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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
Appendix F: Annotated Bibliography

Dailey, S. (2005). Empowering older adults with health information. Journal on Active Aging, 4(2), 61–62. Retrieved from [PDF File - 403 KB]

This background piece heralds the award-winning work of the National Institute on Aging and the National Library of Medicine on the NIH SeniorHealth Web site ( The article describes the purpose of the Web site and provides an overview of some of the lessons learned.

Echt, K. V. (2002). Designing Web-based health information for older adults: Visual considerations and design directives. In R. W. Morrell (Ed.), Older adults, health information, and the World Wide Web (pp. 61–88). Mahwah, NJ: Lawrence Erlbaum Associates.

Echt summarizes the research behind Web-based interface design and explains the special considerations necessary to design Web-based health information for older adults. This chapter includes clear guidelines for layout, organization, navigation, and graphics.

Freimuth, V. S., & Mettger, W. (1990). Is there a hard-to-reach audience? Public Health Reports, 105(3), 232–238.

This article dispels myths, deconstructs assumptions about "hard-to-reach" audiences, and offers alternative perspectives to highlight the strengths of different audience segments, encouraging innovative approaches to communication.

Kaphingst, K. A., Zanfini, C. J., & Emmons, K. M. (2006). Accessibility of Web sites containing colorectal cancer information to adults with limited literacy (United States). Cancer Causes and Control, 17(2), 147–151.

Kaphingst and colleagues found that many colorectal cancer Web sites were too difficult for the average American adult and much too difficult for adults with limited literacy to use. Common problems with the sites included the following: lack of review of key ideas; insufficient use of illustrations for key messages; crowded layout and long line lengths; small type size; lack of cues to highlight key content; and lack of interactive features.

Kodagoda, N., & Wong, W. (n.d.). Why design for people with reading difficulty and low literacy. Retrieved from [PDF File - 121 KB] EXIT Disclaimer

This document summarizes previous research conducted by the authors on users with low literacy and the Web. The authors explain the benefits of semantic Web technology and offer design guidelines for users with low literacy.

Lefebvre, R. C., Tada, Y., Hilfiker, S., & Baur, C. (in press). The assessment of user engagement with ehealth content: The eHealth Engagement Scale. Journal of Computer-Mediated Communication.

This article describes the psychometric testing and evaluation of the eHealth Engagement Scale, which was adapted from commercial advertising research. Internal reliability of each of the two multi-item subscales of the eHealth Engagement Scale was 0.878 for "Involving" and 0.805 for "Credible." The eHealth Engagement Scale may prove to be an important mediator of user retention of information, intentions to change, and ultimately efforts to undertake and achieve behavior change.

Morrell, R. W., Dailey, S. R., & Rousseau, G. K. (2003). Commentary: Applying research: The NIH Senior Health Project (pp. 134–161). In N. Charness & K. W. Schaie (Eds.), Impact of technology on successful aging (pp.134–161). New York, NY: Springer Publishing.

This chapter offers a detailed outline of the special considerations, design principles, and methodology implemented in the NIH Senior Health Project. Not only do the authors explain the unique needs of aging populations, including their usability testing procedures and results, but also they clearly lay out detailed guidelines for Web content development for aging populations.

Neuhauser, L. (2001). Participatory design for better interactive health communication: A statewide model in the U.S.A. Electronic Journal of Communication/La Revue Electronique de Communication, 11(3,4). Retrieved from EXIT Disclaimer

This article provides an example of how participatory design was used by hundreds of parents and people with disabilities to create a health Web site for 33 million residents of the State of California.

Nielsen, J. (2005). Low literacy users. Jakob Nielsen's Alertbox. Retrieved from EXIT Disclaimer

This Web site provides an overview of the user population with lower literacy as well as practical tips for improving the usability of Web sites.

Summers, K., & Summers, M. (2004). Making the Web friendlier for lower-literacy users. Intercom, June, 19–21. Retrieved from [PDF File - 378 KB] EXIT Disclaimer

The authors describe some of the online behaviors of limited literacy users. These behaviors, such as avoiding search functions or reading every word, often contradict developers' most basic assumptions. It's important to address these issues in developing online prevention content.

Summers, K., & Summers, M. (2005). Reading and navigational strategies of Web users with lower literacy skills. Retrieved from [PDF File - 76 KB] EXIT Disclaimer

This research article summarizes results from a study that sought to understand the differences between the reading and navigational strategies of users with low literacy skills and those with medium to high literacy skills. The authors offer strategies and design principles to make Web-based medical content usable and accessible for lower literacy adults.

Zarcadoolas, C., Blanco, M., Boyer, J. F., & Pleasant, A. (2002). Unweaving the Web: An exploratory study of low-literate adults' navigation skills on the World Wide Web. Journal of Health Communication, 7(4), 309–324.

Based on an ethnographic study of a group of low-literate adults, the authors identify specific navigational and content issues that present barriers for this population. They discuss preliminary assumptions that can be used to inform the development of Web tools for low-literate adults and directions for future applied research.

Zarcadoolas, C., Pleasant, A. F., & Greer, D. S. (2006). Health literacy and the Internet. In Advancing health literacy (pp. 117–140). San Francisco: Jossey-Bass.

This book chapter brings together the research from two worlds: health literacy and the Internet. The authors explain the strengths and weaknesses of using the Internet to communicate health information. In addition to reviewing key research findings, the authors outline specific challenges, opportunities, and ethical issues. This chapter contains applied exercises and an abbreviated glossary of commonly used Internet jargon.

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