Patient, heal thyself! Advocating for accessible healthcare websites


  • John Brobst

    1. Florida State University, John Brobst, Information Institute, Florida State University, Room 010 Louis Shores Building 142 Collegiate Loop, PO Box 3062100, Tallahassee, FL 32306-2100
    Search for more papers by this author


The purpose of this research is to examine healthcare websites to determine their current level of accessibility based on the criteria established in Section 508 of the Rehabilitation Act of 1973. Web accessibility refers to providing equal access to the Internet and equal opportunity to use the Internet for people with disabilities. The unique value of this investigation lies in the attempt to identify what interventions could serve to improve the observed levels of website accessibility in healthcare websites.

Federal public laws demonstrate a concern for assuring equal rights and access for those with disabilities. However, the intent of the laws, being to achieve accessibility, has not been accomplished. Recent studies have shown that most categories of websites have low accessibility levels. If allowed to continue, the failure to make accessibility a reality could result in the disenfranchising of a major segment of society.

The goal of this study is to determine what can be done, realistically and pragmatically, to make healthcare websites within the United States more accessible. The approach will be a multi-method examination of accessibility involving: policy analysis, online survey, expert testing, automated testing, and accessibility testing. Each method will add a unique value to the study and in combination will provide a fuller and richer understanding of the current status of healthcare website accessibility. The multi-method approach supports the Action Stance taken in designing this study. This Action Stance approach focuses on designing research efforts that lead to effective and positive change.

For this study, the positive changes will include developing a set of best practices towards attaining web accessibility, identifying interventions that promote accessibility, and making recommendations for improving the federal information policies that address website accessibility.

Patient, Heal Thyself! Advocating for Accessible Healthcare Websites


This paper presents the initial efforts by the author to describe his dissertation research project. This paper presents the proposed methods and overall approach to get critical feedback. It extends preliminary work by the author relating to the accessibility of federal healthcare websites. Website accessibility means “making the web useable by everyone whatever their ability or disability” (World Wide Web Consortium, 2009). Previously, web accessibility meant the providing of equal access and equal opportunity to the Internet for people with disabilities. More specifically, Web accessibility means that people with disabilities can perceive, understand, navigate, and interact with the Web, and that they can contribute to the Web.

In prior research, the author examined the accessibility of websites identified within the federal government's web portal for healthcare services ( This examination provided an indication as to the degree of success attained by the legislative acts that intended to establish website accessibility. The case study examined the healthcare related websites provided by the federal government at the WWW.HEALTHCARE.GOV portal website. That government portal refers the public to 35 federal websites that provide healthcare related information and resources. Of the 35 websites examined, 8 had accessibility errors, as defined by federal law. All federal websites are required to be fully accessible. The finding is that 23% of these websites failed to be fully accessible as mandated by federal laws. This evaluation indicates that the intent of national web accessibility policy has not been fully achieved. The initial review of literature found that no prior research has examined this topic area, being the accessibility of federal healthcare websites.

The overarching research question becomes: What are the problems /issues that impede federal healthcare website managers from attaining accessible websites as required by current legislation. The author's preliminary research indicated the need for identifying the impediments that federal web managers face as they attempt to provide websites that are fully accessible. There is also the need to identify the types of errors and the relative frequency of those errors, so that recommendations can be made to improve accessibility for all individuals to these increasingly important information resources.


The Internet has evolved to have a huge impact on the way we conduct our lives, and has become a key source for many kinds of information. Web based information on matters of consumer health is becoming increasingly important (Disability Rights Commission, 2004). The Internet has been successfully used to make quality health information widely available, to the point where it is available anywhere and anytime – but not to everyone! Consumer healthcare websites have been found to have problems in making their content readily available to individuals with disabilities (McCord, Frederiksen, & Campbell, 2002).

Accessing information over the Internet has enormous potential for individuals with disabilities (Lilly, 2001). Internet access serves to make their lives easier and can effectively “eliminate many barriers by allowing them to do things that might have been impossible or very difficult in the past” (Mancini, Zedda, & Barbaro, 2005, p. 276).

Significance and Areas of Investigation

From the perspective of people with disabilities, the website is a source of information that provides a critically important access point (Kisielnicki, 2002). To be of value to this group, this access point must meet their needs for availability, content, and it must be accessible to meet their special needs. Accessibility problems in healthcare websites can prevent these individuals from using their assistive technologies (Garlock & Piontek, 1999), effectively denying them use of this important service.

Anyone using any kind of Web browsing technology must be able to visit any website and get a full and complete understanding of the information contained there, as well as having the full and complete ability to interact with the site (Letourneau 2003). The Americans with Disabilities Act (ADA) of 1990 is a civil rights law that prohibits discrimination against people with disabilities. In particular the ADA requires that places of public accommodation and the services they provide be accessible. Subsequent court rulings have provided the explicit interpretation that the ADA applies to the web as well as to bricks and mortar establishments (Thatcher, 2009).

While significant research has been accomplished towards a general examination of websites accessibility levels (Lilly & Van Fleet, 2000; Schmetzke, 2001), this author could not find a policy based research effort that identified the significant factors that impede the attaining of full accessibility. This research effort will attempt to:

  • discern the impediments to accessibility that face webmasters,

  • assess the appropriateness of existing federal accessibility policies, and

  • determine the actual accessibility of federal consumer healthcare websites.

The proliferation and use of consumer healthcare websites has been significant, with nearly 10 percent of all web searches related to health or scientific information (Spink, Wolfram, Jansen, & Saracevic, 2001). Another study found that more than 97 million US residents went online to search for healthcare information in 2001, with over 70% reporting that online health information had influenced a treatment decision (Thobaben, 2002; Fox, & Rainie, 2000). Such a demand for quality healthcare information suggests the importance of assuring that this content is fully accessible to all.


This research effort will examine federal websites that provide healthcare information, as federal websites are mandated to provide fully accessible websites by the Rehabilitation Act of 1973. Section 508 of that act identifies specific and testable criteria that will provide an evaluative criteria for determining levels of compliance with current policy. This research effort will employ multiple methods in order to capture a richer and fuller understanding of the state of accessibility within the leading consumer healthcare websites. Each method will be briefly identified and include a description of the unique value or benefits that it contributes to the overall study effort. At this time, the details of the methods have not been finalized.

Survey: The format for the survey effort will be an online questionnaire for IT managers and webmasters. The survey will attempt to identify the perceived problems that web managers face that impede their achieving full website accessibility. The survey will also gather information about the perceived importance of accessibility; their efforts used to build accessibility features into the websites; and will identify their impressions as to the accessibility of their websites. The most important contribution of this research will be to reveal the actual barriers that confront web managers in assuring accessible websites.

Automated Testing: Automated testing for accessibility refers to the use of commercially available software products to examine each healthcare website. These software systems can quickly and thoroughly examine one web page or an entire website to test for accessibility errors. In this situation, accessibility errors will be defined as instances where the website fails to comply with the standards and criteria that is specifically defined by Section 508 of the Rehabilitation Act of 1973. This method supports the case for generalizability of findings by providing a means to quickly and easily test a large number of websites, and thereby providing a revealing depiction of the broad based compliance with current accessibility laws.

Expert Testing: In applying expert testing, an experienced professional executes a defined protocol that examines each website for Section 508 violations (errors). The expert testing approach adds value in that this method provides a means of finding actual errors that may be missed by the software based testing method. This method is more skilled and requires additional time to complete, but it is much more thorough and accurate than the automated testing approach. As such, this method provides a more accurate and definitive assessment of the level of website accessibility, and as to compliance with the legal mandate (Section 508).

Accessibility Testing: This approach employs individuals with disabilities to conduct open ended testing of the website. By using people with actual disabilities, the range of problems that may be discovered is extended beyond the Section 508 criteria. The benefit of this approach lies in its ability to yield the most accurate depiction of the true state of accessibility of the website (Jaeger, 2006). Section 508 standards (developed in 1998) attempted to provide guidelines and criteria that intended to promote accessibility. As these criteria are now over 10 years old, it is important to assure that those criteria still serve to provide accessibility in the current web environment. This method adds significant value by identifying the actual state of accessibility beyond the Section 508 legal requirement.

original image

poster image

Importance of this Research

The approach of using mixed methodologies allows for some interesting and potentially revealing comparisons. Just two of the possible contributions are:

  • The survey will gather web mangers impressions of how accessible their websites are, and the importance of attaining accessibility. These opinions can then be compared to the real levels of accessibility as discovered by the use of expert and accessibility testing methods. The comparison could reveal significant gaps between the stated (opinions) and observed (quantified measures) levels of accessibility.

  • The use of accessibility testing will provide the best means of identifying accessibility problems (Jaeger, 2006). By comparing the real world problems which are encountered to the criteria for accessibility as defined by Section 508, the result will be an indication as to whether the Section 508 criteria remains valid as a set of standards that promotes the legislative intent of attaining full accessibility.

The Internet has become an increasingly essential resource for consumer health information (Thobaben, 2002; Fox, & Rainie, 2000). The intrinsic nature of the Internet provides the ability to obtain accurate medical and health related information quickly and conveniently, and in a setting that provides the individual with privacy. For individuals with disabilities, this way of accessing information may be the preferred method for obtaining supplemental healthcare information. Little is known, however, about the accessibility of the content of these online health information websites (Mancini, Zedda, & Barbaro, 2005; McCord, Frederiksen, & Campbell, 2002). This proposed study will make a significant contribution to the existing body of knowledge by providing an accurate depiction of the accessibility of these websites, and will also identify the barriers that impede attaining full accessibility. Additional value stems from the development of a set of best practices and recommendations that will result in more effective steps towards attaining web accessibility.