for Education Statistics. Retrieved September 17, 2009, from fr_definition.asp 10. U.S. Department of Heath and Human Services. (2000). Heathy Peope Washington, DC: U.S. Government Printing Office. 11. Nationa Center for Education Statistics. (2003). Nationa Assessment of Adut Literacy: Key findings. Washington, DC: U.S. Department of Education. Retrieved September 17, 2009, from naa/kf_demographics.asp 12. Summers, K., & Summers, M. (2005). Reading and navigationa strategies of Web users with ower iteracy skis. Retrieved September 17, 2009, from Summers_ASIST2005.pdf 13. U.S. Department of Heath and Human Services & U.S. Genera Services Administration. (2006). Research-based Web design and usabiity guideines. Washington, DC: U.S. Government Printing Office. 14. Office of Disease Prevention and Heath Promotion. (2006). My heathfinder usabiity testing for ODPHP, fa 2006 (fina report, prepared by ACS Heathcare Soutions). Rockvie, MD: Author. 15. Office of Disease Prevention and Heath Promotion. (2007) heathfinder.gov usabiity testing (fina report, prepared by ACS Heathcare Soutions). Rockvie, MD: Author. 16. Office of Disease Prevention and Heath Promotion. (2007). heathfinder.gov redesign: Prevention prototype usabiity study resuts report (prepared by Z-Tech Corp.). Rockvie, MD: Author. 70 Heath Literacy Onine

76 References 17. Office of Disease Prevention and Heath Promotion. (2007). Prevention content prototype deveopment: ODPHP prevention content prototype evauation resuts report (prepared by Z-Tech Corp.). Rockvie, MD: Author. 18. Office of Disease Prevention and Heath Promotion. (2008). Usabiity review of heathfinder.gov (beta) (PowerPoint presentation, prepared by Summers, K.). Rockvie, MD: Author. 19. Office of Disease Prevention and Heath Promotion. (2008) heathfinder.gov redesign usabiity test (fina report, prepared by ACS Heathcare Soutions). Rockvie, MD: Author. 20. Office of Disease Prevention and Heath Promotion. (2009). Usabiity evauation of heathfinder.gov Quick Guide to Heathy Living (report prepared by UserWorks). Rockvie, MD: Author. 21. Office of Disease Prevention and Heath Promotion. (2008). Resuts of usabiity testing and design preference interviews on ODPHP physica activity finder too (report prepared by Z-Tech Corp.). Rockvie, MD: Author. 22. Stone, D., Jarrett, C., Woodroffe, M., & Minocha, S. (2005). User interface design and evauation. San Francisco: Morgan Kaufmann/ Esevier. 23. Courage, C., & Baxter, K. (2004). Understanding your users. San Francisco: Morgan Kaufmann/Esevier. 24. Hackos, J. T., & Redish, J. C. (1998). User and task anaysis for interface design. New York: Wiey. 25. Cooper, A., Reimann, R., & Cronin, D. (2007). About face: The essentias of interface design (3rd ed.). New York: Wiey. 26. Muder, S., & Yaar, Z. (2007). The user is aways right: A practica guide to creating and using personas for the Web. Berkeey, CA: New Riders. 71 Heath Literacy Onine

77 References 27. Pruitt, J., & Adin, T. (2006). The persona ifecyce: A fied guide for interaction designers. San Francisco: Morgan Kaufmann/Esevier. 28. Snyder, C. (2003). Paper prototyping: Fast and simpe techniques for designing and refining the user interface. San Francisco: Morgan Kaufmann/Esevier. 29. Zaki Warfe, T. (2009). Prototyping: A practitioner s guide. Brookyn, NY: Rosenfed Media. 30. Dumas, J. S., & Redish, J. C. (1999). A practica guide to usabiity testing (Rev. ed.). Bristo, Engand: Inteect, Ltd. 31. Rubin, J., & Chisne, D. A. (2008). Handbook of usabiity testing: How to pan, design, and conduct effective tests (2nd ed.). New York: Wiey. 32. Office of Disease Prevention and Heath Promotion. (2004). Literature review about prevention content iterature (prepared by Abt Associates). Rockvie, MD: Author. 33. Office of Disease Prevention and Heath Promotion. (2006). Structured interview anayses (report prepared by Heath Communication Research Laboratory & Abt Associates). Rockvie, MD: Author. 34. Aexandria Heath Department. (2008). Parent and caregiver discussion groups (discussion group report for ODPHP). Rockvie, MD: Office of Disease Prevention and Heath Promotion. 35. Niesen, J., & Loranger, H. (2006). Prioritizing Web usabiity. Berkeey, CA: New Riders. 36. Office of Disease Prevention and Heath Promotion. (2006). Prevention content prototype deveopment: ODPHP card sort study report (prepared by Z-Tech Corp.). Rockvie, MD: Author. 37. Lefebvre, R. C., Tada, Y., Hifiker, S., & Baur, C. (in press). The assessment of user engagement with eheath content: The eheath Engagement Scae. Journa of Computer-Mediated Communication. 72 Heath Literacy Onine

78 References 38. Zarcadooas, C., Peasant, A. F., & Greer, D. S. (2006). Advancing heath iteracy: A framework for understanding and action. San Francisco: Jossey-Bass. 39. Office of Disease Prevention and Heath Promotion. (2009). Formative research: Report on subject matter expert interviews (prepared by Z-Tech Corp.). Rockvie, MD: Author. 40. Janz, N., Champion, V., & Strecher, V. (2002). The heath beief mode. In K. Ganz, F. M. Lewis, & B. K. Rimer (Eds.), Heath behavior and heath education: Theory, research, and practice (3rd ed.) (pp ). San Francisco: Jossey-Bass. 41. Bandura, A. (1977). Sef-efficacy: Toward a unifying theory of behaviora change. Psychoogica Review, 84, Houts, P., Doak, C., Doak, L., & Loscazo, M. (2006). The roe of pictures in improving heath communication: A review of research on attention, comprehension, reca and adherence. Patient Education and Counseing, 61, Katz, M. G., Kripaani, S., & Weiss, B. D. (2006). Use of pictoria aids in medication instructions: A review of the iterature. American Journa of Heath-System Pharmacy, 63(23), Kripaani, S., Robertson, R., Love-Ghaffari, M., Henderson, L., Praska, J., Strawder, A., et a. (2007). Deveopment of an iustrated medication schedue as a ow-iteracy patient education too. Patient Education and Counseing, 66(3), Section 508. (n.d.). Washington, DC: U.S. Genera Services Administration, Office of Governmentwide Poicy. Retrieved from Summers, K. (2006). Designing onine forms for users with ower iteracy skis. Presented at User Focus Meeting, Washington, DC. 47. Jarrett, C., & Gaffney, G. (2009). Forms that work: Designing Web forms for usabiity. San Francisco: Morgan Kaufmann/Esevier. 73 Heath Literacy Onine

79 References 48. Wrobewski, L. (2008). Web form design. New York: Rosenfed Media. 49. Makou, G., Cameron, K. A., Baker, D., Francis, L., Schotens, D., & Wof, M. (2009). A mutimedia patient education program on coorecta cancer screening increases knowedge and wiingness to consider screening among Hispanic/Latino patients. Patient Education and Counseing, 76(2), Jay, M., Adams, J., Herring, S. J., Giespie, C., Ark, T., & Fedman, H. (2009). A randomized tria of a brief mutimedia intervention to improve comprehension of food abes. Preventive Medicine, 48(1), Sobe, R. M., Paasche-Orow, M. K., Waite, K. R., Rittner, S. S., Wison, E. A. H., & Wof, M. S. (2009). Asthma 1 2 3: A ow iteracy mutimedia too to educate African American aduts about asthma. Journa of Community Heath, 34(4), Horrigan, J. (2009). Wireess Internet use. Washington, DC: Pew Internet and American Life Project. Retrieved October 17, 2009, from Homen, E. (2009). TXTING4HEALTH: The roe of the mobie channe in the heath care industry and in the sphere of pubic heath. Socia Marketing Quartery, 15(S1), Menon-Johansson, A. S., McNaught, F., Mandaia, S., & Suivan, A. (2006). Texting decreases the time to treatment for genita Chamydia trachomatis infection. Sexuay Transmitted Infections, 82(1), Amresh, H., Ash, A., Gazmararian, J., Wof, M., & Paasche-Orow, M. (2008). The Demographic Assessment for Heath Literacy (DAHL): A new too for estimating associations between heath iteracy and outcomes in nationa surveys. Journa of Genera Interna Medicine, 23(10), Agency for Heathcare Research and Quaity. (2009). AHRQ informed consent and authorization tookit for minima risk research (AHRQ Pubication No EF). Rockvie, MD: Author. Retrieved September 17, 2009, from ictookit.pdf 74 Heath Literacy Onine

80 Appendixes Appendix A: Appendix B: Appendix C: Appendix D: Appendix E: Appendix F: Reviewers Sampe Measures Sampe Testing Documents Overview of ODPHP Origina Research Resources for Creating Easy-to-Use Web Sites Annotated Bibiography 75 Heath Literacy Onine

81 Appendix A: Reviewers David R. Baker Senior Web Content Account Manager Web Communications and New Media Division Office of the Assistant Secretary for Pubic Affairs U.S. Department of Heath and Human Services Cindy Brach, M.P.P. Senior Heath Poicy Researcher Agency for Heathcare Research and Quaity Stephanie Daiey, M.A. Senior Pubic Affairs Speciaist NIHSeniorHeath.gov Nationa Institute on Aging Mary Aice Giispie, M.D., F.A.A.F.P. Director Heathy Roads Media Sanjay J. Koyani, M.P.H. Director, FDA Web Communications U.S. Food and Drug Administration (FDA) Linda Neuhauser, Dr.P.H., M.P.H. Cinica Professor, Community Heath and Human Deveopment Co-Principa Investigator, Heath Research for Action Center Schoo of Pubic Heath University of Caifornia, Berkeey Andrew Peasant, Ph.D. Director of Heath Literacy and Communication, Canyon Ranch Institute Assistant Professor, Rutgers University Andrew Pumer, M.L.A. Reference Librarian Nationa Library of Medicine Nationa Institutes of Heath 76 Heath Literacy Onine

82 Appendix A: Reviewers Janice (Ginny) Redish, Ph.D. President Redish & Associates, Inc. Beccah Rothschid, M.P.A. Director, Heath Literacy Projects Heath Research for Action Schoo of Pubic Heath University of Caifornia, Berkeey Sarah Stone, M.P.H. Editoria Director, Womensheath.gov De Perot Systems Christina Zarcadooas, Ph.D. Associate Professor Department of Preventive Medicine Mount Sinai Schoo of Medicine Marcia E. Zorn, M.A., M.L.S. Reference Librarian Nationa Library of Medicine Nationa Institutes of Heath Lead Editors Sandra Wiiams Hifiker, M.A., Project Director, ODPHP Stacy Robison, M.P.H., CHES, Consutant and Lead Writer Sean Arayasiriku, M.S.P.H., CHES, Heath Literacy Feow, ODPHP Contributing Editors Cynthia Baur, Ph.D., Nationa Center for Heath Marketing, Centers for Disease Contro and Prevention Linda Harris, Ph.D., Heath Communication and eheath Team Lead, ODPHP Xanthi Scrimgeour, M.H.Ed., CHES, Consutant 77 Heath Literacy Onine

83 Appendix B: Sampe Measures Beow are sampe measures used by ODPHP to evauate users eve of engagement with onine prevention content and their eve of sef-efficacy. Aso incuded are sampe measures for the acceptabiity and appicabiity of Web content as we as a proxy measure for heath iteracy. Engagement The eheath Engagement Scae* was adapted from commercia advertising research. The scae incudes rating 10 descriptors (α = 0.90), incuding absorbing, attention-grabbing, stimuating, surprising, suspensefu, thought-provoking, convincing, beievabe, not du, and cever (1 = Strongy Agree; 5 = Strongy Disagree). Interna reiabiity of each of the two mutiitem subscaes of the eheath Engagement Scae was for Invoving and for Credibe. Sef-Efficacy The sef-efficacy scae was adapted from the Guide for Constructing Sef-Efficacy Scaes, where Bandura proposes measuring sef-efficacy by having participants rate their eve of confidence in taking an action. The scae used by ODPHP incudes the foowing three items: This information made me fee more confident that I can do something ; This information made me fee more prepared to do something ; and This information made me fee more prepared to do something in the next month (1 = Strongy Agree; 5 = Strongy Disagree). * Lefebvre, R. C., Tada, Y., Hifiker, S., & Baur, C. (in press). The assessment of user engagement with eheath content: The eheath Engagement Scae. Journa of Computer-Mediated Communication. Bandura, A. (2006). Guide for creating sef-efficacy scaes. In T. Urdan & F. Pajares (Eds.), Sef-efficacy beiefs of adoescents (pp ). Charotte, NC: Information Age Pubishing. 78 Heath Literacy Onine

84 Appendix B: Sampe Measures Acceptabiity Acceptabiity is the extent to which the intended users ike the too/content and find it easy to use. ODPHP operationaized acceptabiity (based on the 2006 report, Expanding the Reach and Impact of Consumer E-Heath Toos ) with two items. They incude This information was easy to use and This information was presented in ways that I coud easiy understand (1 = Strongy Agree; 5 = Strongy Disagree). Appicabiity Appicabiity is the extent to which the too/content is reevant to the needs of the intended user; in other words, does it hep him or her in his or her everyday ife? ODPHP operationaized appicabiity (based on the 2006 report, Expanding the Reach and Impact of Consumer E-Heath Toos) with two items. They incude This information was usefu to me and This information gave me some specific ideas about what to do (1 = Strongy Agree; 5 = Strongy Disagree). Limited Heath Literacy ODPHP used proxy measures to identify a imited heath iteracy sampe based on statistics from the heath iteracy component of the 2003 Nationa Assessment of Adut Literacy. Individuas incuded in the imited heath iteracy sampe met the foowing criteria: have a high schoo education or beow, have an annua househod income beow the poverty threshod (under $40,000), and have not searched for heath information onine in the past year. Office of Disease Prevention and Heath Promotion. (2006). Expanding the reach and impact of consumer e-heath toos. Rockvie, MD: Author. Retrieved from eheathtoos/defaut.htm 79 Heath Literacy Onine

85 Appendix C: Sampe Testing Documents INFORMED CONSENT The Agency for Heathcare Research and Quaity (AHRQ) has deveoped an Informed Consent and Authorization Tookit for Minima Risk Research to faciitate the process of obtaining informed consent and Heath Insurance Portabiity and Accountabiity Act (HIPAA) authorization from potentia research participants. The AHRQ tookit incudes a sampe Informed Consent Form written in pain anguage. The sampe form can be accessed at fund/informedconsent/icform1.htm. SAMPLE SCREENER Our desired participants are women, with a mix of age and other characteristics, who have some (but imited) experience using the Internet. Age: Gender: Education: Ethnicity: Income: Peope aged 18 and oder Mosty femae High schoo equivaent or ess An ethnicay mixed group if possibe Househod income of $40,000 or ess We wi excude from participation users who: Have participated in a usabiity test or focus group within the past year. Conduct market research or design and deveop Web sites. Are unabe to speak or read Engish enough to compete the study. Have activey ooked for heath information on the Internet in the ast year. Are everyday users of the Internet. Are unabe to use a computer. 80 Heath Literacy Onine

86 Appendix C: Sampe Testing Documents Heo, This is NAME from COMPANY. We are doing a research study on a heath Web site. If you quaify, we wi pay you $75 to participate in a 1-hour meeting at LOCATION. This is a research study. We are not seing anything. Other peope who have participated have found it to be interesting and fun. Does it sound ike something you woud be interested in? Great. Let s find out if you quaify. I have a few simpe questions to ask. This shoud ony take a few minutes. At some point, I may end the questions if I discover you don t quaify. This has nothing to do with you. We simpy are ooking for peope who meet certain criteria. [Insert standard questions about participation in market research ] How often do you use the Internet? Every day [REJECT] A few times per week [CONTINUE] About once per week [CONTINUE] Less than once per week [CONTINUE] Never or hardy ever [REJECT] Over the past year, have you ooked for information on the Internet about a heath probem that you or someone you knew had? Have done this often [REJECT] From time to time [Incude ony a few in this category] Hardy ever [CONTINUE] No [CONTINUE] [Insert standard demographic questions ] 81 Heath Literacy Onine

87 Appendix C: Sampe Testing Documents In this study, you wi be asked to try out a Web site. This is not a group study; you wi meet one-on-one with a researcher. You wi be recorded on both audio and video. Are you comfortabe with this? Yes [CONTINUE] No [REJECT] In this research study, we wi be asking you questions about how you use the Internet, and we wi ask you to try out some Web sites. It wi take about 1 hour. When you re done, we wi pay you $75. We reay appreciate your hep. I have the foowing times avaiabe. [Insert standard questions about scheduing] [End] 82 Heath Literacy Onine

88 Appendix D: Overview of ODPHP Origina Research ODPHP commissioned 15 studies over a period of 4 years to inform the deveopment of an onine coection of prevention and weness content and to redesign heathfinder.gov. More than 750 peope aged 18 to 84 participated in these studies. Specia care was taken to recruit and test aduts with imited iteracy skis. Beow is an overview of the iterative research process, foowed by a brief description of each study. Formative Research Phase Literature Review Web Site (Content) Anaysis Expert Interviews Structured Interviews Menta Modes Study Card-Sorting Study Prototyping Phase Prototype Test (Paper and Cickabe) Usabiity Studies 1 Through 4 Postaunch Quaity Improvement Phase (Ongoing) Card-Sorting Study Widget Usabiity Test Intermediary Interviews Usabiity Study 5 83 Heath Literacy Onine

89 Appendix D: Overview of ODPHP Origina Research Formative Research Phase Literature Review ODPHP conducted a iterature review to answer the foowing questions: Which audience characteristics are the strongest determinants of homogeneity in terms of seeking prevention information? In what ways and to what extent is currenty avaiabe prevention information responsive to these patterns? Is prevention information that is targeted in content design and deivery more effective than information that is not targeted? How can prevention information be presented effectivey onine? The iterature generay supported the finding that taiored and targeted materias that respond to individua characteristics, such as readiness to change, can be effective in engaging interest and eading to heath behavior change. The review aso found that interactive information is more engaging and motivating than information that is not interactive. Web Site (Content) Anaysis ODPHP reviewed content on nine prevention topics avaiabe from four eading heath Web sites: American Cancer Society, Mayo Cinic, WebMD, and Famiy Doctor. Based on this review, the authors made severa genera recommendations for designing heath information for Web sites, incuding: Keep content at a reasonabe ength. Use headings and subheadings. Use hyperinks so users can expore reevant content. Provide interactive toos as appropriate. Convey information using graphics or visua dispays. Expert Interviews Subject-matter experts in nine heath content areas identified common questions asked by members of the pubic. The goa was to identify audience segments based on motivations for seeking information. The audience segments deveoped from the expert interviews incuded: Segment 1: Those seeking information about a heath probem for themseves or someone they know. 84 Heath Literacy Onine

90 Appendix D: Overview of ODPHP Origina Research Segment 2: Those wanting to find out whether they or someone they know has a heath probem or reason to be concerned about a heath probem. Segment 3: Those seeking information to hep prevent the onset of heath probems. Structured Interviews ODPHP conducted structured interviews with 200 diverse participants between the ages of 18 and 65 to test the audience segmentation strategy mentioned above. Exampes of key findings incude: The audience segmentation strategy was vaidated (significant differences were found in motives/preferences between the three segments). Respondents did not remain in a particuar audience segment over time. Content shoud refect the needs/motives of each segment. Menta Modes Study Indepth interviews were conducted with 35 Engish-speaking aduts, aged 18 to 65, with imited heath iteracy. The primary intent of this research was to determine how peope naturay group disease prevention topics (i.e., their menta modes ) to inform the deveopment of a prevention prototype. Exampes of key findings incude: Participants grouped the topics of nutrition, obesity, and physica activity together. Other topics were commony stand-aone concepts, such as preventing fas and getting fu shots. Participants associated the topics of taking to kids about smoking and taking to kids about substance abuse. 85 Heath Literacy Onine

91 Appendix D: Overview of ODPHP Origina Research Card-Sorting Study Eighty-one diverse participants competed the card-sorting study. As a resut of the study, ODPHP created a prioritized ist of the most usefu types of content across the three audience segments. These content types emerged as generay usefu and important : 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) Prototyping Phase Prototype Test (Paper and Cickabe) ODPHP deveoped and tested a prevention information prototype with a diverse, nationwide sampe of 300 aduts. Participants evauated the prototype and prevention content on measures of engagement, sef-efficacy, acceptabiity, and appicabiity. Exampes of key findings incude: Participants found the content acceptabe (reevant and usefu), but did not rate it as highy for inspiring sef-efficacy. Quaitative data showed participants preference for the foowing content characteristics: Informa, cear, and concise writing Tabbed organization Actionabe information with a sma-steps approach Interactive toos Graphics that aid understanding An interface that aows users to dri down through reated chunks of information 86 Heath Literacy Onine

92 Appendix D: Overview of ODPHP Origina Research Usabiity Study 1 ODPHP performed an initia usabiity study with 40 adut women with imited heath iteracy skis recruited from federay quaified community heath centers in Batimore, MD. The study was designed to observe and record any probems encountered by users as they navigated the prototype, to earn whether changes to the content and interface design woud positivey affect sef-efficacy measures, and to gauge eves of understanding and engagement. Exampes of key findings incude: Participants particuary iked checkists, ists of questions to ask a doctor, access to reated resources, graphics that aid understanding, and options to print. The tabbed approach heped orient participants to where they were in the content. Participants found the interactive toos (e.g., cacuators, quizzes, menu panners) usefu because they were immediate, reevant, and in context. Providing sma steps for taking action heped improve participants sef-efficacy. Content organization of What is the behavior? (basics), Why is it important to me/reevance? (benefits), and What do I do about it? (take action) was ogica to participants. Usabiity Study 2 ODPHP conducted a second usabiity test with 13 adut women with imited heath iteracy recruited from federay quaified community heath centers in Batimore, MD. This test was performed to vaidate changes made from the prior usabiity test (Usabiity Study 1) and to continue to test eves of engagement, sef-efficacy, and understanding. Exampes of key findings incude: Participants had difficuty using the search function and often cicked on the Search button without entering a search term. Most users expected to see a ist of topics in an A to Z format. When using the myheathfinder too, participants did not easiy connect the information they entered into the too with the search resuts they received. 87 Heath Literacy Onine

93 Appendix D: Overview of ODPHP Origina Research Tab navigation needs to be more ceary deineated. Participants preferred photographs of rea peope to icons. Participants noticed content at the center of the page more than top, bottom, and side content. Usabiity Study 3 ODPHP performed a third usabiity test with seven diverse participants recruited in Knoxvie, TN. This study provided an overa test of the new heathfinder.gov site and of the changes made based on previous testing. Exampes of key findings incude: Most participants used the A to Z section, rather than the search box, to browse. When prompted to use the search function, participants had itte troube and were abe to scan the resuts page easiy. Participants were abe to navigate easiy back to the home page through strong efthand navigation. Participants particuary iked the photos of rea peope and the take action content. Usabiity Study 4 (myheathfinder) ODPHP conducted a usabiity test on the first iteration of the myheathfinder too with 15 diverse participants. Exampes of key findings incude: Participants had difficuty signing in. Many attempted to sign in even though they had never created an account. Many participants had difficuty creating an account. For exampe, they did not distinguish between required and optiona fieds, had difficuty creating a unique username and password, and did not understand error messages. Participants did not want to enter persona information (e.g., height, weight, smoking status). Participants often skipped over context and wecome information. Participants needed more than just recommendations; they wanted corresponding how-to information. 88 Heath Literacy Onine

94 Appendix D: Overview of ODPHP Origina Research Postaunch Quaity Improvement Phase (Ongoing) Card-Sorting Study ODPHP conducted a card-sorting activity with 30 aduts with imited heath iteracy recruited through the WIC program (Specia Suppementa Nutrition Program for Women, Infants, and Chidren) in Aexandria, VA, and from a federay quaified community heath center in Batimore, MD. During each of four focus group sessions, participants competed two card sorts to refine the organization of the Quick Guide to Heathy Living topic pages and to deveop categories and abes for a new Quick Guide anding page. Exampes of key findings incude: Participants had difficuty understanding the Benefits tab and tended to organize a information in the Basics and Take Action categories. Participants were very interested in one-page, printabe action-oriented topics and toos using buet points instead of paragraphs. Participants preferred topics to be paced under mutipe categories. Participants tended to ike categories of information abeed for certain groups (e.g., women, oder aduts, parents). Widget Usabiity Test (Be Active Your Way) (Two Rounds) ODPHP hed two usabiity tests with 18 participants recruited from adut iteracy programs in Washington, DC. These studies specificay focused on the usabiity, usefuness, and understandabiity of a widget providing targeted physica activity tips. Exampes of key findings incude: Participants did not notice the widget on the eft and right margins. Many participants thought the sidebar graphic (widget icon) might be an ad. Participants didn t respond we to the word barriers. Participants often gossed over difficut words, such as moderate and vigorous. 89 Heath Literacy Onine

95 Appendix D: Overview of ODPHP Origina Research Participants often ignored or skipped over very short words ike is and in. Participants wanted to use the Back button rather than other navigationa eements. Intermediary Interviews ODPHP conducted interviews with 10 heath intermediaries recruited from WIC programs and federay quaified community heath centers. The goa of the interviews was to obtain feedback on how heathfinder.gov content coud better serve WIC and community heath center cients. Exampes of key findings incude: Participants thought the organizationa structure of the content (Basics, Benefits, Take Action) was ogica and woud hep them expain prevention behaviors to their cients. Participants cautioned that content shoud refect the cutura sensitivities and economic reaities of priority audiences. Participants iked the use of positive, empowering anguage. Participants suggested an increase in the use of images and symbos to make points stick. Usabiity Study 5 ODPHP conducted a fifth usabiity test with nine participants with imited heath iteracy recruited through two community adut earning centers in Coumbia, MD, to provide feedback on a new Quick Guide anding page and topic structure. Exampes of key findings incude: Participants often missed items on the right side. Participants strugged with scroing or didn t scro at a. Participants had high success rates in finding topics through the Quick Guide organizationa structure. Participants easiy noticed and used the efthand navigation. Participants needed everything that ooked cickabe to be cickabe and wanted navigationa eements to be big and easy to notice. 90 Heath Literacy Onine

96 Appendix E: Resources for Creating Easy-to-Use Web Sites CDC Scientific and Technica Information: Simpy Put This guide wi hep you transate compicated scientific and technica information into materia that captures and keeps the interest of your intended audience. Avaiabe at training/content/ activeinformation/resources/simpput.pdf Cear & Simpe: Deveoping Effective Print Materias for Low-Literate Readers This guide, deveoped by the Nationa Cancer Institute, outines a process for deveoping pubications for peope with imited iteracy skis. The process was derived from communications, heath education, and iteracy research and practice. Writers who have produced ow-iteracy materias contributed their expertise. Avaiabe at Creating Websites That Work Kathryn and Michae Summers provide step-by-step information and toos for deveoping effective Web sites. Houghton Miffin Company, 2005 Letting Go of the Words: Writing Web Content That Works Janice (Ginny) Redish provides a comprehensive and accessibe overview of writing Web content, with screenshots and exampes incuded throughout. Morgan Kaufmann Pubishers, Heath Literacy Onine

97 Appendix E: Resources for Creating Easy-to-Use Web Sites NIA: Making Your Website Senior Friendy This pubication summarizes the best practices of the Nationa Institute on Aging (NIA) Web site, NIH SeniorHeath ( Providing practica guidance to deveopers of Web content, this pubication uses exampes to iustrate points such as using action verbs in headers and incorporating video, audio, and pictures to better reach the oder popuation. Avaiabe at PainLanguage.gov Designed to improve communication from the Federa Government to the pubic, this Web site contains exceent toos and exampes of pain anguage. Avaiabe at Quick Guide to Heath Literacy This tookit from the U.S. Department of Heath and Human Services (HHS) provides content deveopment tips and expains why to improve heath iteracy as we as how to do it. You wi find user-friendy, actionoriented materias that can be easiy referenced, reproduced, and shared with coeagues. Avaiabe at 92 Heath Literacy Onine

98 Appendix E: Resources for Creating Easy-to-Use Web Sites Accessibe Heath Information Technoogy (Heath IT) for Popuations With Limited Literacy: A Guide for Deveopers and Purchasers of Heath IT The evidence-based guide from the Agency for Heathcare Research and Quaity incudes a checkist for Web site deveopers as we as genera recommendations for improving the accessibiity of a heath IT. Avaiabe at PTARGS /LiteracyGuide.pdf Usabiity.gov This Web site is a great reference for conducting usabiity testing and user-centered design. The site incudes checkists, descriptions of methods, and sampe testing documents and research protocos. Avaiabe at Research-Based Web Design and Usabiity Guideines These guideines are based on more than 400 separate sources of research and have been reviewed by experts from across Government, industry, and academia. Each guideine incudes a reative importance rating as we as a strength of evidence rating. Avaiabe at 93 Heath Literacy Onine

99 Appendix E: Resources for Creating Easy-to-Use Web Sites Easy-to-Use Heath Information on the Web heathfinder.gov MedinePus a.htm NIH SeniorHeath WomensHeath.gov 94 Heath Literacy Onine

100 Appendix F: Annotated Bibiography Daiey, S. (2005). NIHSeniorHeath.gov: Empowering oder aduts with heath information. Journa on Active Aging, 4(2), Retrieved from This background piece herads the award-winning work of the Nationa Institute on Aging and the Nationa Library of Medicine on the NIH SeniorHeath Web site ( The artice describes the purpose of the Web site and provides an overview of some of the essons earned. Echt, K. V. (2002). Designing Web-based heath information for oder aduts: Visua considerations and design directives. In R. W. Morre (Ed.), Oder aduts, heath information, and the Word Wide Web (pp ). Mahwah, NJ: Lawrence Erbaum Associates. Echt summarizes the research behind Web-based interface design and expains the specia considerations necessary to design Web-based heath information for oder aduts. This chapter incudes cear guideines for ayout, organization, navigation, and graphics. Freimuth, V. S., & Mettger, W. (1990). Is there a hard-to-reach audience? Pubic Heath Reports, 105(3), This artice dispes myths, deconstructs assumptions about hard-to-reach audiences, and offers aternative perspectives to highight the strengths of different audience segments, encouraging innovative approaches to communication. Kaphingst, K. A., Zanfini, C. J., & Emmons, K. M. (2006). Accessibiity of Web sites containing coorecta cancer information to aduts with imited iteracy (United States). Cancer Causes and Contro, 17(2), Kaphingst and coeagues found that many coorecta cancer Web sites were too difficut for the average American adut and much too difficut for aduts with imited iteracy to use. Common probems with the sites incuded the foowing: ack of review of key ideas; insufficient use of iustrations for key messages; crowded ayout and ong ine engths; sma type size; ack of cues to highight key content; and ack of interactive features. 95 Heath Literacy Onine

101 Appendix F: Annotated Chapter Bibiography Name Kodagoda, N., & Wong, W. (n.d.). Why design for peope with reading difficuty and ow iteracy. Retrieved from com/fies/2008liverpoo/kodagoda_and_wong.pdf This document summarizes previous research conducted by the authors on users with ow iteracy and the Web. The authors expain the benefits of semantic Web technoogy and offer design guideines for users with ow iteracy. Lefebvre, R. C., Tada, Y., Hifiker, S., & Baur, C. (in press). The assessment of user engagement with eheath content: The eheath Engagement Scae. Journa of Computer-Mediated Communication. This artice describes the psychometric testing and evauation of the eheath Engagement Scae, which was adapted from commercia advertising research. Interna reiabiity of each of the two muti-item subscaes of the eheath Engagement Scae was for Invoving and for Credibe. The eheath Engagement Scae may prove to be an important mediator of user retention of information, intentions to change, and utimatey efforts to undertake and achieve behavior change. Morre, R. W., Daiey, S. R., & Rousseau, G. K. (2003). Commentary: Appying research: The NIH Senior Heath Project (pp ). In N. Charness & K. W. Schaie (Eds.), Impact of technoogy on successfu aging (pp ). New York, NY: Springer Pubishing. This chapter offers a detaied outine of the specia considerations, design principes, and methodoogy impemented in the NIH Senior Heath Project. Not ony do the authors expain the unique needs of aging popuations, incuding their usabiity testing procedures and resuts, but aso they ceary ay out detaied guideines for Web content deveopment for aging popuations. Neuhauser, L. (2001). Participatory design for better interactive heath communication: A statewide mode in the U.S.A. Eectronic Journa of Communication/La Revue Eectronique de Communication, 11(3,4). Retrieved from This artice provides an exampe of how participatory design was used by hundreds of parents and peope with disabiities to create a heath Web site for 33 miion residents of the State of Caifornia. 96 Heath Literacy Onine

102 Appendix F: Annotated Bibiography Niesen, J. (2005). Low iteracy users. Jakob Niesen s Aertbox. Retrieved from This Web site provides an overview of the user popuation with ower iteracy as we as practica tips for improving the usabiity of Web sites. Summers, K., & Summers, M. (2004). Making the Web friendier for ower-iteracy users. Intercom, June, Retrieved from %20friendier.pdf The authors describe some of the onine behaviors of imited iteracy users. These behaviors, such as avoiding search functions or reading every word, often contradict deveopers most basic assumptions. It s important to address these issues in deveoping onine prevention content. Summers, K., & Summers, M. (2005). Reading and navigationa strategies of Web users with ower iteracy skis. Retrieved from This research artice summarizes resuts from a study that sought to understand the differences between the reading and navigationa strategies of users with ow iteracy skis and those with medium to high iteracy skis. The authors offer strategies and design principes to make Web-based medica content usabe and accessibe for ower iteracy aduts. Zarcadooas, C., Banco, M., Boyer, J. F., & Peasant, A. (2002). Unweaving the Web: An exporatory study of ow-iterate aduts navigation skis on the Word Wide Web. Journa of Heath Communication, 7(4), Based on an ethnographic study of a group of ow-iterate aduts, the authors identify specific navigationa and content issues that present barriers for this popuation. They discuss preiminary assumptions that can be used to inform the deveopment of Web toos for ow-iterate aduts and directions for future appied research. 97 Heath Literacy Onine

103 Appendix F: Annotated Bibiography Zarcadooas, C., Peasant, A. F., & Greer, D. S. (2006). Heath iteracy and the Internet. In Advancing heath iteracy (pp ). San Francisco: Jossey-Bass. This book chapter brings together the research from two words: heath iteracy and the Internet. The authors expain the strengths and weaknesses of using the Internet to communicate heath information. In addition to reviewing key research findings, the authors outine specific chaenges, opportunities, and ethica issues. This chapter contains appied exercises and an abbreviated gossary of commony used Internet jargon. 98 Heath Literacy Onine