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Accessible Online Health Promotion Information for Persons with Disabilities

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Suzanne C. Smeltzer, EdD, RN, FAAN
Vanessa Zimmerman, MSN, RN
Marita Frain, EdM, RN
Lynore DeSilets, EdD, RN, BC
Janice Duffin, MSN, RN, CCM, CDMS

Abstract

Online health promotion materials have great potential to reach persons with disabilities and provide valuable information to this vulnerable population. While health promotion efforts are important for everyone, they are crucial for individuals with disabilities. Yet information needed to support these efforts is often presented in such a way that its access is limited or its content is inappropriate for this population. Whether designing or selecting online materials for individuals with disabilities, nurses can benefit from knowledge about strategies to make web sites more accessible or to assess the accessibility of existing web sites. The task of providing health promotion information to women with disabilities was undertaken as part of the Health Promotion for Women with Disabilities Project at Villanova University’s College of Nursing. A web site was created as one method of providing information. This paper presents strategies that are used to make this site accessible.

Citation: Smeltzer, S., Zimmerman, V., Frain, M., DeSilets, L., Duffin, J. (November 14, 2003). "Accessible Online Health Promotion Information for Persons with Disabilities". Online Journal of Issues in Nursing Vol 9 No 1. Available: http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No1Jan04/ArticlePreviousTopic/AccessibleInformation.aspx

Key words: online information, health promotion, health education, disability, accessible design, accessibility tools, telehealth


One in five Americans (54 million) has some form of disability.

The number of people accessing health information online continues to grow (Schloman, 2002). In fact, the search for health information is one of the most common reasons for using the Internet (Eng et al., 1998). For those individuals with a disability who may have difficulty leaving their homes, the Internet can be a valuable means of increasing their knowledge about health and health promotion strategies. However, most web sites are designed for educated, literate, and non-disabled audiences (Eng et al.).


Nurses are in the ideal position to provide health promotion education...it is important for them to understand what makes the information accessible to people with a variety of disabilities.

One in five Americans (54 million) has some form of disability (U.S. Department of Health and Human Services [U.S.DHHS], 2000; U.S. Bureau of the Census, 1997). A person is considered to have a disability if he or she has difficulty performing one or more activities of daily living (ADLs); has difficulty performing certain functions such as hearing, seeing or walking; or has difficulty with certain social roles such as attending school or work (U.S. Bureau of the Census). The number of Americans with disabilities is expected to rise as baby boomers age. These individuals can benefit from health promotion efforts. Health promotion is defined by O’Donnell (1986) as "the science and art of helping people change their lifestyle to move toward a state of optimal health" (p. 4). Since most people with physical disabilities can expect to have a normal or near normal life span (Trieschmann, 1987; Iezzoni, McCarthy, Davis, Harris-David & O'Day, 2001), maintaining optimal health can improve quality of life (Stuifbergen & Rogers, 1997) and prevent secondary disabilities (Marge, 1988; McMillen, Simeonsson & McDevitt, 1999). A secondary disability or condition is an additional physical or mental health condition that develops in addition to or as a result of the primary disabling condition (Thierry, 1998). Prevention of secondary conditions and health improvement are among the national objectives established for persons with disabilities by Healthy People 2010 (U.S.DHHS, 2000).

While progress has been made regarding health promotion efforts and education of the general population, health and health behaviors of individuals with disabilities have been largely overlooked (Stuifbergen & Becker, 1994). The delivery of health promotion information to persons with disabilities is often neglected by health care providers and health educators (Thierry, 1998).


...the Health Promotion for Women with Disabilities Project...is designed to improve health status [with] an online web site.

Women with disabilities are among the most disadvantaged groups in our society and may have a greater risk for health problems than men with disabilities or women without disabilities (Thierry, 1998). In an effort to develop and disseminate accessible health promotion information to women with disabilities, the Health Promotion for Women with Disabilities Project, supported by a grant from Bristol-Myers Squibb Foundation, was implemented by Villanova University’s College of Nursing. The project is designed to improve the health status of members of this population by promoting their participation in and access to health promotion activities. Development of an online web site (www.nursing.villanova.edu/WomenWithDisabilities) is one approach used to accomplish this goal. A variety of strategies are used to assure that the web site is accessible to women with a variety of disabilities.


Women with disabilities are among the most disadvantaged groups in our society...

Nurses are in the ideal position to provide health promotion education to their patients and to the public at large. In many cases, especially for individuals with disabilities, use of online materials may be the ideal strategy to reach the intended audience. However, whether nurses are developing online materials or using existing online information, it is important for them to understand what makes the information accessible to people with a variety of disabilities and to be able to make informed recommendations about online web sites to individuals with disabilities.

Accessibility of Online Information

Access to information is the first issue that must be considered in design or selection of online materials for persons with disabilities. Accessibility involves the ability to obtain the information being provided. Some web sites by virtue of design limit access to individuals with disabilities. In 1998, Section 508 of the Rehabilitation Act was enacted in an effort to remove barriers in information technology for persons with disabilities. This law requires federal agencies to make their electronic and information technology accessible to people with disabilities. It requires federal agencies to provide employees and members of the public access to information that is comparable to that provided to individuals without disabilities (U.S. General Services Administration, 2002; n.d.) www.section508.gov; www.gsa.gov/Portal/accessibilityaids.jsp. There are specific recommendations about visual presentation and page design, navigation, accessibility tools, and literacy level tools that the developer of online materials can use to make the information more accessible to persons with disabilities. Many of these strategies have been used in developing the web site titled Women With Disabilities.

Visual Presentation


The visual presentation of online materials is an important consideration for many individuals with disabilities.

The visual presentation of online materials is an important consideration for many individuals with disabilities. For those individuals with low vision, selection of appropriate font size and style can facilitate access to the material. Individuals with visual disturbances, such as many people with multiple sclerosis (MS), may have problems reading dense text (e.g., single spacing, little white space between lines) and small letters (i.e., font size less than 14 point). The web site Women With Disabilities uses a minimum of 14 point type with Arial typeface. This serif type font includes horizontal strokes at the top and bottom of the letters and is easy to read (Boyd, Graham, Gleit, & Whitman, 1998). Guidelines that facilitate universal accessibility through general design in the development of online materials are provided in Table 1. These guidelines may be helpful for nurses who are developing or evaluating online education materials for individuals with disabilities.

Table 1 – Making Online Material Universally Accessible

  • Maintain a simple, consistent page layout.
  • Use simple backgrounds with high contrast.
  • Avoid busy background patterns (wallpaper).
  • Make text clear and uniform; use large font (14 point or greater); provide adequate white space between text.
  • Avoid fast moving graphics or graphics inappropriate for the audience.
  • Provide a text caption with each graphic that explains the purpose of the graphic.
  • Maintain consistency of the general site layout through menu selections and navigation buttons.
  • Use standard, basic web authoring language (HTML). Avoid use of java script or similar newer languages that some browsers may be unable to decipher.
  • Minimize scrolling by placing critical information and navigation options at the top of the page.
  • Provide an alternative text-only version for sites with numerous graphics.
  • Provide text caption that explains each graphic and its purpose.
  • Provide keyboard as well as mouse navigation, if possible.
  • Provide alternative language versions other than English.
  • Design to the smaller screen with the lowest resolution.
  • Provide e-mail or telephone options as alternatives to electronic forms used for registration or surveys.
  • Limit a section of material to no more than two screens.

(Adapted with permission from North Carolina Office on Disability and Health, 1999, p. 21-22, www.fpg.unc.edu/~ncodh/TipsonCommunications.pdf

Color selection for backgrounds and print can affect accessibility of online material. People with congenital or acquired color deficit often have problems distinguishing colors (North Carolina Office on Disability and Health [NCODH], 1999). As a result, they will probably see less contrast between colors, may have difficulty discriminating between colors of similar hue or shade, and often have an altered perception of lightness. For example, white lettering on a pastel background does not provide adequate contrast and may make reading of the words difficult for some people. The accessibility of the visual display of the Women With Disabilities web site has been increased by exaggerating differences in foreground and background colors. This can be achieved by lightening the light colors and darkening the dark colors to provide better contrast (NCODH). A wallpaper of pastel colors is used with black print to provide high contrast. When graphics are used, those with rapid movement are avoided and a text description of the graphic is provided. Text describing visual graphics is essential for individuals with vision loss who use a screen reader that "talks" text. For the person not using a screen reader, this description becomes visible when the cursor is positioned over the graphic. An effort is made to use graphics appropriate for the audience. Examples of inappropriate graphics on the Women With Disabilities site would include a bicycle rider or a male figure since the site is designed for women with disabilities.

Navigation

Ease of navigation or moving around within the site is essential for the user, especially persons with disabilities. Repetitive hand movements required for scrolling or for use of a mouse may be difficult to perform for individuals with a physical disability affecting the arms and hands such as MS, spinal cord injury (SCI), and cerebral palsy (CP). Assistive user technology exists for persons with disabilities that are characterized by intention tremor, spasticity, or fatigue; this technology reduces fatigue and provides greater comfort than a standard PC-mouse (Feys et al., 2001). Several suggestions regarding the page set-up that may improve navigation ease for persons with disabilities are provided in Chart 1. In the web site for Women With Disabilities, the arrow keys may be used to scroll up and down the page and there are "home" and "next page" buttons at the top of each page, as well as links at the bottom of each page or section to easily return the user to the top of the page.

Accessibility Tools


Bobby...is a comprehensive web accessibility tool designed to identify and correct barriers to accessibility...

Accessibility tools can be used in web site development to assure that the site is fully accessible. Bobby, an example of such a tool, is a comprehensive web accessibility tool designed to identify and correct barriers to accessibility and to encourage use of existing accessibility guidelines (Bobby, http://bobby.watchfire.com/bobby/html/en/about.jsp).

A "Bobby Approved" icon Bobby icon displayed on the completed web site identifies the commitment of its developers to inclusion and accessibility (Bobby, http://bobby.watchfire.com/bobby/html/en/icon.jsp). Bobby helps web site developers to determine the accessibility of web pages before they are posted on the Internet or verify the accessibility of existing web pages. Bobby provides suggestions to improve web sites for persons with disabilities who use special browsers to access web information. For example, a person who is blind may use a screen-reader software program that, in conjunction with a speech synthesizer, translates the words on the screen into sound (Reardon, 1997) www.washington.edu/doit/Press/mart.html. Bobby will suggest additions to the web page that will facilitate such programs to work more effectively. On the women with disabilities web site, pastel wallpaper and a large number of graphics have been used to create visual interest. Based on Bobby recommendations, a text-only version was also created to facilitate the use of accessibility software such as screen readers. Video clips with sound are being used with increased frequency on web sites and can be helpful to those individuals who are blind or have low vision.

Accessibility tools can be helpful to the nurse when developing online materials. An icon representing the use of such an accessibility tool will serve as an indicator to the nurse reviewing a web site that it is appropriate for patient use. However, it is important to re-evaluate the site through Bobby when new material is added.

There are many other online sources for accessibility issues that will offer helpful recommendations to developers to make web sites accessible to users with disabilities. The Center for an Accessible Society, www.accessiblesociety.org/topics/webaccess/; DO-IT; Disabilities, Opportunities, Internetworking and Technology, www.washington.edu/doit/Resources/web-design.html; the Microsoft Corporation www.microsoft.com/enable/default.aspx; and the Web Accessibility Initiative (WAI), www.w3.org/TR/ATAG20/ are examples of such sites.

Literacy Skills


An important consideration when evaluating online education materials is the literacy level of the information ...[and] that of the intended audience.

An important consideration when evaluating online education materials is the literacy level of the information as well as that of the intended audience. If users are not able to read or understand the information it will be rendered useless. Until recently, literacy skills were universally measured by grade level – the average reading skill level achieved at each year of schooling in the American school system (Doak, Doak, & Root, 1996). Although the average reading level in the United States is 8th grade (Boyd et al., 1998), one of every five people reads below the 5th grade level; this number increases to two out of five for older Americans and inner city minorities (Doak et al.). Reading level is even lower in some populations because of their disability. For example, American Sign Language (ASL) is the primary language of the Deaf community. Since ASL is different in structure from English, reading English is often difficult or impossible for individuals who are Deaf (McEntee, 1995).

Literacy skills, sometimes defined in terms of competency level determined through measures of task difficulty, are now used to assess suitability of written material. Kirsch, Jungeblut, Jenkins, and Kolstad (1993) http://nces.ed.gov//naal/resources/execsumm.asp#litskills summarized the National Adult Literacy Survey (NALS), a large-scale assessment (n=26,000) of adult literacy conducted in 1992. The summary provides a detailed portrait of adult literacy in the United States based on performance across a wide array of tasks. The findings of the survey demonstrated that 90 million Americans had skills in Levels 1 and 2, the lowest two levels, and were unlikely to respond correctly to challenging literacy tasks requiring high level reading and problem-solving skills. Twelve percent of NALS respondents reported having a physical, mental, or other health condition that kept them from participating fully in work or other activities and these individuals (many of whom would be likely to have a disability) were more likely than adults in the population as a whole to demonstrate performance at Levels 1 and 2. Among those participants who reported having visual problems, 54% scored at Level 1 on the prose scale and 26% scored at Level 2.

The findings of the NALS suggest that significant percentages of adults have low literacy levels. Despite these findings the reading level of many online materials is much higher than that of the intended audience. It is recommended that education materials be kept at an 8th grade reading level or lower (Doak et al., 1996; D’Alessandro, Kingsley, and Johnson-West, 2001). In a study to determine readability of quality of care information for consumers on the Internet, Oermann and Wilson (2000) found that the overall reading level of 10 documents reviewed was 9th grade (+ SD 2.2) with a range from 6th to 12th grade. Four of the 10 documents had reading levels between the 10th and 12th grade. Beginning paragraphs were more difficult to read than the middle and ending paragraphs. If readers are unable to understand the first part of the information, they may miss valuable information contained in that section or, worse yet, stop reading altogether.

In a study to evaluate online health information in both Spanish and English on breast cancer, obesity, and childhood asthma, Berland et al. (2001) found that all of the English sites contained material written at a 10th grade reading level or higher, and 86% of the Spanish sites had materials written at 9th grade reading level or higher. In another study, D’Alessandro et al. (2001) found that general readability of 89 online pediatric patient education materials designed for adults was above the appropriate reading level for the average adult, with materials being evaluated between the 10th and 12th grade levels. The researchers recommended that the reading level and methods used to assess reading level be stated in education materials.

A problem with health-related information is the existence of multi-syllable medical terms which increases the grade level. Despite this problem, the developers of the women with disabilities web site are usually able to maintain an 8th to 9th grade reading level. Doak et al. (1996) point out that the NALS report offers no easy formula to rate health care information. This problem is compounded by the fact that new instructional formats such as computer-aided instruction (CAI), multimedia, hypertext, and hypermedia are being used and can be helpful in teaching individuals with low literacy skills. However, these media are evolving so rapidly they represent a difficult and moving target for any one particular literacy evaluation method. Therefore, health educators should consider using one of three assessment methods to determine difficulty level and suitability of patient education materials: a checklist of attributes of the materials, use of readability formulas, or analysis using Suitability Assessment of Materials (SAM) (Doak et al.). See Table 2. These methods can be used to assess existing information and to correct deficiencies in materials as they are being developed.

Table 2. – Methods of Written Material Assessment

    Assessment Checklist

    • Assessment attributes of educational material
      • organization
      • writing style
      • appearance
      • appeal
    • Deficient areas can be revised or supplemental material provided

    Readability Formulas

    Suitability Assessment of Materials (SAM) (Doak et al., 1996)

    • Instrument developed to determine a suitability score of health care instruction

An example of an assessment checklist is offered by Doak et al. (1996). The checklist contains items used to assess attributes of the educational materials regarding organization, writing style, appearance, and appeal. Any item that is missing indicates an area of potential deficiency in suitability. If existing materials are assessed as problematic, supplemental information or teaching can be provided to enhance the understanding of the materials (Murphy, Chesson, Berman, Arnold, & Galloway, 2001).

Readability formulas are available to determine the reading level of written materials. These formulas are based on the grammatical components rather than the substantive content of written materials. The number of syllables, sentence structure and sentence length are analyzed (Boyd et al., 1998). The Fry Formula (Fry, 1977; Fry, 1990) and SMOG grading (McLaughlin, 1969) are among the most common hand calculations. Computer software readability programs are available. Microsoft Word uses the Flesch Reading Ease Score (Flesch, 1974) and the Flesch-Kincaid Grade Level, a modified version of the Flesch Reading Ease Score developed for the military (Kincaid et al., 1975).

Flesch (1974) defines readability as "easy or interesting to read" (p. 172). The Flesch Reading Ease Score ranges from 0 to 100; the higher score is indicative of easier reading. A score greater than 80 is considered easy reading (6th grade level or below), between 60 and 80 is considered fairly easy to standard reading (6th to 8th grade level), and a score less than 60 would be indicative of difficult reading (9th grade level or higher) (Flesch, 1974). The developers of the Women With Disabilities web site try to maintain a reading ease score of 60 or above.

It is important to note that when comparing consistency and comparability of readability of four software programs, Mailloux, Johnson, Fisher, and Pettibone (1995) found statistically different grade equivalent scores of materials assessed by the programs. D’Alessandro et al. (2001) suggest patient education materials be developed using the computer Flesch Reading Ease Score along with a re-analysis by hand of the final document using the Fry Formula (1990) or SMOG grading (McLaughlin, 1969). Material on the women with disabilities site is created in Microsoft Word. After the computerized spell check is completed on the material, the program provides the Flesch-Kincaid grade level and the Flesch Reading Ease Score. Random sections of the material are checked using SMOG grading.

Suitability of Assessment of Materials (SAM) is a tool developed at the Johns Hopkins School of Medicine and is the most widely used tool of its type (Murphy et al., 2001). It was developed as a method to systematically assess the suitability of health information, pinpoint deficiencies, and correct those deficiencies. Although originally designed for use with printed material and illustrations, it has been successfully applied to audio-visual and audio-taped material. SAM addresses 22 factors divided into six categories including content, literacy demand, graphics, layout and typography, learning stimulation and motivation, and cultural appropriateness. When the material is evaluated, each of the 22 items is given a score of 2 points (superior), 1 point (adequate), or 0 points (not suitable). A total score is then obtained. The maximum possible total score is 44 points (44/44) or 100 percent. The following are the interpretation of SAM percentage ratings: 70-100 percent (superior material), 40-69 percent (adequate material), and 0-39 percent (not suitable material). Material with a reading level of 5th grade or below is rated superior. Material at the 6th to 8th grade level is considered adequate. Material at a grade level of 9th or higher is not suitable for the general population and would require revision or additional information to facilitate understanding (Doak et al., 1996).

SAM was used by Murphy et al. (2001) to assess various education information materials (in both written and online formats) for neurology patients to determine if the material was suitable for patients with low literacy levels. Over 500 patients in university-based public and private neurology clinics participated in this study. Patient education materials, including 35 written brochures and eight online versions, were assessed for readability using the Fog Index (Gunning, 1968) and for suitability using SAM. More than 90% of the materials assessed were written at a 9th grade level or higher. The mean reading level of the patients in the sample was 7th to 8th grade, although the mean education level of the patients was 12th grade. Only 14% of the material was rated using SAM as superior, 58% was rated adequate, and 28% was considered unsuitable for the intended audience.

In circumstances in which it is possible and appropriate to assess the reading level, reading tests such as the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Wide Range Achievement Test (WRAT) are available to administer directly to patients to quickly determine their reading level (Doak et al., 1996). This would help the nurse to make recommendations of online material according to the individual’s reading level.

Content of Online Materials


...content of health promotion information...for persons with disabilities must be applicable and relevant to their specific needs.

An important step in providing accessible health promotion information in any setting, including online, is to assure that the content is appropriate. Content is the most commonly cited published criterion for evaluating online health-related information (Kim, Eng, Deering, & Maxfield, 1999). To be appropriate, the content of health promotion information developed for persons with disabilities must be applicable and relevant to their specific needs. However, online health promotion information is often directed toward persons without disability. Appropriate subject matter and language are important to consider when preparing education material for persons with disabilities.

Subject Matter

It is too often assumed that health promotion interventions aimed at promoting quality of life for the general population will result in the same outcomes for persons with disabilities. This universal approach fails to consider limitations of time, energy, and mobility often associated with disability (Stuifbergen & Roberts, 1997). Further, individuals with disabilities may need additional or special health-related information that does not apply to the general population. For example, a program on exercise developed for the general population may fail to take into account the physical limitations of a person who uses a wheelchair all the time.


It is imperative that nurses...be aware of the health-related interests and concerns of the audience.

It is imperative that nurses, as providers of educational materials, be aware of the health-related interests and concerns of the audience. The issue of disability is complex. Those individuals with disabilities are generally considered the most knowledgeable source of information about their own needs (Thierry, 1998; Nosek, 2000). Several studies have addressed the health promotion interests and health promoting behaviors of individuals with disabilities (Hart, Rintala, & Fuhrer, 1996; Stuifbergen & Rogers, 1997; Smeltzer & Zimmerman, 2003). Key topics identified as of high interest in these studies include stress management, exercise, nutrition, sexuality, health-promoting behaviors, mental health issues, osteoporosis, and aging with a disability. The findings of these studies and general recommendations for women’s health were used to select topics for the web site for women with disabilities. Each section of the web site was developed by an individual with expertise on the topic, including faculty members or professionals in the community. The completed web pages were then sent for review to members of the project advisory committee, other faculty members, or experts in the community, both with and without a disability. The project advisory committee consists of women and men who either have a disability themselves or have professional interest in persons with disabilities.

Language


...nurses are in an ideal position to combat discrimination against...disabilities...[by] avoiding educational materials containing such derogatory language.

Appropriate use of terms and language is a major issue to consider in selection or preparation of online education material for persons with disabilities. In one national study involving women with disabilities (Nosek, Howland, Rintala, Young & Chanpong, 1997), women reported feeling that their health care providers viewed them in a negative manner. Furthermore, women with disabilities have reported being refused health care because of their disability. Choice of language can express negative attitudes. Scullion (1999) has pointed out that nurses are in an ideal position to combat discrimination against patients with disabilities and suggests that nurses become familiar with language that is derogatory toward members of this population. Avoiding educational materials containing such derogatory language, or its use in their preparation, will serve to make them more effective.

The North Carolina Office on Disability and Health has published a quick reference guide (NCODH, 1999) to improve communications with persons with disabilities. When referring to persons with disabilities, the use of "people-first" language reflects a positive attitude toward the people themselves and society. "People-first" language emphasizes the individual rather than the disability by placing the person first. For example, "people with disabilities" should be used rather than "the disabled" or "the handicapped". Examples of terms that have negative or derogatory connotations include wheelchair bound, defective, deformed, afflicted, and invalid (Institute on Disabilities, n.d.). An exception to this rule is for people who are hard of hearing or Deaf (NCODH, 1999). Individuals in these groups view themselves as separate and apart from each other. People who have hearing loss and communicate in spoken language refer to themselves as "hard of hearing" or "people with hearing loss." People who are Deaf and communicate with sign language refer to themselves as Deaf with a capital "D." The National Association of the Deaf points out that the term "hearing-impaired" is often used by hearing people since they view the term as politically correct. However, "hearing-impaired" is a well-meaning word that is resented by many hard-of-hearing and Deaf people (National Association of the Deaf, n.d, www.nad.org/infocenter/infotogo/dcc/terms.html; NCODH, 1999). Every effort is made to use people-first language in the women with disabilities web site.

The American Psychological Association (APA) offers online guidelines for non-handicapping language to remove bias related to disability as well as examples of problematic terms and alternative preferred terms (APA Online, 2003) www.apastyle.org/disabilities.html. The word "disability" should be used to refer to an attribute of an individual and the term "handicap" should refer to the source of limitations. It is most often environmental barriers, whether they are attitudinal, legal, or architectural, that handicap the individual with a disability by limiting accessibility. The use of "non-disabled" or "persons without disabilities" should be used rather than the term "normal" when referring to persons without a disability. The use of the term "normal" implies that those individuals with a disability are "abnormal." The APA offers four key points as a guiding principle to use of non-handicapping language. This principle involves maintaining the integrity of individuals as whole human beings by avoiding language that 1) implies that the whole person is disabled such as a "disabled person," 2) labels the person by disability such as an "epileptic," 3) uses expressions with emotional, negative overtones such as "stroke victim," and 4) is regarded as a slur or offensive expression such as "cripple." Language should portray individuals with disabilities as contributing, empowered members of society who can take an active role in their own health promotion.

Word selection is an important consideration when choosing or developing educational materials. Sentences should be written in conversational style, active voice when possible (Doak et al., 1996). Abbreviations should be avoided, or spelled out if they must be used (Boyd et al., 1998). Words that are familiar to the target audience and those that have fewer than three syllables are easier for most people to understand. For example, "doctor" would be preferable to "physician" and "yearly" would be preferable to "annually" (Boyd et al., 1998). The Centers for Disease Control and Prevention offers a list of some replacement words and phrases that can be used in place of terms containing multiple syllables (Snider, 2001) www.cdc.gov/od/ads/smog.htm.

Summary

In summary, for online health promotion information to be useful to persons with disabilities, it must be accessible to the intended audience and have appropriate content. The information must be accessible in its visual appearance, physical navigation, and literacy level of the online site. The content should include relevant topics that are directed towards persons with disabilities and suitable language. Before recommending online educational materials it is important to determine if the materials are truly accessible and appropriate for the intended audience.

Evaluation of the effectiveness of online health promotion materials for persons with disabilities should be ongoing. The evaluation should be performed by both the person using the information and the developer. The person using the information should evaluate its accessibility and the value of the information itself. The developer can then use this information to continue to improve the online medium. These evaluation strategies need to be modified so that they, too, are accessible for use by persons with disabilities. Research is needed to determine effective options for presenting online health-related information to persons with disabilities, a population for whom this information is vital.

Implications for Nursing Practice

Although health promotion is important for everyone, it is especially important for individuals with disabilities if they are to maintain optimal health and avoid a secondary disability. Online health promotion materials can be a valuable source of information for members of this population, particularly for those individuals who are unable or reluctant to leave their homes because of disability. Steps can be taken to make online information universally accessible. The format of the material can be developed and presented in such a way that it is inclusive and accessible to persons with a variety of disabilities. Awareness of these issues can assist nurses, health educators and others in the development of accessible web sites and in careful selection of existing web sites so that health promotion material is accessible to persons with disabilities.

Authors

Suzanne C. Smeltzer, EdD, RN, FAAN
e-mail: suzanne.smeltzer@villanova.edu

Suzanne C. Smeltzer, EdD, RN, FAAN is Professor and Director of Nursing Research at Villanova University College of Nursing. She also serves as Director of the Health Promotion for Women with Disabilities Project, a 4-year project funded by a grant from the Bristol-Myers Squibb Foundation. She completed a two-year postdoctoral research fellowship as a Robert Wood Johnson Clinical Nurse Scholar at the University of Rochester, where she began her research related to MS. Her research related to MS and disabilities has been published in nursing and interdisciplinary journals. Dr. Smeltzer is the recipient of the 2000 Hall of Fame Award from the Greater Delaware Valley Chapter of the National MS Society, Leadership Awards from two chapters of Sigma Theta Tau, the Labe C. Scheinberg Award for the Best Paper in Neurorehabilitation from the Consortium of MS Centers, and Excellence Writing Award from the American Association of Neuroscience Nursing. She is a Fellow of the American Academy of Nursing.

Vanessa Zimmerman, MSN, RN
e-mail: vanessa.zimmerman@villanova.edu

Vanessa Zimmerman, MSN, RN is the administrative research associate with the Health Promotion for Women with Disabilities Project. She has over 15 years of nursing experience in the acute and home care setting. Ms. Zimmerman received her master’s degree in nursing from Villanova University with a focus in clinical case management. Her research interest is in women's health. She is currently involved in several research studies concerning women with disabilities, including health promotion interests, bone density screening, and medication discrepancies in women with disabilities and a disability experience for undergraduate nursing students.

Marita Frain, EdM, RN
e-mail: marita.frain@villanova.edu

Marita Frain, EdM, RN is an Assistant Professor in the College of Nursing at Villanova University. She has been involved in undergraduate nursing education and has taught Computing in the Health Care Delivery Systems for more than 10 years. She has worked to develop web-based health promotion materials and used these strategies with both graduate and undergraduate nursing students. She is a member of university committees associated with information technologies at Villanova University. She is involved in teaching adult and community health content and has an interest in the integration of information and computing technologies in the delivery of nursing education.

Lynore DeSilets, EdD, RN,BC
e-mail: lyn.desilets@villanova.edu

Lynore DeSilets, EdD, RN,BC, is Assistant Dean for Continuing Education in Nursing and Health Care in the College of Nursing at Villanova University. She has taught nursing in diploma, associate degree and baccalaureate programs. She has been involved in professional development for almost 25 years. Dr. DeSilets has been recognized by the Pennsylvania Nurses Association with a Nursing Education Award, and by the Alpha Nu Chapter of Sigma Theta Tau International with a Nursing Leadership Award. She serves as an accreditation appraiser for the American Nurses Credentialing Centers (ANCC) Commission on Accreditation, as a Content Expert for the (ANCC) Nursing Professional Development certification exam, and on the National Board for Certification of Hospice and Palliative Care Nurses.

Janice Duffin, MSN, RN, CCM, CDMS
e-mail: janice.duffin@villanova.edu

Janice Duffin, MSN, RN, CCM, CDMS is a research assistant with the Health Promotion for Women with Disabilities Project. She has worked with people with disabilities for over 25 years. Ms. Duffin has practiced as a professional nurse for over 16 years, with a focus in the areas of rehabilitation and case management. She earned her master’s degree in nursing from Villanova University with a focus in clinical case management. Ms. Duffin is certified in case management, disability management, and legal nurse consulting. Her research interests are disability and aging. She is currently involved in research on medication use in older women with disabilities.

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© 2003 Online Journal of Issues in Nursing
Article published November 14, 2003


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