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Health Communication
Publicat ion det ails, including inst ruct ions f or aut hors and subscript ion inf ormat ion:
ht t p: / / www. t andf online. com/ loi/ hht h20
Health Websites: Accessibility and Usability for
American Sign Language Users
a
b
c
d
Poorna Kushalnagar , Joan Nat urale , Raylene Paludneviciene , Scot t R. Smit h , Emily
b
e
f
Werf el , Richard Doolit t le , St ephen Jacobs & James DeCaro
b
a
Chest er F. Carlson Cent er f or Imaging Science, Rochest er Inst it ut e of Technology
b
Nat ional Technical Inst it ut e f or t he Deaf , Rochest er Inst it ut e of Technology
c
Depart ment of Psychology, Gallaudet Universit y
d
Depart ment of Public Healt h Sciences, Universit y of Rochest er School of Medicine and
Dent ist ry
e
College of Healt h Sciences and Technology, Rochest er Inst it ut e of Technology
f
Cent er f or Media, Art s, Games, Int eract ion & Creat ivit y, Rochest er Inst it ut e of Technology
Published online: 05 Jun 2014.
To cite this article: Poorna Kushalnagar, Joan Nat urale, Raylene Paludneviciene, Scot t R. Smit h, Emily Werf el, Richard
Doolit t le, St ephen Jacobs & James DeCaro (2014): Healt h Websit es: Accessibilit y and Usabilit y f or American Sign Language
Users, Healt h Communicat ion, DOI: 10. 1080/ 10410236. 2013. 853226
To link to this article: ht t p: / / dx. doi. org/ 10. 1080/ 10410236. 2013. 853226
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Health Communication, 1–8, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1041-0236 print / 1532-7027 online
DOI: 10.1080/10410236.2013.853226
Health Websites: Accessibility and Usability for American Sign
Language Users
Poorna Kushalnagar
Chester F. Carlson Center for Imaging Science
Rochester Institute of Technology
Downloaded by [Poorna Kushalnagar] at 11:57 09 June 2014
Joan Naturale
National Technical Institute for the Deaf
Rochester Institute of Technology
Raylene Paludneviciene
Department of Psychology
Gallaudet University
Scott R. Smith
Department of Public Health Sciences
University of Rochester School of Medicine and Dentistry
Emily Werfel
National Technical Institute for the Deaf
Rochester Institute of Technology
Richard Doolittle
College of Health Sciences and Technology
Rochester Institute of Technology
Stephen Jacobs
Center for Media, Arts, Games, Interaction & Creativity
Rochester Institute of Technology
James DeCaro
National Technical Institute for the Deaf
Rochester Institute of Technology
To date, there have been efforts toward creating better health information access for
Deaf American Sign Language (ASL) users. However, the usability of websites with
access to health information in ASL has not been evaluated. Our article focuses on
the usability of four health websites that include ASL videos. We seek to obtain
ASL users’ perspectives on the navigation of these ASL-accessible websites, finding
the health information that they needed, and perceived ease of understanding ASL video
Correspondence should be addressed to Poorna Kushalnagar, Chester F. Carlson Center for Imaging Science, Rochester Institute of Technology, 76 Lomb
Memorial Drive, Rochester, NY 14623. E-mail: poorna.kushalnagar@mail.rit.edu
2
KUSHALNAGAR ET AL.
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content. ASL users (n = 32) were instructed to find specific information on four ASLaccessible websites, and answered questions related to (a) navigation to find the task, (b)
website usability, and (c) ease of understanding ASL video content for each of the four
websites. Participants also gave feedback on what they would like to see in an ASL health
library website, including the benefit of added captioning and/or signer model to medical
illustration of health videos. Participants who had lower health literacy had greater difficulty in
finding information on ASL-accessible health websites. This article also describes the participants’ preferences for an ideal ASL-accessible health website, and concludes with a discussion
on the role of accessible websites in promoting health literacy in ASL users.
According to the Integrated Conceptual Model for Health
Literacy, being health literate requires not only accessing health information but also understanding and utilizing
health information to appraise and use health-related information to maintain and improve health (Sorensen et al.,
2012). In the Deaf health field, health literacy at the basic
levels of accessibility and comprehension is a problem,
which we describe in a review of the literature on the health
knowledge and literacy in the Deaf population. We define
“Deaf health” as the health of people who are Deaf and use
sign language to communicate.
Researchers of Deaf health agree that poor health literacy,
language barriers to health care, and other factors contribute to increased risks for poor health outcomes (Barnett,
McKee, Smith, & Pearson, 2011; Margellos-Anst, Estarziau,
& Kaufman, 2006; Smith, Massey-Stokes, & Lieberth,
2012). Generally, Deaf American Sign Language (ASL)
users report difficulties with understanding health information in print, accessing health services, and understanding treatment-related procedures (McKee & Paasche-Orlow,
2012). A review of seven articles on Deaf patient–physician
communication issues suggested that Deaf adults experience
health disparities due to the lack in linguistic and cultural
competency on the part of health care practitioners in treating Deaf patients (Barnett, 2002). As expected, data from
the Deaf Health Survey revealed that patients whose communication was concordant with the provider were more
likely to utilize preventive services (McKee, Barnett, Block,
& Pearson, 2011). However, the number of physicians who
are culturally competent to care for Deaf patients is small.
As a result, Deaf patients are forced to rely on alternate
sources of health information (i.e., health websites; books;
trusted peers or family members) for preventive care and better understanding of diagnoses (Margellos-Anast, Hedding,
& Miller, 2004). Such an approach increases the risk of misunderstanding and using health information inappropriately,
particularly if the user is not highly literate in English. This
can negatively impact how the user incorporates the newly
learned health information in making decisions related to the
user’s own health and preventive care.
Clearly, there is a need to develop effective health information materials and programs that are accessible to and
benefit Deaf individuals who use ASL. Smith and colleagues
(2012) recommend “planning, implementing, and evaluating a free, web-based repository of reliable health resources
specifically designed for delivery in both ASL and English
print” as the next steps toward promoting accessible health
information for this population. To address this recommendation, we seek to obtain ASL users’ perspectives on the
navigation of four ASL-accessible websites, ease of finding
the health information that they needed, and the quality of
ASL videos. These perspectives are aligned with two basic
components of the Integrated Conceptual Model for Health
Literacy (Sorenson et al., 2012): (a) accessing health information and (b) understanding health information. Both components were assessed subjectively, where the participants
were asked to rate the accessibility and ease of understanding
health information in ASL. If one perceives health information to be inaccessible or difficult to understand, then one
might not be able to appraise and apply this health information in health care and disease prevention, which are
important steps in developing one’s health literacy. Although
important, the objective assessment of participants’ level of
understanding health information is outside the scope of the
present study.
METHOD
Sampling and Participants
Approval for all aspects of this research was received from
the institutional review board at the National Technical
Institute for the Deaf (NTID) in Rochester, NY. Purposive
sampling of 32 Deaf students (age 18 years or older) who
know ASL was planned to provide a range of health literacy (minimal to adequate). While these students also know
English, their preference for using ASL or English depended
on the situation (e.g., academic environment; casual environment that involves communicating with a hearing person or
deaf person). We asked the participants to select which of the
following languages, ASL, English, or equal preference for
both languages, they felt most comfortable using.
Recruitment for the first half of the sample was open to
Deaf students in associate degree programs at NTID in fall
2012. After reviewing the participants’ characteristics and
health literacy scores, we purposively sampled the remaining
participants who were enrolled in an intensive English course
based on English placement test scores in spring 2013.
These participants were recruited through brief classroom
presentations by research staff, presentations that took place
HEALTH WEBSITE ACCESS AND USABILITY FOR ASL USERS
from November 2012 to March 2013. Participants were
given a $20 cash compensation for 1 hour of participation
time and effort and were afforded the opportunity to withdraw of their own volition at any time during the process.
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Design
Step 1: Identify websites for evaluation. To address
Smith and colleagues’ (2012) recommendation to evaluate the Web-based repository of reliable health information
in ASL, we focused on only websites that contained ASL
health videos. As the initial step to selecting four websites
for usability evaluation in our study, a Google search was
conducted using key words “Deaf health information” or
“Deaf medical information.” Only the first few pages of
the search results were reviewed, which included the ASL
health websites that were already linked in the resource
section at the National Center for Deaf Health Research
(NCDHR). We considered the links posted at the NCDHR
website to have been reviewed by experts in the Deaf health
field before listing them in the recommended resource section. All of these searches were narrowed down to the final
four websites, which we do not identify here. Our goal was
not to critique those websites, but to solicit Deaf participants’
perspectives on the websites’ usability, as well as what an
ideal ASL health website should look like. The four websites
met the following criteria: (a) be directed at providing health
information access to ASL users and (b) include ASL videos
about health information.
Step 2: Disorder-/disease-specific information
seeking activities. For the current study, we assigned
a disorder- or disease-specific health information seeking
activity for each website. The assignments were as follows:
anxiety (Website 1), atherosclerosis (Website 2), diabetes
(Website 3), and skin cancer (Website 4). Informationseeking activity procedure is further described in the “Task
and Procedure” section of this article.
Step 3: Expert website evaluation. A researcher with
demonstrated expertise in website, interactive media, and
game design, development, and usability conducted a user
evaluation and ranking (hardest to easiest) of these websites.
The following criteria were applied in the evaluation: (a)
navigation to find the task, (b) website usability, and (c)
video content. Each criterion was assigned a score from 1
(easiest) to 4 (hardest), followed by a detailed rationale for
the score assignment. The overall score for each website
served as a baseline for the participants’ ratings of the four
websites. While these evaluation efforts are not comprehensive, this study is exploratory and takes important first
steps to understanding how online health information can be
presented to Deaf populations.
3
Website 1 (anxiety task) was aimed at being a general
pediatric health site with a wider range of medically related
information for the Deaf, including what to expect at physician visits. Website 2 (artherosclerosis task) had the largest
collection of ASL informational videos but was focused
purely on information about diseases and tests. The textural content of the site seemed to come from a variety
of health sources on the Internet. Content was translated
by an ASL narrator and posted in video format on this
website. Website 3 (diabetes task) was designed to be a general information/encyclopedia site on a wide range of topics
specifically for ASL users that happens to have some medical
information on it. The layout was similar to an “Ask.com”
type of site rather than a “WebMD” type of site. This might
account for the limited depth on the pertinent topic in each
ASL informational video.
Website 4 (skin cancer task) contained a large collection
of detailed, text-based articles on types of cancer, symptoms,
and treatments. Information for ASL users consisted primarily of seven videos with text transcripts created specifically
for this audience. Some streamed lectures were also available, but were created with an outdated streaming software
package, and a player must be downloaded before they can
be viewed.
Website 4 (skin cancer task) was the only site out of the
four that was produced by a large, professional medical organization. The rest (Websites 1–3) were independent efforts.
It was clear that all these sites could benefit from being
redesigned. The reasons for the need of redesigning include
(a) multiple pages of text with small fonts, (b) dated web layout with crawling banners and blocky sponsor ads, (c) older
generation of space-consuming drop down menu system, and
(d) inefficient requirement of accepting terms of use prior to
web browsing.
Ranked 1 to 4 (1 as best and 4 as worst), we found
that Website 1 (anxiety task), with original content produced
exclusively for ASL, was the best of the group in navigation and usability and video content. Website 3 (diabetes
task) was ranked second due to its ease of finding diabeticspecific information in this study. Generally, this website had
limited content, barriers to entry for some of the video content, and used of a transcript of a video for text, rather than
revising and summarizing the content. Website 4 (skin cancer task) was ranked third due to a generalist approach with
an outdated technology. Although this website was orphaned
and/or discontinued at this point, one could find skin cancer
information on this website if given the link as was done
in this study. Website 2 (atherosclerosis task) was as navigable as site 1 but less usable due to its large quantity of
text pulled from other sources across the Internet, despite the
fact that some of the content was translated to ASL in video.
Condensing and revising that content or creating original textural content for the Deaf would have made it more usable.
4
KUSHALNAGAR ET AL.
For this reason, we ranked Website 2 as the hardest site on
which to get information on atherosclerosis.
Task and Procedure: Disorder-/Disease-Specific
Information Seeking Activities
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In our study, the first half of the participants (n = 16) began
with anxiety (Website 1) and ended with skin cancer
(Website 4). This order was reversed for the second half of
the group (n = 16, Website 4 to Website 1). Each participant
was given a link to a website, and then told to navigate and
find disorder- or disease-specific health information in this
website.
If the participant was told to find information on
atherosclerosis on Website 1, the participant had to figure out
where to start searching for this information. Specifically, in
a typical scenario the participant needed to:
1. Keep track of the goal to find the disorder- or diseasespecific information.
2. Find out what resources are accessible at the website.
3. Use search features (e.g., search box) or click on
the website navigation links to arrive at the webpage
that contains the target disorder- or disease-specific
information.
4. Watch the ASL video.
5. Answer questions about the ease of finding the information, using the website, and understanding the
ASL video.
After navigating each website and completing the pertinent health information task, the participant was asked to
answer a set of questions in the following domains: (a) navigation to find the task, (b) website usability, and (c) ease
of understanding ASL video content. We elected to solicit
subjective ratings from the participants, and did not conduct
objective comprehension testing of the participants’ knowledge on the pertinent topic. After completing all tasks, all
participants gave feedback on what they would like to see in
an ASL health library website.
A new question about the video delivery of an animated medical illustration was added later in the study. Only
those in the second half group viewed an animated medical illustration (cancer or diabetes) at Focus Medical Health
Animation Collection CREDO (http://www.focusmedica.
com/) and provided feedback on whether they preferred
to add captions and/or signer model overlay to this medical illustration video. This question was not included in
the analyses, and the responses were used to supplement
other information that was gathered in the interview from
all participants.
Materials
Participants were invited to take part in a confidential, electronic survey consisting of four different tasks. We used
Flesch–Kincaid readability analysis to ensure that the survey
items were wordsmithed at a third-grade level. A Deaf
research staff assisted with ASL translation of the survey
items when needed. Follow-up interviews with all participants were done in ASL.
To ensure participants were kept anonymous, no names
were collected or documented on any of the forms. After
completing a background questionnaire, participants took
a 7-minute Short Form of the Test of Functional Health
Literacy in Adults (S-TOFHLA; 36 items; Baker, Williams,
Parker, Gazmararian, & Nurss, 1999). The S-TOFHLA is a
gold-standard, widely used test of functional health literacy,
and is a test of participants’ ability to read and comprehend
health information in the English language. The reading level
for the first passage is at the fourth-grade level, and tenthgrade level for the second passage. Internal consistency for
the S-TOFHLA is high (α = .97). This test was used in
a recent pilot study with 94 Deaf college students, but no
reliability information was reported (Thew, 2013).
We initially used standard cutoffs in which scores
from 0–16 represented inadequate health literacy (HL),
17–22 marginal HL, and 23–36 adequate HL (Sarkar,
Schillinger, Lopez, & Sudore, 2011). In the current study,
63% of our sample had adequate HL and the remaining
participants had marginal (15%) and inadequate (22%) HL.
For the purpose of the current study, S-TOFHLA scores
of 0–22 were classified as the low health literacy group.
S-TOFHLA scores of 23–36 were classified as the adequate
health literacy group.
Analysis
Using SPSS (version 17.0; SPSS, Inc., Chicago, IL),
bivariate correlation and t-tests were used to provide descriptive analyses of the participants’ perception of health
websites with ASL videos. Tests of homogeneity were carried out to ensure consistency of the distributions across
health literacy groups. Bivariate correlation was used to
examine relationships among the domains: (a) navigation to
find the task, (b) website usability, and (c) ease of understanding ASL video content. Mean differences between
health literacy groups were explored with unpaired t-tests.
All participants participated in an open-ended brief interview following study completion. We first conducted an
inventory of the responses and then codified those using key
words that relate accessing and understanding health information. For example, for the question relating to an ideal
ASL-accessible health website, a response such as “ASL
video overlay with health images” was classified in the category “accessing health information” for this question. The
responses were then summarized within each category and
described in this article.
RESULTS
Out of 32 participants who knew ASL and English, only
three students expressed a general preference for English in
HEALTH WEBSITE ACCESS AND USABILITY FOR ASL USERS
5
TABLE 1
Comparison of Demographics Among ASL-Preferred Users and ASL–English Equal Preference Users
Using t-Test and Chi-Squared
Mean (95% CI)
Variable
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Age (years)
Gender:
Female
Male
Race:
Caucasian (reference group)
Black/African American
Asian/Pacific Islander
Biracial
Hispanic American
Did not answer
Family history of deafness:
Yes
No
Health literacy group:
Adequate
Low
∗p
ASL-preferred
ASL–English
equal preference
Difference or
χ 2 value
p-Value
(two-sided)
22.6
18.0, 27.1
22.0
18.0, 26.0
0.579
−5.31, 6.46
0.130
.842
.719
6
7
10
9
2
3
2
1
4
1
13
2
1
1
2
0
8
5
8
11
5
8
15
4
8.016
.005∗∗
1.166
.280
5.398
.020∗
< .05, ∗∗ p < .01.
daily communication. These three students’ health literacy
scores did not significantly differ from the group of students
who had equal preference for both English and ASL. These
two subgroups were then combined into one group (n = 13),
and compared with a group of students who expressed
a general preference for ASL in daily communication
(n = 19).
Table 1 presents a comparison of participants’ demographics using t-test and chi-squared. Consistent with the
health literacy literature on the general population (Kutner,
Greenberg, Jin, & Paulsen, 2006), race was associated with
health literacy category (χ 2 = 3.70; p < .05). Participants
who chose ASL as their preferred language in general had
a lower health literacy score compared to other participants
who reported equal preference for both languages. The lower
health literacy among primary ASL users was likely to be a
consequence of long-standing restrictions on accessibility to
health communication and health materials in the ASL user’s
environment.
The t-test and bivariate correlation analyses were conducted on website usability between the lower and adequate
health literacy groups. No significant differences across
health literacy groups emerged for any of the websites.
However, there was a tendency for the lower health literacy group to report greater difficulty with using the website
than the adequate health literacy group. With the exception of the website with the atherosclerosis task (link to
the video was broken and not seen by any of the secondhalf participants), the responses were similar for the ASL
video content in three other websites. When the effects of
race and language preference were partialed out, finding
information (navigation) was positively correlated with perceived helpfulness of this information (rpartial ranged from
.48 to .76 across all four websites).
Participants’ overall rankings for the four websites were
compared to the usability testing conducted by an expert who
was blind to the study results. Table 2 shows that the adequate health literacy group’s rankings were similar to the
expert’s ranking for the most difficult and easiest website
to navigate and use. Interestingly, the low health literacy
group’s ranking was very different from both expert and
adequate health literacy group’s rankings. According to the
expert evaluator, Website 1 (anxiety) was judged to be easy
to navigate and find information on anxiety. However, the
participants with a low level of health literacy rated the
same website as difficult to find information. One possible
explanation for these group differences might be related to
how people utilize prior knowledge and current health literacy skills to navigate through websites. We did not record
or track web navigation activity for each participant, which
TABLE 2
Ranking of Website Navigation From Hardest to Easiest
Expert evaluation
1. Website 2 (atherosclerosis)
2. Website 4 (cancer)
3. Website 3 (diabetes)
4. Website 1 (anxiety)
Adequate literacy
Low health literacy
1. Website 2
2. Website 3
3. Website 4
4. Website 1
1. Website 3
2. Website 1
3. Website 4
4. Website 2
6
KUSHALNAGAR ET AL.
would have provided useful clues to the group discrepancy.
Nevertheless, this discrepancy suggests that the perceptions
of people with adequate health literacy skills cannot be
generalized to people with low health literacy skills. ASLaccessible website usability studies should include at minimum people with low health literacy skills. In the following
sections, we provide a summary of participants’ feedback
on designing an ideal ASL-accessible health website for the
Deaf community.
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Accessing Health Information
A popular suggestion was to have an A–Z search format for
easy access to health information. Many expressed a preference for the A–Z format over the other websites. These
participants found the other websites challenging to navigate, especially if one did not know the correct spelling of
the disorder.
For every type of disorder- or disease-specific information, there should be a video made available on that page
so users could immediately access pertinent information in
ASL. Participants agreed that there should be an option for
caption and other video preferences.
Using the Website
Besides the video, participants had many suggestions for
how the website should be structured. Participants expressed
that the website navigation was equally important to accessing health information in ASL. The navigation of the website
should be easily accessible on the homepage to save time in
browsing.
A clean, simple interface was desirable for maintaining
one’s attention to the webpage. Some of the participants
commented that they gave up looking for information on several of the other websites that had complex interface. This
comment tended to come from participants who had lower
health literacy.
As is expected from any user, the participants in our study
frequently commented that the website should be attractive
with appropriate colors and be user friendly. A search box on
the homepage was highly desirable.
Perceived Ease of Understanding Health Information
in ASL
Participants generally agreed that clear and engaging videos
in ASL were critical to understanding the health information. Professional attire and neutral background in the videos
were suggested to minimize visual distractors and maximize
attention to the health information in ASL.
If the captions were available on the ASL video, 71% of
the sample reported that they read the captions. They also
preferred that both ASL and captions be offered as options
in the videos.
The lower health literacy group demonstrated a greater
preference for one person explaining the health problem.
For the adequate health literacy group, some preferred one
person explaining the health problem and others preferred
an informal group discussing the health problem. Less than
10% of the total sample chose “two people discussing the
health problem” as preferred response.
Participants in our study preferred young, skilled signers
as narrators and were more willing to watch videos that were
shorter. These participants also commented that they gave
up after a few minutes of searching for information on the
websites. If they found the disorder, they watched the video
briefly and replayed the video if they found it difficult to
comprehend or had more information than they originally
had intended to find that led to information overload.
Participants provided some suggestions to prevent an
overload of information on health websites: (a) Information
about the disease or disorder should be specific, (b) information should be brief, (c) a link should be available for
more detailed information about the disease or disorder, and
(d) a transcript and/or captions should be made available.
Although the participants watched the ASL video, there was
a desire to have transcripts or captions accompany the video
so they could also read the information in English.
Some participants suggested making contact information
available for those who wish to speak with a doctor or ask
questions about a medical issue that was not available on the
website.
DISCUSSION
The results of this study suggest that simply making a
health website accessible in ASL is not enough. An ASLaccessible health website must also be user-friendly and easy
to navigate. It is important that the ASL users perceive the
video content to be easy to understand. This finding was
pronounced for ASL users who demonstrated low health literacy level. Future development or improvement to existing
ASL-accessible health websites would benefit from usability
testing experience and feedback by ASL users with low
health literacy level. If the websites with ASL videos are
perceived as easy to access and understand by the low health
literacy subgroup, then anyone should also be able to utilize information from these ASL-accessible health websites
to appraise and use health-related information to maintain
and improve health.
In the literature and websites that were reviewed in this
study, there was a wide variety in how information was
presented in ASL. A discussion format was used in some
videos, in which two to four people sat around to talk about
a particular health topic. Also, scenarios with actors were
used to present health information, such as a person visiting a doctor who could sign, two friends chatting at a café,
and more. These types of videos tended to be lengthy due
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HEALTH WEBSITE ACCESS AND USABILITY FOR ASL USERS
to the nature of discussions and scenarios. Feedback from
the current study participants suggested that brief and wellfocused videos with signers from similar backgrounds would
have a positive impact on capturing the intended ASL-user
audience’s attention and reinforcing knowledge of health
information.
For some videos that had dull color or distracting images,
participants suggested that the video background should be
neutral with an attractive color. Such a background should
help reduce cognitive load associated with trying to ignore
distractors or overfocusing on the signing in videos with
dull color. If the videos were too lengthy, ASL users might
be inclined to give up and seek information elsewhere that
might not be accurate. Follow-up health literacy studies
with ASL users are needed to examine the impact of video
focus and brevity on understanding and utilizing health
information to maintain and improve health.
In the current study, participants were instructed to seek
out information about a predetermined health condition and
therefore motivated to carry out this task on ASL-accessible
health websites. As we consider the intrinsic factors such as
motivation and knowledge in the Integrated Health Literacy
conceptual model (Sorenson et al., 2012), participants had
basic knowledge such as the name of the predetermined
health condition and were motivated by the task itself to
watch educational videos about the predetermined health
condition to successfully accomplish this task. Such healthpromotion behavior that drives one to seek out information
on the Internet is an important component of health literacy (Office of Disease Promotion and Prevention, 2004,
2006). If the basic knowledge such as the name of the disease were not given to the ASL user, this user might not
have the motivation or reason to seek out and watch educational videos about managing a particular health condition.
For example, preventive education on diabetes for ASL users
would require an informative video that was visually appealing and engaging enough to encourage sustained attention
so the message could have an indirect impact on improving
health literacy through health-promoting behavior. This type
of informative video might be distributed through various
means such as, but not limited to, social media and advertising (in the form of public service announcements [PSAs]).
The target population that might benefit from such social
media and advertising would be those who have low health
literacy and are less likely to actively seek out health information on the Internet. Ideally, an ASL-accessible health
website would include both educational and informative
videos intended to improve the overall health of ASL users,
both for those who are seeking information about a specific health condition and for those who would benefit
from informative videos distributed via social networks.
Those informative videos would serve as a portal steering the ASL user to the main website source that contains
more ASL-accessible information about a variety of health
conditions.
7
An ideal ASL-accessible website would include the recommendations based on the results of this study. Informative
videos distributed via social networks are one avenue for
alerting and recruiting ASL users with low health literacy
to the ASL-accessible websites, which we hope will lead
to improving the overall health of the Deaf community.
Due to the changing nature of the Internet and new findings in health-related research, it is necessary to continually
redesign websites and to update videos to meet the needs
of ASL users. The demographics of the ASL community,
such as age groups and targeting particular topics that affect
those age groups, should also be considered. For example,
the older adults might be more prone to diabetes type 2 and
heart disease. Websites that include ASL-accessible videos
on these topics would benefit from having narrators from the
older age group, as the target audience is more likely to be
responsive to information presented by their peers. Further
study is needed to determine the type of content as well as
the depth and breadth of health-related information that have
direct impact on health-promoting behaviors and health literacy in ASL users. As future research explores whether ethnic
subgroups within the ASL community are more prone to specific health issues and whether there are cultural aspects, new
findings from such research should be considered in developing and utilizing the videos to best meet the subgroups’
health literacy needs.
A limitation in this study is the administration of STOFHLA and survey items in English. Although the survey
items were written at the third-grade level, future studies
might benefit from making these items available in ASL for
those who might prefer this. An additional limitation is that
the college student sample might not be representative of the
general Deaf ASL population.
For everyone who use ASL, but more so for those with
lower health literacy, it is critically important that health
websites not only are ASL-accessible but also are free of broken links and poor design at both page and site levels. Good
navigation is the cornerstone of a successful ASL-accessible
health website, which has strong potential to promote preventive health and improve health literacy among ASL users.
This, in addition to brief, clear ASL videos, can motivate
the ASL users to seek health care and to discuss any concerns with their providers. When these necessary changes are
implemented for future websites, there should be an increase
in benefits for ASL users with predicted improvements in
health literacy. Therefore, in the long term, improving health
literacy among ASL users can reduce hospitalization, poor
disease outcomes, and mortality rates.
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