title: Designing eHealth Applications to Reduce Cognitive Effort for Persons With Severe Mental Illness: Page Complexity, Navigation Simplicity, and Comprehensibility.
abstract: BACKGROUND
  eHealth technologies offer great potential for improving the use and effectiveness of treatments for those with severe mental illness (SMI), including schizophrenia and schizoaffective disorder. This potential can be muted by poor design. There is limited research on designing eHealth technologies for those with SMI, others with cognitive impairments, and those who are not technology savvy. We previously tested a design model, the Flat Explicit Design Model (FEDM), to create eHealth interventions for individuals with SMI. Subsequently, we developed the design concept page complexity, defined via the design variables we created of distinct topic areas, distinct navigation areas, and number of columns used to organize contents and the variables of text reading level, text reading ease (a newly added variable to the FEDM), and the number of hyperlinks and number of words on a page.
  
  
  OBJECTIVE
  The objective of our study was to report the influence that the 19 variables of the FEDM have on the ability of individuals with SMI to use a website, ratings of a website's ease of use, and performance on a novel usability task we created termed as content disclosure (a measure of the influence of a homepage's design on the understanding user's gain of a website). Finally, we assessed the performance of 3 groups or dimensions we developed that organize the 19 variables of the FEDM, termed as page complexity, navigational simplicity, and comprehensibility.
  
  
  METHODS
  We measured 4 website usability outcomes: ability to find information, time to find information, ease of use, and a user's ability to accurately judge a website's contents. A total of 38 persons with SMI (chart diagnosis of schizophrenia or schizoaffective disorder) and 5 mental health websites were used to evaluate the importance of the new design concepts, as well as the other variables in the FEDM.
  
  
  RESULTS
  We found that 11 of the FEDM's 19 variables were significantly associated with all 4 usability outcomes. Most other variables were significantly related to 2 or 3 of these usability outcomes. With the 5 tested websites, 7 of the 19 variables of the FEDM overlapped with other variables, resulting in 12 distinct variable groups. The 3 design dimensions had acceptable coefficient alphas. Both navigational simplicity and comprehensibility were significantly related to correctly identifying whether information was available on a website. Page complexity and navigational simplicity were significantly associated with the ability and time to find information and ease-of-use ratings.
  
  
  CONCLUSIONS
  The 19 variables and 3 dimensions (page complexity, navigational simplicity, and comprehensibility) of the FEDM offer evidence-based design guidance intended to reduce the cognitive effort required to effectively use eHealth applications, particularly for persons with SMI, and potentially others, including those with cognitive impairments and limited skills or experience with technology. The new variables we examined (topic areas, navigational areas, columns) offer additional and very simple ways to improve simplicity.
authors.affiliation: Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, United States.|School of Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, United States.|School of Medicine, Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, United States.|School of Medicine, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, United States.
authors.forename: Armando J
authors.identifier: http://orcid.org/0000-0002-7529-6753
authors.initials: AJ
authors.lastname: Rotondi
authors.affiliation: Information Science and Technology, School of Information Sciences, University of Pittsburgh, Pittsburgh, PA, United States.
authors.forename: Michael R
authors.identifier: http://orcid.org/0000-0003-2288-6757
authors.initials: MR
authors.lastname: Spring
authors.affiliation: Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, United States.
authors.forename: Barbara H
authors.identifier: http://orcid.org/0000-0002-2347-217X
authors.initials: BH
authors.lastname: Hanusa
authors.affiliation: School of Medicine, Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, United States.|School of Social Work, University of Pittsburgh, Pittsburgh, PA, United States.|School of Medicine, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States.
authors.forename: Shaun M
authors.identifier: http://orcid.org/0000-0001-6368-7004
authors.initials: SM
authors.lastname: Eack
authors.affiliation: Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh, PA, United States.|School of Medicine, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States.
authors.forename: Gretchen L
authors.identifier: http://orcid.org/0000-0002-3413-9196
authors.initials: GL
authors.lastname: Haas
keywords: Internet technology; cognitive impairment; e-mental health; eHealth; eHealth design; mobile application; schizophrenia; severe mental illness; usability; website design