Putting PCT websites at the heart of healthcare-information services

Anna Mieczakowski with Kevin Holdridge and Dr Gordon Rugg describe the results of an extensive evaluation of primary-care-trust websites.

Abstract

All primary care trusts (PCTs) in England are required to have an online presence that effectively communicates the NHS agenda to the end users. We assessed the websites of all PCTs using well-established research methods and found them to be of poor quality in terms of design, quality of content and effectiveness of communication. We propose the 3C Compliance Model as a solution to the problem with PCT websites.

NHS primary care trusts (PCTs) are responsible for ensuring that the right healthcare services are provided for their communities, ensuring these services can be accessed and for identifying the needs and views of their populations.

Websites are an increasingly important tool for PCTs in reaching constituents and in making healthcare information available to them and soliciting their views. Doing this well requires the PCT website to be well designed and structured so that it effectively communicates diverse corporate, clinical, and community-oriented information.

Beyond some information on NHS branding and style guidelines and some out-of-date UK e-government standards, there is no NHS-specific guidance or framework available to PCTs to help them ensure that their websites are fit for purpose. PCTs struggle, therefore, to specify websites well during procurement and have no easy means of measuring the effectiveness of their existing sites.

We carried-out an evidence-based assessment of 303 PCTs’ websites in England. This identified that most of them failed to comply with good practice and could do a much better job of supporting their organisations’ goals. Many were of poor quality in terms of design, quality of content, effectiveness of communication and were rated poorly by users.

Through our study we developed a robust framework to assess the technical effectiveness, quality of patient experience and content and design appropriateness of PCT websites. Our unique framework incorporates national and international standards for compliance, and is based on sound principles and extensive observation of real users’ behaviour and feedback.

Based on the findings of our study, we suggest practical ways in which PCTs can measure and improve the utility and cost effectiveness of their websites and thus make them key tools for the organisation.

The problem: lack of guidance

PCT websites are expected to adhere to the NHS website guidelines and the UK Government website guidelines. Both of these frameworks are limited in scope, and the latter dates from 2003.

Other than this, there does not appear to be any point of advice or reference specifically to help PCTs. The Centre for Health Information Quality (CHIQ) had a brief to check the validity and reliability of content of healthcare sites, but appears to have been defunct for some years.

There is a confusing, rapidly changing and often contradictory tangle of standards and guidelines for websites in general (different html and xhtml releases, W3C standards, various ‘accessibility’ frameworks and schools of thought on ‘usability’). Furthermore, there are many different hardware and software platforms and content-management systems on which websites can be built, all with different feature sets and wildly differing costs and all difficult to evaluate against each other.

Evaluating the reality

Recent research into websites has found that users form their opinions about a site in significantly less than a second and that their reactions are strongly influenced by the site’s design and content attributes.

Based on these findings, we carried out an evaluation of the 303 PCT websites in England in early 2006. Our study, adhering to the latest industry standards, consisted of two parts.

Part one of the study involved assessment of the degree to which each trust’s website conformed to published legal accessibility and usability guidelines. We found that all PCT websites failed on at least one aspect of the industry standards.

The second part of our study involved an in-depth evaluation of a sample of 50 English PCT websites by individual human subjects, who rated each website in terms of a set of key design and content attributes. The methods we used to elicit users’ perceptions of these websites included think-aloud and laddering, both of which are well-established methods in research on human–computer interaction (HCI). We then statistically analysed the results from this, using principal-component analysis (PCA) to identify clusters of related attributes.

User expectations and behaviours

Users’ enjoyment with any website is determined by the quality of that site’s design and content attributes. Our results indicate that users expect PCT websites to convey accurate, timely, and reliable information on diverse corporate, clinical and community-oriented matters and to be navigable by means of intuitive and attractive graphical design.

Design issues

Website experts claim that an unfavourable first impression of a site leads to early rejection of that site, often before its content has been explored in any detail. This was strongly reflected in the results from the data we collected. We found that PCT websites do not effectively incorporate valid and reliable content into a professional and effective graphic design that would assist human comprehension of, and reasoning about, that information.

Website design involves the visual look and feel of the site. People make judgements about this extremely quickly: in about 50 milliseconds. These are typically emotional judgements about whether the site is attractive or not, and they are usually persistent. It is therefore important to get the initial look and feel right, so that the site stimulates users to explore it rather than loses their attention. This is something where adhering to evidence-based design guidelines might prove useful, as they can add value to the website by increasing user satisfaction, keeping users interested in the website and motivating them to revisit it.

The findings of our PCA study suggest that website design could be subdivided into three main areas. The first involves overall look and feel, such as choice of colours and size of images, which can be assessed within the first milliseconds of seeing a site. The second involves balance between text and images. The third involves the look and feel of the text — e.g. font, size of text. A simple way of assessing these for your site is to ask three questions:
1.    what does it look like from across the room? (for overall look and feel);
2.    what does it look like at a distance where you can’t quite read the words? (for detailed layout and balance); and
3.    what would it look like if it was in a language you don’t speak? (for font and size of text, as opposed to the meaning of the text).

Content matters

The other main website attribute is content. Users’ trust in websites is primarily driven by how credible and valid they find the content to be.

Our PCA results showed that content has two underlying components. The first is the completeness of the information. It is worth asking yourself whether a healthcare site you visited recently appeared to give comprehensive and systematic coverage of relevant material. The second component is the quality of the material that is provided on the site.

Content quality can take various forms. One is factual accuracy; another, which is a perennial problem in healthcare, is comprehensibility. It is very easy to use jargon without realising it. For instance, if a PCT site gives information about making an ‘emergency appointment’, the trust’s staff know that it means an appointment for a matter that needs to be attended to quickly, but will all members of the public know what it means? Jargon is a particular problem for those whose first language is not English.

Solution: the 3C Compliance Model

To aid PCTs in the consistent application of design and content guidelines on their websites, we have developed the 3C Compliance Model (the ‘Clinical — Community — Corporate’ Compliance Model), which is a framework aimed at improving the quality of design and content attributes on PCT websites. The 3C Compliance Model supports the development and maintenance of PCT websites in line with the latest standards and it helps to ensure that healthcare-information needs of local communities are met on trusts’ sites through a provision of a visually pleasing and well-balanced content on clinical and corporate matters.

Anna Mieczakowski, Development Manager, Kent House, Innovation Centre 1, Keele University Science Park and PhD student at the University of Cambridge, Cambridge.
Kevin Holdridge, Managing Director, Kent House, Innovation Centre 1, Keele University Science Park.
Dr Gordon Rugg, Senior Lecturer, School of Computing and Mathematics, Keele University.