A Human-centric Accessible eHealth Booking Web Portal

Zhidian Lin

, Hourieh Khalajzadeh

, Humphrey O. Obie

, Jennifer Mcintosh

and Kwangsu Choi

Faculty of Information Technology, Monash University, Clayton, Victoria, Australia

Keywords:

Human-centric Issues, Human Factors, eHealth, e-Booking, Web-based Booking System, Elderly, Language,

Culture, Accessibility.

Abstract:

The use of eHealth web portals is rapidly increasing with the extensive demand for eHealth services and

established beneﬁts of using health-related software. Unfortunately, most of these applications underestimate

or even ignore Human-centric issues (HCIs) and thus result in a system that is not ﬁt-for-purpose. This

emphasises the importance of allowing for diverse end-users characteristics, such as age, gender, culture,

occupation, and cognitive impairment, when designing eHealth web portals. In this paper, we describe a study

we conducted involving a preliminary survey in three languages to determine different users’ needs, taking into

account their human-centric issues. We designed an e-booking prototype and evaluated it with user studies.

Our results suggest that age and language are the most crucial human-centric aspects to be considered when

developing an eHealth web portal. The study also provided recommendations for appropriate web design

elements for building human-centric eHealth applications.

1 INTRODUCTION

With the expansion of the World Wide Web 2.0,

awareness of and demand for eHealth has increased

dramatically. People use eHealth applications to de-

rive valuable health information or services and man-

age health conditions (Schnipper et al., 2008; Van

Gemert-Pijnen et al., 2013). However, eHealth ap-

plications that do not consider human-centric issues

(HCIs) are less likely to be ﬁt-for-purpose (Grundy

et al., 2020) and commonly fail because they were

developed without carefully considering HCIs during

their deployment stages (Shamsujjoha et al., 2021).

This study presents how human-centric aspects

might be incorporated in the design of eHealth portals

with a speciﬁc focus on accessibility. We aim to iden-

tify the signiﬁcant gaps among human-centric aspects

in eHealth web portals, increase inclusiveness for di-

verse users, and provide recommendations for apply-

ing the essential human-centric aspects into eHealth

web development. Fundamental human-centric as-

pects such as age, gender, culture, occupation, and

https://orcid.org/0000-0003-3271-8458

https://orcid.org/0000-0001-9958-0102

https://orcid.org/0000-0002-6322-2984

https://orcid.org/0000-0002-6655-0940

https://orcid.org/0000-0001-6005-2863

cognitive impairment are the main target factors in

analysis. The research focuses on end-users, usually

the primary user groups, during the application life

cycle.

To capture a snapshot of the current state-of-play,

we reviewed a set of 44 existing eHealth web portals

in July of 2021 and compared the results to prelimi-

nary survey results from 138 diverse end-users. The

survey was designed in three languages to increase

the entries of people from different backgrounds and

collect their preferences on colour tone, icon de-

sign, navigation style, and typography. We found

that most eHealth websites were yet to meet different

users’ needs. We implemented an e-booking proto-

type based on the user preferences and requirements

in the survey and evaluated the human-centric issues

through 16 user studies.

By analysing the HCIs, we introduced an in-

tegrated “Accessibility Helper” to increase diverse

users’ access to eHealth web portals. We considered

which features (e.g. changing primary colour, enlarg-

ing font size) were the most popular and necessary

settings, and which design elements (e.g. skeuomor-

phism, ﬂat, material) were the most practical design.

Based on the results, the research ﬁndings improved

the user experience of different users and increased

the efﬁciency and frequency of eHealth services. The

Lin, Z., Khalajzadeh, H., Obie, H., Mcintosh, J. and Choi, K.

A Human-centric Accessible eHealth Booking Web Portal.

DOI: 10.5220/0010992800003176

In Proceedings of the 17th International Conference on Evaluation of Novel Approaches to Software Engineering (ENASE 2022), pages 73-84

ISBN: 978-989-758-568-5; ISSN: 2184-4895

main contributions of this research are as follows:

• We explored the essential human-centric issues

which led to the eHealth web portals failing to ﬁt

different people’s needs and how these issues af-

fected users’ experience.

• We collected the real-world eHealth websites that

were frequently used in three different countries

when conducting this research and summarized

their general web design elements.

• We identiﬁed the different preferences on design

elements, such as colour, navigation, iconogra-

phy, considering different users’ needs.

• We developed an all-built-in-one assistant, “Ac-

cessibility Helper”, for integrating multiple web

accessing features to fulﬁl different users’ needs.

2 BACKGROUND

2.1 eHealth Web Portals

In the 1990s, the term “eHealth” was deﬁned as a

combination of Information Communication Tech-

nology (ICT) and healthcare (Oh et al., 2005). The

demand for online healthcare has seen explosive

growth since the rise of Web 2.0, in which 80% of

online users seek out health services, particularly in

times of health crises (Akerkar and Bichile, 2004; Van

Gemert-Pijnen et al., 2013). The beneﬁts of eHealth

applications are highlighted as i) avoiding delays in

detection of potential diseases and reducing possible

human errors in treatments (Schnipper et al., 2008);

ii) replacing heavy paper-based records and manag-

ing healthcare data efﬁciently for nurses and profes-

sionals (Goel et al., 2011); and iii) increasing access

to share or discuss similar symptoms among potential

users and reducing time sourcing health information

(Ancker et al., 2011). All of these beneﬁts increase

the possibilities for large-scale health research and an

improvement in health.

In particular, eHealth web portals are widely

together with mobile health-care apps, namely

mHealth, due to i) engaging data visualization and in-

teraction for the end-users (Boulos, 2003); ii) author-

itative healthcare information or services provided by

professionals (Das et al., 2015); and iii) increasing

accessibility for more senior users who seek health-

care guidance via portals (Gordon and Hornbrook,

2018). Web-based booking systems, a win-win so-

lution for patients and medical clinics, are the starting

point for most non-urgent healthcare services. The

e-scheduling software brings speciﬁc positives such

as a reduced no-show rate, decreased waiting time

and staff labour, and increased decision-making free-

dom for patients’ preferred time and/or medical pro-

fessional (Par

e et al., 2014; Zhao et al., 2017). Un-

like appointments via phone, booking via emails or

health-related applications is an much preferred alter-

native for some patients, for example autistic people

since they may have limited verbal capacity and ex-

perience anxiety when communicating with strangers

(Bradshaw et al., 2019).

2.2 Human-centric Issues on eHealth

Web Portals

Applications and software systems should be de-

signed and built to allow for human individuality

(Kotronis et al., 2019). In terms of human-centric

aspects, they refer to age, gender, language, culture,

emotions, personality, education, occupation, physi-

cal and mental challenges, and cognitive impairment

(and other traits) (Grundy et al., 2020). Human-

centric issues (HCIs) refer to the problems brought

about by a failure to consider and adapt software for

human-centric aspects (Shamsujjoha et al., 2021).

For instance, there is an increased prevalence

of cognitive degeneration associated with ageing

ongora Alonso et al., 2020), people aged 65 and

over (Au et al., 2017) who, in Australia, are mainly

female. Given most software developers are male in

their 20’s (Grundy et al., 2020), who are less likely

to develop software that identiﬁes distinctive charac-

teristics for diverse end-users (Venkatesh and Morris,

2000; Schnipper et al., 2008; Smail-Crevier et al.,

2019), it is not uncommon for software to be less in-

clusive for older Australians. The lack of access to ﬁt-

for-purpose software to monitor their health can lead

to a negative user experience and potentially worse

health outcomes as a consequence. Speciﬁc cases in-

clude patients with cancer who have identiﬁed a pref-

erence for personalised eHealth tools, as many have

identiﬁed they are no personalised settings in the tools

they used (Van Gemert-Pijnen et al., 2013).

Apart from the eHealth background in academic

literature, reﬂecting available online health systems

in the open market as part of the research is vital

(Maramba et al., 2019). We collected 44 eHealth

websites that were mostly used in Australia, Korea

and China and comparing the design of those web-

sites with a preliminary survey we conducted to col-

lect different users’ preferences on eHealth web por-

tals, more details of which will be discussed in the

following section.

ENASE 2022 - 17th International Conference on Evaluation of Novel Approaches to Software Engineering

3 METHODOLOGY

Questionnaires are still the most frequent approach

of usability evaluation in the eHealth ﬁeld, followed

by task completion and the ‘Think-Aloud’ method

(Maramba et al., 2019). For this reason, the research

was conducted using quantitative and qualitative anal-

ysis. The workﬂow of this study is i) A preliminary

survey was conducted in three languages to under-

stand diverse users’ preferences/needs and how they

feel about the current eHealth portals; ii) The survey

results were compared with the collection of the top

eHealth webs to see the gaps on real-world eHealth

webs; iii) An eHealth web prototype designed based

on the survey responses; and iv) Several user studies

for the prototype using a ‘Think-Aloud’ protocol. We

guide the study by answering the following research

questions:

• What human-centric aspects are essential for

eHealth webs? (Section 4)

• How a prototype take into account these human-

centric aspects? (Section 5)

• How to evaluate such a prototype considering

human-centric aspects? (Section 6)

4 RQ1: WHAT HUMAN-CENTRIC

ASPECTS ARE ESSENTIAL

FOR eHEALTH WEBS?

4.1 Preliminary Survey

4.1.1 Data Collection

An anonymous survey was conducted via Google

Forms in English and Korean, and Wenjuanxing

Chinese to explore a range of answers from peo-

ple from diverse backgrounds. We invited eHealth

web stakeholders such as medical practitioners, re-

searchers, and general users from diverse cultures,

ages, genders and occupations. There were no exclu-

sion criteria at this stage.

The preliminary survey was designed and divided

into three parts as follows: i) The participants re-

sponded if they had used an eHealth website: if YES,

they were asked to leave their impression - using emo-

tional language like trust, surprise, neutral, fear, anger

- and comments about the eHealth website they had

used recently; if NOT, they were asked their per-

spectives of three sample health-related websites sug-

Wenjuanxing: Online survey platform. Retrieved from:

https://www.wjx.cn/

gested by the authors. The three samples were se-

lected because of their different user interface de-

signs; ii) We provided screenshots of different online

eHealth setting examples in the questionnaire. The

participants were asked the purpose of their eHealth

application use, and to choose their preferences re-

garding the colour theme, font size, navigation design

and icon design (see Figure 1). They were asked to

provide information about their speciﬁc devices be-

forehand as the font size may vary depending on their

responsive devices; and iii) Data about their demo-

graphics such as age, gender, education, language,

occupation, and whether they had any chronic health

conditions, were collected.

Figure 1: Screenshot of part of the preliminary survey, ask-

ing for UI preferences.

The aim was to analyze and understand which

human-centric aspects should be considered when de-

veloping an eHealth application based on the data and

preferences of the end-users preferences. We received

146 responses within two weeks of posting the ques-

tionnaire on Social media platforms such as Linkedin,

Wechat, and Kakao Talk. Extracted responses were

recorded on a spreadsheet for data preparation, with

each row representing one participant’s entry. The

study was approved by the Monash University Human

Research Ethics Committee.

A Human-centric Accessible eHealth Booking Web Portal

4.1.2 Data Analysis

Firstly, the researcher whose main language is Chi-

nese/Korean translated the responses from the Chi-

nese and Korean surveys into English and merged

them into the English survey for data preprocessing.

Of all the returned questionnaires, eight were deleted

because two were test answers before ofﬁcially re-

leasing the surveys, and six were invalidated answers

that revealed inconsistency among responses demon-

strating possible biases between occupation and fre-

quency of online access. At this stage, we had a ﬁ-

nal set of 138 valid responses for further data anal-

ysis. We cleaned the dataset using Microsoft Excel

and performed quantitative analysis using Python and

SPSS

with Chi-square. Each human-centric aspect

was analysed individually to see which arguments had

signiﬁcant results and to determine any relationships

between multiple arguments.

4.2 Survey Results

4.2.1 Demographics

Except for two participants who preferred not to iden-

tify their gender, the distribution of gender was 61%

female and 38% male, 55% of them were aged from

18 to 35, while 45% were aged over 35. Among all

the participants, 84% of them had experience with

eHealth applications, and 22.5% disclosed a self-

reported chronic health condition.

People from nine different nationalities ﬁlled in

the survey. They reported having 18 occupations such

as government employee, IT developer, home duties,

health professional, researcher, student, and retired.

Among the sample, 83% lived in urban areas, and

66% self-reported their Internet speed as fast to very

fast and held a college or bachelor degree. They self-

evaluated their basic computer skills as moderate to

high/very high as 51% and 38% respectively, and 85%

of them reported to be daily active users.

4.2.2 Age

Among all the human-centric aspects, older age was

associated with signiﬁcant differences for preferences

with colours, icon and navigation design. We per-

formed a chi-square analysis and found that advanc-

ing age and icon design were signiﬁcantly related

(p = 0.01), which showed a dramatically increasing

trend of preferring skeuomorphic design with advanc-

ing age (see Figure 2).

SPSS Online: data analysis tool. Retrieved from:

https://spssau.com/en/index.html

Figure 2: Correlation between age groups and icon design

preferences.

However, there was no signiﬁcant difference de-

tected in preferences for Colour theme or Navigation

design. The elderly had a strong preference for warm

colour toned web pages while 18 to 65 aged people

were more likely to choose cool colour themes. It

was possible that the colour preferences among el-

derly were more likely to be based on their visual

perception rather than their fondness of that colour.

Regardless of age, both icon and text remained the

most favourite navigation design, which may be be-

cause both icon and text revealed more transparent

navigation than icon only and were a more impressive

design than text only.

4.2.3 Other Human-centric Aspects

Although there was no signiﬁcant difference for other

human-centric aspects, our results describe other

human-centric aspects (other than age) including:

Chronic Health Condition - the only signiﬁcant re-

sult found in people with chronic health conditions

was icon design (p = 0.001). Results showed that

42% of those who answer positively to chronic health

conditions would prefer Skeuomorphism. Those who

responded “Yes” and “Unsure” shared similar prefer-

ences, of which around 70% preferred the bigger font

size. The reason for the font size preference may be

due to a high correlation between having a chronic

health conditions and being an older adult.

Gender - we did not ﬁnd any signiﬁcant differences

between genders since they shared the same pattern

of preferences. Female and male participants’ prefer-

ences for cool colour were 55% and 52%, and warm

was 39% and 40% respectively. Similarly, their pref-

erences for icon design were 20% and 21% for Flat,

44% and 42% for Material, 33% and 37% for Skeuo-

morphism. Interestingly, they both had a strong pref-

erence for both icon and text (85% and 79%).

Occupation - there were no signiﬁcant results found

for occupation. Surprisingly, students were the group

ENASE 2022 - 17th International Conference on Evaluation of Novel Approaches to Software Engineering

that most frequently picked “No preferences” while

the other occupations had preferences for colour and

icon design. As for those who are IT developer and

designer, colour theme was generally the most impor-

tant feature compared to icon design and other web

design elements.

5 RQ2: HOW A PROTOTYPE

TAKE INTO ACCOUNT THESE

HUMAN-CENTRIC ASPECTS?

5.1 Real-world eHealth Webs

To see the gaps between real-world eHealth web por-

tals and HCIs, we collected the top eHealth websites

in Australia, Korea from App Annie

and China from

Top.chinaz

, and eHealth websites collected from the

preliminary survey that will be discussed in the fol-

lowing section.

Forty-four eHealth websites were collected and

reviewed by the ﬁrst author on their colour tones, icon

design, navigation design, language and font size, and

cross validated by two of the other authors. Compared

to the results from 44 online eHealth web and survey

respondents, it was evident that there was a big gap

between what the end-users need and what the on-

line applications looked like (see Figure 3-5). This

included e-booking systems which this study is using

as an example for how to address HCIs in eHealth de-

velopment.

5.2 e-Booking Prototype

Based on the preliminary survey analysis, we de-

signed an e-booking system prototype using Figma

The prototype followed Web Content Accessibility

Guidelines (WCAG) V2.0 Level AAA (Isa et al.,

2016). We introduced features, Language, Colour

theme, Dark mode, Enlarge text, Voice Assistant and

Simplify design for the user to modify the website

based on their personal preferences.

As for the layout of “Accessibility Helper”, we

provided two designs for the users: a robot design

App Annie: Application/Web data analytics platform.

Top eHealth web usage in Australia and Korea. Retrieved

from http://AppAnnie.com. (data collected by July 25,

2021)

Top.chinaz: Website ranking analytics platform.

Top eHealth web usage in China. Retrieved from

http://top.chinaz.com. (data collected by July 25, 2021)

Figma: Interface design tool. Retrieved from:

https://www.ﬁgma.com/

Figure 3: Gaps on colour between the design of online

applications and the preferences from preliminary survey.

79.5% online websites are using cool colours, which is con-

sistent with the result that most participants in the survey

preferred cool colours.

Figure 4: Gaps on navigation style between the design of

online applications and the preferences from preliminary

survey. 82.6% participants preferred both icon & text style

reported in the survey, while 22.7% online eHealth web-

sites designed in both icon & text. Instead, 77.3% online

websites designed in text only.

Figure 5: Gaps on icon design between the design of on-

line applications and preferences from preliminary survey.

33.5% participants preferred skeuomorph design in the sur-

vey, while one online website (2.3%) adapted skeuomorph

design. 68.2% of online eHealth websites designed in ﬂat

icon, while only 20.3% participants preferred ﬂat design re-

ported in the survey.

(Figure 6a) when the user ﬁrst accessed the page and

the other one is a button design (Figure 6b) when the

user continued to browse the page. After clicking ei-

ther design of “Accessibility Helper”, a pop-up win-

A Human-centric Accessible eHealth Booking Web Portal

dow (Figure 6c) lists all the corresponding features.

The summary of each feature in the extended tool

“Accessibility Helper” is listed below:

Figure 6: Screenshot of Accessibility Helper.

Language - There is only an English-Chinese trans-

lation in this prototype, each web page of it was de-

signed in both English and Chinese. User could ap-

plied either language and the ﬁrst author manually did

the translation of the web page.

Colour Theme: We applied the colour palette, which

allows users to feature the signiﬁcant colour of the

web page. Users were able to choose from 70 dif-

ferent colours, which were pre-deﬁned in the primary

colour palette. Moreover, they could also customise

their preferred colours after clicking “More colour”

option.

Dark Mode: Similarly to the Colour theme, we

also performed light-on-dark colour schemes, namely

Dark Mode. The user was able to select this option to

convert all text, icons, and elements light-colour to a

dark background.

Enlarge Text: Participants could control a scroll bar

to enlarge the font size of the web page. As the pref-

erences on font size varied in the preliminary survey,

there was a need to have a wide range of font sizes

collected from 8pt to 22pt.

Voice Assistant: Since there is no natural language

processing (NLP) tool in Figma, the ﬁrst author sim-

ulated this for the user study, which would be con-

sidered for implementation in future research. When

the users accessed the web page, if they would like to

have voice instruction, they were able to click the fea-

ture for requiring voice assistance which the author

simulated.

Simplify Design: From the preliminary survey, most

participants, regardless of their age, felt more hesi-

tant and struggled when seeing too many navigation

options or context on a web page. Therefore, we in-

cluded a Simplify design feature to minimise three

different navigation bars into two and shorten mul-

tiple lines of text into three lines.

Reset All Settings: This enabled all customised fea-

tures to go back to the default setting with English

content, blue colour theme (due to 68% of 44 online

eHealth webs mentioned in the background section

are designed in blue), 10pt font size (due to most par-

ticipants responded to it in the preliminary survey),

simplify design and dark mode off.

6 RQ3: HOW TO EVALUATE

SUCH A PROTOTYPE

CONSIDERING

HUMAN-CENTRIC ASPECTS?

6.1 User Study Design

We performed 16 user studies with participants from

different demographic backgrounds to investigate the

usability of the prototype. Participants were recruited

if they positively responded to a subsequent user

study invitation in the preliminary survey or a sec-

ondary recruitment advertisement on social media. To

increase the reach of the survey, the only eligibility

criteria was being able to access the Internet.

The user study was conducted via different Zoom

sessions and held for 30 (±5) minutes on average.

Each session began with a brief explanation, consent

from the participant and instructions about the user

study mediated by the ﬁrst author, followed by some

basic tasks and a corresponding questionnaire com-

pleted by the participants. The study was approved

by the Monash University Human Research Ethics

Committee. The questionnaires were created in two

languages -English via Google Form and Chinese via

Wenjuanxing- by the ﬁrst author. The other languages

such as Korean will be discussed in the future.

The questionnaire was divided into two parts: i)

the basic background information including age, gen-

der, whether they have any chronic health issues and

a simple vision test; and ii) four major tasks of ap-

plying personalised features through “Accessibility

Helper” for the website layout before booking an

appointment. Those four steps included changing

colour theme, adjusting font size, setting dark mode,

and applying multi-language translation. During the

tasks, each participant was instructed to share his/her

screen and encouraged to state what they were think-

ing as per the ‘Think-Aloud’ approach (Eccles and

ENASE 2022 - 17th International Conference on Evaluation of Novel Approaches to Software Engineering

Arsal, 2017), while the ﬁrst author recorded their

statements. The accessibility of the prototype was

evaluated through the participants’ statements dur-

ing the tasks and their self-reported evaluation of the

questionnaire. In order to evaluate the prototype, we

categorised four domains from the software quality

characteristics including Effectiveness, Satisfaction,

and Efﬁciency (Ferreira et al., 2020) and Adaptation

which emerged from the analysis. The evaluation cri-

teria are examined (see Table 1).

Table 1: Evaluation criteria of the user study.

Domain Domain Description

Effectiveness The completeness and the as-

sociated accuracy of follow-

ing the tasks on the e-booking

prototype.

Satisfaction The score the participants

rated to Language, Colour

theme, Dark mode, Font size

and Overall satisfaction.

Efﬁciency How the participants consider

the e-booking prototype is

easy to learn and easy to re-

member.

Adaptation Which feature/setting of Ac-

cessibility Helper would the

participant adapt on their sec-

ond visit.

6.2 User Study Results

This section follows the four domain evaluation cri-

teria discussed in user study design. The quantitative

outcomes were analysed using SPSS.

6.2.1 Participant Characteristics

Sixteen responses were included in the data analysis

stage. Participant characteristics are presented (see

Table 2). The gender distribution for male and female

participants was 7 to 9, and half of them were over

35-year-old. Four participants responded positively

to having existing chronic health issues and did not

correctly identify all the numbers in the vision tests in

the questionnaire.

6.2.2 Effectiveness

The completeness of tasks was 100%, while the ac-

curacy was 88% since two participants were initially

uncertainty but after being given instructions by the

ﬁrst author, they completed the tasks. As for the

unclickable places, a female participant aged 26-35

clicked the chatbox to apply “Accessibility Helper”

rather than clicking the robot itself instead. This was

likely because the robot view (Figure 6a) of “Acces-

sibility Helper” was not a traditional mode of interac-

tion such as a button (Figure 6b).

However, three participants over 56 highlighted

the attractiveness of the Robot design of Accessibility

Helper. The elderly were less likely to quickly iden-

tify the desired clickable elements of the web page

if there were several selectors or buttons in distinctly

presented places as they felt distracted by a web page

designed with too many colours and long paragraphs.

This was consistent with the ﬁndings from our pre-

liminary survey.

From our survey responses, the third sample

eHealth website had too much text on the web page

(approximately a third of the screen) and was the least

favourable design. 19.2% of people felt a degree of

discomfort and fear; the second sample eHealth web-

site was annoying as it contained too many entries

(eight selectors simultaneously). Participants aged

18-25 could quickly determine the correct approach

to primary navigation, side navigation and foot navi-

gation. At the same time, the elderly preferred to look

at primary navigation ﬁrst regardless of the tasks and

felt confused having more than two navigation bars

on the same web page.

In our analysis of the existing eHealth web portals,

only eight among the 44 objective eHealth portals

observed offered language translation, even though

eHealth recommendations are to provide local lan-

guages supported by pictures and universal icons

(Wickramasinghe et al., 2006). This is because when

people access an eHealth website, not in their mother

language, they typically look at the intuitive icon and

guess where it would navigate them.

We found that not all icons are able to convey

the correct meanings, for example, ﬂat design icons

lose most of the shadow and shape of content to sim-

plify the design but confuse its meaning, especially

for non-active online users. We showed two buttons

designed in icon only (Figure 1b) in the preliminary

survey to two participants aged over 65 and asked

them to guess what the buttons were for. Not sur-

prisingly, one non-active online user considered the

“Listen” button as a “Light” button by which he could

increase the lightness of the tool, and he had no idea

what the “Print” button was. Another daily active user

in a similar age considered the “Listen” button as a

“Speaker” which was close to the proposed meaning

but felt confused by the “Print” button as to whether it

meant “Next page” or “Download”. In this case, with-

out any context near the icon, skeuomorphism design

seemed to be a better alternative compared to a ﬂat

A Human-centric Accessible eHealth Booking Web Portal

Table 2: Participant characteristics of the user study.

Gender Age group

Main Language Chronic health issues

Visual impairment

P1 Male 26 – 35 English Unsure No

P2 Female 18 – 25 Chinese No No

P3 Male 18 – 25 English No No

P4 Female 26 – 35 Chinese No No

P5 Female 26 – 35 English Unsure No

P6 Male 46 – 55 Chinese Yes Yes

P7 Female 36 – 45 Chinese Yes Yes

P8 Female 46 – 55 Chinese Unsure Yes

P9 Male >65 Chinese Yes Yes

P10 Female 18 – 25 Chinese No No

P11 Male 56 – 65 Chinese No No

P12 Female 56 – 65 Chinese No No

P13 Female 26 – 35 English No No

P14 Male 18 – 25 Chinese No No

P15 Female >65 Chinese Yes Yes

P16 Male >65 Chinese Unsure No

design especially for elderly users.

6.2.3 Satisfaction

No negative feedback on “Accessibility Helper” was

revealed from all the user studies and overall, all par-

ticipants were satisﬁed with the Accessibility Helper.

Our analysis showed that Language was the feature

people were most satisﬁed with, with a score of 4.8/5,

followed by Font size 4.4/5, Colour theme 3.7/5, and

Dark mode which was the lowest at 1.9/5. Most par-

ticipants, regardless of age and gender, were pleased

to access an eHealth web portal with the personalised

setting “Accessibility Helper” rating 93.8% satisfac-

tion (see Figure 7).

Figure 7: Distribution of participant agreement with the

prompt “Overall, I am satisﬁed with the Accessibility

Helper”.

Participants were asked to identify their age in a range

rather than speciﬁc chronological age.

Chronic health issues were self-reported by the partic-

ipant himself/herself, we did not go into detail for speciﬁc

health issues if they answered positively to this question.

Visual impairment was evaluated by whether or not the

participant could correctly identify all the numbers in the

colour blindness test in the questionnaire.

6.2.4 Efﬁciency

We found that 81.3% participants considered booking

appointments on the eHealth prototype is easy to learn

(see Figure 8) and same percentage of those who con-

sidered it easy to remember (see Figure 9). However,

the proportion of ”strongly agree” in easy to remem-

ber (50%) is larger than those proportion of ”strongly

agree” in easy to learn (6.3%).

Figure 8: Distribution of participant agreement with the

prompt “I consider this e-booking portal is easy to learn

with the Accessibility Helper”.

Figure 9: Distribution of participant agreement with the

prompt “I consider this e-booking portal is easy to remem-

ber with the Accessibility Helper”.

ENASE 2022 - 17th International Conference on Evaluation of Novel Approaches to Software Engineering

The Participants over 65 preferred a software that

was easy to learn rather than a fancy design software

but difﬁcult to ﬁgure out. They were more likely to

feel less patient and struggled more when complet-

ing the user study. For instance, a participant aged 81

mentioned that he barely used Internet-based facili-

ties, and as for seeing a doctor, he would generally go

to the clinic in the rural area and wait for an on-site

appointment. The beneﬁt of saving time by using on-

line appointment system did not attract older people

since they were not as time pressured when seeing a

doctor in a non-emergency setting. He also mentioned

that there were too many points where he had to press

on the application which would make him hesitate to

continue:

”The ﬁrst step for e-booking was to enter a

keyword of clinic or doctor, but I was bad at

typing. Still, there are several ‘Press’ which

I do not think I can perform correctly next

time on my own. . . . I have plenty of time to

waste. . . . I prefer a face-face appointment at

the clinic from where I can ask the nurse for

further instructions.” [P9]

He also pointed out that less click and entry would

be a must for him to master the tool, which should

be considered since a third of all web searches are in-

voked not by typed but by voice query in 2019 (Cam-

bre et al., 2021). Although Voice Assistant was per-

formed as a roughness of functionality in the pro-

totype design, we could still see there was a huge

need for voice assistance among the elderly through

the user study. While the importance of voice inter-

action with Internet-based applications is obvious, a

tiny fraction was estimated to be available in 2019

(Cambre et al., 2021). All participants over 65 used

Voice Assistant during the tasks, and most of them

mentioned that they usually need instructions when

accessing eHealth web portals on their ﬁrst use.

6.2.5 Adaptation

Studies have shown that the following common prob-

lems affect patients when using web-based schedul-

ing: being unaware of the web-based appointment

service; low penetration and distrust of the Internet;

low computer skills; and the preference for verbal

communication (Zhao et al., 2017). We explored

which accessibility settings the participants preferred

to apply for their subsequent access and found the

features of importance to address for subsequent ac-

cess were Language (13/16, 81.3%), Font size (10/16,

62.5%), Colour theme (4/16, 25%), Dark mode (1/16,

6.3%), although two participants preferred to keep the

default setting unchanged (see Figure 10).

Figure 10: Distribution of participant agreement with the

prompt “I would like to apply this feature on my next access

to the eHealth web portals”.

In order to rank each feature, we combined the

ranking of the Satisfaction and Adaption domains.

Interestingly, we found the ranking of all the features

in the Adaptation domain were the same as those in

Satisfaction, which from high to low were Language,

Enlarge text, Colour theme and Dark mode. We

discuss these in more detail below:

Language - Linguistic differences are one of

the top priorities among human-centric aspects.

Fourteen participants were not native English speak-

ers, and therefore most of them thought Language

was crucial since they were more likely to access

eHealth websites in their mother language. One

Chinese participant aged 26-35 living in Australia

also emphasised the importance of the “Filter doctors

by language” function in the prototype:

“My ﬁrst appointment in Australia was with

a non-Chinese speaking doctor. Before seeing

her, I checked the terms like “symptom” and

“penicillin” which I had a history of drug al-

lergy, in case I did not understand the medical

words. . . . Well, there were still some terms I

did not catch, and I had to use onomatopoeia

to express where I was in pain.” [P4]

She added that Language should be considered in

eHealth web portals, even for people whose second

language is English since they might not understand

all the medical terms.

Enlarge Text - All elderly participants empha-

sised the necessity for enlarged text functionality.

Usually, they would hold the phone close to their face

if they could not see the font clearly on their phones

but they cannot hold the desktop close to their eyes

at home. They would be more likely to bow their

upper body torso or straighten their neck to actively

approach the computer screen to see the content more

clearly. 57.1% elderly prefer to enlarge the text on

the web page and thus they can see a larger font

clearer with a relatively comfortable posture sitting

on a chair.

A Human-centric Accessible eHealth Booking Web Portal

Colour Theme - We should carefully consider the

colour used on the eHealth website since people over

55 usually feel negative if the colour does not ﬁt their

preferences and colour insensitivity and poor eyesight

are strongly correlated older age. For example, an 81

year old participant was only able to identify a red

digit in the colour test, saying that the size of that digit

was the largest even though the size of all the digits

were the same while their contrast colour was not.

Similarly, four participants were not able to recog-

nise a digit in light green colour possibly because they

were not sensitive to light green with less contrast in

background colour. Those four participants with poor

visual impairment had different colour preferences.

Half of them were resistant to the red colour while an-

other half were in blue. It also shows that those with

poor vision or colour blindness demonstrate a more

substantial interest in Colour theme than other users.

Interestingly, most users preferred cool colours,

which was consistent with the results from the

preliminary survey (participants who preferred cool

and warm colours were 53% and 39%, respectively).

This may because participants who preferred the red

colour theme were all from China. This may well be

a cultural association as Chinese people, especially

the elderly with traditional beliefs, consider red as

positive (e.g. luck, marriage and new year) while

others with negative feelings (i.e. anger). These

colour–emotion associations are highly likely to be

reinforced by the culture, given that red is the primary

colour of its national ﬂag (Jonauskaite et al., 2020).

In the same vein, red clothing was highly regarded

as the hierarchy of nobles in ancient times. Even

after thousands of years, this colour has penetrated

the Chinese consciousness and subconsciousness

to affect their feelings and reactions (Ying and

Xiaohong, 2020).

Dark Mode - Among all the features, Dark mode was

the setting with the greatest differentiation among all

the participants. Participants over 65, especially those

with colour cognitive impairment, felt rejected when

seeing a website containing a much darker colour. As

per her comment:

“I do not like this dark design. I feel un-

happy to seek health information. It will leave

a bad impression the ﬁrst time I see a web in a

mostly dark colour. I will change to a lighter

colour to suit my taste through “Accessibility

Helper.” [P15]

Instead, participants aged 18-25 thought it was cool-

looking and reduced visual fatigue in low-light envi-

ronments when using online tools for a long duration

(Erickson et al., 2021), especially for computer graph-

ics artists and software programmers.

7 DISCUSSION

7.1 Key Findings

The ﬁndings of this study suggest that age and lan-

guage are the top priorities among human-centric as-

pects to consider when designing eHealth web por-

tals. Other human-centric aspects, such as gender, oc-

cupation, health condition, and culture, should also be

considered. From the preliminary survey, the design

efforts in the eHealth prototype, and user studies we

conducted, it is obvious that the design elements were

different depending on the users’ age groups and/or

their visual impairment. Their preferences should be

a consideration when designing a more human-centric

tool.

Although there was no statistical signiﬁcance in

the preference of the colour of the web page, most

participants’ emotions were demonstrated to be af-

fected by the colour. They expressed negative feelings

about the inappropriate colour used on the web appli-

cation and positive emotions about being willing to

access the websites if the colours were in their taste.

people over 55 reported similar accessibility issues as

65 and despite not being in the ‘elderly’ category, they

still need their human aspects to be considered when

developing software, especially since visual impair-

ment post 55 is almost universal.

The user studies to evaluate our e-booking web-

portal with the “Accessibility Helper” option revealed

that evaluating eHealth web portals to satisfy diverse

users and accommodate their needs using a prototype

is vital to improving the user experience. An in-built

all-in-one Accessibility Helper could provide differ-

ent users with all the features designed in human-

centric aspects anticipated. A prototype allows users

to have a more intuitive experience before and after

applying different features, and the ‘Think-Aloud’ ap-

proach is a sound method for capturing their feelings

and responses appropriately.

7.2 Limitations

Limited sample size, and not including sufﬁcient

older adults aged over 65 from diverse backgrounds,

are potential limitations for this research. These

groups are less likely to access the Internet as fre-

quently as the people in their 20s. Online recruit-

ment was difﬁcult, especially for the late-elderly (75

ENASE 2022 - 17th International Conference on Evaluation of Novel Approaches to Software Engineering

and older), and the restrictions of conducting face-to-

face user studies were restricted during the COVID-

19 pandemic. We did not include people less than

18 in our participant groups for ethical reasons, and

therefore their needs for eHealth web portals were not

included.

The lack of detail in the preliminary survey about

the speciﬁc chronic health conditions people reported

means our results are not generalisable for all chronic

health issues. Similarly, only four vision tests for

colour-blind or visual impairment are insufﬁcient to

diagnose all visual impairment which might bias the

results leading to colour-blind people considering the

Colour theme as the top priority or short-sighted peo-

ple choosing Enlarge text as the main priority.

The race distribution of the elderly was skewed to

Chinese participants and potentially led to bias. This

result in the fact that most elderly preferred red colour

as the main colour tones of a eHealth web portal be-

cuase of the culture and colour–emotion associations.

7.3 Future Work

This research principally analysed fundamental de-

mographics like age, gender and cognitive impair-

ment. Wider demographic area, including more dif-

ferent languages, more respondents, especially elder

ones with a higher participation of chronic problems,

will be our future direction. This research did not

involve other human-centric issues such as person-

ality, education, and users with special needs. Also,

the prototype involved a robot design of “Accessibil-

ity Helper” without a skeuomorphism button designed

for the evaluation, which we will take into account in

our future work. In the future research, we will also

analyse whether such a human-centric eHealth web

portal is applicable to target users and actual patient

data.

8 CONCLUSION

This research investigated human-centric issues in

eHealth web applications. We conducted a prelimi-

nary survey and designed a prototype which we eval-

uated with 16 user studies. The study suggests that

age and language are two contributing factors to con-

sider when developing a human-centric eHealth web

portal. Different colours for the web page are mostly

preferred based on users’ visual status and their per-

ceptions of that colour by personal taste and culture.

The most compelling evidence could be that tradi-

tional Chinese elderly prefer red colour and feel dis-

comfort with mostly dark colours, while the younger

generation aged 18-25 are more likely to use darker

design (i.e. dark mode).

The majority of survey results and user studies in-

dicate that icon and text buttons could be the best way

to navigate web pages where “icon only” appears to

be a poor design practice, especially for non-active

online elderly users. For most elderly participants,

skeuomorphism is more comprehensive instead of ﬂat

design. Similarly, preventing excessive entries and

clicks as well as reducing redundant paragraphs on

the same page could increase efﬁciency and effec-

tiveness, particularly for the elderly to approach the

eHealth applications by themselves. Not surprisingly,

enlarging font size seems to be a necessary setting for

poor eyesight regardless of age and gender. To em-

phasise, an all-built-in-one “Accessibility Helper” is

sufﬁciently important for different users when access-

ing the eHealth web portal. Such a helper could con-

sider more human-centric issues and, as a result, in-

crease adaptation of the eHealth applications and sup-

port health information widely accessible for diverse

user groups.

ACKNOWLEDGMENT

Support for this work from ARC Laureate Program

FL190100035 and Discovery Project DP200100020

is gratefully acknowledged.

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