Web Accessibility for Health Websites / by P. F. Anderson

Introduction

Patients have a variety of complicated medical conditions which may impact on their use of the computer. The obvious one most people think of is blindness, although that is far from being the only one to consider. I have had clinicians tell me they don't need to worry about having their web site meet the needs of blind patients, since only 5% of their practice is blind. Ahem. Perhaps more relevant (although less obvious) than the moral or ethical aspects of this mentality is the legal aspect. Legally, there are various codes in different countries which require that certain standards be met for web accessibility. Generally speaking, if you want to reach a population in a particularly country, you should be aware of the standards and guidelines for that country, or should at the very least meet the basic international standards and guidelines. Section 508 of the US Code, a refinement of the American Disabilities Act, recommends accommodations for disabled persons in the online environment, similar to those required for a physical environment. The core concept here is the same as in the physical environment -- barrier-free, any barriers, all barriers, for anyone.

Why Universal Design?

The idea of barrier-free access is often also referred to as universal design, the idea that access for one is access for all. Many argue that this is a smart idea for economic reasons, even more so than for any other reason. After all, the more people who can find your site and use it, the better your reputation for whatever service or goods you are providing. It would be over-simplifying to say better access is a better reputation, but not by much -- a reputation can be ruined if people consistently have trouble getting to your site or resources.

What is a Disability?

There are many other types of disabilities which are not as obvious to the (temporarily) able-bodied (TABs). These could include:

• the color-blind;
• persons with bifocals;
• persons who can't select from a drop down menu because of any of the many health issues which impair fine-motor control or cause occasional shaking hands;
• persons with attention-deficit disorders or other cognitive impairments;
• individuals who can't use a mouse because of post-operative lymphedema and swelling in the arms or hands;
• those using computers which don't meet current standards, such as persons whose only access is in very small rural public libraries, those who cannot financially afford new computers, or those using computers which are restricted from certain functions for security reasons.

Some of the examples above only apply to the USA population, and do not even begin to touch on the issues for access to third world populations, or areas of the world in which the network is unstable. Many of the same concerns apply to selected clinician users as well, especially in clinics which are not part of a major academic medical center, such as dentists and private physical therapy or rehab clinics. Clinics which do not have a large corporate affiliation or which are not closely affiliated with a major teaching hospital are not always able to invest the same kind of funding into their computing infrastructure. The same is true for rural clinics, where the network infrastructure may not be as robust or fast as in large population centers. Conversely, in large population centers, the network demand may outstrip the supply, and at peak times connections may be slow or unstable.

Background of Web Accessibility

For all the reasons mentioned above, mentioned above, the accessibility and usability of a web site should be a fundamental underlying concern for any web site open to the public, but especially one providing health information or information about a health resource (such as a clinic).

The World Wide Web Consortium agreed that this concept was so important, that early on they organized a task force to define basic recommendations for accessibility and usability of all web sites. These standards were released in 1999.

The United States goverment had already passed into law their own guidelines on August 7, 1998 -- with the five year anniversary summer of 2003! These were the previously mentioned Section 508 guidelines. Australia released their first web accessibility guidelines around the same time, but have revised these several times, with the first revision in 1999 to account for the W3C document and the most recent in 2002 to include concepts from SENDA.

Each subsequent law or major guideline on web accessibility has tended to be more comprehensive and more detailed, not less. Thus, SENDA in the UK and the guidelines in Australia go far beyond what is required here in the United States. Like Section 508 in the United States, which was an amendment to the American Disabilities Act, SENDA adds on to the Disability Discrimination Act. Variations of SENDA and the Australian guidelines have been adopted by many other previous British colonies, so the implications of this law reach far beyond the United Kingdom.

Testing Web Accessibility

To implement these laws and guidelines requires a testable component and other non-testable aspects which come from experience and being sensitive to the target audiences of the web site. The testable component is certain HTML coding requirements. Having all the required coding requirements does not imply that the web site designer has gone beyond that to the non-testable aspects of sensitive web design. Not having the required coding components does however make it obvious that the web designer either does not know or does not care about accessible design.

For the testable aspects of the coding requirements, there are software tools which can be used to test a web site or web page, identifying where the code does not adhere to the standards. The best known of these are Bobby and LIFT. LIFT tests for adherence to the UK's SENDA standards, which are far more rigorous than the US standards. Bobby tests for adherence to the international W3C Standards or the US Section 508 guidelines.

Selecting a Standard to Follow

Web sites which have a potential international audience should meet or surpass the guidelines for W3C or SENDA. Web sites which have a potential national US audience should meet or surpass the Section 508 guidelines. Web sites based in the US which have an unrestricted audience should meet or surpass the Section 508 guidelines EVEN IF THEY ARE INTENDED FOR A LOCAL AUDIENCE. Web sites which are restricted in access can design to that specific audience and their special needs and characteristics, although it is wise to be aware of these guidelines and to follow them when possible.

Think Like Your Users

Following the guidelines is only the beginning. The trick is to think in the virtual environment the way recommended for the analog environment in Donald Norman's seminal book, The Design of Everyday Things, or as he also refers to the ideas, "the poetry of everyday things." He uses an example of doors -- if there is a horizontal cross bar, this implies press down on the bar; if there is a vertical bar, this implies pull; if there is a vertical panel, this implies push; if there is a knob, this implies turn; etcetera. How do we make the design of an item reflect the intended purpose and most efficient use of that item? To designers, the intended use seems obvious, but this is not always true for the novice or unfamiliar user of the device or service. Think how hard it is to proofread your own writing -- we need to have an outside opinion about whether or not what we wrote makes sense. To find out what people think is the right way to open a door, you have to watch a lot of people. The same is true for web sites. Following the standards will make our virtual doorways meet the standards of the law, but it will not help us think like the persons trying to go through our door -- that takes an extra effort, spending time people watching, asking people what they are thinking, and talking with and watching a very wide variety of people.

Issues of technical and design accessibility and usability contribute to the overall credibility of a site -- the perception on the part of the user of the site that the designers of the site are knowledgeable, informed, caring, and can be trusted. These issues alone cannot carry that message, but must be combined with content that communicates the same message. If design and access are good and the content is not, the site will probably fail to achieve its intended goals; if the content is good and the design and access are poor, the site will again probably fail. Both of these two concerns (design and content) are intertwined in making a web site do what it is meant to do.

Conclusion / Synopsis

Accessibility and Usability Resources

Most Common Impairments and Disabilities