Sandra Williams Hilfiker Writing and Designing Effective Web-Based Health Promotion Content for Limited Literacy Users Sandra Williams Hilfiker Office of Disease Prevention and Health Promotion U.S. Department of Health and Human Services Stacy Robison Z-Tech Corporation Presentation Preview: Background healthfinder prototype proejct Iterative Design Process Examples of key findings from iterative testing

Project Objective Establish an evidence-base for communicating prevention information to limited literacy users to ensure that vulnerable populations gain access to understandable and actionable guidance on healthy decisionmaking. Cut through the clutter of online health information.

Rationale More Americans are expected to take responsibility for managing their health. Understandable and accessible health information is increasingly important. Internet is a key source of health information. 80% of Internet users have looked for health information online.

Rationale Current online health information landscape creates more stress than support. People cannot find the information they seek on Web sites about 60% of the time. Much of the health content on the Internet is focused on disease diagnosis and treatment (rather than prevention). Internet is unfriendly for limited literacy users People cannot find the information they seek on Web sites about 60% of the time 50% of the U.S. population reads at or below an 8th grade level, majority of health Web sites are written at a 10th grad level or above Only 12% of the population has proficient health literacy Vulnerable populations will be even more vulnerable without accessible online health resources Results from the 2003 National Assessment of Adult Literacy (NAAL): Majority of adults may not have the skills to understand and use health information to prevent disease. The report, Low Health Literacy: Implications for National Health Policy, states that the cost of low health literacy to the United States economy is in the range of $106 billion to $236 billion annually. According to the report, the savings that could be achieved by improving health literacy translates into enough funds to insure every one of the more than 47 million persons who lacked coverage in the United States in 2006, according to recent Census Bureau estimates.

Guiding Principles Information on a Web site must be easy to locate, navigate, and use. Health information written for the public should improve understanding, build knowledge of the body and the causes of disease, and facilitate healthy decisionmaking. To influence behavior change, information must be relevant, motivating, and include specific steps for taking action.

Evidence Base Existing research-based recommendations from HHS Leading theories of health behavior change and health communication Original research conducted using an iterative design process with more than 600 participants ages 18-84 Research-Based Web Design and Usability Guidelines Quick Guide to Health Literacy Making Health Communication Programs Work (“Pink Book”) Health Belief Model Consumer Information Processing Model Social Cognitive Theory Social Marketing Special care was taken to recruit and test adults with limited health literacy skills.

Original Research Descriptive Analysis Expert Panel Review Structured Interviews Mental Models Research Card Sort Study Prototype Evaluation (Web-based and in person) Usability Studies

What we Learned… Writing content Navigation and site structure Features and tools Page layout and design Accessibility Usability testing

Writing Content

User Motivations 3 segments of online health information seekers (based on motivation): Those seeking information about a problem affecting them or someone they know. Those seeking to find out if they have a problem or reason to be concerned. Those seeking information on how to prevent the onset of health problems. Rather than looking at traditional audience segmentation strategies (“for professionals” vs. “easy to read” or segmentation based on sex, age, education), we considered user motivations for seeking health information online. Motivation influences user performance in a Web site – looking at motivation helped us tailor content to meet user needs and expectations.

Audience Segments Users shift frequently between segments. “I want information about a topic.” “Should I be concerned?” “I want to do something.” The formula on the next slide is designed to address the information needs of all 3 audiences segments while moving users through the content.

Formula: Behavior, Benefits, Action Address all 3 audience segments using the following formula: Describe the health behavior. Describe the benefits of taking action. Provide specific action steps.

Tone and Style Users want “just the basics” about a topic. Use everyday language and examples. Give users positive reasons to change their behavior. Avoid blanket recommendations – be specific. Tell users how to do the behavior. Break it down into small steps. Don’t dwell on barriers. Provide tools and encouragement.

Small Steps Approach Instead of: Give action steps: Eat a diet rich in fruits, vegetables, grains, and low-fat milk products. Avoid saturated fats, sodium, and added sugars. Give action steps:

Small Steps Approach, cont’d Include simple actions that users can do right away. This reinforces behavior and improves self-efficacy.

Writing Style Before After

Navigation and Site Structure

Simple Home Page Design

Stay “Above the Fold” “Above the fold” refers to the portion of a Web page that is visible without scrolling. Limited literacy users tend to have a narrow field of view; they are less likely to notice content above, below, or to the sides of their focus of attention. Fold

Linear Information Paths Each topic has its own path. Allow users to move in order using “Next” and “Back” buttons. Linear information paths are much easier for limited literacy users to navigate. Simple structure allows users to move from general information to specific.

Make Tools Immediate and Relevant

User Feedback “It’s easy for everyday people like me to read. No big words or medical terms.” “It actually tells you what to do!” “I like this Web site because it gives you the information you want right away. It gives the basics, not too much to read.” “ This [Web site] makes me want to sit down and get busy today. “