A Study of Web Usability for Older Adults Seeking Online Health Resources.
SHIRLEY ANN BECKER. Florida Institute of Technology
S. A. Becker, Computer Information Systems, School of Management, Florida Institute of Technology, 150 West University Blvd., Melbourne, FL 32901; email: abecker@fit.edu.
ACM Transactions on Computer-Human Interaction, Vol. 11, No. 4, December 2004, Pages 387–406.
Abstract
The Web offers older adult users immediate access to health resources that might not otherwise
be available. Older adult users, however, may encounter Web barriers associated with normal
aging and lower education. The National Institute on Aging Web guidelines were used to assess the usability of 125 Web sites offering health resources. Performance, translation, and reading complexity were also assessed. Results showed that many of the sampled sites were not senior-friendly. Only 12% of the sites offered a Spanish version, many containing nontranslated text. Approximately a third of sampled sites required a college education to comprehend extracted health information.
Table I. Guidelines for Making Senior-Friendly Web Sites [NIA/NLM 2002]
Sample Guidelines for Designing Readable Text
Sans serif typeface > Use font typeface that is not condensed (e.g., Arial, Helvetica) to display
information content.
Large font size > Use 12–14 point font size to improve legibility of information content.
Sample Guidelines for Presenting Information
Style > Present information in a clear and familiar way to reduce the number of inferences that must be made.
Simplicity > Write the text in simple language.
Sample Guidelines for Increasing Ease of Navigation
Help and Contact Information > Provide help information as well as phone numbers for personal contact.
Site Map > Provide a hierarchical, visual model (site map) to show the organization and content of the site.
Menus > Use pull down menus (list of options displayed when mouse is placed over it) sparingly so precise mouse movement is not required.
The U.S. National Institute on Aging (NIA) in conjunction with the U.S. National Library of Medicine (NLM) [2002] has readily acknowledged Web usability issues for older adults and the need for addressing them. They have published guidelines for designing senior-friendly sites that are based on scientific findings from research in aging, cognition, and human factors. (Refer to Morrell et al. [2004] for a compilation of research findings.) These guidelines, illustrated in Table I, provide information on how to improve the design and information content of Web pages for older adults. The overall objective is to eliminate barriers to Web use based on vision, cognition, and physical impairments due to the normal aging process.
As adults age, their vision, cognition, and physical skills decline, with an impact on their ability to perform many tasks [Salthouse 1991]. Older adult reading comprehension is affected by cognitive changes associated with normal aging; as well as his or her education level and language proficiency [Qualls et al. 2001].
Vision
For many older adult users, eye fatigue and strain occur even with corrective lenses due to Web design factors such as font size, font style and type, foreground and background colors, patterned background images, and animation [Echt 2002].
The NIA/NLM guidelines recommend that sufficiently large font sizes be used to accommodate aging vision when designing Web content. Other recommendations, not addressed in this study, include the use of sans serif font styles (e.g., Arial, Helvetica), elimination of patterned background images and the use of highly contrasting foreground and background colors (e.g., black text on an off-white background).
Cognition
Strong et al. [2001] identify problem solving, working memory, attention, and concept formation as the cognitive issues influencing an older adult’s use of Web features. Working memory entails temporarily holding and manipulating information while engaging in a variety of cognitive tasks [Baddeley 1986; Strong et al. 2001 p. 263]. An older adult’s performance on working memory tasks declines with age [Holt and Morrell 2002], and he or she has a reduced ability to discern details in the presence of distracting information.
As a result, complex navigation schemas, poorly designed search capabilities, and cluttered Web pages all negatively affect the older adult’s online experience.
To address cognition issues, NIA/NLM guidelines recommend a site map feature to show how the site is organized. It also specifies that help and contact information be made available to provide additional resources for those who need them. Other recommendations not included in this study are design consistency across pages and appropriately labeled links to promote ease of navigation for the older adult user.
Motor Skills
Older adults have decreased motor coordination so that it becomes difficult to move and click a mouse, scroll down a Web page [Hawthorne 2000], or click on standard-size links [Ellis and Kurniawan 2000]. An older adult typically takes longer to complete a movement than younger adults [Chadwick-Dias et al. 2003], and their movements tend to be less smooth and less coordinated [Seidler and Stelmach 1996]. Due to a reduction in fine motor skills, cursor positioning of the mouse is difficult for older adults, especially when interacting with small objects [Chaparro et al. 1999; Walker et al. 1996; Worden et al. 1997].
The NIA/NLM guidelines recommend that the Web design take into account physical impairments by using single mouse clicks to access information and judiciously using mouseover technology. The guidelines also specify large buttons to minimize precise mouse movements needed to activate them.
Literacy
There are numerous Web sites offering access to unparalleled amounts of health information with older adults potentially being major beneficiaries. As a result, more seniors are getting online to search for health or medical information. There has been a 25% increase from 2000 to 2003 in the number of online seniors performing health-related searches [Fox 2004, p. 6].
They have also found that a negative association between literacy skills and age appears to increase after age sixty-five [Kirsch et al. 1993]. As one ages, it becomes more difficult to simultaneously remember and process new information and to comprehend text [Craik and Salthouse 2000].
The NIA/NLM guidelines for senior-friendly Web sites specify that information should be presented clearly, using active voice, and in simple language. The guidelines do not specify a targeted reading grade level, though they recommend a familiar and positive writing style.
USABILITY STUDY
A usability study assessed 125 Web sites for potential usability barriers facing older adult users.
Twenty-five online newspapers were randomly selected from each geographic region in the United States. Twenty-five commercial (.com) and twenty-five nonprofit (.org) Web sites were selected from online searches using health conditions (e.g., stroke, diabetes, cancer, heart disease, lung, arthritis) typically associated with aging. In addition, several Web sites offering a broad range of health content (e.g., Mayoclinic.org,WebMD.com) were included in the study. Each of the 50 state government Web sites was included in the study.
A rater, knowledgeable with the NIA/NLM and homepage guidelines, completed the usability assessment for each of the 125 Web sites. Both usability and performance data were recorded on a checklist containing the NIA/NLM and homepage guidelines used in this study. Translation data was recorded on a second checklist containing English barriers associated with Spanish versions of sampled Web sites.
The focus of Web site usability was on accessing health resources made available on state, commercial, and nonprofit Web sites. Each Web site was assessed in terms of design, performance, translation, and literacy barriers. The NIA/NLM guidelines primarily focused on design issues. Web usability and health literacy guidelines were used to support these components of the assessment process.
Nielsen and Tahir [2002] point out that the homepage is the most important page on a Web site because users view it more than any other page. Its design often determines whether a user will stay or leave the site.
Each homepage design was evaluated in terms of potential usability barriers based on pull-down menus, font sizes, and vertical page length as well as missing site map, help, and contact and privacy information.
CONCLUSION
The NIA/NLM guidelines provided a framework for the design assessment carried out as part of this study. These guidelines are based on past usability research with older adult subjects. Morrell et al. [2004] compiled these research results, which became the foundation for the development of the NIA/NLM guidelines. As such, these guidelines are a significant step forward in eliminating Web barriers that challenge many older adult users.
.....
The impetus for this study is the growing number of older adults going online to access health resources. Given that older adults seek online health information more than any other age group [U.S. Department of Commerce 1999, 2002], the Web could be highly influential in maintaining senior health. Existing usability barriers, however, may prevent senior users from taking full
advantage of Web health resources.
The results of this study show that improvements to Web design are needed in order to accommodate vision, cognition, and motor skills of older adult users. None of the site categories attained high ratings for overall usability in terms of senior-friendliness. Almost all of the sites used small-point font sizes for some Web content, negatively affecting the readability of the site. About onefourth required the use of mouse technology to navigate the site, which poses a usability barrier for those who have unsteady hands. In addition, a large number of sites did not provide help or site map support. ... Only a small number of sites offered a Spanish version many of which contained English text, thus posing a barrier for those with low English proficiency. ...
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