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U.S. Department of Health and Health Services
Office of Disease Prevention and Health Promotion
Health Literacy Online: A Guide to Writing and Designing Easy-to-Use Health Web Sites
Evaluate and Revise Your Site

The Basics

These guidelines have discussed several methods to test your Web site with users. This section addresses some of the lessons learned from conducting user testing with people with limited literacy skills.

Refer to the section A Brief Introduction to User-Centered Design for a brief overview of iterative design methods.

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6.1. Recruit users with limited literacy and limited health literacy skills.

Most screening tools designed to measure health literacy skills (such as the Test of Functional Health Literacy in Adults and the Rapid Estimate of Adult Literacy in Medicine) must be administered in person and intended for patients in a clinical setting.55

These options may not be practical or very useful for Web and health content developers, especially those who are using a private company's recruitment database. Instead, a proxy for health literacy can be used based on commonly collected demographic data.55

ODPHP used the following proxy for identifying Web users with limited health literacy skills:

  • High school education or below
  • Below the poverty threshold (a household income of $40,000 or below)
  • Have not searched for health information online in the past year
  • Recruit from community contexts (e.g., adult learning centers, federally qualified community health centers, senior centers) using trusted community recruiters. You're more likely to get participants from your target populations.

Consider having the community recruiter or representative attend the focus group testing session in an informal capacity, such as a greeter.

Try it icon

Pretest your protocol with at least one participant with limited literacy skills to fine-tune tasks and timing.

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6.2. Choose experienced moderators.

Whenever possible, use moderators who have experience working with people with limited literacy skills or with people with limited experience on the Internet. Local colleges and universities may be a good place to find experienced and affordable moderators.

Expect testing sessions with users with limited literacy skills to progress at a slow pace. It's strongly recommended that you pretest your protocol with participants with limited literacy skills to fine-tune tasks and timing.

  • During sessions, have the moderator both read tasks aloud and provide them in writing (one task per sheet). This will remind users of the task you are asking them to accomplish.

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6.3. Test comprehension in multiple ways.

To evaluate user comprehension:

  • Have participants think out loud as they complete tasks.
  • Ask participants to describe what they've read in their own words.
  • Ask participants to describe what action they would take after reading the content.

Participants with limited literacy skills tend to focus on the specific task—sometimes to a fault. Remind users that you're less interested in the answer and more interested in where and how they would look to find the answer.

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6.4. Consider user engagement and self-efficacy.

Ultimately, you want users to act on the important health promotion messages in your content. User engagement and self-efficacy are two important predictors of adopting healthy behaviors. Similarly, characteristics of the content itself—such as relevance, coherence, and tone—may increase the likelihood that users will take action.38

In addition to standard measures of usability and comprehension, consider using a mix of quantitative and qualitative measures (defined in Appendix B) designed to assess the following:

  • User engagement
  • User self-efficacy
  • Acceptability of the content
  • Applicability of the content

These measures can be adapted for online health promotion content.

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6.5. Create plain-language testing documents.

Write your screeners, consent forms, and moderator guides in plain language. See Appendix C for sample testing documents.

  • As a general rule, limit the number of tasks and questions when conducting usability testing with users with limited literacy skills. Be realistic about what can be accomplished in the time designated for each session.

In addition to providing easy-to-read consent documents, consider using a consent process that does not rely on participants' health literacy skills or English proficiency. See the AHRQ Informed Consent and Authorization Toolkit for Minimal Risk Research [PDF file, 107 pages, 300 KB] from the Agency for Healthcare Research and Quality (AHRQ) for more information.56

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Iterative Design Methods and Tips


  • Clickable prototypes
  • Usability testing

Tips for designing and testing your Web site with users

  • Pretest your protocol with at least one participant with limited literacy skills to fine-tune tasks and timing.
  • If participants get stuck on a task, redirect them by asking where and how they would look to find the answer.
Icon for usability guidelines.

Refer to Research-Based Web Design & Usability Guidelines (PDF, 20.64 MB) sections:

Chapter 18

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