1. Public Health Practice Short
Communication
Awareness and Perceived Usefulness of
the Website Designed to Facilitate Access
and Informed Health Insurance
Decisions
Ravi K. Goyal, BPharm, MS (C)l
Davonda H. Williams, MS2
Sujit S. Sansgiry, PhD3
.Harsbali K. Patel, BPharm, MS (C)4
Jeffrey T. Sherer, PharmD, MPH5
E. James Essien, MD, DrPH6
IDepartment ofClinical Sciences and Administration, Col­
lege ofPharmacy, University ofHouston
2Account Executive, Medco Health Solutions, Inc. Irving,
TX
3Associate Professor, Division ofPharmacy Administration
and Public Health, Department of Clinical Sciences andAd­
ministration, College ofPharmacy, University ofHouston
4JJepartment ofClinical Sciences and Administration, Col­
lege ofPharmacy, University ofHouston
sClinical Associate Professor, Department ofClinical Sci­
ences and Administration, College ofPharmacy, University
ofHouston
6Associate I,>rofessor, Department ofClinical Sciences and
Administration, College ofPhartlfacy, University ofHouston
ABSTRACT
Objectives:
The website www.HoustonHealthChoice.org was launched
by the mayor ofHouston in April 2008 to facilitate informed
decision making among consumers seeking affordable health
insurance plans. The objectives ofthis study were to explore
consumers' awareness of this website and to assess the per­
ceived usefulness ofavailable information from the consumer
perspective.
Methods:
A cross-sectional survey of consumers in the Houston area
was conducted from December 2008 throughApril 2009 using
a pretested, self-administered questionnaire to evaluate con­
sumers' awareness and perceived usefulness of the website.
Participants irrespective oftheir awareness were requested to
review the website using a provided laptop computer before
responding to the questions that evaluated the website's ease
of use and perceived usefulness. English-speaking individu­
als were recruited from two primary locations, those at identi­
fied shopping centers in the Houston metropolitan area and
those enrolled at the University ofHouston.
~.~ , . -"
Results:
A total of 201 completed surveys were received. A major­
ity (80%) of the respondents were not aware of the website.
Ofthose respondents without health insurance, 97% were un­
aware ofthis website. After reviewing the information on the
website respondents indicated that information on the web­
site was clear and easy to understand. They indicated that
the website provided affordable insurance options available
within self-specified price range and that the overall content'
ofthe website was useful in decision making for health insur­
ance needs. They also indicated that the 'frequently asked
questions' and 'glossary of terms' sections provided useful
information.
Conclusion:
Although the website (HoustonHealthChoice.org) provided
useful information and may facilitate access to affordable
health insurance policies, most consumers may not be aware
of its existence. The website should be promoted adequately
to achieve its purpose. Promoting such websites may contrib­
ute toward effective delivery ofhealth insurance information
to the consumers in need.
Key Words:
Houstonhealthchoice.org, website, health insurance, aware­
ness, perceived usefulness, ease ofuse
Background:
The city of Houston accounts. for one-fifth of the total un­
insured population of Texas.l
The largest city in Texas and
fourth-largest in the United States, Houston is not only among
the top 100 cities in population densiif but has the highest
percentage ofuninsured residents ofany major city with more
than 30% ofresidents lacking health insurance coverage.3,4 In
addition to over 1million uninsured residents, around 500,000
are underinsured and unable to receive the necessary health­
care services. These individuals often have no choice but to
delay obtaining the needed medical care or not seek care at
all, resulting in potentially worse outcomes.s The situation in
Houston and Harris County has led to non-optimal utilization
of emergency care departments by uninsured individuals, us­
ing financial resources and overburdening the existing insur­
ance system in a way that the insurance-buying ability of oth­
er residents may be impacted.6
Due to increasing premiums,
currently insured residents are at a higher risk of becoming
underinsured, and likewise the currently underinsured may
become uninsured.7
Responding to the needs, the City of Houston created and
launched a website named HoustonHealthChoice.org in April
2008. It provides information on available health insurance
policies for individuals, families, and small businesses. .The
main purpose of the website is to facilitate informed deci­
sion making among consumers seeking affordable health
insurance plans. The website includes policies offered orily
by companies such as Aetna, Blue Cross, Golden Rule, Hu­
mana, and Unicare, which have been given 'secure' (B+ or
higher) rating on a scale ofA++ through S, by the A.M. Best
TPHAJournal Volume 62, Issue 38

2. insurance-rating agency.8
Insurance companies rated equal to
or greater than B+ are given 'secured' status, and those rated
below B+ are given 'vulnerable' status.9
Their rating is based
on insurer's financial strength and the ability to meet its ongo­
ing insurance policy and contract obligations. An individual
who may be shopping to purchase health insurance'can search
and find available health insurance policies based on the cri­
teria entered in their inquiry. The uniqueness ofthis website
lies in its ability to allow insurance seekers to find insurance
plans within their affordability range. Although this website
made headlines of the local newspapers and TV channels
when it was launched a couple of years ago, very little has
been done afterwards to promote it While the overall content
ofthe website should be useful for consumers, it is not known
whether citizens of Houston are aware of its existence and
whether they find the information presented on the website
helpful towards their health insurance-related decision-mak­
'ing. The objectives of this study were to explore consumers'
awareness ofthis website and to assess the perceived useful­
ness of available information from the consumer perspective.
Population andMethods:
The cross-sectional survey design used a pretested, self-ad­
ministered questionnaire. Participants were recruited from
various public locations such as shopping centers in the Hous­
ton area and the University of Houston. English speaking
adults (aged 18 years or above) were eligible to participate.
A brief overview of the survey objective was provided in a
short memorandum, and a questionnaire was provided to in­
dividuals who agreed to participate. The first section of the
questionnaire examined consumers' awareness ofthe website
and recorded demographic information. All participants were
then instructed to review the website using the provided lap­
top computer. The data collection assistant would open the
website for the participants, who were given as much time as
neededto view and evaluate the website. After each individual
reviewed the information on the website, they were provided
the next set ofquestions. The second section assessed ease of
use and perceived usefulness of the information available on
the website using a 5-point Likert scale (1=strongly disagree,
2= disagree, 3=neutral, 4= agree, and 5= strongly agree). The
scale included 10 items and measured participants' percep­
tion regarding the website (e.g. Information on the website
was clear and easy to understand; I found it easy to navigate
through the website). In the last section, an open-ended ques­
tion asked participants for their comments and suggestions.
Participants who initiated the survey but discontinued in the
middle ofthe data collection process were not considered.
Data were coded and entered into Microsoft Excel. Descrip­
tive statistics and Chi-square tests were performed using
SAS© (version 9.2, SAS© Institute Inc, Cary, NC) to analyze
responses.. T-test analysis was conducted to examine differ­
ences in perceived usefulness between participants from the
shopping centers and the university.
Results:
A total of 370 participants were approached. Of those. 165
individuals declined participation due to time constrains and
4 discontinued in the middle of data collection. The:final sur­
veys considered were 201 with a response rate of54.3%, hav­
ing 100 and 101 surveys collected respectively from shopping
centers and the university. The mean age ofrespondents was
34 years (SD ±14 years) with a majority (60%) being female..
The total responding sample included, 36.3% Whites, 24.9%
African Americans, 23.8% Asians, 11% Hispanics and 4%
others. Almost half(49.2%) ofthe respondents reported their
family income as below $50,000. Although, about 80% ofthe
total respondents had some kind ofhealth insurance, less than
halfhad knowledge regarding the type ofinsurance plan they
were enrolled. Almost 21% ofstudents and 18% ofconsum­
ers reported lacking health insurance coverage. Most (92%)
respondents,had Internet access at home and were employed
in a position other than healthcare (79%).
A majority (80%) ofparticipants were not aware ofthe exis­
tence ofthe website HoustonHealthChoice.org. More respon­
dents at the shopping centers (23%) were aware ofthe website
than those at the University (12.9%). Of those respondents
without health insurance, 97% were found to be unaware of
this website (Figure 1), and this proportion did not differ be­
tween survey locations.
After reviewing the information on the website, respondents
indicated that information on the website was clear and easy
to understand (Mean 3.97, SD ±O.93). Mean responses with
values greater than 3 meant that consumers were in agreement
on various aspects ofthe website assessed in the survey (Table
1). The perceived usefulness as reported by participants who
were aware ofthe website did not differ from those who vis­
ited the website for the first-time. Participants indicated that
the website provided affordable insurance options available
within self-specified price range (Mean 3.46, SD ±1.07) but
were neutral in saying that the overall content of the web­
site was useful in decision making for health insurance needs
(Mean 3.14, SD ±O.98). They also indicated that the 'fre­
quently asked questions' and 'glossary ofterms' sections pro­
vided useful information (Table 1).
Results of the t-test analyses did not indicate a difference in
consumers' perception between the survey locations (shop­
ping centers vs. the university). Only 26.3% of respondents
provided opinions using the open-ended question. Of these
respondents, one-fourth said the website is very educational
and informative. Almost the same proportion ofrespondents
(23%) mentioned thatthe website was notuseful for employed
consumers, whereas 12% said that the concept ofthe website
was good but it was not practical. Some of the other open­
ended comments suggested the need for a larger font size on
the website for elderly use (6%), and some saw it as a waste
oftax dollars (5%).
Discussion:
The findings of oUI study indicated that most consumers in
the Houston area may not be aware of the existence of the
website "HoustonHealthChoice.org". Surprisingly, those who
need such information the most, the uninsured population,
TPHA Journal Volume 62, Issue 3 9

3. were unaware. Attributes of the website were perceived to
be beneficial by individuals·seeking health insurance. The
website was perceived as easy to understand, efficient to
browse and navigate, and provided affordable insurance op­
tions. Considering the requirements of the target consumer
who may not be knowledgeable regarding insurance issues,
the website includes a section that provides answers to gen­
eral health insurance questions, information on government­
. sponsored programs, a glossary defining common insurance
terms, and links to other resources such as Gateway to Care, a
group working in the greater Houston area to serve medically
indigent residents. Despite these positive attnbutes, the web­
site may not achieve its purpose because ofgeneral unaware­
ness. The study findings suggest thatthe City ofHouston may
need to promote the website adequately in order to reach a
greater number of residents in need of insurance and to fa­
cilitate informed decision making. However, the impact of
this website in educating consumers and promoting informed
decision making needs to be further studied. Promoting this
web~ite among Houston citizens struggling with health insur­
ance options would not only facilitate access to affordable
insurance plans, but also contribute to strengthen regional
healthcare coverage in general. Future research should also
evaluate how such websites can contribute to the delivery of
the healthcare insurance information.
Limitations:
The study results should be viewed in the light ofsome limi­
tations. The results may not be generalizable to the Houston
population because this study employed a non-random sam­
pling method that is likely to incorporate bias. Moreover, the
study surveyed a general population at shopping centers and
university locations. Identifying individuals who are unin­
sured andlor underinsured andlor the target popUlations for
the website could provide a more realistic assessment of the
effectiveness of the website. Further, individuals seeking
health insurance have sources other than Internet (e.g. news­
papers, magazines, family, and friends) by which to obtain in­
surance-related information. In such situations, their chances
of using Internet sources to search for insurance options may
be very less. However, literature shows that a growing pro­
portion of uninsured consumers obtain health-related infor­
mation from the Intemet.10
Finally, many individuals who do
not have health insurance may not have access to computers
either. Promoting the website with those that provide indigent
care in the Houston area, including the Harris County Health­
care system may be useful.
Conclusion:
Although the websiteHoustonHealthChoice.orgprovided use­
ful information and may facilitate access to affordable health
insurance policies, consumers were generally not aware ofits
existence. To optimize the usefulness of this website, spe­
cifically for the uninsured, the City ofHouston must enhance
promotion efforts.
REFERENCES
1. Texas State Data Center and Office of the State Demog­
rapher, County Estimates of the Uninsured for Texas, 2005.
ht:W:l!txsdc.utsaedu. AccessedNovember 21, 2009.
2. U.S. Census Bureau. 200&. StatisticalAbstract ofthe Unit­
edStates: 2009. Washington, DC.
3. Associated Press, State with most uninsured residents:
Texas.http=llwww.msnbc.msn.comlidl33006860/nslhealth­
health carel. Accessed October 23, 2009.
4. Uninsured Facts Affecting Houston and Harris County.
http://www.hchalliance.org;ldocumentslFactSheet.pdf.Ac­
cessed at January 11, 2010.
5. Smith DG. 2008. What's in it for you? Understanding the
plight of the uninsured. Journal ofHealthcare Management.
53(3): p. 146.
6. Greater Houston Partnership, Public Health Task Force Re­
port. 2004. ht:W:l1www.hchalliance.org/documentsiArchive/
PublicHealthTaskForceRc;port.pdf. Accessed January U,
2010.
7. Hadley J. 2006. The effects ofrecent employment changes
and premium increases on adults' insurance coverage. Medi­
cal care research andreview. 63(4): p. 447.
8. Mayor Bill White announces new consumer web site to
help consumers make health insurance choices. http://www.
boustontx.gov/mayor/press/20080429.html. Accessed Dec
28,2009.
9. AM Best. Guide to Best's Financial Strength Ratings.
ht:W:llwww.ambest.comiratings/guide.pdf. Accessed at March
9,2010.
10. BundorfMK, Wagner TH, Singer SJ and BakerLC. 2006.
Who searches the internet for health information? Health Serv
Res, DOl: 1O.l11l1j.1475-6773.2006.0051O.x
Texas Public Health
Journal
" Peer-reviewed
" Quarterly publication
" THE Venue for Texas-
based publiC health
practice & research
" Indexed by EBSCO!
Visit the Journal page on our
website
htt(;!:lIwww.texas(;!ha.org
TPHA Journal Volume 62, Issue 310

4. Figure 1. Awareness of the website HoustonHealthChoice.org among insured and
uninsured respondents
120
Chi SQ. P=O.003
100
80
~...CQI
'"tT 60
C
0 • AwareQ.
...
IIJNotAwareco::
40
'"
20
0
Insured Uninsured
Insurance Status
Table 1. Perceived usefulness of the website, showing mean level of agreement on
various items in the survey
Sr.
No.
Item MeanB Standard
Deviation
1 The website was easily accessible 4.17 0.77
2 Information on the website was clear/easy to understand 3.97 0.93
3 I found it easy to navigate through the website 4.14 0.75
4 Text size on the website was easy to read 4.12 0.78
5 Website organization and layout was logical and clear 4.07 0.84
6 Website provided affordable pOlicies available within 3.46 1.07
specified price range
7 Website is helpful in making a decision for health 3.14 0.98
insurance needs
8 The glossary of terms section was useful in helping me 3.54 1.12
understand different terms with respect to my health
insurance
9 The Health Insurance Questions or the Frequently Asked 3.64 1.13
Questions section provided information related to health
insurance coverage that I previously did not know
10 The overall content of the website was useful 3.50 1.20
'Based on as-point Ukert-type scale (1, strongly disagree; 2. disagree; 3, neutral; 4, agree; 5, strongly agree).
TPHA Journal Volume 62, Issue 3 11