Information Design in Healthcare: Critique of a Journal Article (Part 2. Critical Analysis)

In this follow-on article, the seven main claims of the authors receive a critical evaluation.

Claim 1: Health forms are not well designed

The authors main claim is that typical forms used by the medical profession to collect patient data are seldom well designed, resulting in potential loss of data. This claim constitutes the kernel of the hypothesis they tested. Subsequent claims provide supplementary empirical/theoretical argument.

Claim 2:  “Satsificing”, [the] complex cognitive process, and the three factors of responsiveness

These three interrelate. Simon’s concept of “satsificing” (1957) and Krosnick’s (1991) claim that users perform a complex cognitive process when answering survey questions seem connected through Krosnick’s argument (1996) that three factors increase the likelihood that a person responding to questions might begin to “satisfice”.

In short, insufficiently motivated respondents tend toward providing satisfactory rather than optimum answers. Decades ago, satisficing was probably a valid term for whatever context to which it referred. The source of this term is not discussed, so its suitability is a matter of opinion on the part of the authors, and trustful speculation on the part of the critical reader. These days, people encounter forms, surveys, and questionnaires on a daily basis, and are thus much more familiar with their conventions and shortcomings than they were nearly 70 years ago. This raises the issue of whether this term, even if its coinage was originally pertinent to respondent/form interaction, remains applicable.

Claim 3: Surveys should be viewed as a special case of social exchange

According to Dillman (1978), survey completion is a unique form of transaction. This seems sensible enough, but its basis is not explicitly presented. The value component of the exchange is unclear. ‘Rewards’ is possibly an irrelevancy in the medical context, since completing a health form is undoubtedly in the patient’s own interests.

Claim 4: Complaints about health forms are common

According to Bagin and Rose (1991), health surveys are a common cause of patient complaint. These researchers present a highly circumscriptive, ambiguous, and open-ended list of sub claims/respondent complaints, but provide neither definition of ‘health form’ nor accounting for variation in type or subject matter, an oversight that relegates these key issues to the status of discountable, extraneous factors. Of the complaints that the authors of the cited study report, ‘forms too complicated’ and ‘words too difficult’ suggest respondents’ problems stem from more than form design alone, if indeed such complaints were commonplace among respondents to health surveys (the list is based on a study of unspecified surveys and forms). Explanations of problems respondents might face with regard to words and form complexity are likely to differ according to the subject of the form, but this is not discussed. It is equally probable, of much greater potential significance, and similarly unmentioned, that, for the purposes of this study, health literacy, not the form’s design or its words, ought to be discounted as the primary obstructive element before other issues can be isolated as culpable factors influencing respondent feedback.

Claim 5: Forms should be better designed

There are no examples of bad or good forms – only the repeated claim that forms are generally defective.

• Couper and Groves (1996): Not all factors are within the designer’s control. Of course not, but more factors might be within the designer’s control than may be assumed, depending on the designer, resource factors, and the nature of the health form – conditions not represented in this claim.  The respondent’s environment constitutes variables that are outside the designer’s control. But variables such as user environment factors are inherent and intrinsic potentialities that affect any form of communication, and are inevitable, largely unavoidable, and far from unique to health forms. If the designer were able to counter foreseen negative factors, alternative negative effects might be created (especially if usability testing was overlooked in preference to pure presumption on the part of the designer), as the form might suffer from limitations caused by over-design or over-thinking, which could handicap the form’s usability as much as, or more than, the factors being designed out. (This is however, supposition based on supposition.)
• Creators of forms might know nothing about Information Design. Again, more assumption. Although it is incontestably true that they might indeed know nothing, we are uninformed regarding the basis for this claim. Formal qualifications in Information Design, and even Technical Communication in general (if this is the kind of thing the authors of the study consider to be knowledge), are a fairly recent innovation and so it is unlikely that physicians or health care experts will have such a background, but this does not mean all form creators uniformly lack any understanding of methods for making their documents or surveys effective. It is perhaps more plausible that creators are not familiar with or do not acknowledge ‘Information Design’ to the satisfaction of advocates and practitioners of that discipline, or (even more likely) they might not be applying their knowledge for reasons that are invisible to the authors of this study.
• Designers are not sufficiently aware of the audience of their forms. No direct evidence for this is presented.  Implicit in this assumption is the notion that audiences are better evaluated and communicated to using methods tested by Information Design experts, but this is the hypothesis being tested, not freestanding theoretical or empirical support in its own right.  
• Small changes in wording, format, and ordering can improve responses. It is so difficult to imagine any reasonable refutation to this claim that its validity as theoretical argument is questionable.

Claim 6: Information Design borrows from many fields

[Information Design] is an ‘eclectic’ field that borrows from many fields (technology, psychology, and ergonomics amongst others) and it is for this reason its literature is ‘impoverished and scattered’. So it is no surprise that form creators have no training or experience with the principles of Information Design. (Schriver, 1989)

But could the very opposite, for exactly the same reason, be true? Perhaps the strength of the field lies in its transparency within and distribution across so many disciplines, since such ubiquity would expose it to practically every professional in whatever his/her field. Is the problem more one of form creators simply failing to realize that their routine methodologies constitute Information Design in practice? Is it similarly possible that survey creators find no need to identify their methods as ‘Information Design’, they being more concerned with product than process? Or, again, are survey creators merely deficient in the skills of application, or constrained by institutionally imposed variables?

Claim 7: Form designers fail to analyze their audiences sufficiently well

Schriver roots this deduction in a study investigating teenagers’ attitudes to drugs – where the designers of a questionnaire failed, not surprisingly perhaps, to obtain satisfactory feedback. But could Schriver have found a less potentially contentious survey to demonstrate her point? As an age group, ‘teenagers’ are as multifarious as any other, and arguably the most difficult to analyze. Moreover, ‘attitude’ is notoriously problematic to define let alone quantify. And then, the highly emotive nature of the subject of the survey brings to bear a range of psychosocial factors that are likely to confound matters yet further. All in all, such a survey is highly probable to elicit a good quantity of false feedback, and its suitability for illustrative purposes is therefore disputable. Considering the overt lack of obvious commonality that health forms and Schriver’s case survey share, conclusions and expostulation drawn from a study of teenagers’ attitudes to drugs might, at best, be of limited relevance to the specific issue of Information Design in relation to general health forms.