RangeBasicsCause Helen Monkman & Andre Kushniruk A Health Literacy and Usability Heuristic Evaluation of a Mobile Consumer Health Application August 22, 2013

1. Health Literacy – “the ability to access, understand, evaluate and communicate information” (Rootman & Gordon-El-Bihbety, 2008, p. 11) 2. Usability – the extent to which “a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use." (ISO ) Health Literacy and Usability Introduction MethodsResultsDiscussionClosing

Introduction If consumers cannot understand the content, they may have difficulty achieving their goals If the system is hard to use, consumers may have challenges accessing the information Health Literacy Usability Consumer HISs IntroductionMethodsResultsDiscussionClosing Health Literacy and Usability

Introduction The value of consumer HISs hinge on aligning consumers levels of health literacy with the demands these systems place on health literacy IntroductionMethodsResultsDiscussionClosing The Health Literacy Challenge Consumers with Low Health Literacy System Demands on Health Literacy

Introduction Validated measures for evaluating users’ levels of health literacy exist – however, they do not measure system demands on health literacy Readability measures demands on health literacy – but do not assess the impact of system display and design This study focused on lowering demands on health literacy through information display and design IntroductionMethodsResultsDiscussionClosing Lowering Demands on Health Literacy

Introduction To develop a new set of evidence-based heuristics that evaluate both usability and demands on health literacy Based on studies of usable health websites with participants who had limited health literacy IntroductionMethodsResultsDiscussionClosing Study Objectives To determine the utility of these heuristics in identifying opportunities to improve the usability and decrease demands on users’ levels of health literacy in a mobile consumer health application

Introduction Methods Usability experts assess how well a system complies with design principles (i.e., heuristics) Existing heuristics, such as Nielsen’s (1993), or new heuristics can be used ResultsDiscussionClosingIntroduction Heuristic Evaluation When the system violates a given heuristic it is assigned a severity rating A new set of heuristics and severity scale were developed for this study

Introduction Methods Tan, Liu and Bishu’s (2009) severity scale was complemented with explanations of health literacy ResultsDiscussionClosingIntroduction Severity Scale Development Mild Health Literacy: Most users will understand the content. Usability: Users can easily work around these problems. Moderate Health Literacy: Some users will understand the content. Misunderstanding will not result in harm to users. Usability: Users stumble over the problem, but can quickly adapt to it. Severe Health Literacy: Few consumers will understand the content. Misunderstanding could result in harm to users. Usability: Users have difficulty, but can find workarounds and where users are unable to complete tasks.

Some guidelines were modified for mobile devices Introduction Methods ResultsDiscussionClosingIntroduction Heuristic Development Health Literacy Online: A guide to writing and designing easy-to-use health Web sites (HLO Guide) was parsed for design guidelines U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010) Guidelines (e.g., paragraphs < 3 lines; use bulleted lists; avoid long words)  29 heuristics (e.g., Spacious)  5 categories (e.g., Content)

Introduction Methods ResultsDiscussionClosingIntroduction HLO Heuristics Screens Home Screen, Registration Content Hierarchy, Promotion, Positive Tone, Specific, Colloquial, Accurate, Spacious, Personal, Headings Display Consistency, Font, Spacious, Location of Content, Images, Contrast, Accessibility Navigation Topics, Orientation, Back Button, Linear Navigation, Buttons, Links, Search Interactivit y Engage, Print, Multimedia, New Media,

Introduction Methods The mobile consumer health app was described as a clear and simple reference guide for everyone to understand his or her blood test reports An evaluation table of the heuristics and their ancillary guidelines was used to evaluate the app The investigator explored all of the app’s screens and recorded violations, assigned severity ratings and took screenshots of violations ResultsDiscussionClosingIntroduction Procedure

Introduction Results Introduction Results MethodsDiscussionClosingIntroduction Frequency of Heuristic Violations

Introduction Results Introduction Results MethodsDiscussionClosingIntroduction Content Spacious (no bulleted lists, dense text) Specific (no actionable content) Colloquial (acronyms were not explained) Display Images (none to support written explanations) Font (small, not adjustable) Navigation Orientation (random list of 47 topics) Linear Navigation (not obvious more pages existed and available through swiping motion) Interactivity Print (could neither print nor the pages) Examples of Heuristic Violations

Introduction Results Introduction Results MethodsDiscussionClosingIntroduction App Re-Design Orientation & Linear Navigation Buttons & Colloquial Font Headings Specific Spacious Link Linear Nav AccessibilityPrint & Engage Linear Nav

Introduction Discussion MethodsResultsClosingIntroduction Evidence-based heuristics were developed for assessing demands on health literacy and usability These heuristics demonstrated utility in generating design recommendations to improve a mobile consumer health application This set of heuristics provides specific and objective design recommendations based on studies on users with limited health literacy Discussion

Introduction Closing MethodsResultsDiscussionIntroduction Consumer health information systems should be designed with considerations for health literacy and usability Design methods involving users with limited health literacy may help ensure these criteria are met However, existing systems may benefit from inspection methods for adherence to guidelines for usability and health literacy Conclusion

Introduction Closing MethodsResultsDiscussionIntroduction

Closing MethodsResultsDiscussionIntroduction Rootman I, and Gordon-El-Bihbety D. A vision for a health literate Canada. Ottawa, ON: CPHA; ISO Ergonomic requirements for office work with visual display terminals (VDTs) Part 11: Guidance on usability. International Organization for Standardization; Tan W, Liu D, and Bishu R. Web evaluation: Heuristic evaluation vs. user testing. Int J Ind Ergonom 2009; 39(4): U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, DC References

Introduction Closing MethodsResultsDiscussionIntroduction Screens Home Screen Have a simple and engaging home page. Registration Make registration and logging in as simple and obvious as possible Appendix – Screens Heuristics

Introduction Closing MethodsResultsDiscussionIntroduction Content Hierarchy Put the most important information first. Promotion Tell users what to do and how to do it. Positive Tone Stay positive and realistic. Include the benefits of taking action. Specific Provide specific action steps. Colloquial Write in plain language. Accurate Check content for accuracy. Spacious Display content clearly on the page. Personal Include a limited amount of interactive content that users can tailor. Headings Use meaningful headings. Appendix – Content Heuristics

Introduction Closing MethodsResultsDiscussionIntroduction Display Consistency Ensure styles are consistent. Font Ensure the font is easy to read. Spacious Use white space and avoid clutter. Location of Content Keep content in the center of the screen and above the fold. Images Use images that facilitate learning. Contrast Use bold colors with contrast and avoid dark or busy backgrounds. Accessibility Make the system accessible to people with disabilities. Appendix - Heuristics

Introduction Closing MethodsResultsDiscussionIntroduction Navigation Topics Put topics in multiple categories. Orientation Enable easy access to home and menu screens. Back Button Make sure the “Back” button works. Linear Navigation Use linear information paths (e.g., numbered screens). Buttons Simplify screen-based controls and enlarge buttons. Links Label links clearly and use them effectively. Search Include simple search and browse options. Appendix - Heuristics

Introduction Closing MethodsResultsDiscussionIntroduction Interactivity Engage Invite users to share content and provide feedback about their experiences. Print Include printer-friendly tools and resources. Multimedia Incorporate audio and visual features. New Media Explore new media such as Twitter or text messaging. Appendix - Heuristics