Enhancing the efficacy of healthcare information websites: a case for the development of a best practice framework

Clarity on purpose, objectives and impact

Advances in technology and reductions in the cost of website development have enabled healthcare information websites to proliferate. Such sites, however, vary considerably in terms of usability, quality and efficacy.13 This can be attributed, in part, to the fact that the design and development of healthcare websites—which deliver high quality, readily accessible, usable content—requires a complex range of knowledge and skills.14 Arguably, however, an underlying problem with many healthcare information resources is the absence of a clearly articulated purpose, clearly defined goals and identification of measurable outcomes. Indeed as Catwell and Sheikh point out, in order to maximise the benefits (and minimise the risks) of eHealth interventions, the goals of a given project must be clearly defined and objectives clearly specified.15 Unfortunately, restrictions on time, limited resources and inadequate knowledge/skills/expertise often mean that the purpose of a given resource (ie, precisely how the resource will contribute to health outcomes), its objectives and ultimate impact are neither clearly defined nor explicitly articulated.

Clarity on purpose, objectives and (desired) impact are conducive to the efficacy of online resources such as healthcare websites, and the identification and definition of these elements from the outset represent a critical step in the design and development process. Ready definition of the online resource’s purpose, objectives and (intended) outcomes should constitute a core component of a framework designed to enhance the efficacy of healthcare websites. Indicative of the criticality of this step in the design and development process, and the type of approach that could be used by the developers of healthcare websites more broadly, is the ‘maturity model’ that has been advocated in relation to evidence institutes, or organisations established to promote the effective use of evidence in decision-making.16 In their 2023 review of the impact of such organisations in Australia, USA, UK and Canada, Puttick et al created a ‘maturity model’ that is designed to ‘determine the effectiveness of individual evidence institutes…understand the differences between them…help existing evidence institutes improve their practice and guide the creation of new evidence institutes’.16 Noteworthy here is that, of the ‘six key elements’ (distilled from an analysis of 54 institutes) that the authors believed were ‘required to achieve impact’, ‘Definition of purpose’ was required from the outset because:

A purpose, clearly defined, with stated target outcomes, audience, and paths to impact…sets internal and external expectations, fosters a clear method and way of working, helps focus on a specific audience, and creates outputs to meet their needs.16

While the constituent elements of Puttick et al’s maturity model are specific to what the authors believe are the needs of evidence institutes, their model serves as a salient example of the kind of conceptual framework that has the potential to improve the efficacy of online healthcare resources.

Clear identification and definition of audiences

As we have argued elsewhere, careful consideration of the capacities and experiences of the intended users of a healthcare information website, and how they find and use online healthcare information, should guide planning and decision making about format, presentation, design and navigation.14 As Taylor et al have observed, however, healthcare information websites ‘are often developed without consideration of intended users’ characteristics, literacy levels, preferences, and information goals’.17 Nor, often, is the diversity of target audiences, their online behaviours and/or barriers that can prevent different users from accessing and effectively using online information, well understood by creators of healthcare websites. As Kaihlanen et al suggested in their 2022 study of the challenges experienced by vulnerable groups (eg, older people, migrants and those with chronic illness) using digital health services during COVID-19, access to, and use of, websites providing health-related information can be hampered by obstacles ranging from insufficient digital literacy and language skills to cognitive difficulties, lack of resources and inadequate guidance and support.18 Noteworthy here is that for ‘high users’ of health services such as those with a disability, ‘the evidence suggests that health systems do not sufficiently offer digital health for their complex health needs’.18 Thus, while healthcare information websites are a potentially powerful means through which to disseminate evidence-based information, obstacles to the access and use of such information have the potential to increase the disparity—in terms of health outcomes—between those who are able to take advantage of digital advances in healthcare and those who may be unable to do so.18 19 This is despite the fact that ‘digital health equity’ is a guiding principle of WHO’s Global Strategy on Digital Health 2020–2025.2 18

Potentially, one of the primary means by which we can improve the efficacy of healthcare information websites is to help ensure that creators design and develop such resources on the basis of a nuanced understanding of:

• Key characteristics of their target audience/s including (likely) technical and digital skills, literacy levels, language skills, socioeconomic background and other issues that can impact access and effective use.

• How healthcare information provided digitally is accessed and consumed by different groups within a cohort of intended users.

• How the intended users of an online resource actually behave in the digital space and engage with the information provided.

• The digital requirements of audiences with complex needs, such as those with a disability or chronic disease.

Best practice development and design processes

In addition to clear and explicit articulation of purpose, goals, ultimate outcomes and reach, healthcare information websites should be designed on the basis of a nuanced understanding of how target audiences find and use such information. Further realising the potential of healthcare information websites will, however, also require the creators of such resources to ensure that they are designed in accordance with a broader, best practice understanding of what the users of such websites respond to in terms of interface and product design.

While usability guidelines and user-centred frameworks have been available to creators of healthcare information websites since the 1990s13 17 it is by no means evident that healthcare information websites are consistently developed using best practice design processes that ultimately facilitate better professional practice and/or positive behavioural changes. In their 2021 study of 16 US public healthcare websites designed to communicate information about COVID-19, for example, Momenipour et al found that while ‘overall, the websites fared well on usability’, the authors’ ‘main concern’ was that many dedicated COVID-19 websites essentially functioned as information repositories and ‘were not necessarily seen as a venue and a medium to communicate risk of infection or spread, or to extensively promote compliance behaviors’13 (italics added). This suggests that healthcare information websites can be ‘usable’ and/or ‘user centred’ without necessarily achieving the ultimate outcomes for which they were intended. This is peculiar in view of the extent to which users of health information websites report using the information provided by such websites for decision-making.20

In terms of design, a large number of decisions are required to create a healthcare information website. These range from the ostensibly superficial such as colour, imagery, layout and branding to the more substantive such as page design, navigation, search functionality and compatibility with PC, Android and Apple devices. While some of these design decisions may be trivial, others can have a profound impact on target users’ ability to successfully use a given resource, and may mean the difference between a website that helps users and one that essentially functions as an information repository. Indeed, arguably, it is precisely because such a large number of decisions must be made by creators when designing and developing a healthcare website (many of which can impact on efficacy) that a best practice framework such as that which is argued for in this paper is needed (particularly in situations where the complex knowledge and skills required to design and develop an effective site may be lacking or absent).

Evaluation of impact

How do we know if healthcare information websites are achieving their objectives? While such platforms are undoubtedly a powerful vehicle through which to disseminate evidence-based information, in its Global Strategy on Digital Health 2020–2025, WHO states that ‘Research on and evaluation of digital health outcomes and impact are essential to support [their] safe implementation…establish and promote accountability and to justify the financial investment’.2 Although the need for continuous and systemic evaluation of eHealth interventions is well documented,14 15 we argue that to deliver online healthcare information effectively, evaluation processes are required that accurately assess the ultimate impact of healthcare information websites, as well as provide usable information about how such resources can be improved at various stages of a given project.

In terms of evaluation, a spectrum of possible strategies exists. These range from the simple assessment of a system, programme or website (once it has been completed) to a sophisticated evaluation of whether or not desired changes in knowledge and/or behaviour have been achieved as a result of the use of a digital healthcare resource.14 Basic web metrics and usage data are not necessarily sufficient to determine the efficacy of digital knowledge platforms in healthcare, particularly when intended outcomes include behavioural changes, improvements in professional practice or impacts on patient health.14 Meaningful evaluation of the utility of healthcare information websites therefore requires the development and application of metrics that measure the ultimate impact of a digital resource rather than, for example, levels of activity that may or may not be indicative of resource efficacy.

In practice, this will require a reorientation of focus from traditional evaluation processes designed to assess content, structure and usability to those that assess the utility and ultimate impact of a given resource. It will also require the development of evaluation tools and methods of data capture that enable developers of healthcare information websites to assess:

• How knowledge is being encountered, engaged with and used by users.

• Whether the desired users are in fact the actual users.

• Whether the content and format of a healthcare information website is relevant and meaningful to those for whom a resource has been created.