Research

Health Environments Research

& Design Journal
2022, Vol. 15(1) 207-221
Barriers, Enablers, and Consumer ª The Author(s) 2021
Article reuse guidelines:
Design Ideas for Health Literacy sagepub.com/journals-permissions
DOI: 10.1177/19375867211032926

Responsive Hospital Waiting Areas: journals.sagepub.com/home/her

A Framework Method Analysis

Cassie E. McDonald, PT1,2 , Louisa J. Remedios, PT, PhD1,

Kate L. Cameron, PT1,3 , Catherine M. Said, PT, PhD1,4,5,
and Catherine L. Granger, PT, PhD1,2

Abstract
Aim: The study aim was to (1) investigate the barriers and enablers experienced by consumers to
accessing and engaging with health tools in hospital waiting areas and (2) evaluate consumers’ ideas for
designing a health literacy responsive waiting area. Background: Health information, resources, and
supports (“health tools”) in waiting areas should be responsive to the health literacy needs of con-
sumers. However, consumers’ experiences of using health tools and their ideas for improving them are
not known. Methods: Multicenter study was set in hospital waiting areas of outpatient rehabilitation
services. Semistructured in-person interviews were conducted with 33 adult consumers attending
appointments for various health conditions. Seven stages of the Framework Method were used to
analyze data. Results: Six themes were identified which explained barriers and enablers from the
perspective of consumers. The barriers were accessibility issues; personal factors—physical condition,
emotional state, and preferences; and poorly presented and outdated resources. The enablers were
design suits consumer needs and preferences; usable in available time or portable; and compatible
environment for engaging and sharing. Consumers shared design ideas which fit within four typologies.
Conclusions: A range of barriers and enablers exist which have an impact on consumers’ ability to
engage with available health information, resources, and supports in hospital outpatient waiting areas.
Practical insights from the perspective of consumers can be applied to future health service design.
Consumer’s design ideas suggest that partnerships with consumers should be formed to design health
literacy responsive waiting areas.

1
Physiotherapy, The University of Melbourne, Carlton, Victoria, Australia
2
Physiotherapy, The Royal Melbourne Hospital, Melbourne Health, Parkville, Victoria, Australia
3
Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
4
The University of Melbourne and Western Health, St. Albans, Victoria, Australia
5
Australian Institute of Musculoskeletal Sciences, St. Albans, Victoria, Australia

Corresponding Author:
Cassie E. McDonald, Melbourne School of Health Sciences, The University of Melbourne, Level 7, Alan Gilbert Building,
161 Barry St., Carlton, Victoria 3053, Australia.
Email: cassie.mcdonald@unimelb.edu.au
208
Keywords
health literacy responsiveness, health literacy, health information, resources, hospital, waiting area
Health information, resources, and supports are
commonly available for consumers in health ser-
vice waiting areas. Sharing health information,
resources, and supports (which we have referred
to as “health tools” from here on) with consumers
appears to be a long-standing, accepted, and rou-
tine practice internationally in primary care set-
tings (Blum, 1982; Gignon et al., 2012; Maskell
et al., 2018; Protheroe et al., 2015; Ward &
Hawthorne, 1994). Anecdotally, this practice is
also common in hospital waiting areas, although
there is considerably less research in hospital set-
tings (McDonald et al., 2020; Tony et al., 2013).
This practice of sharing health tools in waiting
areas is intended to contribute to the health lit-
eracy of consumers. Theoretically, health tools
can contribute to health literacy in a range of
ways, depending on their design and content. For
example, health tools can build consumers’
knowledge of health conditions, treatment
options, and health services or they can empower
consumers to think critically about information
when making informed decisions (Dodson et al.,
2017).
This practice of sharing health tools in
waiting areas is intended to contribute to
the health literacy of consumers.
Drawing from limited research in general
practice settings, health tools in waiting areas
show promise for contributing to health literacy.
One study in general practice waiting areas found
that health-promoting materials contributed to
health literacy by positively influencing con-
sumer knowledge, intentions, healthcare use, and
behaviors relating to healthy lifestyle (Cass et al.,
2016). Another study found that health informa-
tion and patient education in general practice
waiting areas are valued and used by patients and
clinicians (Williams et al., 2019). However, mak-
ing health tools available does not guarantee they
will be appropriate, accessible or used by consu-
mers. One observational study in hospital waiting
Health Environments Research & Design Journal 15(1)
areas found that available health tools were rarely
accessed by consumers (McDonald et al., 2020).
This finding raises the question: Why are consu-
mers not using available health tools in hospital
waiting areas? Potentially, this may be due to the
design, delivery, content, or complexity of the
health tools. Or perhaps other environmental fac-
tors may be impacting on consumers’ use of
health tools.
Other potential influences on health tool use
are indicated in the definitions of health literacy.
Health literacy can be defined at two levels: indi-
vidual health literacy and the health literacy envi-
ronment. Firstly, ‘individual health literacy’ is the
skills, knowledge, motivation, and capacity of a
person to access, understand, and appraise health
tools to make decisions about health (Australian
Commission on Safety and Quality in Health
Care [ACSQHC], 2014). Secondly, the ‘health
literacy environment’ is defined as the
“infrastructure, policies, processes, materials,
people and relationships” within health services
which have an impact on consumers’ ability to
access, understand, use, and appraise health-
related tools and services (ACSQHC, 2014). This
second definition highlights that there are many
environmental factors which impact on health
literacy. We propose that it is useful to concep-
tualize the ‘health literacy environment’ within
waiting areas as this highlights the myriad of
complex factors which may impact on consu-
mers’ ability to access and engage with health
tools in this setting. Previously, if consumers had
difficulty using complex health tools or navigat-
ing complex health environments, their low
health literacy was blamed (Frosch & Elwyn,
2014). Now the onus, appropriately, is on health
services to create health literacy environments
which are responsive to the needs of their consu-
mers (Liang & Brach, 2017; Lloyd et al., 2018).
However, there is limited empirical guidance on
how to create health literacy responsive environ-
ments in practice (Lloyd et al., 2018) including in
waiting areas.
McDonald et al.
This study focusses on hospital waiting areas
because: (1) it is common for health tools to be
available in hospital waiting areas; (2) developing
health tools requires an investment of time and
cost for hospitals which may be wasted if they are
not useful to or used by consumers; (3) to the
knowledge of the authors, no studies have been
conducted in hospital settings which explore con-
sumers’ perspectives on health tools in waiting
areas; and (4) understanding consumers’ experi-
ences is essential to ensuring that health tools in
hospital waiting areas are responsive to their
health literacy needs. A recent study confirmed
that consumers attending hospital outpatient reha-
bilitation want to use health tools in the waiting
area but many of the available items did not meet
their health literacy needs (McDonald et al.,
2021). Therefore, understanding the barriers and
enablers experienced by consumers using health
tools in hospital waiting areas is important before
we can seek to improve them.
Therefore, understanding the barriers and
enablers experienced by consumers using
health tools in hospital waiting areas is
important before we can seek to improve
them.
Method
Study Aims
1. To investigate the barriers and enablers,
from the perspectives of consumers, for
accessing and engaging with health infor-
mation, resources, and supports in hospital
outpatient waiting areas.
2. To evaluate consumers’ ideas for the
design of an improved health literacy
responsive waiting area.
For the purposes of this study: Barriers were
defined as factors preventing or limiting access to
or engagement with health information,
resources, and supports in the waiting area;
enablers were defined as factors supporting or
facilitating access to or engagement with health
information, resources, and supports in the wait-
ing area.
209
The concept of the ‘health literacy environment’
was used to inform the breadth of barriers and
enablers investigated in this study (ACSQHC,
2014). Barriers and enablers inherent in the
health tools (i.e., content of health information)
were considered alongside broader ‘health lit-
eracy environment’ factors which could impact
on consumers’ experiences of accessing and
engaging with health tools, such as infrastructure,
processes, and relationships occurring within the
waiting area.
Study Design and Setting
This was a multicenter qualitative study con-
ducted within a larger grounded theory study. The
study setting was the waiting areas of outpatient
rehabilitation services at two major tertiary public
hospitals in Melbourne, Australia. All sites had
ethical approval (HREC/43635/MH-2018) and
participants provided written informed consent.
These outpatient rehabilitation services
offered multidisciplinary, goal-based care to con-
sumers for a broad range of health conditions.
Consumers attend regular rehabilitation appoint-
ments typically over a period of weeks to months
to achieve their goals. Consumers wait in the
waiting area prior to each appointment. Both ser-
vices provided health information, resources, and
supports in their waiting areas, the details of
which are reported in our prior research (McDo-
nald et al., 2020). To view the design of the wait-
ing area, please refer to this article. In summary,
the waiting areas were open plan areas adjacent to
the reception desk located close to the front
entrance of the outpatient rehabilitation build-
ings. Multiple doors and corridors led from the
waiting areas to nearby offices and therapy areas.
Both waiting areas contained clinical chairs with
armrests for waiting patients configured with
some chairs facing each other and some facing
toward wall-mounted televisions. Aside from the
television, there was limited technology avail-
able to consumers in these waiting areas (i.e.,
no information kiosks). A range of hard copy
health information and resource types and
topics were displayed on the walls and tables
of each waiting area (McDonald et al., 2020).
210
Framework Method was used in this study
because it aligns with the initial analytical proce-
dures of constant comparison in grounded theory
and can be applied to large qualitative data sets
(Gale et al., 2013). The Framework Method fit
with the researchers’ positioning within a para-
digm of constructivism. Standards for Reporting
Qualitative Research (SRQR) was followed for
the design, execution, and reporting of this study
(O’Brien et al., 2014). In keeping with the con-
structivist paradigm and SRQR reporting stan-
dards, researcher identity statements as well as
practices utilized to enhance the rigor of this qua-
litative study are outlined in Supplemental Files
S1 and S2.
Participant Recruitment
Participants were recruited using a combination
of purposive and theoretical sampling. Eligible
participants were adults currently receiving
center-based outpatient rehabilitation. Partici-
pants were excluded from this study if they were
unable to participate in an interview due to severe
cognitive and/or communication impairments or
if they required a language interpreter as no fund-
ing was available for language interpreters.
Recruitment ceased when theoretical saturation
was achieved where new data ceased to reveal
new theoretical insights (Charmaz & Thornberg,
2020).
Data Collection
Data collection involved an in-person, semistruc-
tured interview with an average duration of
48 min per participant. Interviews were held
between May 2019 and February 2020. The inter-
view guide was piloted and refined for clarity.
During the interview, a checklist (Figure 1) was
used as a prompt to explore with participants how
they currently prefer to find or learn health
information.
Data Analysis
To analyze the data, the seven stages of Frame-
work Method were applied: (1) transcription, (2)
familiarization, (3) coding, (4) developing a
Health Environments Research & Design Journal 15(1)
working analytical framework, (5) applying the
analytical framework, (6) charting data into the
framework matrix, and (7) interpreting the data
(Gale et al., 2013). The interview transcripts were
deidentified and transcribed verbatim. The pri-
mary researcher conducted the analysis from
steps 1 to 7. A second researcher checked a subset
of interviews at each stage (L.R. or K.C.). Dis-
cussions and revisions of developing codes, the
analytical framework, and final themes occurred
between team members (C.M., L.R., and K.C.).
Data were managed in QSR International’s
NVIVO Version 12 Software (QSR International,
2020).
Results
Thirty-three adults participated in the study.
Participant demographics are reported in
Table 1.
Barriers
Three themes were identified which explained the
barriers consumers experienced when engaging
with health tools in the waiting area. These bar-
riers included both individual and environmental
factors which either completely prevented access
to or disincentivized engagement with health
tools. Participant quotes are included to illustrate
each theme. The coding system for participant
quotes is: ‘site number, participant number’.
Accessibility issues. Participants described a host
of accessibility-related issues which prevented
them using available health tools, including:
physical location of items, visibility of dis-
plays, unable to hear audiovisual displays,
information content being too detailed or com-
plex, insufficient time to read or engage with
items, and limited language options. In sum-
mary, physical inaccessibility or inappropriate
informational content prevented consumers
from attempting or continuing to engage with
available health tools. In addition to these
issues, two subthemes were identified which
related to accessibility.
Subtheme: Crowded or uncomfortable environment.
When the waiting area was busy and crowded,
McDonald et al. 211

Medical text book c

Health book written by a celebrity c
Health magazine c
Government webpage c
Hospital webpage c
Health organisation webpage i.e. Heart Foundation c
Other webpage i.e. Google c
Talking with a trusted health professional c
Talking with any health professional c
Health App c
Health podcast c
Radio program c
Talk to a friend c
Talk to a family member c
Talk to someone else in the community
c
Please describe:
Television show c
Online video c
Health brochure c
Scientific journal article c
Poster on the wall at your health service c

Other
c
Please describe:

Figure 1. Checklist used in participant interviews as a prompt to explore and discuss how consumers prefer to
find or learn health information. Note. The above checklist was used as a prompt after first asking an open-ended
question during the interview. The initial open-ended question was: “When you want to learn something new
about your health, where do you look for information?”. After the participant had responded, they were shown
the above checklist as a prompt and asked a follow up question: “Would you use any of these resources to learn
new information about your health?”. The checklist highlights a range of resources which could be offered in
waiting areas to contribute to health literacy and allowed the researchers to explore consumers’ preferences in
detail.

consumers reported that it was physically diffi-
cult to navigate around to look at or select avail-
able resources. At such times, the waiting area
was also very noisy and distracting. This affected
consumers’ ability to concentrate which limited
their engagement with available health tools.
I was so conscious of there being so many people
there that I couldn’t do anything but look at a
magazine. I couldn’t look at the information on
the walls there . . . . I think that’s too much to take
in, in a crowded situation. (Participant 1,04)
Consumers reported physical discomfort at
times due to the cold temperature (i.e., when the
adjacent entrance doors opened), seating, and lay-
out of the waiting area. They reported that this
again affected their willingness and/or ability to
engage with available health tools.
Subtheme: Brief waiting time. The brief waiting
time before appointments limited consumers’
opportunities to engage with available health
information and resources. Participants’ consis-
tently reported short waiting times and spoke
highly of the prompt and timely service: They
contrasted this to experiences of long waits at
other health services. There were occasional
exceptions whereby the consumer’s means of
transport (i.e., a communal taxi-share service)
212
Table 1. Participant Demographic Characteristics.
Characteristic
Age years, median [IQR]
Gender female, n (%)
Born in Australia, n (%)
Participants who spoke >1 language n (%)
Languages spoken by participants
Reason for current outpatient rehabilitation, n (%)
 Musculoskeletal
 Neurological
 Vestibular/balance disorder
 Cardiovascular
Living arrangement, n (%)
 Lives alone without any support services
 Lives with family and/or receives support services
Level of education, n (%)
 Higher education
 Vocational training
 Some schooling
 No formal education
Access to own technology devices n (%)
Types of technology devices owned
Access to internet at home n (%)
meant significantly longer waiting times. The
short waiting time limited consumers’ engage-
ment with some of the lengthier or more detailed
health tools.
You never know how long you’re going to be sitting
in a waiting area. You don’t want to read something
that’s going to be four pages long. You want some-
thing that’s short and straight to the point, light
pamphlets or an article that just covers one page
because there’s nothing worse than you get halfway
through. (Participant 2,02)
As such, consumers chose to avoid lengthier or
time-consuming resources, concerned that they
would not be able to finish engaging with them
before being called away for their appointment.
Personal factors—Physical condition, emotional state,
and preferences. Personal factors which consu-
mers identified as barriers to accessing and enga-
ging with health tools in the waiting area
Health Environments Research & Design Journal 15(1)
Study Participants (n ¼ 33)
65 [51–74.5]
18 (55%)
15 (45%)
7 (21%)
English, Italian, Maltese, Spanish,
Cantonese, Singhalese, Malay,
Hindi, Indonesian, and Tamil
17 (52%)
8 (24%)
7 (21%)
1 (3%)
13 (39%)
20 (61%)
15 (45%)
8 (24%)
9 (27%)
1 (3%)
32 (97%)
Portable laptop computer, desktop computer,
handheld smart devices, or wearable
smart devices
30 (91%)
encompassed their physical condition, emotional
state, and personal preferences. Negative physical
conditions or emotional states such as low mood,
high anxiety levels, fatigue, or pain were identi-
fied by consumers as limiting their capacity for
engaging with health tools. For example, consu-
mers experiencing high pain levels felt this
restricted their physical ability to access health
tools.
I was really in a lot of pain before. It was a bit
harder. But now I’m more mobile so I can go and
stand up and have a look and read all the things that
are on the wall. (Participant 1,13)
Consumers experiencing high anxiety felt like
they emotionally did not have the capacity to
engage with health tools. Such emotional states
also desensitized consumers to the environment
around them, so they were less likely to notice
available tools. Consumers reported that their
physical condition or emotional state resulted in
McDonald et al.
reluctance to converse with other consumers on
occasions.
Just sit there, I don’t look at anybody, I don’t talk to
anybody, I don’t read anything. I just sit and
wait . . . I mean, yeah I’ve got mental issues as well.
(Participant 2,04)
Another barrier to engaging with health tools
was consumers’ own personal preferences. At
times, consumers preferred to use the waiting
time for other activities, so they chose not to
engage with health tools. For example, consu-
mers who perceived their waiting time as ‘relaxa-
tion time’ preferred to use their smartphone for
other activities such as catching up on messages
or social media. One consumer explained that
using their own device is always their preference
and they would “look around more” “only if my
[phone] battery dies” (Participant 2,07). Other
consumers brought along their own book, maga-
zine, or puzzles and preferred to use this to enter-
tain themselves whilst waiting.
Poorly presented and outdated resources. Poorly
presented information was reported by consumers
as an issue with the current noticeboard and
resource displays. Consumers described how
poor presentation, especially too much informa-
tion, resulted in the health information and
resources becoming like “wallpaper” (Participant
1,03). When information displays were cluttered,
messy, or lacked clear messages, consumers
reported being unsure of where to start reading.
I think there’s too much information, personally. I
feel on those notice boards, there’s far too much
information. (Participant 1,06)
Consumers reported being deterred from
browsing health information that was not eye-
catching, engaging, or appeared outdated. Consu-
mers were particularly concerned when they
noticed that health tools were out of date, as this
undermined their confidence or trust in available
health information. This links to the finding
within the enabler theme ‘health content and
delivery suits consumer needs’: Consumers
reported they were more likely to engage with
213
available health information if they perceived it
as trustworthy and reliable. Therefore, leaving
outdated health information in the waiting area
may have negative consequences for health tool
use which in turn may limit the potential of health
tools for contributing to health literacy.
Consumers also reported feeling self-
conscious about engaging with sensitive health
topics in the waiting area if the display did not
afford them privacy and allow them to browse the
information discretely.
When it’s on a wall, everyone can see every single
thing . . . . A lot of people ask questions about sex
post stroke. I wouldn’t want to pick up something
for everyone to see—those sort of more intimate
[topics]. (Participant 2,17)
Consumers described some design ideas
(reported later) which they thought could afford
privacy when browsing to overcome this issue.
Enablers
Three enabler themes were identified which pro-
moted engagement with available health tools in
the waiting area. The first two themes pertained
to using health information and resources only.
The third theme highlighted the opportunities for
engaging with health information and resources
as well as social support with other consumers.
Health content and delivery suits consumer needs. To
be useful to consumers, content of available
health information and resources must align with
their needs. The first criteria defined by consu-
mers was that the information content should be
relevant and of interest to them.
Relevance to me. Full stop. That’s really it, yes.
(Participant 1,12)
Health topics should be relevant to consumers’
current reason for attending the service or address
other health information needs.
If you’re conscious that you’re there for a specific
reason and you see something of that reason. You’re
going to be curious. (Participant 1,11)
214
Other health information needs highlighted by
consumers included information about preventa-
tive lifestyle changes or health service informa-
tion. For example, consumers described a desire
to learn more about how to make healthy lifestyle
changes in terms of exercise and diet. Regarding
health service information, consumers described
a desire for information to be available on how to
access other local health services.
Consumers were more likely to engage with
available health information if they perceived it
as trustworthy and reliable. To facilitate trust in
the information, consumers valued knowing the
source of the health information.
Some consumers inherently trusted health
information shared by the hospital expecting
that it would have been vetted and approved by
health professionals before being displayed.
Finally, a subset of participants in this study
spoke more than one language and felt more
confident reading in a language other than Eng-
lish. Information provided in their language
caught their attention.
That’s captured my attention at first place, mostly
because you do have my languages. (Participant
2,06)
For this group of participants, when health
information was available in their preferred lan-
guage, it enabled them to autonomously and con-
fidently read and use that information. The issue
of inclusivity was also highlighted by some con-
sumers who only spoke English but recognized
the diversity within the community; they advo-
cated for providing multilingual resources recog-
nizing that this would cater to the needs of more
people.
Usable in available time or portable. Information
presented in a short, simple, and easy to read or
view format was considered most usable in the
available time.
Things have got to be short so you can get in the
time that you are here. (Participant 1,14)
Consumers also valued information and
resources that were portable. Takeaway
Health Environments Research & Design Journal 15(1)
information was considered useful as it could be
reread or viewed; taken directly to a health pro-
fessional for further discussion; or shared with
consumers’ family, friends, or peers outside of
their health appointments. Consumers valued
being directed to trustworthy and quality online
information as another example of “portable”
health information. Most consumers had access
to a smart device (i.e., smart phone or tablet).
Consumers identified that waiting areas could
be used to direct them to reputable health infor-
mation online which they could access on their
personal smart device within and outside of the
waiting area. A key benefit of being directed to
online information, especially videos presenting
health information, was that consumers could
control when they wanted to start, stop, or replay
the video. Consumers noted this in comparison
with televisions in the waiting area which they
could not control or replay if they missed compo-
nents of the information.
Compatible environment for engaging and sharing.
Consumers described how the waiting area phys-
ical environment and social culture could enable
engagement with health tools and sharing with
others. The features of a waiting area perceived
to be compatible with these activities were the
following: it was comfortable, spacious, had a
calm ambiance, was hygienic and clean, and set
up with some “communal” space with some
chairs facing each other. Such an environment
was felt to allow easy navigation around the
space.
There’s a lot of space for wheelchairs to get around
and I think that’s important. There’s heaps of room
in that area for people to maneuver with their
crutches and walkers. (Participant 1,13)
Having a calm ambiance allowed audiovisual
health information displays to be read and heard.
When the physical layout and atmosphere offered
comfortable communal spaces, this encouraged
consumers to strike up conversations with each
other if they wished. When consumers did initiate
conversations with other consumers, they shared
health information, experiences, and peer sup-
port. One example of this was when a stroke
McDonald et al.
survivor who had attended rehabilitation for
many months shared their experiences of the
rehabilitation process at the health service with
a stroke survivor who was new to the service. For
the new stroke survivor, gaining insight into a
health service may assist them with navigating
the rehabilitation service, anticipating future
decisions about their rehabilitation and stroke
care, and enacting these decisions—all examples
of health literacy.
Design Ideas for the Waiting Area
The design ideas shared by consumers to create
a health literacy responsive waiting area fitted
within four typologies: (i) built environment,
(ii) social culture, (iii) administrative pro-
cesses, and (iv) information content and deliv-
ery. These four typologies are interrelated as
indicated in the descriptions below. The cate-
gories and supporting quotes of the four design
typologies are presented in Table 2 to highlight
the nuanced and informative design ideas
shared by consumers.
Built environment. The built environment pertains
to the physical layout and interior design features
of the waiting area which could be enhanced to
promote access to and engagement with available
health tools. Basic amenities such as toilets and
water coolers along with comfortable furnishings
(i.e., chairs) were highlighted by consumers to
promote physical relaxation and comfort. A mod-
ern and vibrant feel was reported as instilling trust
and confidence that the health service is contem-
porary and well maintained. The configuration of
the furniture was considered integral to navigat-
ing the space and accessing available information
and resources. Similarly, consumers suggested
that the physical layout had potential to facilitate
social interaction and thereby promote or restrict
social support.
Social culture. The social culture is the ambiance
experienced by consumers when present in the
waiting area. The example set by staff established
an “atmosphere” (Participants 2,09; 1,12; 2,12;
and 2,13) in the waiting area. Consumers
described how the friendly and welcoming nature
215
of administrative staff influenced how they felt on
arriving at the service and contributed to feeling
welcomed and relaxed. This “atmosphere” was a
key facilitator of subsequent social interactions
and peer support between waiting consumers and
therefore highlighted as a design concept for pro-
moting support.
Administrative processes. The local administrative
processes are the steps inherent in presenting
and waiting for an appointment which occurs
adjacent to and within the waiting area. Pro-
cesses such as checking in for an appointment
should be easy to navigate and clearly identifi-
able to consumers through signage and other
environmental cues. Ideally, consumers should
be offered the explanations of what to expect on
arrival and during the first appointment to alle-
viate their anxiety about attending a health ser-
vice for the first time. Consumers reported that
intuitive check in processes make it easier for
them to navigate to their appointment and to
explore the available health information,
resources, and supports on offer.
Information content and delivery. Information con-
tent and delivery incorporates the content (i.e.,
health information topics), modes of delivery
(i.e., resource types), and the desired presentation
styles of information. Consumers reported that
information content and delivery should be con-
siderate of the available time and space. Consu-
mers wanted the available resources to be tailored
to their needs and to offer choice. Consumers felt
that graphic, distressing, or negative health infor-
mation should not be displayed. They suggested a
range of criteria for designing and maintaining
content so that it is current and regularly updated;
digestible in available time or for “takeaway”;
eye-catching and engaging; focusses on health
and well-being; simple and easy to read or use;
and organized, convenient, and thoughtfully pre-
sented. Audiovisual displays should be commu-
nication accessible for people with vision and
hearing impairments by using large font sizes or
enabling subtitles. Finally, consumers suggested
that smart phone–enabled content would be very
practical.
216
Table 2. The Four Design Idea Typologies With Their Categories and Example Quotes.
Typology Categories
Built environment Basic amenities
Enables access and
engagement
Facilitates social interaction
Vibrant, modern, and
comfortable space
Social culture Clear, friendly communication “They all say, ‘How are you?’ Nothing’s a problem . . . It makes
from staff
Relaxing and welcoming
“Have a cushion or things like that—things to make it a bit
ambiance
Administrative Easy to navigate
processes Clear processes
Information Avoid graphic, distressing, or
content and negative material
delivery Caters to diverse learning and
information needs
Offers choice
Current and regularly updated
Digestible in available time or
take away
Eye-catching and engaging
displays
Focus on health and well-being
Incentives for engaging with
health information or peers
Organized, convenient, and
thoughtfully presented
Simple and easy to read or use
Smart phone enabled
Health Environments Research & Design Journal 15(1)
Example Participant Quote(s)
“It’s like what restaurants do now. Instead of one table, they
actually have community tables, and people talk.”
(Participant 1,06)
“Make it a bit more comfortable and more homely. Get rid of
those terrible chairs. Get some new furniture and even if
they put a bit of music to relax.” (Participant 2,11)
me feel good. I don’t feel disabled.” (Participant 1,09)
less clinical, I guess . . . ” I feel like it can help you change
mindsets if you come in stressed and then yeah change to
be more relaxed so you are potentially more likely to recall
what you’ve been told and take that on board a bit more.
And even be more willing to participate.” (Participant 1,17)
“Yeah, like meditation music. That nice soothing music like
rainwater on pebbles or you know the Tibetan singing
bowls. That kind of nice, relaxing music.” (Participant 1,13)
“You want it to be as clear as possible, to see, ‘This is where
you are. This is what we need from you,’ or something like
that. Yeah.” (Participant 1,06)
“Particularly because when you first arrive you are not sure
whether you should go to reception and every time you
arrive you are supposed to check in at reception? . . . So
that kind of information should be provided to people.”
(Participant 1,14)
“I guess they have to be very well decided upon and filtered,
because you don’t want to shock people.” (Participant 1,07)
“You could put an information rack there and let people take
what they want for later.” (Participant 2,13)
“I’d simplify that board and if I was using that board to impart
messages, I’d have two. I’d have two. I’d change some as
well, otherwise they’re wallpaper after a while.”
(Participant 1,03)
“So, if a notice is meant to be read or catch the eye it needs to
have a simple design . . . but the main thing is the notice
should relay the message.” (Participant 1,12)
McDonald et al.
Discussion
The findings of this study provide empirically
informed, practical solutions for hospital waiting
areas to better respond to consumers’ health lit-
eracy needs. Consumers highlighted nuanced bar-
riers and enablers which impact their ability to
access and engage with health information,
resources, and supports in the waiting area. Bar-
riers limit opportunities for consumers to build
health knowledge within the waiting area. In con-
trast, enablers afford learning opportunities not
only in the waiting area but facilitate conversa-
tion with clinicians during appointments and pro-
vide the opportunity to take information away.
Consumers highlighted nuanced barriers
and enablers which impact their ability to
access and engage with health
information, resources, and supports in
the waiting area.
The barriers identified in this study offer new
insights as to why consumers may have trouble
accessing available health tools. A review by
Ramsay et al. (2017) reported that complex health
information and limited language options are
widespread issues for consumers seeking health
information. In our study, the theme of
“accessibility issues” highlighted these same
issues plus additional factors such as: physical
location of items; visibility of displays; and
unable to hear audiovisual displays. Consumers
also highlighted nuanced language preferences.
For example, some consumers did not require
an interpreter for their health appointments (they
felt comfortable conversing in English); however,
they preferred reading or engaging with health
information and resources in another language.
Therefore, consumers may have differing lan-
guage preferences depending on the complexity
of the health information and the type of resource.
“Outdated resources” was a barrier to resource
utilization. Health services should consider pro-
cesses for monitoring and updating health infor-
mation and resources on offer. Previously, it has
been argued that producing high-quality health
information requires staff expertise and the adop-
tion of systems which ensure that health
217
information remains up to date (Hill & Sofra,
2018), which may be time intensive and challen-
ging to manage. Perhaps a feasible way to
address this is to use digital displays and con-
nect with services which offer publicly avail-
able, quality assured, and regularly updated
information, for example: government health
department websites, condition-specific research
organizations or other global health organiza-
tions producing contemporary, evidence-based,
and peer-reviewed resources. In terms of phys-
ical displays of information, processes to man-
age these could include assigning this
responsibility to a team of staff and scheduling
regular audit dates for review. Uniquely, the
design ideas and enablers identified in this
study point to practical solutions for effectively
displaying, signposting, and sharing health
information and resources in hospital waiting
areas.
Health services should consider processes
for monitoring and updating health
information and resources on offer.
Previous research has focused on health infor-
mation content and design, but not on optimal
display presentation. For example, seminal health
literacy tool kits describe thoroughly how the
content of materials should be designed (Brach
et al., 2012; Brega et al., 2015); however, they
offer limited recommendations about how to best
display and share information within the health
service. “Ten Attributes of Health Literate Health
Care Organizations” (Brach et al., 2012) suggest
that “walls and bulletin boards are not covered
with lots of print information.” The “AHRQ
Health Literacy Universal Precautions Toolkit”
(Brega et al., 2015) recommend using “the wait-
ing room to display important information” and
briefly mention strategies such as to provide tar-
geted health information on bulletin boards and to
offer easy-to-understand education materials.
Similarly, recent guidelines, research studies, and
systematic reviews have contributed to an exten-
sive evidence base for patient information design
(Coulter et al., 2006; Giguère et al., 2020; Walsh
et al., 2019; Wilson et al., 2012) but lack insights
218
into sharing and distributing information effec-
tively within health service environments.
In terms of enablers, the theme of “health
information content and delivery” strongly aligns
with international, evidence-based recommenda-
tions for person-centered health information shar-
ing (ACSQHC, 2011; Clarke et al., 2016; Coulter
et al., 2006). The need for high-quality health
information which conforms to evidence-based
patient communication principles and meets
diverse and complex consumer needs is well
established (Hill & Sofra, 2018). The next chal-
lenge for health service providers and designers is
to effectively disseminate and share the informa-
tion, including in settings such as waiting areas.
Short waiting times may limit the effective use
of complex or detailed resources in the waiting
area. Short waiting times were regarded posi-
tively by consumers, and we advocate that health
services should continue to minimize or eliminate
wait times for consumers as a priority. We posit
that the waiting area may not be an effective
environment for learning or attaining complex
health knowledge when there are short waiting
times. However, it can still contribute to health
literacy by directing consumers to information
they can use later or by providing accessible
resources that offer short and easy to engage with
content.
Short waiting times may limit the effective
use of complex or detailed resources in the
waiting area.
Many of the design ideas shared by consu-
mers promoted easy access and inclusiveness.
This concept of an inclusive environment which
meets the needs of most/all users aligns with the
paradigm of ‘universal design’ from the field of
architecture. Universal design aims to create
healthcare environments that are accessible and
usable for diverse populations (Story, 2011).
Universal design has seven principles, including
equitable use, flexibility in use, simple and intui-
tive use, perceptible information, tolerance for
error, low physical effort, and size and space for
approach and use (Story, 2011). These principles
can be applied to the design of healthcare build-
ings, products, and environments. Where
Health Environments Research & Design Journal 15(1)
empirical evidence is lacking, the universal
design principles could be used as a starting
point for designing inclusive waiting area
environments.
Many of the design ideas shared by
consumers promoted easy access and
inclusiveness.
The design ideas regarding “information con-
tent and delivery” reinforce that multimodal
information delivery is important. In this study,
consumers suggested ideas for incorporating
hardcopy options, audiovisual displays, and
online digital options. These ideas illustrated the
range of preferences apparent among the commu-
nity. Variable health literacy skill and preferred
learning modes among consumers are widely
reported in many health contexts (Ramsay et al.,
2017). Gaglio et al. (2012) found that participants
with higher health literacy and numeracy scores
were more likely to access a range of health infor-
mation sources when compared to participants
with lower scores who were more likely to rely
on receiving health information from their health-
care provider during face-to-face consultations.
Further to this, Ledford et al. (2015) found in their
survey of patients attending hospital appoint-
ments that younger participants with higher
health literacy scores were more likely to inde-
pendently seek health information, usually
online, prior to their clinical appointments. Given
this variability, Hill and Sofra (2018) advocated
for health services to offer information in a vari-
ety of media and formats. We also propose that to
suit the range of consumer preferences and health
literacy skills, health information and resources in
waiting areas should be codesigned with
consumers.
We also propose that to suit the range of
consumer preferences and health literacy
skills, health information and resources in
waiting areas should be codesigned with
consumers.
Importantly, this study identified a number of
design considerations for addressing health lit-
eracy in waiting areas. It is not just the design
McDonald et al.
and content of the health tools themselves which
impact on whether consumers can access or
engage with them in waiting areas. The typolo-
gies of “built environment,” “social culture,” and
“administrative processes” point to broader fea-
tures of waiting areas which may impact on
health literacy and should be considered when
designing such areas. In summary, designing a
health literacy responsive waiting area requires
consideration of the local physical, social, and
cultural factors; administrative processes; and,
importantly, the needs of consumers.
A limitation of this study was the exclusion of
people unable to participate in an interview in the
English language. Future research should explore
culturally and linguistically diverse consumers’
experiences of barriers, enablers, and their design
ideas. Future interventions which address the bar-
riers and enablers reported by consumers in this
study should also measure the impact on con-
sumer health literacy, behavior, and outcomes.
A key strength of this research is the application
of practices to enhance the rigor, quality, and
therefore trustworthiness of the qualitative find-
ings. Participants with broad demographic char-
acteristics were recruited and their design ideas
offer solutions which could be implemented to
address the existing barriers. Finally, this
research was conducted across two sites reflec-
tive of characteristics common to tertiary, metro-
politan hospitals which may increase the
transferability of the findings to similar health
services.
Conclusion
This study has demonstrated that a range of bar-
riers and enablers exist which impact on consu-
mers’ ability to engage with available health
information, resources, and supports in hospital
outpatient waiting areas. These barriers, enablers,
and consumer design ideas highlight opportuni-
ties for creating accessible and usable health
information and resources in addition to promot-
ing social support among consumers. Consumers’
design ideas demonstrate that they are important
allies and should be included in health service
design projects. Further research is needed to
evaluate the impact on health literacy and health
219
outcomes for consumers when these design attri-
butes are implemented into practice.
These barriers, enablers, and consumer
design ideas highlight opportunities for
creating accessible and usable health
information and resources in addition to
promoting social support among
consumers.
Implications for Practice
 The barriers, enablers, and consumer design
ideas described in this study highlight
opportunities for creating accessible and
usable health information and resources in
outpatient waiting areas.
 The design ideas shared by consumers could
be implemented into the design of health
information, resources, and the physical
environment of waiting areas to promote
easy access and inclusiveness for consumers
attending outpatient health services.
 Designing a health literacy responsive
waiting area requires consideration of
the local physical, social, and cultural
factors; administrative processes; and,
importantly, the health literacy needs of
consumers.
Acknowledgments
The authors wish to acknowledge the support
of the following managers: Alana Jacob, San-
dra Savy, Susan Cronin, Michelle Mews, and
Gillian Dickman. They also wish to offer
thanks to the following departments: Depart-
ment of Allied Health—Physiotherapy and the
Community Therapy Service at The Royal
Melbourne Hospital, and Western Health
Department of Physiotherapy and the Commu-
nity Based Rehabilitation Service at Sunshine
Hospital.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
220
Funding
The author(s) disclosed receipt of the following
financial support for the research, authorship,
and/or publication of this article: Cassie McDo-
nald and Kate Cameron are supported by Austra-
lian Government Research Training Program
Scholarships. Kate Cameron’s PhD candidature
is also supported by the Centre of Research
Excellence in Newborn Medicine.
ORCID iDs
Cassie E. McDonald, PT https://orcid.org/
0000-0001-9518-5869
Kate L. Cameron, PT https://orcid.org/0000-
0001-5447-594X
Supplemental Material
The supplemental material for this article is avail-
able online.
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