Cure4Kids: Research challenges in the design of a website for global education and collaboration

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1 Information Design Journal 16(3), John Benjamins Publishing Company DOI: /idj qui Yuri Quintana, PhD, Richard O Brien, Aman Patel, Jared Becksfort, Ana Shuler, Ayda Nambayan, RN, DSN, Dorothy Ogdon, Guillermo Chantada, MD, Scott Howard, MD, and Raul C. Ribeiro, MD Cure4Kids: Research challenges in the design of a website for global education and collaboration Keywords: web site design, usability, internationalization, localization, information architecture, web site navigation, iterative design The Cure4Kids Web Site ( brings the latest medical knowledge and continuing education on the treatment of pediatric catastrophic diseases to thousands of health care providers worldwide. The website offers a digital library, on-demand seminars with slides and audio in several languages, and online meeting rooms for international collaborations. In this paper, we describe the design challenges of the Cure4Kids Web site as an online learning and collaboration center, including the web interface design, content organization, and usability. The solutions to these design challenges may help other web designers facing similar issues in the design of international web-based projects. St. Jude Children s Research Hospital (SJCRH) is internationally recognized for its pioneering work in finding cures and saving children with cancer and other catastrophic diseases. In order to bring the latest medical knowledge on the treatment of pediatric catastrophic diseases to health care providers worldwide, the SJCRH International Outreach Program developed the website Cure4Kids ( The site offers a digital library; on-demand seminars with slides and audio in several languages; and online meeting rooms and working groups for international collaboration. The site is provided at no cost to registered users. As of May 12, 2008, Cure4Kids content had been accessed more than a million times by 14,033 users in 161 countries. About 60,000 items on the site are accessed each month. Among these users, 35% identify themselves as pediatric oncologists, 17% as nurses, and 48% as health professionals in related fields. A total of 1,064 on-demand seminars with slides and audio are available for online viewing or download in several languages including English, Spanish, Portuguese, Chinese, Arabic, French, and Russian. In this paper, we describe the design challenges of the Cure4Kids Web site and the solutions used, which may be useful for other web designers working on international projects. Cure4Kids website The main components of Cure4Kids are: (1) online seminars, (2) a digital library of journals and textbooks, and (3) collaboration tools. 243

2 1. Online seminars The majority of the seminars (Figure 1) on the Cure4Kids website were presented at St. Jude Children s Research Hospital; these comprise a variety of topics on pediatric hematology, oncology, infectious diseases, other catastrophic illnesses, and general pediatrics. The site also offers seminars from international conferences and workshops. Annotations, references, and abstracts created by medical writers are added to the seminars. Selected seminars are translated into Spanish, Portuguese, Arabic, Russian, and Chinese. Some seminars include online quizzes. Written permission is obtained from all presenters, and slides are modified to meet patient confidentiality requirements. 2. Digital library The Cure4Kids Digital Library offers users full-text access to medical journals and textbooks, including Principles and Practice of Pediatric Oncology (Pizzo & Polack, 2006), a leading reference textbook. The digital library contains downloadable patient education material (Caniza et al., 2007) and relevant links to additional patient education materials in several languages. Figure 1. Screen shot of the Cure4Kids.org Web site 244

3 3. Collaboration tools Cure4Kids provides online meeting rooms to groups working to improve pediatric care in low-income countries. Meetings are used for teaching as well as for discussing clinical cases (Chantada, et al., 2008) and issues of program development (Howard, et al., 2008). These discussions not only help improve the care of individual patients but also promote the development of treatment guidelines and protocols. International physicians often share a single computer and Internet connection in order to participate in online meetings. Designing a website for a global audience is a challenge due to the large variation in user skills, experience and expectations. Below are some of the ways these variations pose a challenge to the design and implementation of the Cure4Kids Web site. Navigation While there have been many studies on web-based browsing and searching (Chung, et al., 2004; Bhavnani, 2005), few formal studies have been conducted on an international scale with diverse healthcare professionals (Williams, et al., 2002; Wutoh, et al., 2004). The Cure4Kids web design team has developed the Cure4Kids web interface over a six year period using an iterative design process (Nielsen, 1993), guided by existing web standards (W3C, 2008; WSP, 2008), web design guidelines (Follet, 2007), annual user surveys, and individual user feedback. Navigation is one of the greatest challenges due to the large variation of user skills, as well as the growing number of web-based interface standards and interactive elements. Some users are not familiar with basic navigation analogies (links, buttons, pop-ups, windows, tabs, pull-downs, etc). Fear of doing something wrong may inhibit users from exploring options that are not patently obvious. In fact, most novice users have indicated a preference to have fewer, but more succinct choices, often opting for hierarchical and categorical browsing options. On the other hand, advanced users have requested more shortcuts as well as more powerful searching and filtering tools. This is often called the simplicity versus power tradeoff (Hoekman, 2006; Krug, 2005). Designing interfaces that are both simple and powerful is an ongoing challenge (Norman, 2007). Our current approach is to redesign the website to have a simple initial interface, but allow the user to customize the interface to include more powerful search features. As part of this approach, we will also include the ability for users to customize the preferred content that is displayed or filter personalized content (Quintana, 1998). The Cure4Kids website has grown to include a variety of sub-sites, some of which have a distinct navigation philosophy, structure and appearance. Current efforts are underway to provide a consistent and seamless navigation experience throughout all of the sub-sites. Layout and media formats The selection of media formats and layout of content is also challenge given the wide range of monitor resolutions, CPU power, RAM and storage. This greatly influences the methods in which content needs to be provided (on-screen vs. download, file types and sizes). The skill level of Cure4Kids users may range from the very technically sophisticated users who wish to have content offered in a sparse and efficient format, to those users with limited computer experience who may prefer a more graphical and friendly environment. For example, the layout and presentation of educational content for physicians could conceivably be very different than the presentation formats designed for nurses or allied health technicians. Currently, only a small portion of the existing seminar content has been formatted to suit 245

4 specific audience types. The ultimate goal is to display content in a customized manner, providing considerations to the profession, subject matter, culture, language and, of course, individual profile settings. Internationalization versus localization Internationalization refers to having a single design that can be used worldwide, and localization refers to having a site that has been adapted to a specific local group (Kurniawan & Zaphiris, 2006). Efforts have been made to both internationalize and localize Cure4Kids to the best effect. Among these efforts are the implementation of a calendar and meeting planner that provides users with both the local time of the meeting requester and the local time of the participant. The choice of icon and menu labels has been consistently reviewed to ensure that the site can be used effectively by all users. For example, in the main menu, the label Meetings is used for online Web conferences instead of Webinar (US specific) or Conference which might imply online recorded conferences available on-demand. Several professional resources on international icon design were researched during the design process (Dreyfus, 1984; Brigham, 2001; Horton, 2004). More efforts are planned in this area based on usability testing to determine the interpretation of icons by international users. Menus on the Cure4Kids website have also been translated into Spanish, Portuguese, Russian, Chinese and Arabic. More effort could be made to highlight content that is contributed by local or regional authors or content that is of specific interest to a particular region of the world. Language and translations Most of the content on Cure4Kids is likely to continue to be offered in English; however, efforts are underway with international collaborators to contribute content in their native languages. There are regional variances in language (for example Spanish from Spain versus Spanish from Central or South America) that require a selection of words that are understood by most of our users. Supporting regional language variations is a major challenge due to limited staff and volunteers available for translation projects. Administration of the translation process, including reviews by subject matter experts and quality control procedures has proven to be very labor intensive and expensive. The choice of menu labels on the main navigation bar remains a constant challenge. As we acquire more material, the menu bar becomes crowded and difficult to translate. Word choice and semantics becomes a critical issue given the vast range of technical skills and navigational paradigms inherent in our international user community. Efforts are underway to create an expandable and graphical site menu that allows both novice and advanced users to find information quickly and easily. Content organization Organizing content is a particular challenge, given the large cross-section of disciplines that use Cure4Kids. Half of our users (50%) are either pediatric oncology physicians or nurses. A limited controlled vocabulary (200 terms) has been developed to classify the content for this user group to allow for easier browsing and searching. These terms have been linked to relevant terms in the US National Library of Medicine s (NLM) Medical Subject Headings (MeSH) terms so that users can find related materials on PubMed.org (NLM database of medical literature). Maintaining this controlled vocabulary and finding qualified staff to classify pediatric oncology content remains an ongoing challenge. Efforts to create a cross-referencing system to link related content across Cure4Kids sub-sites are underway. The organizational design of a site-wide content classification 246

5 system should reflect how the users are most likely to want to access the content (Djonov, 2007 Hackos & Redish, 1998). Online accessibility The benefits of online education include flexibility, convenience, and the ability to deliver cost-effective educational opportunities almost anywhere and anytime (Carnevale, 2000; Dutton, et al., 2002) to anyone with access to a computer, modem, and telephone lines. However, many challenges persist. Although technology is improving in most countries, computer maintenance and the inconsistent quality of Internet connections continue to be a problem for some users despite efforts to simplify technical requirements for accessing online content. Technical support Providing technical support to the large Cure4Kids global user base is a challenge given the great variation of user skills, languages, and computer hardware and software used. Some novice users may have difficulty with basic concepts such as mouse manipulation, setting up microphones and speakers, adjusting system settings, file management, and the installation and use of basic, required applications such as web browsers and plug-ins (eg. Adobe Acrobat Reader ). Local technical support is often not available. Assisting a remote user in the diagnosis of a problem poses a particular challenge, since it is often not clear what is on that user s screen (software error messages). Remote web-based training also poses some challenges in terms of language and the computer skill level of the user. Cure4Kids offers online help in English and Spanish, and soon other languages will be added. Until access patterns and feedback to online help information is collected and analyzed, it will not be clear how useful online help content is to the users who manage to find it. It is possible that some users may hesitate to seek live online help because of difficulties in explaining their problem, language issues, or not feeling comfortable asking for help online. Usability evaluation Like most rapidly growing programs, Cure4Kids requires additional evaluation in order to address the quality of the service and to evaluate the usability of the website (Nielsen, 1993). Remote usability studies are possible with web-based technology (Kushniruk & Borycki, 2006) but these studies may not provide complete or accurate information since some users may not feel comfortable with remote monitoring. Usability observation studies (Lindgaard & Chattratichart, 2007) are planned with on-site visiting international health professionals to analyze the current site and test the improvements after each major interface redesign. Summary of design challenges The design challenges we have faced in the development of Cure4Kids have made the final website better, more robust, and flexible. It seems likely that other web designers face similar challenges. We therefore summarize these challenges in the form of design recommendations: Provide a simple initial interface, but allow the user to customize the interface to include more powerful search features. Provide a consistent and seamless navigation experience throughout all of the sub-sites. Display content in a customized manner, providing consideration to profession, subject matter, culture, language and, of course, individual profile settings. Create an initial site that can be used worldwide (Internationalization) 247

6 Develop sub-sites and customization features that are adapted to a specific local groups or regions (Localization) Translate using the most common and universal terms, providing regional language choices for localized sub-sites. The organizational design should reflect how the users are most likely to want to access the content. Provide content in media formats that are widely used internationally and compatible with most browsers. Provide help and support in various languages and delivery formats. Conduct usability studies with real users in both local and remote settings. Conclusions Despite these challenges, Cure4Kids is a unique international resource for pediatric healthcare providers and can serve as a model for the development of timely and cost-effective continuing medical education. The Cure4Kids program has developed a website that provides free digital library access, educational opportunities, and a communication forum for pediatric professionals worldwide. The growing number of Cure4Kids users worldwide suggests that the site is successfully serving the educational and collaboration needs of pediatric healthcare professionals throughout the world. The success of the technical delivery platform, which takes the advantage of the Internet, continues to attract high-quality content from collaborating organizations including renowned international pediatric societies and hospitals. Through a careful selection of technology that minimizes the hardware and software requirements for downloading and viewing content, and careful consideration of online interface design, the Cure4Kids Web site provides a reliable, economical global education and collaboration tool for healthcare professionals in both high- and low-income countries. References Bhavnani, S.K. (2005). Why is it difficult to find comprehensive information? Implications of information scatter for search and design. Journal of the American Society of Science and Technology, 56, Brigham F. (2001). Graphical symbols for consumer products in an international context. Information Design Journal, 10, Chung, W., Zhang, Y., Huang, Z., Wan, G., Ong, T.H, & Chen, H. (2004). Internet searching in a multilingual world: An experiment on the Chinese Business Intelligence Portal (CBizPort). Journal of the American Society of Science and Technology, 55, Caniza MA, Maron G, Moore E.J, Quintana Y, Liu T. (2007) Effective hand hygiene education with the use of flipcharts in a hospital in El Salvador. Journal of Hospital Infection. 65, Carnevale, D. (2000). Study assesses what participants look for in high-quality online courses. Chronicle of Higher Education, 47(9): A46. Chantada G.L, Doz F, Orjuela M, Qaddoumi I, Sitorus R.S, Kepak T, Furmanchuk A, Castellanos M, Sharma T, Chevez-Barrios P, Rodriguez-Galindo C (2008). World disparities in risk definition and management of retinoblastoma: a report from the International Retinoblastoma Staging Working Group. Pediatric Blood and Cancer, 50, Djonov, E (2007). Website hierarchy and the interaction between content organization, webpage and navigation design: A systemic functional hypermedia discourse analysis perspective, Information Design Journal, 15, Dreyfuss, H. (1984). Symbol sourcebook: An authoritative guide to international graphic symbols. New York, NY: John Wiley & Sons. Dutton, J., Dutton, M., & Perry, J. (2002). How do online students differ from lecture students? Journal of Asynchronous Learning Networks, 6, Follett, J. (2007). Interfaces that flow: Transitions as design elements. Published Online on April 26, Accessed at 248

7 Hackos, JoAnn T. and Janice C. (Ginny) Redish. (1998). User and Task Analysis for Interface Design. New York: John Wiley & Sons. Horton, W. (1994). The icon book: Visual symbols for computer systems and documentation New York: John Wiley & Sons. Hoekman, R. (2006). Designing the obvious: A common sense approach to web application design. Berkeley, CA: New Riders Press. Howard S.C, Metzger M.L, Wilimas J.A, Quintana Y, Pui C.H, Robison L.L, Ribeiro R.C. (2008). Childhood cancer epidemiology in low-income countries. Cancer. 112, Krug, Steve (2005). Don t make me think: A common sense approach to web usability. Berkeley, CA: New Riders Press. Kurniawan, S. & Zaphiris, P. (eds) (2006). Advances in universal web design and evaluation: Research, trends and opportunities. London, England: Idea Group Kushniruk, A, & Borycki, E. (2006). Low-cost rapid usability engineering: Designing and customizing usable healthcare information systems. Electronic Healthcare, 5, Lindgaard, G. & Chattratichart, J. (2007). Usability testing: what have we overlooked? Proceedings of the ACM SIGCHI conference on human factors in computing systems. New York, NY: ACM Press, pp Pizzo, P. A. & Poplack, D.G. (2006). Principles and practice of pediatric oncology. Philadelphia, PA: Lippincott Williams & Wilkins. Quintana Y (1998). Intelligent medical information filtering. International Journal of Medical Informatics, 51, Nielsen, J. (1993) Usability engineering. San Francisco, CA: Morgan Kaufmann. Norman, D.A. (2007). The design of future things. New York: NY: Basic Books. Williams, P., Nicholas, D., Huntington, P. & McLean, F. (2002). Surfing for health: user evaluation of a health information website. Part two: fieldwork. Health Information and Libraries Journal, 19, Wutoh, R., Boren, S.A., & Balas, E.A. (2004) elearning: A review of Internet-based continuing medical education. Journal of Continuing Education Health Professionals, 24, W3C (2008). The World Wide Web Consortium (W3C) interoperable specifications and guidelines. Retrieved from on May 1, WSP (2008). The Web Standards Project Guidelines. Retrieved from on May 1, Contact Yuri Quintana PhD Director of Education and Informatics International Outreach Program St. Jude Children s Research Hospital, 332 N Lauderdale St, Mail Stop 721 Memphis, TN Phone Fax

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