Understanding our users: How to better deliver health information online to American Indians and Alaska Natives

 

Report on Evaluation Set-Aside Project Tailoring Web Sites to Special Populations

Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
November 2002

 

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Special Acknowledgements
This report could not have been compiled without the support of Dr. Ted Mala, Southcentral Foundation, and Ursula Knoki-Wilson, Chinle Comprehensive Health Care Facility, who arranged many of the interviews for the Office of Disease Prevention and Health Promotion (ODPHP). ODPHP also would like to thank all the individuals whom we interviewed for this report. We are grateful for all their suggestions. We hope that what we learn can be shared with other organizations that are working to deliver better health information to American Indian and Alaska Native (AIAN) populations.

Data collection for this report was supported by Jody Cole and Susan Cuviello of Superior Consultant Holding Corporation and Sarah Baron of IQ Solutions under ODPHP’s National Health Information Center contract. Data analysis was supported by Thom Haller, Info.Design.

For more information or to make comments or suggestions, please contact Leslie Hsu at lhsu@osophs.dhhs.gov or 202-401-0732.

ODPHP Staff
David Baker
Senior Publishing Advisor

Christy Choi
System Administrator

Mary Jo Deering, Ph.D.
Deputy Director for e-Health and Management

Leslie D. Hsu, M.P.H.
Consumer Health Informatics Advisor
Lead, Evaluation Projects Tailoring Web Sites for Special Populations, and
Writer, "Understanding Our Users" Reports

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Table of Contents


Executive Summary

Section One: Introduction

Section Two: Goals

Section Three: Background Research

Section Four: Study Overview

Section Five: Research Results

Section Six: Recommendations

Footnotes

 

Appendix A: Alaska Populations

Appendix B: Navajo Nation

Appendix C: Audience Profiles

Appendix D: User Task Matrix

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Executive Summary

The Office of Disease Prevention and Health Promotion conducted this qualitative study to build user-focused Web sites, especially for www.healthfinder.gov. This report presents findings from September 2002 users research conducted to better understand American Indian and Alaska Native (AIAN) online health information seekers.

Section Two describes the specific goals of the study and the report. Section Three provides background research to better understand the diverse AIAN populations. Section Four lays out the methods of the study, and Section Five summarizes the results for each goal of the study. Section Six outlines recommendations based on the research results.

Appendices A and B provide background information about Alaska and the Navajo Nation, respectively, where the interviews took place. Appendices C and D are tools that can be used as key building blocks for a health information Web site, especially for AIAN populations.

Figure 1: This ceremonial robe carved on cedar panels is on the wall outside the healing room in the Alaska Native Medical Center. It is one of numerous art pieces and exhibits that decorate the medical center. Art is integrated into the daily lives of American Indians and Alaska Natives, who believe that art speeds the healing process.

Source: Leslie Hsu, 2002

Figure 1: This ceremonial robe carved on cedar panels is on the wall outside the healing room in the Alaska Native Medical Center. It is one of numerous art pieces and exhibits that decorate the medical center. Art is integrated into the daily lives of American Indians and Alaska Natives, who believe that art speeds the healing process.

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Section One: Introduction

The Office of Disease Prevention and Health Promotion (ODPHP) seeks to provide reliable health information for a variety of audiences through www.healthfinder.gov. (See figure 2.) Launched in 1997, www.healthfinder.gov is a portal site, linking the general public to quality health information resources. Known for being user friendly, www.healthfinder.gov is continuously evaluated by its users through interviews, usability tests, online comments, and expert reviews.

In fall 2002, ODPHP focused on expanding resources for American Indian and Alaska Native (AIAN) populations. From September 13, 2002, to September 30, 2002, ODPHP representatives met with AIAN leaders, patients, and students in Anchorage, Alaska; the Navajo Nation; and Denver, Colorado. Through interviews and usability tests, we collected qualitative data on how AIAN peoples access health information on the Internet. Because of its limited scope, this study is not representative of all AIAN people.

Figure 2: Screen capture of 
			www.healthfinder.gov as of September 2002. This version was shown to our interviewees.

Figure 2: Screen capture of www.healthfinder.gov as of September 2002. This version was shown to our interviewees.

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Section Two: Goals

Goals for the Study

Goal 1: To assess the range of health-information-seeking behaviors in the AIAN population

  • Identify who their authoritative information sources are
  • Discover when they would use health information
  • Find out when they would look at the Internet, and why they would choose this option
  • Name occasions when they would access healthfinder®

Goal 2: To identify tasks that AIAN individuals want to accomplish on a health information Web site

Goal 3: To understand how healthfinder® can best serve the AIAN population

  • Learn how to improve our resources and the usefulness of healthfinder® for AIAN populations

Goal 4: To investigate the overall usability of healthfinder®

  • Identify differences between expressed preferences for seeking health information and actual use
  • Evaluate the main site’s usefulness to special populations
  • Compare navigation strategies on the entire site and in the “Just for You” section
  • Explore users’ patterns for searching and filtering

Goal 5: To understand how users experience the current “Just for You” section on healthfinder®

  • Identify differences between expressed preferences and actual use
  • Determine whether AIAN individuals want a separate section like “Just for You” or whether they would rather search the main healthfinder®
  • Explore users’ patterns for searching and filtering

Goals of This Report

This report summarizes the data we collected and provides recommendations related to improving resources for AIAN persons on a health information Web site. Specific recommendations for healthfinder® are not included in this report.

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Section Three: Background Research

Nearly 4.1 million Americans identify themselves as American Indians and Alaska Natives, even though only 2.5 million Americans are enrolled as members of tribes with their own distinct languages, cultures, and governments.1 Approximately 1.5 million AIAN persons use the Indian Health Service (IHS), the agency of the U.S. Department of Health and Human Services that is responsible for providing Federal health services to American Indians and Alaska Natives. IHS is organized into 12 area offices that oversee 150 service units. (See figure 3.)

Figure 3: Indian Health Service Area Offices, FY 2000.

Source: Trends in Indian Health 1998-99

Figure 3: Indian Health Service Area Offices, FY 2000.

Background on Tribes

The Federal Government has recognized 558 tribes located in 35 different States.2 Approximately 229 of these tribes are in Alaska. (See appendix A for more information about Alaska.) Of the 558 tribes, the largest tribe is the Navajo Nation, which has about 250,000 members in 3 States and comprises nearly 10 percent of the American Indian population. (See appendix B for more information about the Navajo Nation).

In the 1950s, the Federal Government terminated 109 tribes by terminating their treaty rights. This action resulted in the destruction of their culture and a rise in alcoholism and suicide rates. Most reservation Indians were relocated to major urban areas.

Urban Indians

Urban Indians, who are members of, or descendants of members of, one of the many Indian tribes, represent more than 56 percent of the total Native population.3

Urban Indians face unique health challenges. Few know that when tribal members leave their home reservation, they are covered by IHS for only 180 days. Urban Indians have access to urban health clinics,4 but few urban Indians are aware of these clinics and many are generally reluctant to use non-Indian, Government-sponsored resources.

Lack of health insurance is a serious problem for urban Indians. Only one in three AIAN persons was insured in 1999, and more than one-third of these reported no regular source of medical care.

Health Disparities

Significant health disparities exist for the AIAN population. The health status of this population continues to be worse than that of other races in this country. For Indian males, the top two leading causes of death are diseases of the heart and accidents. For Indian females, the top two causes are diseases of the heart and malignant neoplasms.

Death rates for the following causes were significantly higher for the AIAN population than for the general U.S. population: alcoholism (627 percent greater), tuberculosis (533 percent greater), diabetes mellitus (249 percent greater), accidents (204 percent greater), suicide (72 percent greater), pneumonia and influenza (71 percent greater), and homicide (63 percent greater).5 Many of these chronic diseases can be prevented by healthier lifestyles.

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Section Four: Study Overview

This section identifies the research audiences and summarizes the research process.

Audience

ODPHP met with 85 AIAN individuals from 9 target populations (organized according to the context in which they might use the Internet to find health information).

  • General public: Alaska Native patients
  • General public: Navajo students
  • Intermediary: Decisionmakers/influentials
  • Intermediary: Health educators
  • Intermediary: Nonprofit executives
  • Intermediary: Field nurses/community health aides (representatives)
  • Intermediary: Researchers
  • Intermediary: Traditional healers
  • Intermediary: Urban leader

Intermediaries were selected based on word-of-mouth recommendations. General public interviewees were recruited with fliers and posters.

To synthesize the research findings into a valuable tool for Web development, we extracted similarities to build audience profiles—personas. Appendix C provides brief personas of typical participants.

Methods

ODPHP representatives gathered information from interviews and surveys.

Interviews: From September 13 to September 27, 2002, ODPHP representatives conducted 18 one-hour interviews and usability tests with intermediary audiences. (See figure 4.) These interviews were in workplace environments. ODPHP representatives also conducted 15-minute interviews and usability tests with individuals. Table 1 identifies locations and audiences for these interviews. Additional information about the interviews and locations is provided in appendices A and B.

Surveys: A five-question survey was distributed during the Office of Minority Health (OMH) National Summit on Addressing Health Disparities for AIAN. Held in Denver from September 24 to 26, 2002, the summit was attended by tribal leaders, researchers, community leaders, urban Indians, representatives from academia, and advocates for improving AIAN health from all over the United States. ODPHP hosted an exhibit during the conference and invited feedback from all conference participants. Twenty-five surveys were completed.6

Figure 4: Leslie Hsu interviewing a student at Diné College Library.
Source: Susan Cuviello, 2002

Figure 4: Leslie Hsu interviewing a student at Diné College Library.

Type of interview
Location
Audience
One-hour interviews Alaska Native Medical Center (ANMC) 5 intermediaries
  Alaska Native Science Commission 1 intermediary
  Chinle Comprehensive Health Care Facility, Arizona 6 intermediaries
  Albuquerque Restaurant, New Mexico 1 intermediary
  Office of Minority Health Conference, Colorado 5 intermediaries
15-minute interviews Health Information Center at Anchorage Native Primary Care Center of ANMC 21 patients
  Diné College Library, Arizona 21 students

Table 1: Locations and audiences for interviews.

Limitations of the Study
Due to limited resources, ODPHP interviewed only 18 intermediaries, 21 Alaska Native Medical Center patients, and 21 Navajo students for this project. The following limitations were identified:

  • Tasks identified by intermediaries were mixed between what they want to perform on behalf of their clients and what they want to do for themselves.
  • Video recording documentation was inaudible for some of the interviews.
  • Tape recorder documentation was not done for most of the Alaska Native Medical Center patients and Navajo students.
  • Views represented in this report reflect the experiences of only the 18 intermediaries, 21 Alaska Native Medical Center patients, and 21 Navajo students interviewed.
  • 5 intermediaries and 5 Alaska Native Medical Center patients did not participate in the usability testing portion of the interview due to time constraints or locations that did not have Internet access.

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Section Five: Research Results

This section summarizes the results for each goal.

Goal 1: To assess the range of health-information-seeking behaviors in the AIAN population

All AIAN interviewees had used computers before, although their skills varied. Intermediaries and college students had the most experience using computers. The location for going online varied. Intermediaries were more likely to use computers at work, whereas patients reported using computers at home, the medical center, and work.

Intermediaries

All the interviewed intermediaries use computers and the Internet to find health information, or they request staff to access the Internet on their behalf. A total of 56 percent use the Internet 8 to 50 hours per week. The intermediaries reported that they consider Government sites to be authoritative sources of information. A few of them currently use healthfinder® to access health information.

Patients and Students

Although most participants had used the Internet, most had not used healthfinder® (17 percent of Alaska Native patients and 0 percent of Navajo students) before our meeting. As many as 52 percent of the Alaska Native patients used the Internet to find health information. They had experience using sites such as WebMD, Yahoo, PubMed, the National Institutes of Health, and the Anchorage Daily News. A total of 62 percent of the Navajo students had used the Web to find health information. They also use Yahoo and WebMD.

In the rural areas, community health aides or community health representatives provide primary care and emergency care via telephone supervision or telemedicine. Recruited by the village, these individuals, who do not have any formal medical training, are responsible for delivering health information to tribal members. Community health aides or community health representatives are trained in basic first aid, patient education, health promotion, disease prevention, making home visits, taking vital signs, and assisting in case management. Some are Internet savvy and often e-mail the trainers to request additional health information.

Most Alaska villages have schools with computers and Internet capabilities. They also have clinics that sometimes offer computers. At Chickaloon Village, computers with Internet capability were reserved primarily for villagers to do job searches. (See appendix A, Chickaloon Village.) Reservations face significant economic barriers, such as high startup charges, to Internet access. Several technology initiatives are under way to address this problem; for example, one initiative seeks to connect tribal colleges with wireless technologies.

Mervin Savoy, Chairwoman of the Piscataway Conoy Confederacy and Subtribes, Inc., of Maryland, sends out health information regularly to her tribal members through e-mail. Tribal members contact her for reliable health information, especially for preventative care such as health screening tests.

That’s another thing that they do: “Okay, have you done it?” If I haven’t done it, they wait for me to do it. I’ve had more tests done that my doctor said I don’t need. Still, if I want the rest of the tribal members to go in for some of these check-ups, I have to do it first.

~Mervin Savoy, Piscataway Conoy Confederacy and Subtribes, Inc., of Maryland

Goal 2: To identify tasks that AIAN individuals want to accomplish on a health information Web site

To achieve this goal, interviewers gathered information specifically about what AIAN populations would do on a site.

Among the most significant tasks, from the perspectives of the AIAN population, are the following:

  • Find information on traditional/holistic healing practice and methods
  • Look up information about herbs
  • Find updates on recent health news (daily)
  • Learn how diabetes affects people
  • Find information on alternative nutrition
  • Find strategies for mental/spiritual wellness
  • Gather information on exercise
  • Determine risks
  • Compare traditional ways to Western biomedicine
  • Find user-friendly summaries of studies
  • Gather information on drugs

Specific information on users and their tasks is provided in appendix D.

Goal 3: To understand how healthfinder® can best serve the AIAN population

Intermediaries were asked the question, “How can healthfinder® best serve AIAN populations?” Most respondents were very pleased that ODPHP was conducting these interviews. The face-to-face contact is extremely important when working with AIAN communities. It shows commitment and builds trust. In addition, this approach facilitates expert reviews, as Dr. Ted Mala, Director of Tribal Relations at the Alaska Native Medical Center, suggests:

I think that what you’re doing is wonderful. I think it’s extremely important for you to be here, extremely important for the face-to-face contact. I think that you should develop in your time here a list of people that your office can use to bounce things off with…people who are really in tune with the tribes to look at this and critique in a good way.

~Dr.Ted Mala, Alaska Native Medical Center

Many respondents also talked about how important it was to keep the information updated. Ursula Knoki-Wilson, Director of Midwifery Services at Chinle Comprehensive Health Care Facility, commented:

Keep it up and keep it updated. Come back again to field test. That’s important because that’s the way you get our opinions. You get consultation that way, whereas if you just have a telephone consultation, then you don’t know the person. You don’t know their commitment to it, and things like that.

~Ursula Knoki-Wilson, Chinle Comprehensive Health Care Facility

They also wanted more information about traditional healing, diabetes, domestic violence and sexual abuse, hepatitis, fetal alcohol syndrome, HIV/AIDS, environmental issues, asthma, eye care, Indian health policy, individual tribes and their culture, insurance policies, women’s health, and research data.

Recommendations for improving the resources and usefulness of healthfinder® for AIAN populations are not included in this report.

Goal 4: To investigate the overall usability of healthfinder®

During our interviews, we asked participants to accomplish specific tasks. As evaluators, we watched participants interact with the interface. We noted the decisions and choices they made as they tried to perform efficiently. We were specifically interested in ascertaining the following information:

  • Identify differences between expressed preferences and actual use (including patterns for searching and filtering)
  • Evaluate the main site’s usefulness to special populations
  • Compare navigation strategies on the main site and “Just for You” section

Expressed Preferences Versus Actual Performance

When users were asked to perform a task on www.healthfinder.gov, 43 percent used the search bar, while 57 percent of users chose to accomplish the task by other means. (See table 2.)

  Search Bar Health Library Just for You Health News Online Checkups
One-hour interviews 5 4 1    
Alaska Native patients 5   4 2  
Navajo students 8 7 3 1 2
Total 18 11 8 3 2

Table 2: When users were asked to accomplish a task on healthfinder®, they chose to use these options on the site.

When using the text search bar, users expressed the following preferences. Some suggested that they wanted to be able to search within each section of www.healthfinder.gov, especially within the AIAN section, or have an advanced search option right next to the search bar.

Most felt that the search results were overwhelming. When they tried to narrow the search, all users could not figure out what the drop-down menu choices meant. (See figure 5.) The choices available in the drop-down menu for “type of information” were especially confusing to users.

Figure 5: Screen capture of what users saw when they selected the ?narrow your search? link while using the text search.

Figure 5: Screen capture of what users saw when they selected the “narrow your search” link while using the text search.

Patricia Cochran, Executive Director of the Alaska Native Science Commission, expressed her concern as she tried to gather information on asthma:

So I typed in Native American plus asthma. Two hundred documents—I don’t want to go through 200 documents. I’m trying to figure out a way that I don’t have to do this. I need to narrow this better. [User selects “narrow your search” link.] I just expanded from documents into documents and organizations. Best matches first. We’re going to leave that where it is. Types of information [paused for a while]…I think I’ll stay with all at this point, although I’m just concerned that we’re going to get back to the same thing as before. Well, this is interesting. I wonder what alternative medicine will bring up? Okay, so I’m keeping this in English, and I’m going to submit this. Okay, hmm. It says that the Internet resource I selected is based at a university. I’m just not exactly sure where I want to go with this. 

~Patricia Cochran, Alaska Native Science Commission

For users who did not use the search bar, the experience was smoother. No user had problems looking up a topic alphabetically.

Oh, I see, there’s an alphabet. I love alphabets, so I would actually probably go under traditional or Native. [User selects Native Americans.] This is it. I love this right here. This is exactly where I would want to be, in something like this.”

~Marcia Anderson, Alaska Native Medical Center

One user expressed a preference for having the A-Z choice on her results page so that she would not have to keep going back to the A-Z list.

Destination Site Versus Linking Site

Before users select a document, most of them are not sure whether they are leaving www.healthfinder.gov. More experienced users are aware that they are leaving the site only because they wait for the page to load and check to determine whether the page looks different.

Previous usability tests demonstrated that users seemed to be confused about whether healthfinder® is a portal site or a destination site. In this study, it seemed that users would wait until information loaded to figure out where they were. They did not seem to mind that it was a portal site. Users seemed to be most interested in finding information that supported them in answering specific questions they were researching.

Navigation Strategies on the Entire Site and the “Just for You” Section

Users navigated easily through www.healthfinder.gov using the browser’s Back button or selecting the “apple” logo or selecting Home. However, many users experienced trouble getting back to www.healthfinder.gov once they selected a document that automatically put them in a second window. Users who were more Internet savvy had no trouble closing the second window. However, if they did not know how to close the second window, they would continue using the browser Back button or try the browser Home button until they gave up.

Very few users noticed the “refine your search” link (shown in figure 6). One user selected “refine your search” because she wanted to narrow her search to Alaska Native. However, once this person saw the choices offered in the “refine your search” page, she got interested in “broader topics” (shown in figure 7).

Figure 6: Screen capture of topic search page.

Figure 6: Screen capture of topic search page.

Figure 7: Screen capture of "refine your search" page.

Figure 7: Screen capture of “refine your search” page.

Goal 5: To understand how users experience the current “Just for You” section on healthfinder®

Participants were asked how they experienced the current “Just for You” section.
Specifically, they were asked to respond to the following requests:

  • Identify differences between expressed preferences and actual use
  • Specify whether AIAN users want a separate section such as “Just for You" or whether they would rather search the main healthfinder®
  • Identify patterns for searching and filtering

Expressed Preferences Versus Actual Performance

When asked what people thought they would find at the “Just for You” link, the majority of participants expected information to be filtered specifically for them. Often they expressed the expectation of reading personal information.

I expected more “Just for You,” maybe like talk with your kids when they have problems with their health.

~Navajo student, age 53

I guess it pertains to you, as like your health and just some things that you’re curious about, like if you’re aching or something’s wrong with you. I thought there would be—I don’t know—just topics after topics about symptoms that you could develop.

~Navajo student, age 18

After they clicked on the “Just for You” link, we again asked participants if what they expected to find was already there. (See figure 8.) The results are provided in table 3. Even those who said that this was what they expected to find noted that there was a mix of audiences here. Most users thought the “Just for You” section was valuable and interesting.

Figure 8: Screen capture of http://www.healthfinder.gov/justforyou.

Figure 8: Screen capture of http://www.healthfinder.gov/justforyou.

  Yes No
One-hour interviews 6 6
Alaska Native patients 15 6
Navajo students 12 9
Total 33 21

Table 3: Responses when asked, “Is this what you were expecting?” after showing participants the “Just for You” section.

Some confusion was caused by the differences in meaning in content groupings. For example, there is currently a list that includes men, women, infants, teens, adults, seniors, etc.

First of all, you’re not going to have infants clicking on this, right? They don’t know how to use a computer. My other thought was “What’s the difference between a man, an adult, and a senior?” Can’t you be all three? I would say a better way would be to break it down by ages: man, women. Maybe men on one side, then ages; women on another column and ages. So then the question is “Are you a man that’s a parent? Are you a woman that’s a parent? Are you a man that’s a caregiver?” It’s just a little confusing.

~Dr. Ted Mala, Alaska Native Medical Center

When users saw the prototype site (see table 4 and figure 9), the reaction was enthusiastic. Overall, their expectations were met because the users who answered “no” meant that they were surprised and pleased with what they found. In fact, all users said that the AIAN section was interesting and valuable to them. The medicine wheel image was well received, and all topics, especially “Traditional Medicine,” elicited excited remarks, such as “This looks really really good.” “I would send this out to my staff.” “I’m clicking on traditional medicine because I can’t stand it anymore.” “Yeah, there’s some good stuff here!”

  Yes No
One-hour interviews 4 6
Alaska Native patients 14 7
Navajo students 11 10
Total 29 23

Table 4: Responses when asked, “Is this what you were expecting?” after showing participants the AIAN section.

Figure 9: Screen capture of prototype, as tested.

Figure 9: Screen capture of prototype, as tested.

Preference for a Separate Section

When asked whether they would prefer to go to a “Just for You” section or to the main site for AIAN concerns, the majority of participants stated that they prefer an AIAN section. (See table 5.) However, they noted that they would prefer to see the AIAN section from the homepage, for example, a link directly to the AIAN section from the homepage.

  AIAN Main Site Both
One-hour interviews 5 1 9
Alaska Native patients 9 6 1
Navajo students 14 7  
Total 28 14 10

Table 5: Preference for a separate “Just For You” section for AIAN populations.

I’m really excited because what you’re doing with these cultural Web sites is really important. I’m excited you guys are considering this. I really admire this agency that’s doing this, to have this, to have somebody working on it.

~Marcia Anderson, Alaska Native Medical Center

User’s Patterns for Searching and Filtering

When participants saw the top 20 topics, they were eager to dive into them and learn more about each topic. Some users did not see the A-Z list. However, once they did, they easily found their way to resources. The prototype did not have a search bar, so some people commented about wishing they could search within this section.

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Section Six: Recommendations

This section provides general recommendations based on the research results. Recommendations specific to healthfinder® are not included.

Recommendations Regarding the Use of Visuals

For the Web site, intermediaries recommended using artwork or a graphic from various tribal regions, especially because AIAN populations believe that artwork inspires healing. (See figure 1.) For example, the medicine wheel is a symbol of health that originated with the Plains Indians, and the basket is a symbol of health in the Southwest and California.

“This symbol right in the center, as a Navajo person, I don’t really relate to that symbol. It looks like it’s a medicine wheel of some kind. A medicine wheel is not specific to Navajo culture. This is a symbol from Plains or other tribes that use a medicine wheel. But I think if this symbol periodically changed to other symbols from various tribes, it would be nice.”

~ Ursula Knoki-Wilson, Chinli Comprehensive Health Care Facility

Recommendations Concerning Usability

Some general usability issues that require further testing include the following:

  • Inexperience/confusion with the use of a second Web browser window to display linked sites.
  • Text search results that produce an extremely large number of resources.
  • Lack of familiarity with the terminology used to label advanced search options.
  • Grouping of information into categories that match user expectations.
  • Providing more instructional content on sites to help users determine where to go to get the specific answers they are seeking.

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Section Seven: Conclusion

Web quality is judged by the ease with which diverse users enter the electronic environment and accomplish their goals. In our investigation of the AIAN population, we gathered significant information about various AIAN audiences and their reasons for visiting health-related Web sites and healthfinder® in particular.

Up-to-date content is very important to AIAN users who are searching for health-related information. Various strategies (such as Advisory/Review boards) should be examined for reviewing the content of health-related Web sites to ensure that it provides these populations with the information they need.

The tools in appendices C and D are designed to be building blocks or foundations for better understanding what users want to accomplish on healthfinder® as well as other health information Web sites. These tools should be continually referred to throughout the Web development process.

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Footnotes

1U.S. Census 2000 data
The Federal Government identifies Indians in four ways: (1) federally recognized tribes having a treaty with the Federal Government; (2) tribes recognized by the government and legislature of the State in which they reside; (3) terminated tribes for whom Congress has terminated all treaty rights; and (4) organized tribes recognized by neither the Federal nor State government but recognized as Indian.

2All statistics in this section of the report are from Mim Dixon and Yvette Roubideaux, eds. Promises to Keep. Washington, DC: APHA, 2001.

3Cities with the highest numbers of American Indians and Alaska Natives are New York, Los Angeles, Phoenix, Anchorage, Tulsa, Oklahoma City, Albuquerque, Tucson, Chicago, San Antonio, Houston, Minneapolis, San Diego, Denver, San Jose, Fresno, Mesa, Dallas, Seattle, and Portland (Administration on Aging, 1990).

4The clinics differ greatly from IHS facilities. They must charge for services and are required to offer services to anyone seeking assistance. Very few urban clinics offer more than general primary care services.

5Regional Differences in Indian Health 1998-99. Indian Health Service. U.S. Department of Health and Human Services. Rockville, Maryland, 1999.

6Tribes represented include Assiniboine, Choctaw, Colville, Hualapai, Iowa Tribe of Kansas-Nebraska, Lumbee Tribe of North Carolina, Navajo, Northern Ute, Oglala Sioux, Oglala Lakota, Omaha Tribe of Nebraska Osage/Cherokee, Northern Cheyenne, Penobscot, Prairie Band Potawatami/Cherokee, Round Valley Reservation, Ute, and Wailaki. Most of the 25 participants use Government sites to find health information, but only 6 have used healthfinder®.

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