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Digital Public Health at the Scale of Government: Little Nudges Result in Big Usability Ripples for the Public

Meaghan Hudak | Reading time: 4 minutes 

This panel included three designers from Digital Service at CMS, an organization that supports over 181 million people living in America in getting the health care (and insurance) they need. Ensuring that the design of our social safety nets include Human-Centered Design (HCD) at their core, this often means doing small but meaningful things that set up later work to be more equitable and sustainable. 

We discussed approaching government public health projects as a Digital Service team, working on cross-agency initiatives that increase access to mental health and/or substance use disorder treatment, advocating for HCD and trauma-informed user research with our partners, and creating the capacity within the government to include those with disabilities in our research.   

Attendees learned: 

• About the team's usability work within the behavioral health space, and 
• The panelists' experiences working within the government and supporting cross-agency and countrywide initiatives.

Mathias Rechtzigel,Design Technologist and Educator, facilitated the discussion with panelists, Aayat Ali, User Experience Designer, and, Melissa Eggleston, User Experience Researcher and Educator. 

What is a little nudge? 

Mathias starts us off with explaining to the audience what a little nudge is. It could be ensuring the usability of minor things on the interface, like buttons versus text links. Taking into consideration accessibility, and what type of accessibility are we considering. For example, people  who rely on screen readers or those who might have various cognitive abilities. Nudges are the things that are part of a process or ensuring the usability of interface or accessibility are we considering. Ensuring we not only talk about it but we act on it.  These little nudges should be considered on a day to day basis and If we are mindful, could make a really big difference in peoples lives. The panel discussion will be focusing on healthcare. 

“Much like if a room, each individual room, in a house is accessible, if the doorways aren't accessible that connect all those components, it really breaks down for people who really need it.”

Mathias Rechtzigel

What nudge did you make to make things more usable? 

Melissa:

My goal is always to be putting whatever we're making in front of people to get their reaction and trust that if we put put items in front of people who are in our desired audiences, they're gonna lead us the right direction. When we get information we're actually testing things and making sure we're meeting the needs for those people who are serving. One of the nudges we made recently, working for people seeking substance use treatment, is running usability testing, and we decided let's just include a few people who do use screen readers. It made a huge difference because when we were running this website through accessibility checkers, it was coming in the nineties. It was coming up as very high because there were many, many things that were done correctly about this website that was making it accessible in terms of its colors. But unfortunately, the main purpose for the website is for those seeking help with substance use, was breaking down for people.

Once we started putting real people through the process who were using screen readers not just testing ourselves, test ourselves, we discovered a real problem and barrier. It was not operable and doesn't work for them. We immediately went back to the owners website to let them know it needed to be fixed. The website owners were able to view the recordings and get a firsthand view of the struggles people were going through. Making that extra effort to include somebody with a disability related to their eyes in our process, made a real difference. 

Now that website will be coded correctly, so the people who come to it who are  already in in tough times seeking help for substance use, who have low vision, can actually get to a provider before they would have run into a big barrier. Making sure to think a lot about who we're including in our research. We do that at DSAC in various ways: trying to have diversity in terms of geographic location, gender, race, and cognitive disabilities. Trying to get the widest variety of people as possible, since we're creating things for the general public.

Aayat: 

I will call on two experiences. One, is a campaign titled, 'Los Angeles Free the Vote.' This was a legislation pass that allowed folks who are on probation and parole to actually be eligible to vote in the State, of California. So, what we did is working with the county registrar's office, we put up a website that folks could navigate to and actually understand their voting rights. Oftentimes, especially in in sort of like urban planning and social workspaces, sometimes there's a lag between policy being implemented and what the people know. So, that was a nudge.  There were limitations in that this was before the pandemic, and we were considering how many people had internet access could navigate to the site. We ended up creating lots of print material to supplement and spread it across the city and share it with our community based organizations.

Another example of nudge, to make things more usable, in a lot of homeless services or social services, databases, there can be lots of jargon. It can be hard to understand. What we did with the intensive case management database that we implemented back in 2017, it's called CHAMP. It essentially took into consideration literacy rates and cognitive abilities. We did a lot of the user testing to understand where people were having pain points and we demystified a lot of what the medical profession kind of has sometimes in these databases. In California there's a new policy called Cal AIM, and it's the use of Medicaid funds into homeless services. And so understanding, that legislation, what you can build to and what you can't build to as a community health worker was super important. We decoded a lot of those referral codes and shared it with folks so that way they're able to get into the services and the places they need to be. 

What outcomes did you see with that nudge? 

Melissa: 

Touching base on the outcomes that came out of making sure that we have somebody with vision challenges in our usability testing. For three years, nobody ran an individual through it who is using a screen reader. That's just something we need to change and is unacceptable for our website. To be out to the public for three years, and and not have this very basic flow address that was a barrier to the front door. I thought Mathias' analogy was really good enough bias of of you know you can have all the accessible parts, but if like, there's something in the cohesive part that's like bring keeping it all together, isn't working or the front door is not working it's not gonna be useful to

People and it really is useful. And it's just really, you know.

So now we have this outcome of you know colleagues, partners recognizing.

Oh, it actually is important that we we actually run the this with a real person, not just like through accessibility checkers which absolutely have value.

But don't go they don't necessarily tell us it's gonna perform in the wild right?

So it showed our colleagues that it's you know the website's being transformed now, and changes are being made so that it will be accessible to folks using screen readers or screen magnifiers and that sort of thing so that's like big improvements for the public and just

awareness that wow! It just takes, you know, grabbing a few extra people to really make a difference to understand how something's used and my vision in our research desk is that we're not you know separating out people who have special needs and doing separate studies like let's do study just with people

With screen readers, let's just say we just want in any study we run, and any kind of research we're doing.

Let's make sure that we've got some different folks with different types of abilities in there each time.

And so the more we can do that. I feel like the better we're gonna get something that works for everybody, and that's included, and that takes extra effort with recruiting.

You know Matthias referred to us. Being in Fargo.

We were there a few weeks ago, and we went to a mental health fair, and that was a really great way for us to do research with people with Syria.

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Mental illness, and also who a couple of them expressed.

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You know they haven't had challenges with reading as well.

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And so it was just a wonderful way to kind of get get a different group of folks together that we can't get, and that likely would not have participated had we just been doing remote research right?

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So it's actually like going to where people are, and that makes it a big difference, and we'll be going to La next week a yacht and I will be there next week, in la!

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In a much more urban environment doing some research with folks there.

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So I think. I don't know. I think it's all about building trust with the public, and we build trust with the public by giving them great experiences and positive experiences with our institutions, and that starts.

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With the website. You know I was trained. I I remember reading Jenny Reddish, who who's been around a long time like 40 years in our field, and throughout the scrapebook letting go of the words and really talked about how a great website is a great conversation and so when somebody is coming to a website

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They're starting to initiate a conversation with you, you know, in the case of a substance, abuse treatment website you know they're coming to get help.

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And so we certainly want that to be a positive experience, and not have a door slammed in their face from the can't go, and it's really about.

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What are those people experiencing when they first come? Are they overwhelmed because the language is full of jargon, and it's written at like a postgraduate level or is it accessible and friendly you know does it seem like it's for them and like they are included when

The services are, described for example, so I think there's just a lot of lot of thought that needs to go into how do we make things inclusive for everybody, and we can only figure that out by testing with lots of different types of people it's it's it's the hard part about the government

Yeah.

It it's we need to be sure. We're serving everybody, and that's very different than a private organization.

That's got a really clear audience

Aayat: 

The people who are closest to the problem are our closest to the solution. For example, thinking about really complex issues like homelessness, which is a symptom of lots of other systems, we see when we're talking to people about what they actually need. Understanding the deep distrust that people might have with institutions and helping them understand what the system is and how it could help them is, is really incredible. You see people's lives change through it. People getting into housing and just by making it simple and taking away all of the conditions. Program staff are dealing with the intricacies and the ins and outs, and not putting it on folks who are in need of services. So, the outcomes that we've seen in in these small nudges, whether they be tack or or even in print, design, or public health information out to the people is better health outcomes. We see more PCP visits, folks getting into housing and staying in housing, or hoarding problems. Whatever the case may be. that is what human-centered design truly is.

How can we further advocate for little nudges to be a more common part of the process? 

Melissa: 

Aayat: 

If you missed the panel discussion, check out the transcript and recording on the CCSQ World Usability Daypage. This page also includes an archive of transcripts and recordings of speaker presentations, session materials, and event photos. For more information about the Human-Centered Design Center of Excellence, refer to the HCD CoE Confluence page.