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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: 7 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. All speakers are with the Digital Service at CMS. 

What is a little nudge? 

Mathias started 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 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. This is practice that needs 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. You can have all the accessible parts but if there's something, in the cohesive part keeping it all together, isn't working or the front door is not working it's not gonna be useful to people. So now, partners recognizing how important it is that we run this with a real person, not just through accessibility checkers which absolutely have value but don't necessarily tell us it's gonna perform in the wild. 

It just takes enlisting a few extra people to really make a difference to understand how something's used. We're not separating out people who have special needs and doing separate studies. In 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. The more we do it, the better we're going to get something that works for everybody. 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. We need to be sure we're serving everybody and that's very different than a private organization.

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: 

I think it's it's extremely hard if you're stressed out to treat other people with good care. It's just really hard. It does come back to self care. If I'm demonstrating care back and forth with some of my colleagues, I do feel like I'm more likely to be able to demonstrate that type of care with people, and I'd be doing research with government partners or other people who can outside my team. When we get stressed, all kinds of things come out sideways. Giving people the time, care and showing that I care about you as a whole person. That's what we hope to do with our when we're researching with people. We want you to share about yourself and hear what you think of this product. It's more about intention behind whether it's an interaction with a work or colleague. Questions, am I intending to be fully human or show up fully human as myself. All of it is the messiness and beauty. 

Aayat: 

I think I think whether we're talking about civic tech or any anything else, it's just the relationships that really matter. It's having really deep trusting relationships. When people see you coming up and showing up day in and day out, whether it's whether it's a good day or a bad day. That is what really really matters. I think the way that we can further advocate for a little nudges is understanding that no matter where people are at in this process, they do have a big role, to play in the end product and what a good outcome could look like. Whether they are in the contracts and grants, division procurement, working on like the the program staff side or the direct service delivery, all of those people have a big role to play. So, I do think at the start and end of every single day, it really is the relationship building that that matters the most. Based on just historically, people don't have trust in healthcare systems either. It's racial, sometimes ethnic, and it's, rightfully so, too. There have been horrible things that have been done to to groups of people, and handling those with care, and trying to understand where people are coming from is the most important thing

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.