Elaine Marieb College of Nursing Faculty Publication Series

Publication Date


Journal or Book Title

International Journal of Medical Informatics



Low health literacy has been associated with poor health-related outcomes. The purposes are to report the development of a website for low-literate parents in the Neonatal Intensive Care Unit (NICU), and the findings of heuristic evaluation and a usability testing of this website.


To address low literacy of NICU parents, multimedia educational Website using visual aids (e.g., pictographs, photographs), voice-recorded text message in addition to a simplified text was developed. The text was created at the 5th grade readability level. The heuristic evaluation was conducted by three usability experts using 10 heuristics. End-users’ performance was measured by counting the time spent completing tasks and number of errors, as well as recording users’ perception of ease of use and usefulness (PEUU) in a sample of 10 NICU parents.


Three evaluators identified 82 violations across the 10 heuristics. All violations, however, received scores <2, indicating minor usability problems. Participants’ time to complete task varies from 81.2 s (SD = 30.9) to 2.2 s (SD = 1.3). Participants rated the Website as easy to use and useful (PEUU mean = 4.52, SD = 0.53). Based on the participants’ comments, appropriate modifications were made.

Discussion and conclusions

Different types of visuals on the Website were well accepted by low-literate users and agreement of visuals with text improved understanding of the educational materials over that with text alone. The findings suggest that using concrete and realistic pictures and pictographs with clear captions would maximize the benefit of visuals. One emerging theme was “simplicity” in design (e.g., limited use of colors, one font type and size), content (e.g., avoid lengthy text), and technical features (e.g., limited use of pop-ups). The heuristic evaluation by usability experts and the usability test with actual users provided complementary expertise, which can give a richer assessment of a design for low literacy Website. These results facilitated design modification and implementation of solutions by categorizing and prioritizing the usability problems.