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Advanced Human-Computer Interaction (ADV-HCI)
SEEKING HEALTH INFORMATION
UNDER PERSPECTIVE OF ACTIVITY THEORY
Instructors:
Tessy Cerratto Pargman, DSV
Petter Karlström, DSV
Preben Hansen, DSV
Student:
Mai Bodin
October 31, 2014

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I. Introduction
There are a lot of changes in the field of human computer interaction (HCI) since its mission and
goals have been set in the ’80s to response to rapid development of technology and the needs
human being. The field has growth without boundaries (1). These changes creates opportunities
to design for support people in all types of activities, at much broader settings, at any time (2).
Together with these development, perspectives from other fields, such as, cognitive science,
social sciences, information science, science and technology studies, communication studies, and
management information systems, have been integrated into HCI research and practice (1).
Following is the figure illustrates main theories which have been being applied in HCI during the
last 30 years.
Figure 1. Theories applied in HCI. Source: Human Computer Interaction (1)
Health care is one of the fields that receiving consideration of researchers and practitioners from
Information Communication Technology (ICT) and HCI fields. The number of applications and
systems to support not only health providers but also patients and general population to gain
better health status are increasingly. Many systems are trying to providing wide range of
information to people, so that they could take the measures to prevent diseases through
adopting healthy lifestyles or to carry self-monitoring and self-care at home, or seeking health
services when needed. Due to increasingly the number of population who could be able to access
to internet (3), websites that disseminate health information also growth quickly, about 70,000
websites in the year 2010 (4). Vårdguiden 1177.se is one of the popular health information
websites in Sweden. It is a combination between Vårdguiden.se and 1177.se during autumn
2013. More than one third of interviewed people (36%) reported that they knew about the
website 1177.se (among 41,810 persons in the whole country, who answered telephone
interviews in the year 2013) (5). Even this number was higher in comparison with previous year
(27% in 2012), there is still a need for the further improvement of website in order to provide
“good answers” to users and in the way that “easy to find answers” (6). Therefore, we choose

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the website Vårdguiden 1177.se as a tool to be assessed. A situation in which people using
computer to interact with website to find health information was analyzed. Hope that our
findings could be used as inputs for the larger evaluation study in the future.
Picture 1. Homepage of Website Vårdguiden 1177.se. (Source: picture was taken from 1177.se)
To assess the website, I decided to use Activity Theory as this it is “a basic for understanding how
people act with technology” and could act as a descriptive theory, explanatory and generative
theory (7). Activity theory is belong to the second generation of HCI theories (2) and introduced
to international audience since late 70’s . The framework was originally developed by a Aleksey
Leontiev (1904-1979) based on cultural-historical psychology which founded by his teacher, Lev
Vygotsky (1896-1934) (7). It was then further developed by Yrjö Engeström in 1987(8). Activity
theory uses, as its name, “Activity” as a focal point to understand the interaction between
“subject” and “object” (8), means to understand human beings in daily life environment (7). It is
interest to see the basic notion of activity. Firstly, it states that “no properties of subject and
object exist before and beyond activities” and activity is the “key sources of development of
subject and object” (7). It means that it is important to analyzing human beings in the larger social
contextual circumstances at the same time and under development perspective. With these
notions, it could help designers finding the way to design for long term development and to
remind designers to focus on users, who have different needs, concerns and problems at the
different contexts.
Situated Action could be other possible appropriate for analyzing our situation as it also focuses
on the “context”. It is rooted from cultural anthropology and usually employs different
ethnography methods to understand how people using technology in the different settings. It
encourages designers taking into account the role of context when designing (2).

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II. Description of Activity Theory and the artifact in use
1. Activity Theory and five perspectives
In this section, I will elaborate the basic principle of Activity Theory toward five main themes of
HCI as introduced in the Adv-HCI course.
The basic represent of Activity Theory is represented as follow firgure:
Figure 2. Basic representation of Activity theory(7)
In this model, subject (S) initiate the activity and object (O) carry out to reach the need.
This model has extended by Engeström as followed:
Figure 3. The Structure of Human activity system according to Engeström (9)
Let’s take the look at five perspectives.
User. In the Activity Theory, user is equal to subject, that “live in the world” and more important,
“have needs that can be met only by being and acting in the world”. When talking about user, we
should not forget the notion of agency “the ability and the need to act”. Need could be or not be
“objectified” but when “need” meet “object”, the activity happened. That’s why “Object-
orientedness” was considered as one of the basic principles of Activity Theory. Objects of
activities is considered as “prospective outcome” of activities and as “motive” in the Activity (7).
Context. The perspective context is highlighted in the AT theory. It is cultural-historical theory,
so it sees the culture and society in social world is generative force to shape the nature of human
mind. With concept Internalization and Externalization, the AT theory shows us the relationship
between human mind and social and culture context. Internalization talks about a process that
external activities transform to the internal activities. For example, people, who used external
artifacts to solve a task, reduced the use of tool and become more competent in doing the task

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overtime. As opposite, externalization transform internal activities to external activities. The
other concept in this principle is about Interpsychological and Intrapsychological. It follows the
law of psychological development that explains that the new psychological functions start from
a stage in which an individual share with other people (interpsychological). After a period of time,
that individual could manage more and more components of function and finally s/he could reach
a stage in which s/he could perform the function by him/her self (intrapsychological).(7).
Interaction. In AT theory, interaction refers to “Activity”. Leontiev developed an Activity
hierarchy that consists of three levels: Activity, Actions and Operations. According to him, activity
is a basic unit of life and the top level of the hierarchy show activity and its object is motive.
Under each activity is a set of actions that represent different steps and their objects are so called
goals. Action consists of a set of operations that usually are not aware of people, means become
automatically. It is interesting that there are a transformation between levels in the hierarchy, in
which a conscious action become an operation or an action become an activity. (7)
Artifact. Tools or instruments is the important mediator in the human activity as in almost of all
cases, human beings interact with the world via mediator, instruments. AT theory explain why
tool is one of three main aspects of culture that impact on human mind, beside language and
division of labor. The first reason is that “tools shape the way human being interact with reality”.
The second is tools are created and changed during the development of activity, and transfer
from generations to generations, from people to people. This process also transfer the
knowledge and experience to make use of the tool more effectively and more efficiently. (7)
AT theory based on the Vygotsky’s concept of psychological functions that includes natural
psychological functions and higher mental functions. The notions of technical tools and
psychological tools also was introduced by Vygotsky, in which, people use technical tools (like
axe, hammers, …) to effect things, meanwhile people use psychological tools to effect other
people or themselves (7). Psychological tools also have two groups, physical/external artifacts
(such as maps, diagram,…) and symbolic system, (such as language, numeric system ..). It is
interesting to learn that physical external artifacts could support for the process of
internalization. (7).
Design. According to Victor Kaptelinin and Bonnie A. Nardi, there was significant change in the
international interested in Activity Theory from the 1990s. The AT provides a extended
framework for interaction design. It supported for reformning the objectives of HCI which focus
on context of use of technology in the daily life and for rethinking of HCI concepts, including,
transparency, affordable and direct manipulation. (7)

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2. Introduction of the research methods
Methods. Qualitative research approach was employed in the study, in which ethnographically
observation and semi structure interview were used as they showed the appropriate in
evaluation of health informatics (10). Think Aloud method was conducted in the study as it allows
researchers capture only actions of participants, but also how and why they choose these actions
(11).
Study participants. Due to limited time and resources, we use convenient and purposive
sampling method. We were looking for people who were around Kista Library during one
morning. Our goal was to involve at least five people with different age, sex, ethnicity and
experience to use computer. After approaching a number of people, there were three people
willing to participate in the study. We invited two more people nearby our home, so the total
participants was five people. Their information background as stated as following:
Participant #1. Male, 60 years old. From Hungary, first language is Hungarian, spoken Swedish
for 42 years. Computer experience ranking: 7. Never seen or used 1177.se before.
Participants #2. Male, 31 years old, 9 years in Sweden, can speak Swedish and English, first
language is Armenia, come from Ethiopia. Computer experience ranking: 8.
Participant #3.Female, 24 years old. Born here. Parent from North Africa, speak Berberiska as
first language and start speak Swedish since the time going to kindergarten. Computer
experience ranking: 8.
Participant #4. Female, 29 year old, from Thailand. Speak Thai. Start speak Swedish about two
and half year. Computer experience ranking: 8.
Participant #5. Male, 57 years old, Swedish, Computer experience ranking: 8.
Process of study. After agree to involve in the study, participants were asked to read one scenario
that created by researchers as follow:
“You are living in an apartment near Kista centrum. One day, when walking from the subway to
your home, you fall and hurt yourself. The injuries are minor and there is no blood. You can walk
home. However, after you get home, you feel some pain in the knee. The pain is increasing and
you notice that the knee is swollen. Finally, around 6 pm the pain is too much and you decide to
go to the clinic and have it checked by a doctor.
You decide to use the website Vårdguiden 1177.se to find the clinic where you want to go. Please
visit this website, using our computer. Could you please speak out what you are thinking while
you are finding the information. Take your time!”

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Then computer with homepage of the website 1177.se (as showed in picture 1) was provided to
participants, together with mouse. Participants used computer to perform the task and spoke
out what they thought during searching for information in the website. The whole processes
were recorded by video. When they open search for Hitta Vård (Finding health service), the
website led them to two following scenes.
After finished the process, participants were interviewed by semi-structured interview with
around ten opened ended questions related to their fresh experience of using the website
1177.se and the results that they found. Interview also tried to explore why they chose different
steps during carrying out the process and their opinions about the website. (Please refer to Annex
1. Guideline for semi-structure interview for more detailed information).
We prepared both English and Swedish for scenario and questions and used one version based
on the preference of participants.
Study tools. The function “Searching for clinic” was used as the study’s tool. Following is some
snapshots of this site.
Picture 2. Webpage for finding health service. (Source: picture was taken from 1177.se)
Analysis of data. Research team members reflected on notes and observation together after
each interview, to get preliminary reflection and analysis of cases. Review notes, video and

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meetings for further discussion were conducted for analysis. Five themes under perspective of
activity theory were used to analyze collected data.
Ethical issue. Oral informed consent was taken before every interviews. Participants were asked
to agree for taking video of when they performed the task. Participants are anomynous and video
recorded only their hands and their voice.
Research team. Team members of research team are two students of the Advance course on
HCI. We designed the study, develop the research tool, interviewing and filming participants. One
more student joined to the group at the analysis phase. Writing report was conducted
individually.
III. Main findings
This part presents results of analyzing data on seeking health service (clinic) under the
perspective of Activity Theory and according to the five themes of HCI: user, context, tool,
interact and design. Theory activity could reflected in our situation as follow:
Figure 4: A simple activity of finding health services (Hitta Vård)
User and interaction
As introduced in the methodology part, our participants were five people, including two women
and three man. This is small sample but hoping that they could represent for many users in Kista
area in Stockholm. Our users have different characters in term of sex, age, ethnic, occupation
and living conditions. But they have same expected outcome which was created in the scenario

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“finding the clinic that you want to go”, or in other word, “the name and address of the clinic”,
to have check for the pain in knee.
According to the hierarchy of activity in the AT, in this situation, finding the clinic is the motive,
the need of participants, the object in the S-O model. It took about 6 minutes to find an
appropriate clinic for participant #1 (Närakuten Järva), about 3 minutes for participant #2 (two
places: Bromma and Rinkby), about 5 minutes participant #3 (Järva Närakuten) and about 1
minute for participant #5 (Närakuten Löwet). Participant #4 spent about 10 minutes and could
not find any clinic.
In order to do this activity, participants need do conduct a set of actions: 1) search for a list of
clinics because there are many clinics in Stockholm; 2) select clinic that they want to go; and 3)
check of that clinic still open at 6.00 pm. These actions conducted to fulfill goals in the AT activity
hierarchy. The website (as showed in the picture 2) suggests a number of ways to find clinic, such
as, a) Free text; b) Based on common categories (primary care, nearby emergency, gynecological
clinic, psychological clinic and birth delivery clinic); c) Suggested based on the places (nearby me,
Solna, Vaxholm, Nacka and Södermalm); and d) Opening time (currently open, daytime open,
nighttime open and weekend open). It is interesting to see different people took different ways
to search. Participant number #3 selected Emergency nearby, meanwhile two others type free
words. They type “Kista”.
In order to accomplish these actions, participants need to take a several operations, such as,
moving the mouse, clicking the mouse, typing the words, open different screens, looking at the
map. These operations fulfill conditions to search clinic in the website. Our observation showed
that most of these operations were not aware of participants as they did it without conscious.
When they speak out what they did, they usually said “I go to” and or “I press” or “I choose”.
Picture 3. Participant #2 is searching information in website Vårdguiden

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Of course, if we expand our situation, the activity will be bigger, for example, to prevent a disease,
to change a behavior, to cure a disease, to be healthy, to live longer. At that time, the activity in
our situation “finding the clinic” would became an action in that new hierarchy.
Context
We tried to find a mixed group of people to perform the task in the scenario as bearing in mind
that different background, culture, computer skills could affect the way people doing the task.
Even with small number of participants, we could see clearly the notion of Internalization here.
Participant #4, who could not find any clinic, is a woman who is newly moving to Sweden and
participant #5, who could find the clinic in about one minute is a man who was born and living in
this area for the whole his life. It seems that “geographical map” plays important role here.
Participants # 5 know the area very well and even have been in selected clinic several times, so
the map of area became “map inside his brain” and he can “draw” the way in his mind. He even
said that the clinic he chose could be reached in the shortest time because he could drive on
highway. Participant #2 spent also short time to find the clinic as he had visited the clinic before
and he lives in the area. Participant #1, even though he has been living in Sweden for more than
40 years, but he lives in the other area and it may make him spend longer time to find the clinic
nearby Kista.
Process of internalization could help to explain why a user, who know very well about the
geography of the city could easier to find the clinic in our situation. People need to have a map
to find out the way and when they use map many times and get familiar with the area, the map
become “inside their brain”.
Knowledge about health system and situation in Sweden also is a factor affect the performance
of participants. Two young women participant #3 and #4 are not familiar with the system and
they only searched without focus. Meanwhile participant #2 and #5 knew that with their health
problem at the evening, it was better for them to look for Närakuten as there are not many
people there and they could be examined after a short waiting time comparison with waiting
time in the big hospitals.
Tools
The Vårdguiden (1177.se) website is the tool that participants used to find information.
Participant #2 has used this website several times before involving in this study. Participant # 3
has heard about the website but never been used it. Three others never hear about this. Knowing,

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or using the website before could be a factor contribute to help participants easier to find
information.
In this situation, people did not interact with computer, they interact with the health information
system (the website) via the computer. So, computer here is artifact that mediate the process.
Level of experience in using computer also play a role here even we only asked participants to
rank the level by themselves. Participant #4, who could not find any clinic, ranked her experience
in using computer was 6, the lowest one. Participant #1 also ranked his experience was 7 and he
also the one who found clinic with longer time.
Website 1177.se provide information in different languages for the main part of information.
However, function “Finding health service” is provided only in Swedish. Looking to data, we see
that capacity in using language plays also an important role in performing task here. All four
people who could find the clinic are quite fluently in Swedish and have been using Swedish at
least nine years meanwhile the woman who could not find the clinic has just started speak
Swedish in about 2 years.
Design
Analysis of results from interviews and observations of the study using activity theory provided
us more insights in designing and implementation of the website, even in this assignment, we
interviewed a limited number of people and looking at only one function of the website. It
showed that designers took into account the user aspect when designing. Website provides
different types of searching, with different criteria could help users easier to find clinic. Different
languages are using in the website shows the consideration of designers to context aspect.
Especially, using geographical map showed that the designers have thought about internalization
process. However, more language needed to be used in the “finding for health service” function.
The principle of “development” need to be address here, for example, through adding a guideline
section that step by step guiding user to use the website.
IV. Discussion
After the process of designing, implementation and analysis of data, we confirm that Activity
theory is very useful perspective in assessing the task of searching health information in the
internet, specifically in this assignment was finding health service in the website Vårdguiden
1177.se. All five aspects of HCI in this specific situation could be reflected using almost all basic
principles of AT theory. It could help to reflection whether designers have addressed these five
aspects or not and find out issues that need to be improved for better meet the needs of users.

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When searching for work conducted by other researchers using AT theory, I found several
interesting studies. For example, a research conducted by Helen Hasan since the year 1991 to
use AT as framework to understanding Usability (12). Related to Usability, Egil Boisen and
colleagues using AT to analyze the concepts Usability, Utility and Copability in the context of
Medical Informatics (13). In health care, AT could be used as an approach to understanding
“challenges of addressing complex healthcare problems” as illustrated by research in UK by G.
Greig and colleagues(14) or Y. Engeström in Finland in the “longitudinal intervention study of
children’s medical care” (15). Recently, there was a research that using AT as framework to
answer question of “Activity” in the context of ICT4D (Information Communication and
Technology for Development)(16). It showed that AT approach could be used as a framework to
analyze or assessing different levels of activity, from very small and practical to very complex and
theoretical one and at the different fields, including health care.
Our study is a starting point in using Activity theory to assess how people using one function in
one website for health seeking information. It could be expand to a study that assess how users
using all functions of the website 1177.se or even larger, such as, how people using internet for
health seeking information.
V. References
1. Carroll JM. Human Computer Interaction - brief intro. In: Soegaard, Mads and Dam, Rikke
Friis (eds.). “The Encyclopedia of Human-Computer Interaction” [Internet]. 2nd Ed.
Aarhus, Denmark: The Interaction Design Foundation.; 2013. Available from:
https://www.interaction-
design.org/encyclopedia/human_computer_interaction_hci.html
2. Rogers Y. New Theoretical Approaches for Interaction. Annu Rev Inf Sci Technol.
2002;87–143.
3. O Higgins, J Sixsmith, MM Barry CD. A literature review on health information-seeking
behaviour on the web : a health consumer and health professional perspective
[Internet]. Stockholm; 2011. Available from:
http://www.mendeley.com/catalog/literature-review-health-informationseeking-
behaviour-web-health-consumer-health-professional
4. Cline RJW, Haynes KM. Consumer health information seeking on the Internet : the state
of the art. 2010;16(6):671–92.

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5. Sofia Tullberg. Vårdbarometern- Befolkningens Attityder till, Kunskaper om och
Förvantingar på Hälso och Sjukvården. 2014.
6. Bushra F, Hamdani A, Alikhani I, Palme HJ. Utvärdering av hälsosajter.
7. Victor Kaptelinin and Bonnie A. Nardi. Acting with Technology. Activity theory and
Interaction design. London: MIT Press; 2006.
8. Victor Kaptelinin. Activity Theory. In: Soegaard, Mads and Dam RF, editor. Interaction
Design Foundation; 2013. Available from: http://www.interaction-
design.org/encyclopedia/activity_theory.html
9. Yrjö Engeström. Activity theory and Expansive design. 1999;
10. Borycki EM, Househ M. Use of Qualitative Methods Across the Software Development
Lifecycle in Health Informatics. 2011;293–7.
11. Brender J. Handbook of Evaluation methods for Health Informatics. Academic Press is an
imprint of Elsevier; 2006.
12. Hasan H. 84 . A Cultural-Historical Activity Theory Approach to Users , Usability and
Usefulness. 1991;(1986):1–10.
13. Egil BOISEN , Ann BYGHOLM OKH. Activity Theory and Medical Informatics : Usability ,
Utility , and Copability. :826–31.
14. Greig G, Entwistle V a, Beech N. Addressing complex healthcare problems in diverse
settings: insights from activity theory. Soc Sci Med [Internet]. Elsevier Ltd; 2012 Feb
[cited 2014 Oct 25];74(3):305–12. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21420212
15. Engeström Y. Activity theory as a framework for analyzing and redesigning work.
Ergonomics [Internet]. 2000 Jul [cited 2014 Oct 18];43(7):960–74. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/10929830
16. Karanasios S. Framing ICT4D Research Using Activity Theory : A Match Between the
ICT4D Field and Theory. 2014;10(2):1–17.

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Annex 1. Finding information on 1177.se (Vårdguiden)
Consent form
Hi,
We are Mai Bodin and Tor Simensen, students of Stockholm University and Karolinska Institutet. We are
conducting a small study to see how people interact with a website in order to learn how to improve the
design for people in the future. We will ask you to visit the website to find some simple information and
then ask you some questions. It will take about 10 to 15 minutes and the information is only used in our
study. It is not about checking your ability and there is no right or wrong. It is simply to see how it works
and you can stop anytime if you don’t want to continue.
Are you willing to help us by participating in this study? Yes…….No……
It would be best if you would allow us to record our conversation and your actions?
(If you don’t want your face appear, we only film your hands and screen). Yes……..No…….
Many thanks and now we start.
Annex 2. Guideline for semi-structure interview
We ask these questions after observation on how people find information on 1177.se. (The questions
will be in English and Swedish).
Experiences using the website
It is interesting to see you using this website.
● So, which clinic did you choose and why?
● Now, could you please tell us how do you see the process of searching? (If they could not tell,
we could suggest by “if possible, using some words that best capture your comments, for
example, easy, difficult, crazy, messy, nice, well organize,...”.)
● I see that you first click on “....”? Why you choose that button?
● Then I see that you click on “...”? Why you choose that button?
● ...
● When you are using the website what is the most difficult for you? What are the other
difficulties? According to you, why you face these difficulties?
● Please tell us, what you like the most in this website? What other things did you like?
● Please tell us, what you dislike the most in this website? What other things did you dislike?
● If you could involve in designing this website, what would you do to improve it?
● Did the website respond as you expected? (time, results)
(If the interview don’t mention about following issues, continue to ask their opinions about these issues:
● Could you tell us how do you think about the text (the parts you have visited)? Which parts are
easy to read? easy to understand? which parts are clear? which parts you didn’t understand or
hard to understand?
● What are your comments for the design of the web?
● What do you think about the colours used in the website?)

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● Have you ever seen 1177.se (Vårdguiden.se) before? Have you ever used it?
● Anything else you want to share with us regarding this activity?
Personal information
If possible, we would like to know a little about you.
● What is your first language?
○ If not Swedish. How long have you been talking Swedish?
● Where are you from?
● How would you rate your experience using computers?
1 (no experience)-----2-----3-----4-----5-----6------7------8------9------10 very experienced
● How old are you?
● Gender (observe)