Presented by Sandy Williams Hilfiker, MA, on March 12, 2015 at the fifth Center for Health Literacy Conference: Plain Talk in Complex Times.

1. Sandy Hilfiker, MA
Plain Talk 2015
Involving Users with Limited
Literacy Skills in Co-Creation of
Health Websites

2. Presentation Overview
1. What is UCD?
2. What we know about limited literacy users
3. Getting to know your audience
4. Organizing your information
5. Testing a draft
6. Involving participants with limited literacy

3. What is User Centered Design?

4. UCD:
Involving end-users (your audience) in the
design and development of a product or
campaign
 Co-creation
 Participatory Design

5. User-Centered Design Process
① Research the user/audience
① Design a prototype
① Test it
① Tweak it
⑤ Test it again

6. User-Centered Design Process
v

7. 5 Reasons to Involve Your Users
1. Just because you think your material is awesome doesn’t mean
that your audience does.
2. You can waste a lot of time and money developing messages and
materials that nobody uses.
3. It’s the only way you can be sure that your messages will be
understood.
4. Target audience members will be empowered and invested in the
success of your product.
5. It will make you a better communicator.

8. What’s the point?

9. You want your design to be:
 Usable
 Useful
 Appropriate
 Appealing

10. Usable
Usability: ease of use (and satisfaction with)
a product, website, or material
 Does it work?
 Can the user get from A to B?
 How easily can the user accomplish the task?
 Goal: find problems in a design in order to make it better

11. Useful
Usefulness: level of value that a product has for
the user
 Is it helpful?
 Is it what the user expected?
 Will users want to interact with the design?
 Goal: understand how a design aligns with user needs

12. Appropriate (Suitable)
Suitability: extent to which a design matches users’
skills and experience
 Is it easy to understand?
 Is it motivating?
 Is it familiar?
 Is it accessible to your audience?
 Is it culturally relevant?

13. Appealing
Appeal: people’s emotional feelings about a
product or design
 Is it attractive?
 Do people want to interact with it?

14. How long do you have to grab a user’s attention on your
website?
 5 seconds
 15 seconds
 25 second
 45 seconds
 60 seconds
Web pages with clear value to the user will
hold a her attention longer.
[Source: Nielson Norman Group, 2000]

15. What we know about users with
limited literacy skills

16. What We Know
Users with limited literacy skills are…
 Willing to use the Web to access health information
 Able to accomplish tasks when Web sites are designed
well
 More likely to use a mobile phone to access the the
Web than a desktop

17. Prone to skipping & Focus on the center of the screen
Source: Colter, A and Summers, K (2014). Low Literacy Users. In Bergstrom &
Schall (Eds.), Eye Tracking in User Experience Design (p. 339). Waltham, MA:
Elesvier.
Gaze path of a participant with
low literacy skills who reads only
the text that looks easy to read.

18. Easily overwhelmed & Limited working memory
Source: Colter, A and Summers, K (2014). Low Literacy Users. In Bergstrom & Schall (Eds.), Eye Tracking in User
Experience Design (p. 339). Waltham, MA: Elesvier.
Gaze path of a participant who does not
have low literacy skills
Gaze path of a participant with limited literacy
skills attempting to read every word

19. Do I need to worry about health literacy?
About 9 in 10 Americans have limited health literacy skills.

20. ALL users benefit from improved readability and usability
Comparing time-on-task on the original site with a prototype (designed
to support users with limited literacy skills):
Time on Task
(Mean)
Original Site Prototype Improvement
High literacy 14:19 5:05 +182%
Lower literacy 22:16 9:30 +134%
All users 17:50 6:45 +164%
High Literacy Users:
3x as fast with the
revised site
93% success rate
on revised site
(compared to 68%
with original)
Source: Summers, K., & Summers, M. (2005). Reading and navigational
strategies of Web users with lower literacy skills.

21. Who is your audience?

22. Know your users
Who are they?
What motivates them?
Talk to them!
 Never assume you understand your audience
 Hold an informal focus group
 Conduct 1-on-1 interviews

23. Methods
 Interviews
 Surveys
 Focus Groups
 Collaging

24. Sample Method: Collaging
 Participants create a collage
that represents the
characteristics they would like
to see in a new Website
 Result: Provides insights into
users’ needs normally not
revealed in interviews and
focus groups

25. “This is how I feel, free and full of energy. I
want my doctor to understand that this is how
I want to feel with her help.”

26. Practice
+ Circle 2-3 images that represents qualities of your ideal work
environment.
+ Circle 1-2 images the represents the qualities you would NOT want
in your work environment.
+ Write a brief description why you chose each image.

27. What do you do with the information?

28. Create a user-centered product!
 Create a persona
 Create use-cases or user scenarios
 Inform product design and/or delivery
 Fine-tune your messages

29. Create a Persona
Persona: a pretend user who represents a
population
 Typically a combination of several real people
 Used to drive product design

30. Sample Persona: Laura

31. How to use Personas
 Will Laura use/understand this website?
 Will this design appeal to her? Is she likely to
notice it?
 What about Laura — we need to make sure this
website reaches her…

32. Practice
Create a brief persona that represents one of your
key target audiences.
Include information on:
 Demographics
 Information Needs
 Health Literacy Skills
 Technology Use/Savviness

33. What’s the best way to organize your content?

34. Methods
 Card sorting
 Tree testing
 Click testing

35. Sample Method: Card Sorting
 Participants organize topics
from a website or app into
categories that make sense
to them.
 Provides insights into a site
structure and labels that will
be intuitive for users.

36. Sample Method: Click Testing
 A technique for gathering quick feedback on wireframes
or mock-ups of webpage designs
 Provides a ‘heat map’ of where participants expect to
find specific types of information on page mock-ups
 Provides the ability to gather feedback on specific labels
and visual design elements

37. Click Testing: Sample Results

38. Click Testing: User Interface

39. Demonstration

40. Tree Testing: Word of Caution
 A technique for evaluating how
easy it is for people to locate
information within a material or
website structure
 Participants are given a topic to
find within a text version of a site
map or table of contents
 May not be an effective method
with limited literacy participants
due to the lack of visual cues

41. Tree Testing: Case Study
Task: Where would you find healthy
snack ideas for kids?
 Participants nominated 14 different
pages as the correct answer.
 Participants did very little
backtracking
 Typically, we see more blue
indicating participants have gone
down multiple paths before selecting
an answer

42. Tree Testing: Case Study
Task: Where would you go to
learn what Wisconsin is doing to
support Healthy People 2020?
 This chart represents an
unsuccessful task in on a
professional website
 The blue dots indicate where
participants went down a
path and backtracked to look
for the right answer.

43. How do I know if my product is usable?

44. Methods
 Prototype and usability testing
 Eye tracking
 A/B testing

45. Sample Method: Prototype Testing
 Participants use a paper version of an app or
website to provide feedback on 'flow' and
navigation.
 Provides helpful feedback early in the process
before valuable resources have been spent on
development.

46. Paper Prototype Testing

47. Prototype Testing: Before/After
 6 pages were redesigned based on prior user research findings
 Developed as clickable web prototypes
Before After

48. Usability Testing in Action

49. Involving Participants with Limited Health Literacy

50. Top Ten Tips
① Partner with community organizations to recruit special
populations
② Screen for participants with limited health literacy using
proxy measures
③ Develop screeners, consent forms, and moderator’s
guides in plain language
④ Limit the use of Likert-style questions
⑤ Use cash incentives when possible

51. Top Ten Tips
⑥ Screen for participants for limited technology use
⑦ Limit the number of tasks
⑧ Pre-test your protocol with at least one participant with
limited literacy skills
⑨ Choose a moderator with experience conducting
research with limited literacy participants
⑩ Conduct testing sessions in a setting that is familiar and
accessible to participants

52. Wrap Up

53. Why should I do user testing?
 When it comes to understanding your materials/website
– your users are the experts.
 All materials have problems. (Some more than others.)
They may not obvious to you. But your users will almost
always find them.
 Investing in user-friendly products pays dividends;
ignoring usability issues can be costly – affecting
DASH’s effectiveness and reputation.

54. Helpful Resources

55. Thank you!
Sandy Hilfiker
sandy@communicatehealth.com
communicatehealth.com