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CSC8499 Individual Project:

Developing a web-based dementia

communications toolkit

Sujith Kumar Anand

MSc in Advanced Computer Science,

School of Computing Science,

Newcastle University, s.k.anand@ncl.ac.uk.

Abstract. The number of people diagnosed with dementia are increasing con-

stantly so the demand for their carers. However, hardly any information can be

found that helps people living with dementia and their carers for providing bet-

ter care through websites. The burden on care providers increases as the de-

pendency of the people with dementia increases and that dependency tends the

communication between the people with dementia and their formal and infor-

mal carers’ decreases. The aim of the project is developing a dynamic website

exploring how the tools and the information that supports communication be-

tween the people with dementia and their care givers can be provided to im-

prove the overall quality of support. Two background research studies were per-

formed, i) To identify the problem why the target users were not using the web-

sites to access health related information, and to identify what the problems that

are stopping these groups accessing such information. ii) To collect different

guidelines to build the website as user centered as possible. The stakeholders

are involved using participatory design process to provide feedback on the de-

sign of the web-based DEMTEC (Dementia Toolkit for Effective Communica-

tion). The dynamic website developed during the project is made available for

general use.

Declaration: I declare that this dissertation represents my own work except

where otherwise explicitly stated.

1 Introduction

The term dementia denotes a syndrome (collection of interconnected symptoms)

which includes predominantly loss of short term memory, i.e., not remembering what

happened earlier in the day, mood changes where people living with dementia feel

worried or to get angry about what is happening to them, and problems with commu-

nication and reasoning that includes inability to find the correct words [1]. The above

mentioned symptoms occur when the brain is damaged by certain diseases such as

Alzheimer’s disease or can be the result of damages caused by a series of small

strokes [1, 2]. Dementia mainly affects people aged over 65 [1] and likelihood for it

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increases with age. In most people who are diagnosed with Alzheimer’s disease, the

above mentioned symptoms often appear after the age of 60 years [3]. Figure 1 shows

the trend of world population for people aged above 60 years. It is predicted that near-

ly 2 billion people will be aged over the 60 years by the year 2050.

Figure 1. World Population of people over the age 60 years from 1950-2050 [4, 5]

By 2050, people aged 60 and above will account for 22% of the entire global popula-

tion. Furthermore, the occurrence of dementia is predicted to double every five years.

In 2011 the number of people living with dementia was estimated to be 35.6 million

and this number is expected to double every 20 years, to 65.7 million in 2030 and

115.4 million in 2050.

Dementia is progressive, which means the symptoms, i.e., loss of memory, mood

changes, communication problems and reasoning will get gradually worse. Progres-

sion of dementia depends totally on the individual and the type of dementia they ex-

perience. Dementia will be experienced by the individual in their own way, since

every individual is unique [1]. Generally people living with dementia require help

making decisions in their daily life from carers, be their family members, friends or

relatives [2]. Carers play an important role in the life of an individual with dementia.

Specially during the later stages of dementia, an diagnosed individual will face prob-

lems carrying out routine tasks or develop behavioural disturbances and may become

totally dependent on their care givers [1, 6]. As the dependency of the person diag-

nosed from dementia on support rises, the level of pressure on the care giver increas-

es. Increasing dependency often results in developing feelings of anger, grief, loneli-

ness and hatred [7]. This may negatively affect the care providers health and well-

being. Services of social and health care professionals, i.e., general practitioners, psy-

chiatrists, psychologists, speech and language therapists and educational researchers

are needed for both people with dementia and their carers. The effects of dementia in

people’s life can change the interaction of communication on both the sides of con-

versation, i.e., sending a message that can be understood and understanding any mes-

sage that can be sent back. Poor or damaged skills can lead to people getting the

wrong idea about each other and may cause bad feelings between them.

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There is a real need for advice and guidance on communication skills to help every-

one affected by dementia, i.e., people living with the condition, their carers and health

& social professionals. The above issue related to communication for people with

dementia and their carers has led Young et al. [8] to develop the Dementia Toolkit for

Effective Communication (DEMTEC). DEMTEC is a book that is shaped over an

eighteen-month consultation process, which took place in the UK and elsewhere in

the world. During the consultation process the authors have asked for views, ideas and

experiences of people living with dementia and their care providers, including care-

home managers, speech and language therapists, nurses, psychiatrists and psycholo-

gists. Along with the best practice as documented in past and present research, this

book pulls together all the elements gathered during the consultation process and aims

towards helping everyone touched by dementia to use simple, accessible strategies to

improve commutation skills (i.e., sending a message that can be understood and un-

derstanding the message sent back) whether involved through work or in contact

through friends or family. There are different versions of DEMTEC toolkit tailored to

different people, i.e., the people with dementia, family carers, social carers and health

and social care professionals. It was also facilitated by Alzheimer’s Society and in the

future web-based DEMTEC will act as a base for attaining Engineering and Physical

Sciences Research Council (EPSRC) funding.

This Human Computer Interaction (HCI) project investigates the feasibility of devel-

oping a web-based version of DEMTEC. This project focuses on scoping the design

and developing a dynamic website which provides an interactive version of the

DEMTEC toolkits given by Young et al. for three different user groups, i.e., people

with dementia, their carers and social and health care professionals (see Figure 2).

Figure 2. The web-version of DEMTEC aimed for three different user groups.

1.1 Aims and Objectives

The aim of this project is to create a web-based version of DEMTEC and make it

available as an information source with some evaluative and basic interactive ele-

ments (i.e., commenting facility and feedback form) for people who are directly or

indirectly related to dementia.

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The objectives of this project are. i) The website should be suitable for different

users and so should support different ‘pathways’ for advice given to family carers,

social carers and health or social professionals. ii) The website should be editable by

the DEMTEC authors. iii) Along with the strong feedback and evaluative element

built-in, in order to put into the development of further tailored versions of DEMTEC

suitable for different users. iv) The website to be live and usable by the public in au-

tumn 2012.

1.2 Stakeholders

There are different stakeholders present in this project, i.e., the people with dementia,

carers and social and health care professionals. Throughout the course of this project

four health care professionals who develop the original DEMTEC tool were consulted

using participatory design process [9], providing feedback on the design and devel-

opment. Their team consists of different specialists like education and communication

researcher, social care specialist and an old-age psychiatric specialist.

The initial architecture of the web-based DEMTEC is proposed by observing websites

like Alzheimer’s society UK [10], US [11], Canada [12], Australia [13], Dementia

UK [14], Young Dementia UK [15] and Care Well UK [16]. These websites provide

health related information for people with dementia, their carers and health and social

care professionals. Later, the design of web-based DEMTEC was presented before the

stakeholders who appreciated it. Designing the website is a challenging task, since the

website targets three user groups who are most likely to be aged above 65 years apart

from the health and social care professionals. Also, the website has to predict what

kind of user is arriving to the site in order to display different versions of the toolkit

which is tailored for different user groups. An additional challenge in the develop-

ment of the web-based DEMTEC system is to bear in mind that the end user might

forget the task at hand [17]. There are a number of websites available providing health

related information and advice to older people. However, the website designers fail to

accommodate all the needs of the target user groups. As result the websites is too

difficult to browse or navigate [18, 19]. The web-based DEMTEC followed two

background research work, one to identify the problem why the target users were not

using the websites to access health related information, thereby identifying what are

the problems stopping these groups from accessing such information. Later another

research work was carried out to collect different guidelines, i.e., tools to build the

website to improve the usability and accessibility of the website for targeted users.

Interaction between the stakeholders is not straightforward, as the feedbacks from the

stakeholders often oppose to each other. The stakeholders are located in different

geographical locations, hence the feedbacks are always sent via email. To help stake-

holders to provide feedback and to check on the progression of the work, a web-

address was set-up (i.e., http://www.sujithanand.com/projects/demtec/). Initially the

design was consulted with three stakeholders, i.e., A, B and C. Later one additional

stakeholder (i.e., stakeholder D) was recruited by stakeholder A. The stakeholder D is

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an education and communication researcher, who provided advice on the use of

graphics and textual reformatting to be used in the web-based DEMTEC.

1.3 Structure of Project Report

Section 2, is devoted to literature review, where the background research on three

target user groups is provided. The background research work was conducted to iden-

tify what might be the problems that the target users were facing towards using web-

sites. Similarly studies were made to understand the drawbacks of the existing web-

sites that disappoint users groups to access websites. Additionally, a survey was con-

ducted to check the awareness among younger generation of people aged between 20

-35 years about dementia and what they feel about people with dementia and theirs

carers using websites for improving their daily life is described. Section 3, introduces

the Design Process, which explains the guidelines from design literature. The section

also explains how these guidelines were implemented in the web-based DEMTEC

website and how the objectives of this project were achieved from information col-

lected through the literature review and guidelines. Section 4, describes Participatory

Design, approach for the design of web-based DEMTEC by involving the stakehold-

ers during the design phase. The next section introduces the testing strategies used

throughout the process of design and the participatory design. The final section draws

conclusion and points out the future work

2 Literature Review

As indicated in the introduction, the target users except health and social care profes-

sionals is people over the age of 60 years. Hence, the background research was per-

formed individually to identify the problems in greater detail from both the websites

and end user’s point of view. Several research papers, journals and websites who

provide the technology and health related information for the three identified targeted

users were consulted to find a solution.

2.1 Introduction to Dementia

Dementia is referred to as an umbrella term which describes a group of disorders in

the brain involving progressive deterioration in cognitive function later resulting in

severe cognitive impairment [20]. There are several types of dementia even though

some are far more common than others. The different types of dementia are Alz-

heimer’s disease which is also the most common cause of dementia (Dementia occur-

rence rate for this type is 62%)1, Vascular dementia (occurrence rate is 17%)

1, Mixed

dementia (occurrence rate is 10%)1, Dementia with Lewy bodies (occurrence rate is

4%)1, Rarer causes of dementia (3%)

1 and Fronto-temporal dementia including Pick’s

disease (2%)1 [21, 22].

1 Dementia 2012 infographic. Available from: http://www.alzheimers.org.uk/infographic.

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The awareness and understanding of dementia among society is very low, causing

barriers to diagnosis and care, stigmatization, and impacting people involved with

dementia. There have been arguments that dementia should no longer be neglected,

instead it must be considered as a part of public health agenda in all the countries and

in the field of HCI [4].

There are an estimated 36.5 million people living with dementia worldwide in 2010

and this number is projected to nearly double every 20 years, to 65.7 million in 2030

and 115.4 million in 2050. Wherein, each year the total number of new cases of de-

mentia reported is approximately 7.7 million, indicating one new case every four

seconds [4]. In the UK, it is estimated that there are 800,000 people living with de-

mentia and 670,000 family and friends acting as primary care givers. Current finan-

cial costs for the NHS, local authorities and families on dementia per year is £23 bil-

lion and this cost will grow to £27 billion by 2018 [23, 24].

Figure 3. Cost of dementia care compared to national economies.

Data source: World Alzheimer Report 20102

As illustrated in Figure 3, if cost of caring for dementia were compared to the econo-

my of the country, then it would be the world’s 18th

largest economy positioned be-

tween Turkey and Indonesia. The total global cost of dementia is estimated to be

US$604 billion in 2010. This cost accounts for 1% of the world’s gross domestic

product [25].

2 www.alz.co.uk/research/files/WorldAlzheimerReport2010.pdf

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Figure 4. Cost of dementia compared to company revenue.

Data source: World Alzheimer Report 20103

As noted in Figure 4 if caring for dementia to be thought as a company, then dementia

care would have a world’s largest annual revenue exceeding that of Wal-Mart

(US$414 billion) and Exxon Mobil (US$311 billion) [25, 26]. The cost of informal

care, i.e., care from family members, friends or relatives and voluntary social care

contributes to 84% of the total worldwide cost, while direct medical care cost are

16%.

Search methods. This section highlights on how the background information was

collected from previous Human Computer Interaction (HCI) resources and the differ-

ent search terms that was used in search engines such as Google and Bing.

Inclusion Strategy. This section explains the strategy used in selecting papers and

research works on target user groups. Empirical research papers, literature reviews and unpublished work conducted in

the UK and the rest of the world.

Research involving people with dementia, carers and health and social care pro-

fessionals.

Previous and current research works were considered without restriction.

Search terms. The main topics of interest here are people with dementia, carers and

health and social care professionals. The search terms for each strategy area were

refined after running preliminary searches which yields expected result, i.e., collect-

ing search term which produces maximum results related to this project. The search

terms that were used include:

3 www.alz.co.uk/research/files/WorldAlzheimerReport2010.pdf

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For people with dementia the search terms are:

o Website for + “People with dementia”.

o Technology used for + “People with dementia”

For carers the search terms are:

o Website for + “Carers”.

o Technology used for + “Carers”

For health and Social care Professionals the search terms are:

o Website for + “Health or Social Professionals”

o Technology used for + “Health or Social Professionals”

2.2 People with Dementia

The overall population of the UK as of 2010 was 62,262,000 [27], and currently

800,000 people are living with dementia condition [23] of which 648,895 people are

from England (including Scotland) whereas Wales with 43,614 and the Northern Ire-

land with 18,286 (see Figure 5). By the end of the year 2021 there might be 1,000,000

people living with dementia condition [22, 23]. Dementia is commonly seen in aged

people over 65 years [28].

Figure 5. Breakdown of the population with dementia across the UK,

Data source: Alzheimer’s Society, 20124.

4 Dementia 2012 infographic. Available from: http://www.alzheimers.org.uk/infographic.

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Figure 6. UK dementia population in the years 2012 and predicted population for 2021 and

20515

The above figure shows the UK dementia population with current and future projec-

tions, i.e., 800,000 people with dementia as in 2012 where as in 2021 a prediction of

1,000,000 people with dementia and 1,700,000 people with dementia in the year

2051. Every person in the above figure accounts to 10000 people.

Figure 7. Projected growth of People aged over 65 years and 85 years. Data source: UK Office

of National Statistics6

5 Dementia 2012 infographic. Available from: http://www.alzheimers.org.uk/infographic. 6 UK Office of National Statistics http://www.statistics.gov.uk/hub/index.html

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The Figure 7 provides a comparison between the percentage of the population aged

over 65 and 80 years and how this is expected to change in the next 40 years. From

the figure it can be clearly seen that the population of people aged over 65 years are

more than 80 years and there is a constant increase in both their population over

years.

In the UK, in 2012 15% of the population are aged over 65 years and 5% of the popu-

lation are aged over 85 years. The prevalence rate of dementia [23] between age 40-

64 years is 1 in 1400, 65-69 years is 1 in 100, 70-79 years is 1 in 25 and 80+ years

is 1 in 6. By 2051 there will be a 10% increase in both people population aged over

65 years (to 25%) and 85 years (to 10%).

A cure for dementia is yet to be identified as it is a brain related disease where once

damaged brain cells cannot be brought back to life or be replaced. However, epidemi-

ological research provides a considerable amount of suggestions of modifiable caring

factors that can be addressed to prevent or delay onset of Alzheimer’s disease and

dementia [29, 30].

A study conducted by Jing et al. [31] from a population of 13,004 people aged 65

years and over in which 438 people developed dementia and later 356 people who

developed dementia died during the study. The results drawn from the study is “Esti-

mated survival time from onset of dementia to death was 4.1 years (interquartile range

2.5-7.6) for men and 4.6 years (2.9-7.0) for women. There was a difference of nearly

seven years in survival between the younger old and the oldest person with dementia:

10.7 (25th centile 5.6) for ages 65-69; 5.4 (interquartile range 3.4-8.3) for ages 70-79;

4.3 (2.8-7.0) for ages 80-89, and 3.8 (2.3-5.2) years for age’s ≥90”. This study points

out that the people who are diagnosed with dementia die within the period of seven

years.

Selwyn et al. [32] used a survey to highlight that the number of older people using

computers and the internet is relatively low and often restricted to sending and receiv-

ing emails. The main reason for not using website was lack of perceived utility of

many applications and services [32]. Fisk et al. [33], identified that 47% of problems

for older people are due to financial limitations, health difficulties or other main con-

cerns. The remaining 53% can be solved by user centred design and providing proper

training, i.e., 25% will be improved by providing better designed websites and the

remaining 28% will be solved by providing proper training and redesigning websites

(i.e., after taking feedbacks/comments from focus groups). Previous studies have

indicated that older people who have less knowledge of the internet might benefit

from being provided with proper training classes [18, 34].

Due to the early drug treatments and diagnosis, the progression of dementia is often

reduced and this results in an increase in people diagnosed with early stage dementia

[35]. Several studies have revealed that older people who have knowledge of the in-

ternet (i.e., regularly use websites) use websites as a valuable source of health infor-

mation and to find health related advice [18, 36]. A number of websites provide in-

formation and advice to people who are living with dementia, be these carers, friends

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and family, or those diagnosed with dementia. But designers of websites often fail to

deliver designs that are suitable for people with dementia. Often this is because they

do not consider the problem from the perspective of the people with dementia and do

not involve them in the design process even though the website is created for people

with dementia [35].

To date, there is little information on people with dementia in terms of the usability of

websites that are mainly targeted for them. Additionally, there is hardly any research

is done on people with dementia using websites as an interactive medium. However,

there is a lot of research into ways to improve the quality of life of people with de-

mentia with other technologies like assistive technology to improve the independency

in people with dementia through the tracking devices, e.g., Keeping In Touch Every-

day (KITE) project [37] apart from the websites. In order to improve the quality of

life and to ease the daily burden, people with dementia need to interact with websites

[38].

2.3 Carers

In the UK, 670,000 people act as primary carers to people with dementia, be they

family members, friends or private members due to which £8 billion is saved every

year for the state [22, 23]. Carers often find caring for people with dementia is de-

manding and stressful. Also, they themselves have lower levels of life satisfaction

and high anxiety levels that often lead to depression. This distress is often the result of

having to manage behavioural problems related with dementia and also need to pro-

vide constant supervision [39].

Because of the above condition related to heavy burden, caregivers often do not have

motivations to use websites. However, Brodaty et al. [39] points out that caregivers

might swap the assignments of work, i.e., caring for people with dementia between

other caregivers depending upon the need of care which reduce the burden to some

extent. Broadly the care givers can be categorised as below:

Care givers who do not prefer to use the websites: These are caregivers who are

handling the pressure of care giving and do not need any assistance from websites.

They are also characterised by very low levels of burden and they have adequate sup-

port from family members and friends. Also they are caring for care recipients with

varying levels of dependency.

Care givers who are not willing to use the websites: These are caregivers who have

been offered services, but appeared reluctant to use them despite the indications that

they are not managing with the demands of care giving. Some of these caregivers are

characterised by high levels of burden, poor health and a lack of awareness. Often

these caregivers are supporting someone with high levels of dependency. Some of

these caregivers did not identify themselves as caregivers because they viewed caring

as part of their duty or role like a parent or partner.

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Care givers who are willing to use the websites: Some of the caregivers are willing

to use the website services but are unable to do so because of hectic work schedule,

such as difficult hours of operation, lack of accessibility or cost. Often the caregivers

in this group showed high levels of burden and poor health.

Care givers who do not know information provided through the websites: Many

of the caregivers did not know about the availability of the website proving health

related information. This might be due to the lack of awareness.

Websites which provide daily tips, i.e., what precautions to be taken at what time

during the period of caring and the alternating approaches to improve the standard of

care giving can support the caregivers either in home or in the work place by provid-

ing caregivers a break from work and to get help from the health care professionals.

Also, their knowledge can be updated with new ideas about caring for people with

dementia.

2.4 Health and Social care Professionals

Health and social care professionals provide advice and the treatment to people with

dementia and their carers. There are a huge array of different health and social care

services relevant to dementia care, i.e., home care and day care, as well as, services

provided by doctors and nurses [40]. There is no estimation of how many profession-

als providing support for people with dementia and carers. Social and health care

professionals do not face any widely reported single problem in using websites be-

cause the majority of the professionals use the websites daily as part of their work

lives. However, the information providing support to care recipients through the web-

sites is very low due to their work schedule [40]. Furthermore, little research can be

found on social and health care professionals providing support for care recipients

through the websites.

2.5 Survey

A web-based survey was performed by me to check the awareness of people aged

between 20 to 35 years about dementia who are active internet users, i.e., use social

media through Facebook and studying in university level. This survey was created

using survey monkey [41]. Six questions (4 multiple choice and 2 textual) asked after

a review from the stakeholders in three different Facebook groups related to Newcas-

tle University.

The three Facebook groups are Newcastle University - Science, Agriculture & Engi-

neering Postgraduates7, Newcastle University

8 and NCL Uni CS 2011-2012

9. The

7 https://www.facebook.com/#!/groups/5224352377/ 8 https://www.facebook.com/#!/groups/273077652712326/ 9 https://www.facebook.com/#!/groups/290000711030233/

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three groups are equally distributed with male and female participants. The people in

the group use Internet frequently in their daily life. The above groups were selected

since the majority of the people are into science related field and diverse in ethnic

backgrounds. The questions were framed in a way they are easily understandable and

do not impact on any person or pressurises someone’s belief. Overall 38 people par-

ticipated in the survey and 31 of those answered all the questions. The first question

was to describe themselves as either of British, European or International.

Figure 8. The percentage of different ethnic people who took part in DETMEC survey.

Data source: Results of DEMTEC survey

The Figure 8 shows the percentage of people who took part in DEMTEC survey ac-

cording to ethnic origin in which majority, i.e., 50% of the people are international

students.

Figure 9. The result of participant’s knowledge about the term dementia in DETMEC survey.

Data source: Results of DEMTEC survey

The second question (see Figure 9) was asked to know the participant’s level of un-

derstanding of the term dementia, to which majority, i.e., 54% of the participants

answered they have some knowledge about dementia, but not well enough.

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Figure 10. The result of participant’s knowledge about the term dementia in DETMEC survey.

Data source: Results of DEMTEC survey

In Question 3, the participants were asked to select one appropriate answer that best

describes the term dementia (see Figure10). But majority 60%, answered it incorrectly

saying that the dementia is a disorder of brain which is actually a mental health condi-

tion.

Figure 11. The result of participant’s opinion for carers and people with dementia using web-

sites to improve daily life. Data source: Results of DEMTEC survey

In the fourth question, the participants were asked to express their opinion to the peo-

ple with dementia and carers using websites to improve their daily life (see Figure11).

The majority of the participants who answered were not sure but 23% of the partici-

pants felt it is very important for carers and people diagnosed with dementia to use

websites.

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In question 5, the participants were asked to provide textual answer for what they

think about the barriers for the people with dementia and their carers to use websites.

The participants answered separately that if the barrier was due to personal problems

like “inability and lack of a computer”, “forgetting the things very soon” and the

drawbacks from the websites “small fonts, too much animations, too bright colors,

hard to use”, “Difficult or unordinary page layout, structure” but the barrier for the

end users not accessing website is because of both the problems. In the last question,

the participants were asked to suggest any websites regarding people with dementia

and carers, out of 21 participants who took part only two answered correctly, e.g.,

“care well UK” , “www.dementiaweb.org.uk, dementia-care-

notes.in/resources/other/, www.dementiacareaustralia.com/, dementia-care-

notes.in/”. (For results of survey refer Appendix 2)

Finally, as the researchers have expressed about the lack of awareness in people about

dementia in past [42] and present [43]. This survey shows that still there is lack of

awareness about dementia among students and considering people from the science

related field. This emphasises the need for more awareness of dementia in HCI field

and in the real world.

2.6 Literature review overview

Computing and information technology have become an integral part of our daily life.

Unfortunately, an age related divide still exists in the population in terms of use of

technologies. Complex commands, input device design, usability problems and inad-

equate training with less instructional support prevent older adults from effectively

interacting with websites [32]. Additionally, to a large extent, designers do not con-

sider older adults as active users of technology, and thus many interfaces are designed

without considering the aged users. Moreover, many designers have very limited un-

derstanding of dementia or how to design the websites to accommodate this user

group. As discussed in this project, there is a need for people with dementia, carers

and social and health care professional to use websites to improve the daily life condi-

tion and to reduce the burden. Hence, there exists a need for research in this area.

Many studies that have been conducted so far have fewer considerations of websites

as a medium for improving quality of life for people with dementia and care givers.

Finally, to improve the quality of life and the daily problems faced by people with

dementia, carers and social and health care professionals there is a need for all of

those to interact with websites which are specifically targeted for them.

3 Design Process

This section describes how the web-based DEMTEC was designed and developed,

including what guidelines was used in designing and the changes that were done to

the web-based DEMTEC design which was provided by the stakeholders.

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3.1 Overview of Design process

Below a step-by-step overview of the web-based DEMTEC design process is shown

with information on what procedure was followed to build the initial design (see Fig-

ure 12).

Figure 12. This overview of the web-based DEMTEC process.

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Information gathering. In the first stage of the Web-based DEMTEC process the

initial textual information for the website (i.e., word documents of the original

DEMTEC book) was collected from the stakeholder A.

Planning. At this stage, web-based DEMTEC architecture was planned after observ-

ing several websites like Alzheimer’s society UK [10], US [11], Canada [12], Aus-

tralia [13], Dementia UK [14], Young Dementia UK [15] and Care Well UK [16]

who provide health related information for people with dementia, their carers and

health or social care professionals.

Recruitment. In this stage, web-based DEMTEC architecture was presented before

the stakeholders. Regular meetings were organised to show the web-based DEMTEC

designs and feedbacks regarding design was gathered. Also, textual information relat-

ed for the website (e.g., welcome page description and contact details.) was collected

from the stakeholders. The stakeholder D was recruited by stakeholder A to provide

support for use of graphics and textual reformatting.

Participatory Design. At this stage, the gathered feedbacks from the previous discus-

sion section were implemented. This stage is important since the guidelines which

was followed to design the web-based DEMTEC had to be removed, i.e., static navi-

gation bar, etc. while implementing changes to the design of web-based DEMTEC.

Webpage Development. In this stage, all the static webpages were converted to dy-

namic webpages. Finally, the fully functional web-based DEMTEC was developed

and provided to stakeholders for their feedback.

Testing. Website testing is performed throughout the design process. Since there are

three different designs developed and every design was tested before being provided

to stakeholders for feedback.

3.2 Languages and tools used

In this study, HTML, CSS, JavaScript, PHP and MySQL are used. HTML (Hypertext

Mark-up language), CSS (Cascading Style Sheets) and JavaScript is used for Front-

end programming and Word Press powered by PHP (Hypertext Pre-processor) and

MySQL for Back-end (server-side) programming and database storage are used for

this website. Later, Adobe Photoshop for editing pictures and Adobe Dream viewer

for writing the codes were used. (For source code refer Appendix 1)

3.3 The guidelines used while designing the web-based DEMTEC

The web-based DEMTEC is aimed for people aged over 65 years expect for health

and social care professionals, so a secondary background research was conducted to

identify guidelines, i.e., tools to build the website. A website is a collection of infor-

mation which can be presented in many different ways [44]. The challenge here is to

enable older adults and people diagnosed with dementia to successfully access health

18

related information from the website. The websites provide users with the opportunity

to become more informed, which also allow users to be better prepared and oppor-

tunity to discuss the possibilities and benefits associated with treatment procedures,

and communicate with peer groups in new ways [45, 46]. However, website design

often acts a barrier to people with dementia or older adults due to the designer’s fail-

ure in recognizing them as a potential user group [47, 48]. Hardly any web accessibil-

ity guidelines exists to create a website which is used as a reference worldwide [49].

Along with World wide web consortium’s Web Content Accessibility Guidelines

(WCAG) [50] an extensive review of previous guidelines from various researchers

was performed. From this a set of guidelines were grouped for the specific needs of

the web-based DEMTEC. Inevitably there were many overlaps, i.e., guidelines which

aim to highlight the same problem but phrased differently or have different focus

were grouped together [35]. These are summarised in Table 1.

Table 1. Guidelines grouped together which have the same meaning.

Guidelines Closely related to

guideline

Links should be clearly named Links should be in a bulleted list

Links should not be tightly clus-

tered

Links should be clearly named

Links should be in a bulleted list Links should not be tightly clustered

There should be differentiation

between visited and unvisited links

There should be no link with the

same name that goes to a different

page

The font size should be 1–4 point The font type should sans serif (i.e.,

Helvetica, Arial)

Avoid decorative fonts The font type should sans serif (i.e.,

Helvetica, Arial)

Avoid decorative fonts The font size should be 1–4 point

There should be high contrast be-

tween the foreground and the back-

ground

Background should not be white

Blue green tones should be avoided Colours should be used conservative-

ly

Content should not all be in colour

alone

Coloured text on coloured back-

ground should be avoided

Pop up/animated advertisements

should be avoided

Multiple overlapping windows

should be avoided

Screen layout should be simple,

clear and consistent

Consistent layout should be present

Support recognition rather than

recall

Reduce the demand on working

memory

19

However, there were also many conflicts among researchers, so a systematic ap-

proach10

was followed to re-consider the following set of 27 guidelines which were

grouped under 9 distinct category in-order to improve the usability and accessibility

of the web-based DEMTEC for target user groups.

The guidelines which are described below were implemented in the web-based

DEMTEC design and their relevant figures (i.e., Designs developed according to the

guideline) are provided.

Target button layout design. This is the first category of guidelines which provides

the information about how the target button in the website has to be represented for

different target users.

Larger buttons. User’s ease (speed and accuracy) to select an icon/buttons depends on

their size and the distance the cursor has to be moved [51]. Older adults face in-

creased difficulty when the targets become smaller when compared to younger peo-

ple. Studies done in [17, 33, 34, 52] have shown that providing an increase in size of

the target, i.e., buttons, which must be clearly visible to select particular option will

improve the older adults accessibility of the websites.

Figure 13. Screenshot from the web-based DEMTEC website where larger targets are used to

improve the accessability of the targeted user groups.

Figure 13 provides the view of the larger button target guideline that is used in the

web-based DEMTEC design. There are two representations of the larger button target

guideline used in the design as in shown in the figure, one is box shape and another is

horizontal elongated strap line.

Confirmation of target capture. Older adults have difficulty in identifying smaller

movements, i.e., the functionality of mouse over should not be present in the website.

Moreover, older adults are very careful in their movements, it will help if they get

feedback for their actions which could be changed in screen status, i.e., getting new

page when clicked on a link [53, 54].

Avoiding double-click of targets. As age increases, older adult’s mouse controlling

activities will reduce. Fisk et al. and Zaphiris et al. [33, 53] specify that using single

clicks of the mouse on targets buttons will reduce usage-time for users and also re-

duce users getting confused.

10 www.turning-the-tide.org/files/NAOMIE%20handout.pdf

20

Graphic Usage. This is the second category of guidelines which provides the infor-

mation about how the graphical representation in the website has to be presented for

the target users.

No animations. Graphics which are irrelevant to the website will distract users by

making it more difficult to read and identify the information of their choice [53].

Graphics should be relevant to the specific information and by avoiding animations

improves accessibility of the target users.

Icons should be simple and meaningful. In the current generation of websites, use of

icons is very normal for navigation. Simple and meaningful icons will be easier to

differentiate. If icons are used then there should be a meaning to the icon and users

should know the functionality of the icon before using the website. For example pre-

vious or next icons are often used in improving the navigation process (figure14).

Figure 14. The figure shows images of the previous and next button used in the web-based

DEMTEC design.

Extra and bolder navigation cues. This allows users to see and identify a layout loca-

tion For example Users should be able to understand at which webpage they are cur-

rently reading information. This will help older adults in scanning the website and re-

tracking the previous steps.

Clear navigation. Generally, older adults will get very upset if they could not find

what they are looking and they would probably just not use the website at all [50].

Clear navigation helps users to move smoothly through the webpages [55] This can be

achieved by providing a constant navigation bar, so that people can select the naviga-

tion option whenever they are stuck and lost in finding content menu (see Figure 15).

Figure 15. The image of the constant navigation bar from the web-based

DEMTEC design.

21

Avoid pull down menus. Older adults will have slower hand movements than younger

adults [52, 56] and it will be difficult for them to co-ordinate scrolling a menu and

clicking at the same time. Many studies have pointed out that older people have prob-

lems with scrolling through webpages [17, 18, 34, 57].

Grouping of information into meaningful categories. Previous studies have reported

the importance of grouping of information in categories that help users in searching

and locating the information they are looking for quickly and also helps n scanning

the webpages [53, 55, 58, 59].

Improving browsing window features. This is the third category of guidelines

which provides the information about how the website has to be represented for the

target users.

Avoid Scroll bars. Scrolling is required in a long page. While horizontal scrolling bars

can be avoided vertical scrolling bars typically have to be displayed generally in web-

site. Older adults will face difficulty in scrolling down the page and trying to read and

find the information that they are looking for [49, 52, 53]. In web-based DEMTEC the

paging concept (i.e., the DEMTEC toolkit or case studies or stories separated into

different sections along with the index page and stored into database accordingly to

provide a better accessibility for the users) is used to improve end users when reading

the DEMTEC toolkit and to avoid vertical scroll bars. Since web-based DEMTEC is

an information source with majority of webpages containing only textual information.

Providing only one open window. Older adults will be distracted and face difficult to

read the information present in the website if there are multiple overlapping windows

or pop-up/animation/flashing banner advertisements [49, 55, 60]. In web-based

DEMTEC, targeted users will have a facility to download the toolkit that is dedicated

to the users in the same window without opening a new one. This provides better

accessibility for the users to navigate the site.

Content Layout design. This is the fourth category of guidelines which provides the

information about how the content in the website has to be represented for the target

users.

Language should be simple and clear. Language used in a website should be simple,

natural and relevant to the users and should avoid any technical terminology [50, 53],

since older adults might have problems understanding complex language [49]. Web-

based DEMTEC uses simple language in website as well as in the different versions

of the toolkit.

Avoid irrelevant information on the screen. The page content should be reduced to the

most relevant information to make the website easier for the users to find what they

are looking for. It is always important to make sure that the webpage is kept simple

and understandable [59].

22

Important information should be highlighted. Websites should provide important

information in the centre of the webpage to older adults. If any information is provid-

ed in the bottom of the webpage, older adults will not necessarily see in the first

glance and this increases the time for the users to search a particular information

[61].

Screen layout, navigation and terminology used should be simple, clear and con-

sistent. In order to avoid complexity it is important to provide simple screen layouts

wherever possible in website. Therefore there is need to be consistency between ter-

minology used and the modes of navigation. Readability of the website increases with

simple screen layouts whereas cluttered appearances will distract users and make it

difficult to identify specific layout [52, 62].

Use of Links. This is the fifth category of the guidelines which provides the infor-

mation about how the hyperlinks in the website have to be represented for the target

users.

Links should be clearly named in a bulleted list and not tightly clustered. Links repre-

sented in the form of bullet points will help the user’s visibility and provide clarifica-

tion to the information. Clusterisation will always make information more difficult for

the user to identify [55, 63].

User cognitive design. This is the sixth category of the guidelines which provides the

information about how to improve the user usability for websites

Providing ample time to read information. Older adults need longer time to recognise

characters and therefore it is best to let them read the information in their own pace.

Therefore, it is advisable to allows older adults enough time to understand the infor-

mation being presented [64].

Providing fewer choices to the users. The older adults require more response time if

they have more choices to select from the webpage and this will result I slow response

and reaction time. Additionally as, older adults have a decline in short-term memory,

it is very important that they can able to offload information onto the interface itself.

Thereby facilitating older adults to recognize material rather than requiring their

memory in trying to remember where they found an item [52, 65, 66].

Use of colors and background. This is the seventh category which provides the in-

formation about how to use the color variation and the background screens in the

website for the target users.

Color should be used conservatively. High contrast colors in WebPages will distract

older adults and make them very difficult to see the text properly. Too many colors

would need constant refocusing which older adults feel uncomfortable.

Background screens should not be pure white or change rapidly in brightness be-

tween screens. There needs to be consistency between the screens on the website, e.g.,

23

all the screen should be the same in terms of their background colour. This is because

it will be difficult for the older adults to adapt to the new changes in brightness be-

tween the screens. A high contrast on the foreground and low on background or vice

versa will help the visibility of the text and make it more readable to the older adults

[50, 63].

Text Design. This is the eighth category of the guidelines which provides the infor-

mation about how to represent the textual information on the website for the target

users.

Avoiding moving text. Older adults will have great difficulty following moving texts,

i.e., scrolling text should be avoided. Information that is important should be present-

ed in a simple way to attract attention and reduce confusion [64].

Text should be left aligned and text length should be short. Short sentences instead of

a long page of text will always help older adults to read and understand the infor-

mation quickly which will later increases their ability to read. Since often they have

problems with reading [67].

Spacing between sentences. This guideline will help the older adults identify the be-

ginning and ending of a sentence. A paragraph with text not clustered together will

increase readability [68].

Text should have clear large headings. This guideline will help older adult with re-

gards to reading and allows users to search for the information on the webpage more

efficiently [69].

Use of sans sheriff type font, i.e., Arial of 12 or 14 pt. It is difficult for older users to

see small font therefore the font size and font type should be large and clear enough to

aid visibility and readability. Complicated fonts like calligraphic reduce the readabil-

ity of text and make it more difficult to see and read [52, 67].

User feedback and support. This is the final category of the guidelines which pro-

vides the information about how to represent error message and to include support in

the website for the target users.

Site Map. A site map will enable users to see what is available to them and will assist

them in identifying what is relevant and what is not in the website, i.e., by providing a

clear and accurate overview of the website [55].

Error messages should be simple and easy to follow. Older users tend to slow down

after making errors. It is important not to further slow them down by providing an

unfriendly message or pop-ups, which does not help them at all [65].

24

3.4 Objectives achieved

There are four objectives in this project. The first objective is to display DEMTEC

toolkits to the target users in a suitable way, e.g., family carers to read DEMTEC

toolkit for carers easily. The second objective is to provide DEMTEC authors to

manage the website. The third objective is to include evaluative and feedback facility

for the target users. The final objective is to deliver the website live and make availa-

ble for public usage.

First Objective

“The website should be suitable for different users, and so would have different

‘pathways’ of advice for, for example, health and social care professionals, care

workers and family members”

The targeted users are separated in the home page of the DEMTEC website11

into 3

different groups (see Figure 15) so that the content presentation, i.e., various

DEMTEC toolkits is made easily available. To make content presentation available to

the target users several guidelines were followed. In order to provide ease of naviga-

tion to users the DEMTEC toolkit was made available within three mouse clicks from

the home page of the website [70]. After selecting a particular version of the toolkit to

read, an index page is provided for the users to select different section of the toolkit

according to their interests. For paging concept, the navigation buttons are imple-

mented according to the guidelines so that the users can move back and forth easily

without any confusion. Additionally, the targeted users will have the facility to print

the page they are viewing and also to email the web-address of the page to other peo-

ple. The figures 16, 17 and 18 show the DEMTEC toolkit that can be accessed within

three mouse clicks from home page.

Figure 16. A screenshot of the home page from the web-based

DEMTEC design.

11 http://www.sujithanand.com/projects/demtec/

25

Figure 17. Screenshot showing the family carers page from the web-based

DEMTEC design.

Figure 18. Screenshot showing the DEMTEC toolkit page from the web-based

DEMTEC design.

Figure 19. Screenshot showing an inner page content mangement system from the web-based

DEMTEC design.

26

Second Objective

“The website should be editable - by the development team”

The web-based DEMTEC is built on WordPress 3.4.1(see Figure 19) using PHP (for

server side scripting) and MySQL (to store all the information). Currently there are 44

webpages in web-based DEMTEC and all the webpages are stored in the database.

DEMTEC development team can easily publish, edit and modify the webpages. How-

ever, they require to login using username and password (see Figure 20).

Figure 20. Screenshot illustrates an login option for DEMTEC authors from the web-based

DEMTEC design to manage the website.

Third Objective

“Feedback and Evaluative element”

Commenting facility. A commenting facility is provided to the users where the pagi-

nation concept is used, i.e., display of different version of DEMTEC toolkit. Here the

users of the DEMTEC tool can leave a comment on the page. Apart from displaying

the comments in the website, all the comment information will be stored in the data-

base (see Figure 21).

Figure 21. This screenshot shows the commenting facility provided in the web-based

27

DEMTEC design

Feedback form. The feedback form is provided to targeted users to comment about

the website. Also the information sent from the targeted users through the feedback

form in the website will be stored in the database (see Figure 22).

Figure 22. This screenshot shows the feedback facility provided in the web-based

DEMTEC design.

Fourth Objective

“Website to be live and usable by the users”

The website is already made available for general use but not made publically

accessible, since the current web-address is used for private purpose only, i.e.,for trail

run and to collect feedbacks from stakeholders but in future the web-based DEMTEC

will be provided for public use.

4 Participatory Design

Participatory design, which is also known as Cooperative design or Scandinavian

Participatory design, is an effort to involve stakeholders, i.e., end users in the design

process to ensure the product design meets with user requirements [19, 71]. The in-

clusion of stakeholders in the design process will increase the chances of design to be

successful and in turn, increases likelihood of user-acceptance of the design [72]. The

stakeholders in this project are distributed geographically, i.e., London, Cardiff and

Newcastle, so to reduce the time and cost involved through the participatory design a

28

web-address12

was setup to provide stakeholders ample time to review the website and

provide the feedback. The feedbacks as always sent through email. One of the draw-

back in the participatory design is the difference in stakeholder’s opinion [73]. This

project also experienced the problem and later solved systematically. In this project,

the stakeholders are from health and social care professionals and despite the best

efforts of the stakeholders focus group meetings with carers and people with dementia

could not be organised due to the time frame of this project. The conversations and

communications between the stakeholders are included in this section through quota-

tions wherever necessary to highlight the difference in opinion.

Figure 23. Feedbacks provided from the stakeholders for the different design of web-based

DEMTEC.

Figure 23 shows the feedbacks provided by the stakeholders A, B, C and D during

participatory design process for the web-based DEMTEC design. The focus group

meetings were conducted twice a month for the duration of around one hour with

stakeholder A to display the progression of work and display the implemented feed-

backs. In the initial meeting, I was informed by stakeholder A that there would be a

DEMTEC toolkit on people with dementia and accordingly the design of the web-

based DEMTEC was designed, i.e., by providing four options in the home page of the

web-based DEMTEC but later on, option for people with dementia was removed

since the toolkit was not yet ready for display.

12 http://www.sujithanand.com/projects/demtec/

29

The first feedback was provided on 25th

June 2012 by Stakeholder B after going

through the initial design of web-based DEMTEC. They are important and also to

some extent contradictory. To start with, the different fonts to show the full form of

DEMTEC “DEMtec Toolkit for Effective Communication” is considered to be used

in the cover page of the DEMTEC book and the comment from the Stakeholder B

regarding this was “I do like the idea of the different font to illustrate where the

DEMTEC name comes from so I would say flog this idea to death on every bit of

promotional material we have – this is the Brand!”. Also three options provided to

separate target users in the home page (see figure 16) was also appreciated “I like the

3 main options in terms of navigation”.

Further, the opinions that were contradicting between stakeholders A and B are inclu-

sion of login facility to the web-based DEMTEC which was agreed by the stakehold-

ers in the initial meetings and Stakeholder B in this feedback mentions to do some

changes in the login facility representation “The member access section should form

part of the top ‘strap line’ or be vertically aligned on the right hand side as in most

other websites”. But in the further feedback I was informed to remove this option to

provide easy access to the website to the end users

Additionally, Stakeholder B expressed: “There also doesn’t seem to be a section for

PLWD (People Living with Dementia)” but before providing the first design draft of

the web-based DEMTEC, I was informed by Stakeholder A that “After enquiring, it

seems we don’t yet have Basic DEMTEC for PLWD. What we have instead is a very

basic, introductory DEMTEC suitable for all users. We’ll need to remove the

‘PLWD’ tab from the home page”. Therefore the option of people living with demen-

tia from the home page was removed. Additionally, there were separate opinions on

representations of the logo, pictures and the textual information which was changed

according to the request.

The second feedback was provided by Stakeholder C for the first draft of web-based

design on 26th

June 2012. The initial opinion was: “The graphics are weak and some

simplification of sentences is always a good thing. Can we get someone to look at

graphics for us? It's not an area of strength for me”. So Stakeholder D was recruited

by Stakeholder A to the team to provide support for use of graphics and textual

reformatting. Finally, the graphics for the website was improved by consulting stake-

holder D.

The third feedback was provided by DEMTEC authors, i.e., three stakeholders A, B

and C combined on 27th

June 2012 towards the first design of web-based DEMTEC

itself. There was one opinion which was contradicting the previous feedback and two

guidelines which were followed had to be neglected. The contradicting opinion was

removal of login facility for users “We don't want people to have to fill a form in to

use the site - could this be removed?” The removal of login facility also leads to secu-

rity threat, i.e., users can send and comment malicious information through feedback

and commenting facility which couldn’t be identified. Later, “Overall, things need to

be made simpler to look at, less light colors, more bold, and with a very simple and

direct 'look' that will be easy for older people to look at and use”. To implement this,

30

certain guidelines such as fixed navigation bars and on mouse over facility was ne-

glected. Also there was a further opinion on logo representation and textual represen-

tation which was completed according to their request.

Later on 27th

June 2012 Stakeholder D provided more feedback regarding the initial

draft of web-based DEMTEC in which some opinions were already considered by

following certain guidelines, i.e., inclusion of text enhancer to improve the user ac-

cessibility and readability in websites for target users. But opinion like “Even with the

addition of the navigation bar to the homepage, I think I'd be inclined to add some-

thing providing a clear link to more information about what DEMTEC is -- i.e., as

well as having the 'About/FAQs' tabs in the navigation bar” in navigation bar is com-

pleted as they requested. But the information relating to that page is yet to be given.

Further changes relating to content alignment and change in textual information is

changed according to their suggestions.

On 18th

July 2012 I received fifth feedback from Stakeholder D for the second design

of web-based DEMTEC. In this, there are opinions which were not considered since

that had to be discussed with other stakeholders for approval. This included “Some

link on the homepage for new / 'inexperienced' users that will take them to a (fuller)

guide on what the website is and how it is structured. This could simply be a way of

highlighting and directing people to the 'About us' section” and “Reduction in the

amount of text on some pages and/or editing of the text to reduce further the length of

paragraphs/amount of text on individual pages, etc.”.

Also opinions regarding textual changes like “Removal of remaining references to

"HTML" etc. e.g., under the ‘Carers’ and 'Health Experts' tabs” i.e., removing

HTML and PDF words. Later by changing certain textual words from

“'Long' and ‘Short’ versions of the toolkit” to “'Full' and 'Summary'” and the remov-

al of social media icons from the home page and “I wondered whether it would be

useful to have some sort of 'index' / summary for the Case Studies” were completed

according to their request.

Finally, there are issues regarding the use of pictures starting from the first feedback

to fifth feedback, i.e., “a bit over-emphasized on the medical angle though” in first

feedback, in third feedback “The pictures so far are rather 'clinical' - could we have

more overall (at least 2 per page), and not of doctors and business people, but (ideal-

ly) of older people (who look 70+) interacting with middle aged people (50ish) - this

will reflect the realities of most care situations”, during the fourth feedback “The

pictures. You (Stakeholder A) and (Stakeholder B) note that these look rather clinical.

They are also clearly stock photos” and in fifth feedback using images to real life

stories which are not related to story. Although it was initially agreed that the relevant

pictures was supposed to be given later it was not. This did not affect the process,

since an online search for relevant images was performed to collect which were relat-

ed to web-based DEMTEC from the Google, Bing and Flickr and later those were

implemented. The feedback regarding that was “Sujith (i.e., myself) has found some

new (and more varied) pictures, and integrated them very nicely into the pages” and

31

later raised a question of copyright, which will be dealt when hosting the website

(Refer Appendix 3 for further information on feedbacks).

On 3rd

August 2012, I received final feedback for the third design of web-based

DEMTEC from the Stakeholder A and it said “Thanks for this - and well done! In

terms of architecture, this is a big improvement. It looks good and is easy to navi-

gate, very professional- a good basis for what we'd like DEMTEC to be. It is also

great that it is so easily accessible”.

5 Testing

For Web-based DEMTEC testing was performed when every design draft was pro-

vided to stakeholders for reviewing. The different kinds of testing [74] which was

performed are:

5.1 Smoke Testing or Unit Testing

This testing is the initial testing process where the website is exercised to check

whether the website under test is ready/stable for further testing, i.e., to check the

objectives is providing the expected outcome (see Table 2).

5.2 Functionality Testing

This testing is used for checking all the interconnecting links in the WebPages and

forms used in the WebPages for submitting or getting information, e.g.,

Checking all the links in the website. Initially testing the outgoing and internal links

from all the pages. Later, testing the links that are interlinking on the same pages.

Then, testing the links which are used to send the email to admin from the web pages

and Lastly the link checking, i.e., check for broken links in all the above-mentioned

links.

Test forms in all pages. Firstly, checking all the validations on each field. Later,

checking for the default values of fields then the wrong inputs to the fields in the

forms and finally checking options to create forms if any, form delete, view or modify

the forms.

5.3 Usability Testing

Usability testing includes. Web site need be made easy to use. Instructions should be

provided clearly and the provided instructions should be of correct means to satisfy

the purpose. Main menu should be included in each page to maintain consistency.

32

Content checking. Content should be logical and understandable and should be

checked for errors in spelling. Use of dark colours should be avoided in the website.

Content used in the website should be relevant to the website. All the links with an-

chor text should be working appropriately. Images should be placed correctly with

correct size and resolution.

Like search option, sitemap, help files etc. Sitemap should contain all the links in web

sites with the suitable hierarchy view of navigation. Check for all links on the

sitemap. “Search in the site” option should help the users to find the page they are

looking for easily and quickly

Compatibility Testing.

Compatibility for web site is very important aspect of testing. There are two different

types of compatibility testing used in this project which are:

Browser compatibility. Some applications are very dependent on browsers. Different

browsers have different configurations and settings that the website should be com-

patible with. Your web site code should be compatible with cross browser platform

and website should be tested on different browsers like Internet explorer, Firefox,

Netscape navigator, AOL, Safari, Opera browsers with different versions.

Operating System (OS) compatibility. Particular functionality of the website may not

be compatible with all operating systems. All new technologies which are used in the

web development like graphics designs may not be available in all Operating Systems

and website should be tested on different operating systems like Windows, Unix,

MAC, Linux is important.

Some of the test cases which were performed from social carers point of view to

check the functionality of the testing, i.e., hyperlinks, feedback and commenting facil-

ity are shown below. Table 2. Test case for Family Carers

Test Description Test Case Input Expected Output Actual Output

Home Click on the

home button in

the navigation

bar in the home

page

It should display

the home page

It will display the

home page

Family Carers A) Click on

Family Carers

option in the

home page

It should display

family carers page

with four options

It will display

family carers page

with four options

33

B) Click on to

read DEMTEC

toolkit

It should display

DEMTEC toolkit

for family carers

page with two

option, one to read

full version and

another option to

read summary

version

It will display

DEMTEC toolkit

for family carers

page with two

option, one to

read full version

and another op-

tion to read sum-

mary version

C) Click on to

read full version

option in

DEMTEC toolkit

for family carers

page

It should display

DEMTEC toolkit

full version for

family carers page

It will display

DEMTEC toolkit

full version for

family carers page

D) Type some

comment in the

family carers

page

It should display

the typed comment

in the same page

with the name as

anonymous

It will display the

typed comment in

the same page

with the name as

anonymous

Home Click on feed-

back option in

the navigation

bar

It should display

the feedback page

with form fields

It will display the

feedback page

with form fields

Feedback Enter name,

email, subject,

rate this website

and your mes-

sage and click on

send button

It should send the

message without

error

It will send the

message without

error

This is the initial part of the test that was carried out and more detailed testing can be

seen in Appendix 4.

Testing to find errors in the linking pages are as follows.

Table 3. Flowchart of testing family carers random movement through website.

Home page of web-based DEMTEC

Click on family carers option

34

Click on people interested in case study

Click on read more under scenarios,

It opens the scenarios page and click the family carers

Click on people looking for advice link which opens the feedback

form

Enter the name, email, subject,

rate the website and your message and

click on to the send button and click on to the family carers in navi-

gation bar

Click on DEMTEC tool kit which opens the DEMTEC toolkit page

Click on full version or summary version on DEMTEC toolkit page

and click on family carers

Click on share your experience link in family carers page it displays

stories page

Click on read more on stories page and click on family carers link

Write a reply and click on submit comments

Click on Home Page in navigation bar

35

6 Conclusion

In this HCI project, the aim was to develop a dynamic website with contents of

DEMTEC suitable for different target users. To achieve this two background research

studies were performed. During the first research study it was identified that majority

of the targeted users are willing and already used websites to find health related in-

formation. But the websites failed the users by not following guidelines and using

their websites for commercial purpose. So the second research study was performed

to identify what guidelines had to be followed in the website to help target users. Fi-

nally after a systematic approach13

by neglecting similar guidelines with alternate

representation, 27 guidelines were identified and implemented in web-based

DEMTEC.

By participatory design process the targeted users are involved in the design process

to provide feedback for the design of web-based DEMTEC. The stakeholders who are

involved in this project are located in different geographical locations so to help them

online focus groups were conducted and a web-address was setup. The feedbacks

from the stakeholders were accepted via emails and ample time was provided to go

through the website. The participatory design process was not straight forward, since

there was difference in opinion with the feedbacks and while following some feed-

backs the guidelines which were followed had to be neglected, so to overcome the

problem with difference of opinion between stakeholders, stakeholder A was consult-

ed and some guidelines had to be removed because stakeholders felt those guidelines

will reduce the usability and accessibility of the website. Finally through iterative

design the web-based DEMTEC is completed and user-friendly for one half of the

target users.

The objectives in this project are completed and the problem relating to the target

users, i.e., not involved them in the design process is also achieved using participatory

design process. The inclusion of end users in the design process has helped a lot and

the end users are very satisfied with the design. Finally, the lack of awareness in the

end users about the available information through websites and providing user friend-

ly website holds the key for targeted user’s involvement in the websites.

6.1 Evaluation

The overall design of the web-based DEMTEC turned out to be as expected as user

friendly to one half of the end users. The improvisation in content management and

involving the people with dementia and their carers in participatory design process is

the two tasks that would have been performed in further days of this project.

13 www.turning-the-tide.org/files/NAOMIE%20handout.pdf

36

6.2 Future Work

This Human computer Interaction (HCI) project was an attempt to improve the daily

experiences of people with dementia, carers and health and social care professionals

by improving the communication skills between them. This was of course just a very

small study and small-scale design. There are a number of improvements that can be

done to iterate the website in the future:

Login facility for users. Use of this facility will improve the security features for

the website so that all the comments and feedbacks can be monitored. Also, this

will help in separating targeted users in using other user’s information which is

not dedicated to them.

Online chat. Providing online chat to the targeted users will increase the user’s

involvement to the website, i.e., if a health and social care professionals is

providing an online support for people with dementia and carers will reduce the

burden of visiting personally to get the advice.

Forum. Using this facility will bring together all the targeted users into one place

and information flow between the targeted users from the experienced people to

un-experienced people is very vital and will help in reducing the burden of users.

Tips. By providing daily tips for people with dementia and carers about what

activities they could do to support effective communication. Also can be done

during stressful periods and by providing information resources to improve the

state of mind and well-being of people with dementia and their carers.

Focus groups. Despite the efforts from DEMTEC authors the involvement of

people with dementia and their carers’ in this project was not possible due to the

time limit. Involvement of people with dementia and their carers’ in focus

groups meetings will make the website, i.e., web-based DEMTEC more user-

centred.

Acknowledgements. I am sincerely and heartily grateful to my supervisor

Dr Stephen Lindsay and Dr John Vines for their constant support and guidance shown

throughout my dissertation. I am sure it would have not been possible without their

help to reach this stage. Besides I would like to thank Dr Tony Young and their team

for their feedbacks provided on the design of this project. Also I would like to thank

Sourav Bhattacharya and Ankur Srivastava for proof-reading my dissertation and the

people who took part in the web-based survey which was conducted for this disserta-

tion.

Last, but not least, I would like to extend my sincere gratitude to my parents and

brother. Without their love, support and encouragement I could not accomplish this

work.

37

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41

Appendix

Appendix 1 – Source Code

Source code for all the designs can be downloaded from this web-address

http://www.sujithanand.com/projects/demtecsourcecode/

Appendix 2 – Web-based survey information.

The results of the survey can be viewed from the web-address below

http://www.surveymonkey.com/MySurvey_Responses.aspx?sm=qgH65m7Uhr6H82rmZYhYs

uPE4AhJHGB7%2bZ0neNyMKA%3d

Username – suj009

Password – sujith5999

Appendix 3 – Feedbacks from Stakeholders.

They below are the feedback from Stakeholder B for the first design of web-

based DEMTEC

Initially difficult to identify the main title of the website, i.e., where to draw

the eye.

DEMTEC, top left is the largest but on a blue background, reducing the im-

pact. The 2 smaller ones below are backed onto white, therefore giving a

more pronounced effect but of the same colour as the main title, making a

‘title’ difficult to establish.

Recommendation: Have a more impactful title. Either have the top-strip as a

smaller banner for overall navigation and have the white backed one larger

or change the top one to larger/more impactful colour. Also should the EM

in DEMTEC be slightly smaller on design? i.e. DEMTEC

The strap line, ‘DEMENTIA TOOLKIT FOR EFFECTIVE

COMMUNICATION’ breaks a readability rule regarding UPPERCASE

verses mixed. e.g., as in motorway road-signs. (The ‘Basic Skills Agency’

produces a simple ‘Readability’ doc.)

I know this b*ggers with the idea behind the different colours in the white

backed version in the middle but the ‘title’ at the top and the one on its side

do not make use of this anyway. Having said that I do like the idea of the

42

different font to illustrate where the DEMTEC name comes from so I would

say flog this idea to death on every bit of promotional material we have –

this is the Brand!

Not sure why the DEMTEC logo is on its side on the left at all – it just con-

fuses matters and suggests to me that someone just wants to fill space, rather

than convey a message or make the website simple to use (I think we should

resist the fear of being too simple).

The member access section should form part of the top ‘strap line’ or be ver-

tically aligned on the right hand side as in most other websites. The font

colour is also a bit light and unassuming and does not invite those not a

member to sign up, i.e. ‘Register’ with the site.

‘Welcome to’ is too small and unassuming. I am not sure about the font for

‘DEMTEC’ title in the middle would be good to have some options – again

this is to be the brand forever! - The text below detailing the concept is too

small, too closely spaced and does not make use of the two-colour text

idea. Someone perhaps thought of this then decided against it as the second

word ‘Dementia’ has a capital whereas no other mid-sentence word does?!

Too many concepts in too short a paragraph. Shorter sentences with clear

message. One concept here only – what is DEMTEC. The ‘choose a tab’

invite should be separate and much more inviting and obvious for the sec-

tions below – so people do not have to read the blurb about what it is if they

don’t want to or can figure it out for themselves.

The last concept here on feedback is not central enough to be on the first

paragraph; seems too early to be asking for people to commit to before being

sold on the idea. Also ‘and take a look’; ‘please give feedback’ – sounds a

bit desperate and does not highlight the interactive/collaborative approach

enough.

I like the 3 main options in terms of navigation but would benefit from a

quick-navigation panel to jump directly to where you want – e.g.,

rums. This would bug me if I was a regular visitor and had to wade through

too many options. I suppose it’s a balance of simplicity and

ty. Also would it be useful to have an icon somewhere (again? navigation

bar) to make layout etc more or less complex according to audience. I as-

sume this was the intention of the 3 levels (with different content for differ-

ent audiences) but this ‘readability’ could be a separate feature. There also

doesn’t seem to be a section for PLWD.

The pictures for the 3 sections are nice and convey well – a bit over-

emphasised on the medical angle though. I think these risks alienating the

lay audience, who are a key part of our demographic. My initial reaction

was ‘like a bupa website’ – felt a bit too clinical (although I liked the clear

43

lines, clarity of message and simple layout). Could have an extra explana-

tion when hovering cursor over the pictures.

An ‘about us’ link on the main page (e.g., as part of navigation bar or some-

where on the front page) would be good.

They below are the feedback from Stakeholder C for the first design of web-

based DEMTEC

The graphics are weak and some simplification of sentences is always a good

thing. Can we get someone to look at graphics for us? It's not an area of

strength for me.

I'm not sure about navigational routes because I have trouble conceptualising

it but I suspect Dave is right.

They below are the feedback from Stakeholders A, B and C for the first design of

web-based DEMTEC

Overall, the mock-up is a good start - thank you very much for your good

work so far!

We definitely need a big, prominent and recognisable 'DEMTEC' logo -

could you please give us some suggestions/ideas/possible ones to look at?

Overall, things need to be made simpler to look at, less light colours, more

bold, and with a very simple and direct 'look' that will be easy for older peo-

ple to look at and use

Generally, the pages are too text-heavy. Could we have less text per page,

with more links to other pages (so more pages, but each with less text)?

The pictures so far are rather 'clinical' - could we have more overall (at least

2 per page), and not of doctors and business people, but (ideally) of older

people (who look 70+) interacting with middle aged people (50ish) - this will

reflect the realities of most care situations. Generally please, lots of pictures,

etc.

Could the navigation tabs be removed to the side on most of the pages?

We don't want people to have to fill a form in to use the site - could this be

removed? We will need a counter, ideally indicating the national location of

the user, and a good feedback section asking for both comments and evalua-

tion - but only 1 page, we think, easy to use, etc.

44

They below are the feedback from Stakeholder D for first design of web-based

DEMTEC

Even with the addition of the navigation bar to the homepage, I think I'd be

inclined to add something providing a clear link to more information about

what DEMTEC is -- i.e., as well as having the 'About/FAQs' tabs in the nav-

igation bar, I'd have some sort of "For more information ..." or even "New

visitors start here" kind of statement and link on the homepage that would be

a clear starting point for people who are a bit at sea when it comes to navi-

gating a website (though I don't think you'd want this to detract from the

clarity and simplicity of the three big user panels).

Speaking of the three big user panels. The text isn't aligned the same in each.

The text in the 'Family Carers' panel is slightly higher in the box than that in

the other two.

The 'Carers' and 'Health Experts' pages have buttons providing options to

'read HTML version' and 'read PDF version'. I'd steer well clear of using

terminology like HTML and PDF, at least in the first instance. Things like

"Read the DEMTEC Toolkit online" and "Download the DEMTEC Toolkit

to your computer" would be better I think (admittedly the latter would prob-

ably need to state somewhere that what you're getting is a PDF, which there-

fore requires Adobe Reader, or a similar program).

The 'Case Studies' page appears to be largely the same (in terms of content)

as the 'Scenarios' page. The alignment of the text on these pages (flush

against the very edge of the text boxes) adds to the sense of an overcrowded

page.

Thinking about accessibility and readability, I wonder if it would be a good

idea to add some option onto the pages themselves to make the text bigger.

Obviously, any user can elect to make a webpage (and thus its text) bigger

by using the zoom function of their browser, but given that you're looking at

users who are less familiar with this sort of thing, maybe a nice clear button

that says something like "Enlarge text on this page" (with an accompanying

"Reset text on this page") would be useful. I believe that this kind of thing

can be done through appropriate code in the/a CSS. If you go down this

route, then you might also think about giving users the option to change the

colour scheme, if possible (e.g., offer a 'high contrast' theme to improve

readability).

The pictures. You and Dave note that these look rather clinical. They are also

clearly stock photos -- for example, the old woman in the wheelchair in the

Social/Health Professionals panel on the homepage (who appears again on

the Family/Social Carers page) can also be found on the following sites:

o http://www.carersuk.org.uk/ [approx. 2/3 way down]

45

o http://www.cardiff-home-care.co.uk/penarth.html [page banner -

same image as DEMTEC homepage]

o http://www.healthezine.org/facilities-for-senior-care-in-somerset-

county.html

o http://www.publicfinance.co.uk/news/2012/02/mps-call-for-joint-

commissioning-of-health-and-social-care/

They below are the feedback from Stakeholder D for the second design of web-

based DEMTEC

Some link on the homepage for new / 'inexperienced' users that will take

them to a (fuller) guide on what the website is and how it is structured. This

could simply be a way of highlighting and directing people to the 'About us'

section (obviously the content of this section would need to be expanded;

currently it is just a few sentences on the authors).

Removal of remaining references to "HTML" etc. e.g., under the

Carers' and 'Health Experts' tabs.

Addition of options to increase the size of text and change text color (reada-

bility options).

The 'Case Studies' and 'Scenarios' sections are still essentially the same. Su-

jith said that you had indicated a need for both sections (but presumably not

with exactly the same content?).

Reduction in the amount of text on some pages and/or editing of the text to

reduce further the length of paragraphs/amount of text on individual pages,

etc. (I'm happy to start looking at that this week, if you wish, to kick start the

process of producing suitable 'web versions' of the text.)

Other issues (not vital to 'road-testing' this particular mock-up).

Photos -- Sujith has found some new (and more varied) pictures, and inte-

grated them very nicely into the pages. However, it occurred to me after I'd

spoken to him that he seemed to be working on the assumption that any pic-

ture that comes up in a Google image search is free to use (in the final web-

site). This really isn't the case -- see e.g.,

http://support.google.com/images/bin/answer.py?hl=en&answer=9299. The

thing that made me think this was how he was approaching it was a reference

he made to put a 'disclaimer' on the site to the effect that you will remove an

image if someone (the owner) asks you to. At first, I thought he was refer-

ring to pictures that users might send in with their stories/experiences. But in

hindsight, I think he may have meant this more generally. Now, I suppose

you could proceed on this basis -- a picture found through Google image

search may well not have a clear statement of copyright, so you could work

46

under the assumption that you can use everything, with a 'promise' to remove

immediately items that a copyright holder objects to. And it could be that

nobody will ever make such an objection. I don't think that would be consid-

ered best practice, though (especially with most of the photos clearly being

stock images). One of the things I was going to do this coming week was

collect a large number of potential images. I've found one site

http://www.freedigitalphotos.net/) that does indeed offer absolutely free

stock images (they make their money by selling the larger resolution ver-

sions). If I combine what I can find here with other possibilities that can be

bought from the royalty-free stock image sites I mentioned to you, that

should (hopefully) give a reasonable number to pick and choose from, while

also keeping down the cost.

Another photo issue. I mentioned to Sujith the desirability of having photos

on all pages, including the scenarios/case studies pages. He suggested that

this would be difficult, because the pictures would need to match the details

of the case study story. How concerned are you at the matchup between the

photos and the case studies? e.g., providing that a case study about an old

man had a picture of an old man, would you be any more concerned about

how they matched up?

I wondered whether it would be useful to have some sort of 'index' / sum-

mary for the Case Studies. In other words, rather than going directly to "Sce-

nario 1" (and with the option to choose "Scenario 2" etc. in the left-hand

menu) when you click the 'Case Studies' tab, I wondered whether there

should be a list that indicates, e.g., that Scenario 1 deals with a 68 year old

married male (plus any other key details) and so on for the other scenarios.

In a similar vein, I wonder if the pages of text for each scenario / case study

should highlight the key themes and/or key terms, and perhaps even provide

links to other scenarios / case studies that deal with similar themes. (Natural-

ly this would only really work well if you have a sufficient number of [dif-

ferent types of] case studies.)

There are references on various pages to the 'Long' and ‘Short’ versions of

the toolkit. Would there be better as 'Full' and 'Summary' or something?

What will the Gallery section be used for exactly?

What does someone achieve by Logging in? (i.e., what is it that they get that

an unregistered / 'unlogged' user doesn't get?)

The top right corner of the pages has the Twitter / Facebook /YouTube log-

os. What will you get from following these links? I notice that the 'Social

Media' section of the menus at the bottom of the pages have "Follow us on

Twitter". It's a great idea to tap into social media, of course, but do/will you

47

have someone in place who can deal with keeping these things updated? (We

considered such things for DECTE, but had to leave them for the moment,

because there was no provision for monitoring them.)

In a similar vein, in the Family Carers / Social Carers section the 'People

looking for Advice' panel takes you to a page that invites queries with "Enter

details below to get advice". Will someone be in place, or in a position, to

deal with these queries (and reasonably rapidly)?

Also on the Family Carers / Social Carers section, there is the 'If you want to

narrate a Story' [nb. capital for story?] panel. Might this be better as some-

thing like "Share your experiences". When you get to the page itself, I pre-

sume there will be some (clearer) indication of how these stories are going to

be dealt with, where these stories are going to go (on the site), the

terms of use/privacy, etc.

Just looking at these last two points has made me wonder -- on the homepage

there are the three user panels for the different kinds of users: Family Carers

/ Social Carers / Professionals. Choosing "Family Carers" or "Social Carers"

takes you to the same place. So what's the difference between these two

groups?

Also the 'introductory page' you go to from selecting

one of these homepage user panels isn't the same as the page you get to from

selecting 'Carers' (note only one option covering both Family Carers /Social

Carers) or Health Experts (note not called 'Social/Health Professionals) in

the

navigation bar. The latter seems to take you to a 'deeper level' of the user

section in question.

I realize that having the homepage panels and the navigation bar tabs take

you to the same place may seem like a duplication, but there have been a few

times as I've been navigating through that I've been trying to get back to the

'introductory page' for a user type and have gone to the navigation bar link,

before remembering that I'll have to go back to the homepage and click on

one of the user panels.

They below are the feedback from Stakeholder A for the final design of web-

based DEMTEC

Thanks for this - and well done! In terms of architecture, this is a big im-

provement. It looks good and is easy to navigate, very professional- a good

basis for what we'd like DEMTEC to be. It is also great that it is so easily ac-

cessible.

48

Appendix 4 – Testing (Test cases and flowcharts)

Testing all the hyperlinks, feedback and commenting facility are working from social

carers point of view.

Table 4. Test case for Social Carers.

Test Description Test Case Input Expected Output Actual Output

Home Click on the

home button in

the navigation

bar in the home

page

It should display

the home page

It will display the

home page

Social Carers A) Click on so-

cial carers option

in the home page

It should display

social carers page

with four options

It will display

social carers page

with four options

B) Click on to

read DEMTEC

toolkit

It should display

DEMTEC toolkit

for social carers

page with two

option, one to read

full version and

another option to

read summary

version

It will display

DEMTEC toolkit

for social carers

page with two

option, one to

read full version

and another op-

tion to read sum-

mary version

C) Click on to

read full version

option in

DEMTEC toolkit

for social carers

page

It should display

DEMTEC toolkit

full version for

social carers page

It will display

DEMTEC toolkit

full version for

social carers page

D) Type some

comment in the

social carers

page

It should display

the typed comment

in the same page

with the name as

anonymous

It will display the

typed comment in

the same page

with the name as

anonymous

Home Click on feed-

back option in

the navigation

bar

It should display

the feedback page

with form fields

It will display the

feedback page

with form fields

Feedback Enter name,

email, subject,

rate this website

and your mes-

sage and click on

send button

It should send the

message without

error

It will send the

message without

error

49

Testing all the hyperlinks, feedback and commenting facility are working from So

cial/ Health Professionals point of view.

Table 5. Test case for Social and Health care professionals.

Test Description Test Case Input Expected Output Actual Output

Home Click on the

home button in

the navigation

bar in the home

page

It should display

the home page

It will display the

home page

Social/Health

Professionals

A) Click on so-

cial/health pro-

fessionals option

in the home page

It should display

on social/health

professionals page

with one option

It will display the

social/health pro-

fessionals page

with one option

B) Click on to

read Full Ver-

sion

It should display

DEMTEC toolkit

Full Version for

social/health pro-

fessionals

It will display

DEMTEC toolkit

Full Version for

social/health pro-

fessionals.

C) Type some

comment in the

social carers

page

It should display

the typed comment

in the same page

with the name as

anonymous

It will display the

typed comment in

the same page

with the name as

anonymous

Home Click on feed-

back option in

the navigation

bar

It should display

the feedback page

with form fields

It will display the

feedback page

with form fields

Feedback Enter name,

email, subject,

rate this website

and your mes-

sage and click on

send button

It should send the

message without

error

It will send the

message without

error

50

Testing for social carer’s random movement in the website.

Table 6. Flowchart of testing social carers random movement through website.

Home page of web-based DEMTEC

Click on Social carers option

Click on people looking for advice

Enter the name, email, subject,

rate the website and your message in feedback section and

click on to the send button

Click on stories in navigation bar

Write a reply and click on submit comment

Click on About us page in navigation bar

Click on Home page in navigation bar