Designing an Online Appointment System for Semiliterate Users
, Fakhra Batool
, Abdul Hafeez Muhammad
and Ansar Siddique
Department of Computer Science, Bahria University Lahore Campus, Punjab 54600, Pakistan
Department of Software Engineering, University of Gujrat, Punjab 50700, Pakistan
Corresponding Author: Ansar Siddique. Email: firstname.lastname@example.org
Received: 28 December 2020; Accepted: 14 February 2021
Abstract: Information and Communications Technology (ICT) has revolutionized
the healthcare leading to provision of eHealth facilities remotely. During the peak
time of COVID-19, as the long queues at health care facilities can result in spread
of the virus. ICT can play an effective role especially for reducing the extended
waiting time of patients to consult a medical practitioner which is considered
as a source of hazard during the pandemic. However, in developing countries
where majority population is semiliterate so ﬁnd difﬁculty when come into
contact with appointment systems which are not particularly designed keeping
in consideration the requirements of semiliterate users. It is extremely important
to better understand how to design user interface which allow semiliterate users
to effectively perform the tasks. So there is a dire need to develop a simple,
effective, easy to learn user interface (UI) of an online appointment system for
the productive doctor-patient consultation. Therefore, this study aimed to
providing an effective user interface of web based online appointment system to semi-
literate users through User-Centered Design (UCD) methodology. To achieve this, a
prototype was designed to overcome issues in the existing appointment systems
gathered through a ﬁeld study. The needs and expectation for semiliterate users were
fulﬁlled by incorporating the requirements of UI development for the target users. A
sample of forty-two semiliterate users was used to evaluate the prototype. The
evaluation results showed that semiliterate users’performance measured using—
effectiveness, efﬁciency and satisfaction signiﬁcantly improved while interacting
with the prototype as compared to existing interfaces. The effectiveness is measured
through number of errors and tasks accomplished in UI, efﬁciency by the time
required to complete the task and satisfaction by System Usability Scale (SUS).
The SUS score improved from 50.8 to 77.6 for the prototype.
Keywords: Information and communication technology; human-computer
interaction; user-centered design; e-health; semiliterate users
The advancement in Information and Communication Technology (ICT) has revolutionized the various
sectors such as such as healthcare, agriculture, education, defense, media, manufacturing, and many others in
This work is licensed under a Creative Commons Attribution 4.0 International License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Intelligent Automation & Soft Computing
delivering services effectively to the stakeholders . The prevailing situation of Corona Virus Disease
(COVID-19) stressing the importance of technology innovation in providing the safe and effective health
care services in order to support good health and prevent population from the infection . However,
adapting to ICT solutions is still a challenge as most of the applications provide textual interfaces which
are difﬁcult to be comprehend by semiliterate users . A large number of world population is consisting
of semiliterate people which are almost 773 million of world populace, mostly living in developing
countries . The term ‘semiliterate’means a person who is unable to read or write with ease or ﬂuency
. A great number of computer application present an ease of access challenge to those who are unable
to read ﬂuently. The hefty use of text over the interfaces of computer applications make it difﬁcult to
access such applications especially for those who are semiliterate. A major obstacle in delivering service
through ICT means is that the large number of user are semiliterate . On the other hand physical
access and interaction to service providers has been abated due to COVID-19 pandemic as it spread from
human to human by droplets or by direct contact and has taken the death toll to millions across the globe
[6,7]. To curtail the infection, strategies including smart lockdown and social distancing were practiced
by most of the countries . These circumstances have resulted in restricted access to basic facilities for
humans including basic healthcare facilities where access to hospitals is limited, due to fear of the
pandemic. However, some patients who require medical consultations during the pandemic need to
follow guidelines speciﬁed by the authorities and practice the precaution steps while waiting for their
turn. ICT has provided various solutions for eHealth, varying from containment of the COVID-19,
prescription, awareness to facilities. Patient overcrowding due to medical appointments can result in the
spread of coronavirus and to avoid this situation there is an urgent need of an Online Appointment
System (OAS). Although many hospitals and polyclinics offered facility of an OAS but it is difﬁcult for
users to book appointment through these systems. As majority of the population (i.e., around 60%) of
developing countries (e.g., Pakistan) resides in rural areas which have poor literacy skills as well as they
avoid the use of technology. Their major interaction with technology is the use of phones for
synchronous voice communication . They are not as effective as literate people so remain unable to
book an online medical appointment which indirectly caused increasing health issues due to untreated
illness and improper medication consumption without doctor’s consultation. The design of existing OASs
does not accommodate the limitations of semiliterate that is why they can’t directly interact with them
and always rely on external assistance to perform the task. Only less than 40% of the population of
developing countries can take beneﬁt from such OASs. In the presence of innovative digital technologies,
patients in rural areas and those who do not have access to healthcare professionals in remote areas of
developing countries cannot be relegated to a powerless position. As per author’s knowledge, so far, there
is limited research is available on designing healthcare systems especially OAS for rural semiliterate
community . It has shown through research that semiliterate users varied from literate user with
respect to their low cognitive processing speed, low memory, ICT skills and low ability to process
language. Language barrier becomes a major constriction for semiliterate user while accessing digital
service including healthcare services, banking services and other online services. Moreover, the literate
and semiliterate population of developing countries is different from each other in terms of their life
experiences, expectations, needs and difﬁculties. It will not be favourable to imitate the western-centric
interface, symbols and feature without analysing in detail the requirements of semiliterate users of
developing countries. The use of multimedia (i.e., images, audio, animations and graphics etc.) to design
interfaces can potentially facilitate the semiliterate users . This research premised on the belief that if
the user interfaces designed well, user would not have any need of formal literacy, ICT skills or external
aid to operate the computer applications. Therefore, the primary objective of this study is to provide
useful online appointment system to the semiliterate users, with a user interface designed in such a way
that semiliterate users required absolutely no external assistance from any person at all to operate. To
achieve this goal, user cantered design methodology was employed in order to understand and
380 IASC, 2021, vol.28, no.2
accommodate the needs of semiliterate users and to design corresponding prototype that was also evaluated
by semiliterate users in real environment. The major research questions investigated during this study are as
(i) How to design interfaces for semiliterate population of developing countries? (ii) What particular
challenges involved in the design of interfaces for the semiliterate user of developing countries? (iii) How
the interface product could be developed especially for semiliterate users? (iv) How the interfaces
designed considering the needs of semiliterate facilitate them?
Rest of the paper is organized as follows: Section 2 presents the literature relevant to online appointment
systems. Section 3 is about the research methodology. In section 4 we present and discuss the ﬁndings of this
study. In section 5 the recommendations related to interface design are presented. Finally, in section 6 we give
our conclusion and future work.
2 Literature Review
It has been shown through research that semiliterate users get easily confused and distracted while
working with software application especially information intensive applications such as web based ones.
They usually took more time and longer steps to complete the task as well navigate slowly the desired
pages in comparison to those users who are high literate. Several research initiatives have been taken to
design OAS for semiliterate users in developed countries. As an OAS was introduced in 40 different
healthcare institutions in Lithuania and the system increased the effectiveness of healthcare management.
The system has numerous advantages for the patients and is being steadily utilized . In Denmark, a
public health portal enables online medical appointment scheduling for patients which beneﬁted the
management where appointment conﬁrmation was performed via e-mail relieving them from being bound
to phone calls . Positive feedback was received from patients using an online appointment booking
system in Estonia, East Tallinn Hospital  where the system was regarded as convenient as the
appointment can be booked from any location. This ﬁnding is consistent with that found by  where
web-based online appointment system of China’s Xijing Hospital was preferred as compared to the
traditional queuing method due to lesser waiting time which increased patients’satisfaction level.
Likewise, a renowned hospital in Uganda has also launched an OAS . The Spanish Government
launched an initiative to implement online appointments to all healthcare centres in Spain
where12 million online appointments were recorded with 3,321 registered healthcare centres and 86% of
the citizens as the users . A study  in China claimed that patients have complained multiple times
about the long outpatient registration queue to book an appointment with a healthcare professional. On
the contrary, patients portrayed a positive attitude towards the advantageous online appointment system.
Astudy carried out in Iran, a developing country highlighted the importance of web-based OAS to
overcome the long waiting time of patients and increased administrative paperwork. The research was
supported by the Iran Ministry of Health where the system was encouraged to be implemented at a larger
scale. In another study, existing Indian OAS were analysed, usability issues were identiﬁed and a model for
improvement was proposed . A framework was proposed where both urban and rural populations to be
facilitated for e-health services including the appointment booking service with a doctor . Meanwhile,
in another similar study  an approach to provide OAS facilities for remote communities in developing
countries was presented. Dissemination of e-health services in developing countries speciﬁcally on the
appointment with doctor modules for patients using cloud services was also researched .
In Pakistan, e-health services evolved from telemedicine in 1998 in Northern areas. It composed of
different communication modalities comprising of video conferencing, web-based communication
systems, and telephone services that were used during the treatment and management of injured patients
and their rehabilitation due to earthquake in 2005 . Electronic Health Record (EHR) is also being
implemented in Pakistan where the Indus Hospital was the ﬁrst hospital to implement EHR .
Meanwhile, Shaukat Khanum Memorial Hospital  uses ORACLE hospital management information
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system. The Punjab Information Technology Board (PITB)  is a government institution working towards
the digitization of health, agriculture, education, and other sectors in Pakistan. A great work has been carried
out in the ﬁeld of e-health by PITB including systems such as e-vaccination, disease surveillance, dengue
activity tracking, biometric attendance for health facilities, polio monitoring, drug inspection and
evaluation, drug testing and laboratory automation, hospital and health watch. Many hospitals in Pakistan
offer online appointment facility via their websites and start-up companies are also working consistently
to develop OAS for facilitating users . Healthcare is one of the sectors given priority for digitization
for the beneﬁt of the community. OAS facility are also provided by various organizations. The author
 observes that the healthcare access has become easier than it has ever been before, as providing
facilities of the OAS. One of the main beneﬁts of these applications is to use it for patient appointments.
The paper states the statistics that in Pakistan and abroad more than 1.5 million users use these websites.
These websites are beneﬁcial to the community. However, the previous work done so far mainly
emphasized to provide online appointment facility to the mainstream population. The research on user
interfaces (UI) speciﬁcally UI of OAS for semiliterate users is limited. There is a need to accommodate
the needs of 60% urban population speciﬁcally to assist the semiliterate users in the digitized UI
interfaces in OAS domain . They should also take the beneﬁts of these systems. In our research,
semiliterate users were studied with regard to user interfaces and a prototype of OAS was designed to
measure their performance and satisfaction.
Human-Computer Interaction (HCI) has played a vital role in designing interactive products. User
Centered Design (UCD) is one of the commonly used development methods in HCI for building
interactive user interfaces. UCD process helps designers to understand the users’requirements
expectations from an interactive product. The needs and expectation such as easy-to-use, easy to
remember, effective and efﬁcient interfaces, there could be many other needs which depends on the
segment of population that is under study. UCD requires much effort, time and though to create an
interactive product because this process involves potential users in the design process, get their feedback
on everything from feel of interface to use of interface with ease and efﬁcacy. Resultantly, UCD creates a
usable, appealing and successful interactive product . It is therefore, UCD is known as a methodology
which enables useful, usable, and satisfying healthcare technology applications. Several studies have
utilized UCD approach to design e-health interfaces [27–29]. In this study, UCD was applied for the
development of OOBS.
According to the ISO 9241-2010  standard on UCD, four important steps should be undertaken to
incorporate usability requirements of semiliterate users into the design of online appointment systems. Such
four steps are as follows:
i) Understanding user and context of use
ii) Specifying the user requirements
iii) Producing design solutions
iv) Evaluating the design
In the ﬁrst phase, subjects were requested to use the existing interfaces for an appointment with their
medical specialist. At the end of users’interaction with the original interface, user’s suggestion, feedback,
and design recommendations were acquired. In the next phase, a prototype was developed and evaluated
by the semiliterate users. Both existing and proposed interfaces were compared to evaluate usability.
Further explanation of these steps is as follows.
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3.1 Step 1-Understanding User and Context of Use
End users have speciﬁc objectives to use a system. Therefore, in order to accommodate the users’
requirements into the system, the UCD process was utilized. The development of a system begins with an
understanding of semiliterate users’needs and expectations with regard to usability. The aim of this phase
is to understand as much as possible about the users, their work and the context of that work so the
system being designed can aid them in achieving objectives.
3.2 Step 2-Specifying User Requirements
This step is intended to collect user requirements as well as discover usability issues exist in existing
interfaces with respect to semiliterate users. The ultimate objective of this stage is to develop from the
needs identiﬁed, a set of stable requirements that establish a sound basis to make progress into thinking
about design activity.
3.3 Step 3-Producing Design Solutions
This step is meant to design a prototype in order to cater the needs of semiliterate users and usability
issues they face while interacting with interfaces of existing websites designed to make online medical
appointments. The prototype allows semiliterate users to interact with proposed interactive product to
explore intended uses as well as get some experience of using it in a real environment.
3.4 Step 4-Evaluation
The last step is performed to evaluate the envisioned product that users can use the product and how they
feel and experience about it. Moreover, this step is intended to evaluate the performance of semiliterate users
in comparison to existing to interface through different metrics. The user experience is measured using
different standard instruments.
4 Findings and Discussion
The ﬁndings of the steps discussed above are discussed below.
4.1 Findings of Step 1
In this phase, the functionality of the system concerning tasks to perform and the selection of users was
conducted. The ﬁndings of this this phase are as follows.
4.1.1 Literacy Levels of Users
School-based education is compulsory and free of charge for the ﬁrst ten years in Pakistan. Traditionally,
the education system speciﬁcally in Pakistan is divided into pre-primary (until class 2), primary (until class
5), and middle (until class 8) . In this study, participants were divided into three categories as shown in
Tab. 1. the users who completed: (i) pre-primary, (ii) primary, and (iii) middle education.
The purpose of this study was to evaluate different interfaces from the semiliterate users’perspective.
Therefore, our target subjects were the people neither completely illiterate (absolutely cannot read or
write) nor properly literate (beyond the middle education). The pre-experiment questionnaire was
distributed among participants to evaluate their traditional literacy skills and acquaintance with
technology. The questionnaire was translated into users’native language, Urdu. Its validity was veriﬁed
by an Urdu language as well as by an HCI expert. The subjects participated voluntarily in this study. The
selection of participants includes snowball sampling. Employees from a university, a nearby hospital, and
workers from a construction company participated in the experiment conducted in a metropolitan city,
Lahore. Participants’demographic characteristics and acquaintance with technology are displayed in Tab. 2.
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4.1.3 Task Analysis
Before the commencement of the experiment, the participants were briefed. Participants were also given
additional time to get acquainted with the system. There were three steps in the experimentation process:
The ﬁrst step was to complete a pre-experiment questionnaire, to know the users’literacy levels and
previous exposure with the technology.
The second step was to accomplish some tasks on the existing OAS, a locally designed website for online
medical appointments. It was divided into sub-tasks require to be performed to make an appointment.
The last task was about the completion of the questionnaire to determine the users experience.
4.2 Findings of step 2
The experimentation procedure was followed to collect users’usability issues with the existing interface.
The following steps were implemented for the collected requirements.
4.2.1 Experimental Setup and Procedure
The study was conducted at different organizations (university, hospital, construction company). All the
laptops used during the experiment were homogenous concerning the operating system. All the participants
received oral and written information about the project and their participation was voluntary. The participants
were given a consent form and were guided, and if they felt uncomfortable at any point they could withdraw
without any reason. The questionnaire assisted in identifying user ability to interact with technology. All
users were informed at the beginning of the study that if they do not feel comfortable with the
Table 1: Categorization and literacy levels of participants
Number of Participants
Education (Years) Male Female Total
Basic Users Pre-Primary Education (≤2 Years) 11 3 14
Moderate Users Primary Education (≥3 and ≤5 Years) 11 3 14
Expert Users Middle Education (6≥and ≤8 Years) 11 3 14
Table 2: Demographics and ICT related statistics of the participants
Participants Characteristics ICT Related Statistics
Demographic area Lahore, Pakistan Using simple cell phones 40.5%
Number of participants 42 Using simple phones 57.1%
Mean Age 28.7 Can handle calling only 19.0%
Age range in years 15–50 years Can handle messages 81.0%
Educational level range 0–8 ATM User 31.0%
User using the ICT devices 97.6%
User using own ICT devices 88.1%
User not owning ICT devices 9.5%
User interacting with ICT devices daily 61.9% Daily
User using the internet 61.9%
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experiment, or if they feel it is beyond their capability, or due to any other reason they decided to quit from the
experiment at any stage, the questionnaire should not be submitted and mentor should be informed. The
participants were also requested about their experience of using ICT devices for research purpose. Nineteen
participants were excluded from the study based on the pre-experiment questionnaire. Five guards of a
university and two janitors were found completely illiterate. One café employee and a maid from university
refused to take part in the study due to the unfamiliarity of technology. Three laborers were excluded from
the study as they were confused about the basic interaction with the keyboard and mouse. Seven female
participants were intimidated during the study and were excluded. Overall, the number of women was less
than the number of men due to a limited number of women working in organizations and construction sites,
however, the male-to-female ratio was similar among the selected groups.
4.2.2 Usability Evaluation of Interfaces
According to ISO 9241-11, usability is deﬁned as the “the extent to which a system, product, or service can
be used by speciﬁed users to achieve speciﬁed goals with effectiveness, efﬁciency, and satisfaction in a speciﬁed
context of use”. In this study, four usability metrics based on Nielsen  criteria for measuring usability
were used. These include task completion time, number of errors, number of tasks accomplished and
satisfaction. The afore mentioned metrics were used to measure the usability. Upon completion of tasks,
users’interaction and satisfaction with the interface was also determined. User satisfaction was measured
using the System Usability Scale (SUS)  and After Scenario Questionnaire (ASQ) .
4.2.3 User Interaction with Existing Interfaces
The users were not interrupted during the task performance, however, each user was closely observed by
a mentor. The mentor was present to guide the users and ensure smooth experiment.
4.2.4 Usability Barriers
The users were given an existing interface to perform various tasks to make an appointment with a
medical practitioner. Semiliterate users were observed for the following difﬁculties:
a) Language Difﬁculty: Users were unable to understand the terms as “speciality”or “name of diseases”
as the interface content was not in the native language which was a hurdle for the semiliterate users.
b) Typing Issue: Users felt difﬁcult in typing rather than clicking the interface.
c) Navigation Issues: Due to complex website structure, participants clicked the interface wrongly
d) Email literacy: The users were unable to understand the email address.
e) Other issues: Users were unable to read the name of cities and ﬁnd the required city during the task
performance. Most users were clicking the wrong item when they were directed to perform the
The graph in Fig. 1. illustrates the statistics of usability issues faced by the semiliterate users during
interaction with existing interface. These usability issues identiﬁed the areas to be taken into
consideration for the development of prototype. The most frequent issue faced by the users is in
understanding the speciﬁc terminologies of specialties and to input the email id.
4.3 Findings of Phase 3
The prototype was developed to overcome the usability issues highlighted when interacting with the
existing interface. It was designed in a way that semiliterate users can have a clear understanding of how
to interact with the interface easily. The bootstrap framework was utilized for the development of the
website was kept simple with all the functional aspects (i.e., Selecting speciﬁc specialty to make an
IASC, 2021, vol.28, no.2 385
appointment, Selecting speciﬁc doctor to make an appointment and Apply for online consultation with a
doctor) provided on the navigation pane of the website to reduce the complexity of web structure as
illustrated in Fig. 2. Navigation was linear with the absence of hierarchical structure. The tasks to perform
were made concise and simple. The webpage was designed in the native language, Urdu. Hand-drawn icons
were created for selecting a specialty to assist the semiliterate user as they can easily comprehend the hand-
drawn. A real image of a person was displayed and when clicked, vocal assistance was provided to the user
to decrease the textual content in the system and assistance in the form of real-life images was integrated.
On clicking the selection of specialty, a hand-drawn speaker icon provides text to speech functionality. If
the semiliterate users were unable to read correctly, they can click the speaker icon for audio support as
depicted in Fig. 3. Icons were provided along with caption and audio facility. After clicking the required
specialty, the user was directed to the webpage of a list of doctors available. Here, only the required
timing and book an appointment buttons were present. Less text was appreciated as it is easy for
semiliterate users to comprehend. Real life pictures of doctors and localization of text was provided to
capture the attention of the target participants.
After the selection of a doctor, the user was directed to the screen of booking date and time. Here, the
semiliterate user was provided with audio support and short video support to perform the task as illustrated in
Fig. 4. The next UI was directed for selection of time for an appointment with a doctor. Here, the number of
clicks was reduced. As the user clicks the time, participant was automatically directed to the next tab of
entering the participant’s phone number. The tasks breath was shortened by providing one webpage with
embedded tabs to complete the tasks.
Figure 1: Usability issues faced by semiliterate users
Figure 2: Screenshot of the main page of the prototype
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The user was provided with the interface to add user phone number in digits. When the “Submit”button
was clicked, the user was directed to the UI of task accomplishment of appointment with a doctor. The user may
provide feedback once a message indicating the completion of the task with audio support was displayed.
The login process was made as easy as possible. The original interface requires an email ID and setting
of a password. However, in this prototype the user entered his/her phone number and a code was generated by
the SMS server and sent to the phone. Now, the user can enter their code and gets logged in to the website.
Therefore, the interaction complexity was reduced. During the registration, the ‘login’module. The input of
city was in form of selection of pictures as shown in Fig. 5. The cities were indicated by the famous places of
which cities were recognized. Therefore, the mental model concept for semiliterate user was implemented.
The prototype also provided the facility of online consultation with doctor. Consistency was maintained
between the screens illustrated in Fig. 6. Same colors and pattern was followed in UI design. The input
automatically directed the user to the next tab for the completion of the task. Maintaining the consistency
video support was provided at each UI. In order to provide less interaction with the interface the users were
provided with recording module to record their disease and input the number to be contacted for later use.
Figure 3: List of doctors for an appointment
Figure 4: Appointment with a doctor
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4.4 Evaluating Prototype
The usability of interfaces was compared between the existing and prototype interfaces. The parameters
of Task Time, Number of Errors, Task Accomplished and Satisfaction through SUS and ASQ were analyzed.
4.4.1 Task Accomplished
For task completion, it was observed that the users entered valid data. If any ﬁeld in the interface is
incomplete, empty, ﬁlled with invalid data or makes no sense then it is not considered complete, e.g.,
numerical values in name or email address without proper structure. In the existing interface, only 55.1%
of the total tasks were completed by the users while in the prototype 83.7% tasks were completed. Fig. 7.
shows the comparison of the results between the existing interface and prototype of accomplishment of
the tasks. The graph illustrates the comparison of the percentage of tasks accomplished by basic,
moderate and expert user categories of each group. An independent sample T-Test was conducted that
shows the statistical signiﬁcance (t(2) = 8.4 > Tcrit(two-tail) = 4.3, P-value < 0.05) and reject the null
hypothesis that the tasks completed by all the users in existing interface and prototype are equal.
Figure 6: Online consultation with doctor
Figure 5: Login UI of prototype
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4.4.2 Number of Errors
The error metric measures the number of errors that occurred during a participant’s performance of the
test tasks. The errors included wrong clicks, wrong input. t-Test was conducted shows statistical signiﬁcance
(t(2) = 4.5 > Tcrit(two-tail) = 4.3, P-value < 0.05) and rejects the null hypothesis that the number of errors by
all the users in existing interface and prototype is equal. Fig. 8. simplicity shows that the number of errors by
basic, moderate and expert users in the existing interface was more signiﬁcant than the prototype.
4.4.3 Level of Success for Task Accomplished
The level of success is an important parameter. Levels of success for task accomplished are shown in
Tab. 3. Furthermore, the number of tasks not accomplished, tasks accomplished with and without error in
existing interface and prototype are illustrated in Tab. 3.
Figure 7: Percentage of tasks completed by each category of users for OAS
Figure 8: Number of errors in the existing interface and prototype
Table 3: Level of success of participants
Level of Success Existing Interface Prototype
Task not accomplished 45 16
Tasks accomplished with errors 41 51
Tasks accomplished without errors 15 32
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The graph bar of prototype illustrated in Fig. 9. the level of success in prototype. The graph illustrates
that the tasks accomplished and tasks accomplished with errors in prototype is higher, and the number of task
failure in existing interface is higher than the prototype. It proves tough the users were able to accomplish the
tasks in prototype with errors but in existing interface, they ultimately failed.
4.4.4 Task Time
Task Time metric concerns the amount of calculated time that it takes a participant to ﬁnish a selected
test task. It is important to question whether the meantime on the prototype was improved. In Fig. 10.itis
depicted the meantime variation found within basic, moderate and expert user categories of each group in
existing interface and prototype. Expert users spent the least time in interaction, in contrast to basic users,
who consumed the most time in interaction with the existing interface. There is a signiﬁcant difference
between mean time of accomplishing a task in existing interface and prototype. T-Test was conducted
shows statistical signiﬁcance (t(2) = 10.7 > Tcrit(two tail) = 4.3, P-value < 0.05) and reject the null
hypothesis that average time consumed by all the users in existing interface and prototype is equal.
After performing all the tasks on the existing interface and prototype the users were given a SUS
questionnaire to collect their feedback on the subjective usability of each interface respectively. The
average subjective usability of the prototype is 26.7% higher than the existing interface. The SUS score
for existing interface is 50.83 below average to the scale. However, for prototype is 77.6, which indicates
a satisfactory response. According to Tab. 4. it is depicted that basic user average score is 47.9 and
moderate user is 49.6, the score is below average, thus they showed least interest in the existing interface.
Figure 9: Level of success for both interfaces
Figure 10: Average time consumed by each category of user for OAS
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The average SUS score for prototype (M = 77.6, SD = 10.7) is signiﬁcantly greater than the SUS score
for the existing interface (M = 50.8, SD = 15.4). An independent samples t-test was conducted to compare a
newly designed interface with the existing interface. The conditions (t(2) = 13.5 > Tcrit(one-tail) = 0.002,
P-value < 0.05) illustrates a signiﬁcantly greater values of prototype than the existing interface. These
results shown in Fig. 11. suggests that the prototype resulted in a good SUS score by the users.
4.4.6 Ease of Use Rating
ASQ questionnaire was completed for both interfaces. It is shown in Fig. 12. the average user’s response
against all three questions of ASQ. Each question represents the usability metric efﬁciency, effectiveness, and
satisfaction in the interface. The results show that the effectiveness, efﬁciency, and satisfaction all have
higher ratings in the prototype.
Table 4: Average Score of SUS
Participants Existing Interface Prototype
Basic User 47.9 75.2
Moderate User 49.6 79.5
Expert 55.0 78.0
Figure 11: Average SUS Score for both interfaces
Figure 12: Rating of effectiveness, efﬁciency and satisfaction
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5 Design Recommendations
Helping semiliterate users to interact with computing devices is challenging and unravels more layers of
complexity as it is explored. Some recommendations that should be taken into consideration by designers
during the OASs development as interpreted from the results are as follows:
5.1 Avoid Rich Multimedia Support
During the evaluation of the prototype, it was observed that the semiliterate participants focused on one
item at a time in the interface. Those who cannot read utilized the audio support. As the abilities of the
semiliterate participants are limited, the interface should not be too cluttered that could hamper the ability
of the target user to interact with the interface. Rich multimedia are appreciated  but the cognitive
ability of semiliterate should be taken into consideration and interface provided should be simple enough
with not many modalities to avoid distraction.
5.2 Help Feature Assistance in the Video Was not Supported
Participants appreciated the help feature in an interface as exciting and exploring [37–39]. However,
during the experiment, it was observed that participants were confused when they have to seek assistance
using the help videos. No quantitative study was performed but it was observed during the
experimentation. Therefore, the tasks should be short and simple as possible; self-explanatory excluding
the need of watching videos for assistance. Participants did utilize audio support when they could not
read, but watching a half minute or a minute long helping videos were not appreciated.
5.3 Combination of Native Language and Digits
The localization concept mentioned in [36,40–42] suggest the use of local language. The prototype
interface was designed in the native language of users. In some studies, it was mentioned that semiliterate
users can comprehend Arabic numerals [43–45]. However, to the best of our knowledge, no literature that
reported on the comparison of native language numerals and digits for the semiliterate population.
Participants were comfortable in comprehending task in their native language, Urdu. However, they
preferred Arabic numerals than the numbers in their native language. It is suggested for future designers
to use Arabic numerals, avoiding numerals in the native language.
5.4 Hand-drawn or Real-life Images
The participants were provided with hand-drawn images of doctor’s specialty and real-life images of
doctors in the interface. Although hand-drawn icons were preferred according to the literature [37,46,47],
ﬁndings from this study showed that semiliterate users were more excited to see real-life images. A
combination of hand-drawn images and real-life images is recommended. The semiliterate population
easily understands the hand-drawn images while the real-life images were exciting for them to gain attention.
5.5 Replace Typing Input with the Recording Module
It was observed that the participants found it difﬁcult to type sentences using the keyboard. To overcome
this problem, they were provided with the recording module to record their issues for the doctor’s review
using the prototype rather than interacting with the hardware for typing as illustrated in Fig. 6. The target
population appreciated this module. Therefore, it is recommended to devise a mechanism that semiliterate
users have the least contact with hardware for text input. Although speech interfaces can be applied, more
effort is needed as errors encountered during speech recognition input may produce strings of text which
sound alike but different from words spoken by users. Even usage of different regional languages and
dialect of users can create an issue and requires an extensive development. Overall, easy and acceptable
UI design guidelines should be prepared and available for designers to implement at the front-end.
392 IASC, 2021, vol.28, no.2
6 Conclusion and Future Work
In this study, an OAS for semiliterate user prototype was proposed. This system can play a role in
disseminating ICT to all and control the digital divide. During the design process, it was discovered how
profoundly the various type of literacy challenges complicate a user’s ability to interact with the existing
interface. Apart from having difﬁculties in reading the textual information from the interface, the users
also faced challenges in interacting with buttons and menus, browsing a list of selections and even
understanding the graphics. However, the prototype showed that the performance of semiliterate users
improved signiﬁcantly. The usability of the system for the semiliterate users increased from 50.83% to
77.60%. Therefore, the recommended design guidelines should be incorporated during the interface
development for semiliterate users for better usability. The developed prototype is in the form of online
web application and can be extended as a mobile application for Windows Phone, iPhone and Android. A
portal can be established to enhance the interface according to the needs of users. Through the portal,
new variants and improvements of existing icons and features can be suggested. To increase the
scalability, some experiments can be performed to receive feedback from users on the icons for different
specialties. A different study can be conducted for the remaining specialty icon design in the interface
according to the requirements of target users. In future, a face recognition module can be added to
enhance the registration process. It is good for the semiliterate users to have the least interaction with
keyboard and mouse clicks to avoid high cognitive pressure. The recommended guidelines can be
incorporated into interface development for semiliterate users by exploiting ICT.
Acknowledgement: Authors thankfully acknowledge all those who contributed this work in any capacity.
Funding Statement: The authors have no speciﬁc funding.
Conﬂicts of Interest: The authors declare no conﬂicts of interest to report regarding this study.
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