Human-Centered Design Study: Enhancing the Usability of a Mobile Phone App in an Integrated Falls Risk Detection System for Use by Older Adult Users

Smartphone App Designed to Collect Health Information in Older Adults: Usability Study

BACKGROUND

Studies evaluating the usability of mobile-phone assessments in older adults are limited.

OBJECTIVE

This study aims to identify design-based barriers and facilitators to mobile app survey completion among 2 samples of older adults; those in the Framingham Heart Study and a more diverse sample from a hospital-based setting.

METHODS

We used mixed methods to identify challenging and beneficial features of the mobile app in participants from the electronic Framingham Heart Study (n=15; mean age of 72 years; 6/15, 40% women; 15/15, 100% non-Hispanic and White) and among participants recruited from a hospital-based setting (n=15; mean age of 71 years; 7/15, 47% women; 3/15, 20% Hispanic; and 8/15, 53% non-White). A variety of app-based measures with different response formats were tested, including self-reported surveys, pictorial assessments (to indicate body pain sites), and cognitive testing tasks (eg, Trail Making Test and Stroop). Participants completed each measure using a think-aloud protocol, while being audio- and video-recorded with a qualitative interview conducted at the end of the session. Recordings were coded for participant usability errors by 2 pairs of coders. Participants completed the Mobile App Rating Scale to assess the app (response range 1=inadequate to 5=excellent).

RESULTS

In electronic Framingham Heart Study participants, the average total Mobile App Rating Scale score was 7.6 (SD 1.1), with no significant differences in the hospital-based sample. In general, participants were pleased with the app and found it easy to use. A large minority had at least 1 navigational issue, most committed only once. Most older adults did not have difficulty completing the self-reported multiple-choice measures unless it included lengthy instructions but participants had usability issues with the Stroop and Trail Making Test.

CONCLUSIONS

Our methods and results help guide app development and app-based survey construction for older adults, while also giving consideration to sociodemographic differences.

Effects of player-video game interaction on the mental effort of older adults with the use of electroencephalography and NASA-TLX

While player-video game interaction appears to affect older adults in gaming, there is limited knowledge regarding the cognitive demands associated with the anticipation of performing a button press, specifically focusing on the input and game elements relation (I/E relation) in game environments. The study aims to investigate the effects of lateral and rotational displacement amplitudes of game elements, triggered by a single button-press, on the cognitive effort of older adults. Both subjective and objective measurement methods were employed to assess these effects. A total of 48 older adults participated in three casual video game tasks encompassing lateral and rotational displacements at varying I/E relations (low, medium, and high). Results obtained from the NASA Task Load Index and electroencephalography (EEG) measurements revealed significant differences between the I/E relations. Specifically, the subjective rating of cognitive demand among older players was significantly impacted by a small rotation angle associated with a button press, leading to increased mental, physical, and temporal demands, along with decreased performance. Surprisingly, the analysis of EEG data, particularly the theta-alpha ratio, revealed significant interaction effects of I/E relations, button press type, and game type on the cognitive demand required during gameplay. These findings offer practical implications and point towards future avenues for developing player-video game interactions that are more cognitively friendly for older players in gaming environments.

Evaluating the Usability of an mHealth App for Empowering Cancer Survivors With Disabilities: Heuristic Evaluation and Usability Testing

BACKGROUND

More than 18 million cancer survivors are living in the United States. The effects of cancer and its treatments can have cognitive, psychological, physical, and social consequences that many survivors find incredibly disabling. Posttreatment support is often unavailable or underused, especially for survivors living with disabilities. This leaves them to deal with new obstacles and struggles on their own, oftentimes feeling lost during this transition. Mobile health (mHealth) interventions have been shown to effectively aid cancer survivors in dealing with many of the aftereffects of cancer and its treatments; these interventions hold immense potential for survivors living with disabilities. We developed a prototype for WeCanManage, an mHealth-delivered self-management intervention to empower cancer survivors living with disabilities through problem-solving, mindfulness, and self-advocacy training.

OBJECTIVE

Our study conducted a heuristic evaluation of the WeCanManage high-fidelity prototype and assessed its usability among cancer survivors with known disabilities.

METHODS

We evaluated the prototype using Nielsen's 10 principles of heuristic evaluation with 22 human-computer interaction university students. On the basis of the heuristic evaluation findings, we modified the prototype and conducted usability testing on 10 cancer survivors with a variety of known disabilities, examining effectiveness, efficiency, usability, and satisfaction, including a completion of the modified System Usability Scale (SUS).

RESULTS

The findings from the heuristic evaluation were mostly favorable, highlighting the need for a help guide, addressing accessibility concerns, and enhancing the navigation experience. After usability testing, the average SUS score was 81, indicating a good-excellent design. The participants in the usability testing sample expressed positive reactions toward the app's design, educational content and videos, and the available means of connecting with others. They identified areas for improvement, such as improving accessibility, simplifying navigation within the community forums, and providing a more convenient method to access the help guide.

CONCLUSIONS

Overall, usability testing showed positive results for the design of WeCanManage. The course content and features helped participants feel heard, understood, and less alone.

Old age or cognitive decline? Examining the usability of a mobile health app for older Australians

There is a growing literature on the role of mobile health applications (mHealth apps) in supporting older adults and the self-management of personal health. The purpose of this pilot study is to assess the usability of a government-funded mobile health app amongst older Australians and to evaluate whether cognitive function and demographic characteristics (i.e. age, gender, education) are associated with usability. A total of 28 older adults living in a regional city in Australia took part in the study. The participants were recruited using purposive sampling. Data collection instruments consisted of validated cognitive tests, task-based usability tests, and a questionnaire. The data was analyzed using non-parametric strategies. The findings of this study demonstrated that a government-funded, mHealth app was usable by older adults. Users were able to perform basic tasks in an effective and efficient manner. The hypothesis that elderly age would be significantly associated with performance on cognitive tests, as well as usability, was not supported. Performance on some cognitive tests was significantly and positively related to usability. Education and gender were not related to usability. The results suggest that traditional stereotypes surrounding aging and cognitive decline need to be reexamined.

A systematic review of menopause apps with an emphasis on osteoporosis

BACKGROUND

Menopause can significantly hasten bone loss. Mobile phones provide an efficient way to manage, track and understand menopause using apps. A previous review of menopause apps found numerous apps designed to help women manage menopause. However, it did not use validated measures to assess the quality of the apps and did not focus on content related to osteoporosis.

METHODS

This app review aligns with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The keywords used to search for the apps were "menopause" and "menopausal". Apps were included if they were in English, for individuals or groups and had a lifestyle focus. Apps that looked at other aspects of women's health, required external devices, cost to download, or were symptom-tracking were excluded. The quality and functionality were assessed using the Mobile App Rating Scale and IMS Institute for Healthcare Informatics Functionality score. Data were synthesised descriptively.

RESULTS

Twenty-eight apps were selected and reviewed from the 236 apps screened from the Apple store and Google play store. Only 57% of the apps reviewed (n = 16) had content on osteoporosis which was educational in purpose. The readability of the apps was complex and best understood by university graduates. The average functionality score of the apps reviewed was 4.57 out of 11 and that of quality is 3.1 out of 5, both of which need improvement.

CONCLUSIONS

Existing menopause apps need more input from experts to improve the quality and functionality, using simple language. More emphasis on specific health problems during menopause, including osteoporosis, is required.

TRIAL REGISTRATION

Not relevant.

Design Guidelines of Mobile Apps for Older Adults: Systematic Review and Thematic Analysis

BACKGROUND

Mobile apps are fundamental tools in today's society for practical and social endeavors. However, these technologies are often not usable for older users. Given the increased use of mobile apps by this group of users and the impact that certain services may have on their quality of life, such as mobile health, personal finance, or online administrative procedures, a clear set of guidelines for mobile app designers is needed. Existing recommendations for older adults focus on investigations with certain groups of older adults or have not been extracted from experimental results.

OBJECTIVE

In this research work, we systematically reviewed the scientific literature that provided recommendations for the design of mobile apps based on usability testing with older adults and organized such recommendations into a meaningful set of design guidelines.

METHODS

We conducted a systematic literature review of journal and conference articles from 2010 to 2021. We included articles that carried out usability tests with populations aged >60 years and presented transferable guidelines on mobile software design, resulting in a final set of 40 articles. We then carried out a thematic analysis with 3 rounds of analysis to provide meaning to an otherwise diverse set of recommendations. At this stage, we discarded recommendations that were made by just 1 article, were based on a specific mobile app and were therefore nontransferrable, were based on other authors' literature (as opposed to recommendations based on the results of usability tests), or were not sufficiently argued. With the remaining recommendations, we identified commonalities, wrote a faithful statement for each guideline, used a common language for the entire set, and organized the guidelines into categories, thereby giving shape to an otherwise diverse set of recommendations.

RESULTS

Among the 27 resulting guidelines, the rules Simplify and Increase the size and distance between interactive controls were transversal and of the greatest significance. The rest of the guidelines were divided into 5 categories (Help & Training, Navigation, Visual Design, Cognitive Load, and Interaction) and consequent subcategories in Visual Design (Layout, Icons, and Appearance) and Interaction (Input and Output). The recommendations were structured, explained in detail, and illustrated with applied examples extracted from the selected studies, where appropriate. We discussed the design implications of applying these guidelines, contextualized with relevant studies. We also discussed the limitations of the approach followed, stressing the need for further experimentation to gain a better understanding of how older adults use mobile apps and how to better design such apps with these users in mind.

CONCLUSIONS

The compiled guidelines support the design of mobile apps that cater to the needs of older adults because they are based on the results of actual usability tests with users aged >60 years.

Developing the Speaking Out and Allying Relationships Intervention on Videoconference for HIV-Positive GBMSM in Eastern Cape, South Africa

In South Africa, HIV prevalence for gay, bisexual, and men who have sex with men (GBMSM) is as high as 49.5%, yet only 25.7% are taking treatment, resulting in transmission risk between partners and the need for dyadic interventions for men in relationships. Through our preliminary research, we identified the evidence-based intervention Healthy Relationships (HR)-an HIV risk assessment and status disclosure intervention for those in relationships-to be tailored into videoconference format for partnered HIV-positive GBMSM in South Africa. The HR adaptation, called SOAR (Speaking Out & Allying Relationships), applied a human-centered design approach. In-depth interviews were conducted with HIV-positive GBMSM (N = 15) to refine intervention preferences with results used to establish a beta SOAR. A trained interventionist conducted SOAR functionality (n = 6) and usability (n = 7) tests with separate invited groups composed of the original participants interviewed. Field logs, focus group discussions, and a study-specific preference survey were administered. Thematic analysis and descriptive statistics were completed with a convergent analytical approach used to understand usability. Overall experience of GBMSM in SOAR was good (69%) or excellent (31%). More than half of the participants (61%) rated using videoconferencing for SOAR as good, with 38% rating it as fair. All participants stated that SOAR was understandable and satisfactory with willingness to recommend it to other GBMSM. This adaptation approach was effective, and the resultant SOAR intervention has the potential to improve individual coping and HIV communication skills with partners to engage with biomedical prevention and in turn support GBMSM couples.

Ageism in the Discourse and Practice of Designing Digital Technology for Older Persons: A Scoping Review

BACKGROUND AND OBJECTIVES

Involving older persons in the design process of digital technology (DT) promotes the development of technologies that are appealing, beneficial, and used. However, negative discourse on aging and ageism are potential underlying factors that could influence which and how DTs are designed and how older persons are involved in the design process. This scoping review investigates the explicit and implicit manifestations of ageism in the design process of DT.

RESEARCH DESIGN AND METHODS

Seven databases were screened for studies reporting on the design of DT with older persons between January 2015 and January 2020. Data regarding study and DT characteristics, discourse about older persons, and their involvement in the design process were extracted, coded, and analyzed using critical discourse analysis.

RESULTS

Sixty articles met the inclusion criteria and were included in the analysis. Various forms of exclusion of older persons from the design process were identified, such as no or low involvement, upper-age limits, and sample biases toward relatively "active," healthy and "tech-savvy" older persons. Critical discourse analysis revealed the use of outdated language, stereotypical categorizations, and/or design decisions based on ageism in 71.7% of the studies.

DISCUSSION AND IMPLICATIONS

A discrepancy was found between an "ideal" discourse regarding the involvement of older persons throughout the design process and actual practice. Manifestations of ageism, errors, and biases of designing DT with older persons are discussed. This article calls for more authentic inclusion of older persons and higher awareness toward the implications of ageism in the design process of DT.

Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention

BACKGROUND

Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care.

METHODS

Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation.

RESULTS

We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users.

CONCLUSIONS

We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Usability evaluation of mHealth apps for elderly individuals: a scoping review

BACKGROUND

Usability is a key factor affecting the acceptance of mobile health applications (mHealth apps) for elderly individuals, but traditional usability evaluation methods may not be suitable for use in this population because of aging barriers. The objectives of this study were to identify, explore, and summarize the current state of the literature on the usability evaluation of mHealth apps for older adults and to incorporate these methods into the appropriate evaluation stage.

METHODS

Electronic searches were conducted in 10 databases. Inclusion criteria were articles focused on the usability evaluation of mHealth apps designed for older adults. The included studies were classified according to the mHealth app usability evaluation framework, and the suitability of evaluation methods for use among the elderly was analyzed.

RESULTS

Ninety-six articles met the inclusion criteria. Research activity increased steeply after 2013 (n = 92). Satisfaction (n = 74) and learnability (n = 60) were the most frequently evaluated critical measures, while memorability (n = 13) was the least evaluated. The ratios of satisfaction, learnability, operability, and understandability measures were significantly related to the different stages of evaluation (P < 0.05). The methods used for usability evaluation were questionnaire (n = 68), interview (n = 36), concurrent thinking aloud (n = 25), performance metrics (n = 25), behavioral observation log (n = 14), screen recording (n = 3), eye tracking (n = 1), retrospective thinking aloud (n = 1), and feedback log (n = 1). Thirty-two studies developed their own evaluation tool to assess unique design features for elderly individuals.

CONCLUSION

In the past five years, the number of studies in the field of usability evaluation of mHealth apps for the elderly has increased rapidly. The mHealth apps are often used as an auxiliary means of self-management to help the elderly manage their wellness and disease. According to the three stages of the mHealth app usability evaluation framework, the critical measures and evaluation methods are inconsistent. Future research should focus on selecting specific critical measures relevant to aging characteristics and adapting usability evaluation methods to elderly individuals by improving traditional tools, introducing automated evaluation tools and optimizing evaluation processes.

A time motion study of manual versus artificial intelligence methods for wound assessment

Objectives

This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.

Methods

Clinicians practicing at Valley Wound Center who agreed to join the study were asked to record the time needed to complete wound assessment activities for patients with active wounds referred for a routine evaluation on the follow-up days at the clinic. Assessment activities included: labelling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient’s record.

Results

A total of 91 patients with 115 wounds were assessed. The average time to capture and access wound image with the AI digital tool was significantly faster than a standard digital camera with an average of 62 seconds (P<0.001). The digital application was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001). Overall, the average time to complete a wound assessment using Swift was significantly faster by 79%. Using the AI application, the staff completed all steps in about half of the time (54%) normally spent on manual wound evaluation activities. Moreover, acquiring acceptable wound image was significantly more likely to be achieved the first time using the digital tool than the manual methods (92.2% vs. 75.7%, P<0.004).

Conclusions

Using the digital assessment tool saved significant time for clinicians in assessing wounds. It also successfully captured quality wound images at the first attempt.

Codesign approaches involving older adults in the development of electronic healthcare tools: a systematic review

OBJECTIVE

The primary aim was to review and synthesise the current evidence of how older adults are involved in codesign approaches to develop electronic healthcare tools (EHTs). The secondary aim was to identify how the codesign approaches used mutual learning techniques to benefit older adult participants.

DESIGN

Systematic review following the Preferred Reporting Items for Systematic Reviews 2020 checklist.

DATA SOURCES

PubMed, Embase and Scopus databases were searched for studies from January 2010 to March 2021.

ELIGIBILITY CRITERIA

Inclusion criteria were studies employing codesign approaches to develop an EHTs, and the study population was aged 60 years and older.

DATA EXTRACTION AND SYNTHESIS

Data were extracted for analysis and risk of bias. We evaluated the quality of studies using the Agency for Healthcare Research and Quality Evidence-based Practice Center approach.

RESULTS

Twenty-five studies met the inclusion criteria for this review. All studies used at least two involvement processes, with interviews and prototypes used most frequently. Through cross-classification, we found an increased utilisation of functional prototypes in studies reaching the 'empower' level of participation and found that studies which benefitted from mutual learning had a higher utilisation of specific involvement processes such as focus groups and functional prototyping.

CONCLUSIONS

We found gaps to support which involvement processes, participation levels and learning models should be employed when codesigning with older adults. This is important because higher levels of participation may increase the user's knowledge of technology, enhance learning and empower participants. To ensure studies optimise participation and learning of older adults when developing EHTs, there is a need to place more emphasis on the approaches promoting mutual learning.

PROSPERO REGISTRATION NUMBER

CRD42021240013.

Interactive Visualizations of Transparent User Models for Self-Actualization: A Human-Centered Design Approach

This contribution sheds light on the potential of transparent user models for self-actualization. It discusses the development of EDUSS, a conceptual framework for self-actualization goals of transparent user modeling. Drawing from a qualitative research approach, the framework investigates self-actualization from psychology and computer science disciplines and derives a set of self-actualization goals and mechanisms. Following a human-centered design (HCD) approach, the framework was applied in an iterative process to systematically design a set of interactive visualizations to help users achieve different self-actualization goals in the scientific research domain. For this purpose, an explainable user interest model within a recommender system is utilized to provide various information on how the interest models are generated from users’ publication data. The main contributions are threefold: First, a synthesis of research on self-actualization from different domains. Second, EDUSS, a theoretically-sound self-actualization framework for transparent user modeling consisting of five main goals, namely, Explore, Develop, Understand, Scrutinize, and Socialize. Third, an instantiation of the proposed framework to effectively design interactive visualizations that can support the different self-actualization goals, following an HCD approach.

Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi

Background

Neonatal mortality is high in low-resource settings. NeoTree is a digital intervention for neonatal healthcare professionals (HCPs) aiming to achieve data-driven quality improvement and improved neonatal survival in low-resource hospitals. Optimising usability with end-users could help digital health interventions succeed beyond pilot stages in low-resource settings. Usability is the quality of a user's experience when interacting with an intervention, encompassing their effectiveness, efficiency, and overall satisfaction.

Objective

To evaluate the usability and usage of NeoTree beta-app and conduct Agile usability-focused intervention development.

Method

A real-world pilot of NeoTree beta-app was conducted over 6 months at Kamuzu Central Hospital neonatal unit, Malawi. Prior to deployment, think-aloud interviews were conducted to guide nurses through the app whilst voicing their thoughts aloud (n = 6). System Usability Scale (SUS) scores were collected before the implementation of NeoTree into usual clinical care and 6 months after implementation (n = 8 and 8). During the pilot, real-world user-feedback and user-data were gathered. Feedback notes were subjected to thematic analysis within an Agile “product backlog.” For usage, number of users, user-cadre, proportion of admissions/outcomes recorded digitally, and median app-completion times were calculated.

Results

Twelve overarching usability themes generated 57 app adjustments, 39 (68%) from think aloud analysis and 18 (32%) from the real-world testing. A total of 21 usability themes/issues with corresponding app features were produced and added to the app. Six themes relating to data collection included exhaustiveness of data schema, prevention of errors, ease of progression, efficiency of data entry using shortcuts, navigation of user interface (UI), and relevancy of content. Six themes relating to the clinical care included cohesion with ward process, embedded education, locally coherent language, adaptability of user-interface to available resources, and printout design to facilitate handover. SUS scores were above average (88.1 and 89.4 at 1 and 6 months, respectively). Ninety-three different HCPs of 5 cadres, recorded 1,323 admissions and 1,197 outcomes over 6 months. NeoTree achieved 100% digital coverage of sick neonates admitted. Median completion times were 16 and 8 min for admissions and outcomes, respectively.

Conclusions

This study demonstrates optimisation of a digital health app in a low-resource setting and could inform other similar usability studies apps in similar settings.

FHIRedApp: a LEAP in health information technology for promoting patient access to their medical information

Objective

Our aim is to develop a patient engagement technology that makes it easy for patients to access their own medical information and share it with others.

Materials and Methods

This paper describes our design through an adapted Community Engagement Studio methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American individuals in the community. We use Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients.

Results

We designed and developed FHIRedApp, an app platform, that allows patients to access their data and to share that access as HL7^® FHIR^® application programming interfaces with third-party app developers. We accomplished 2 major tasks: first, to demonstrate the use of interoperability and authentication standards, such as HL7^® FHIR and OAuth2, to help develop patient engagement technologies, and second, to co-develop and co-design FHIRedApp with active involvement of African–American, Latinx, and Asian–American community members. Usability results show high satisfaction rates for FHIRedApp.

Conclusion

The development of FHIRedApp demonstrates how technology innovations using national interoperability standards can be informed through a methodology of community engagement and human-centered design that involves local racial and ethnic groups.

Our aim is to develop a patient engagement technology (PET) that makes it easy for patients to access their own medical information and share it with others. We adapted a methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American patients. We used Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients. We designed and developed FHIRedApp, a platform that allows other applications to work on it. Patients showed high satisfaction with the use of FHIRedApp. The development of FHIRedApp demonstrates how technology innovations using national standards for exchanging data can be informed through a methodology of community engagement and human-centered design.

Flu@home: The comparative accuracy of an at-home influenza rapid diagnostic test, using a pre-positioned test kit, mobile app, mail-in reference sample, and symptom-based testing trigger

At-home testing with rapid diagnostic tests (RDTs) for respiratory viruses could facilitate early diagnosis, guide patient care, and prevent transmission. Such RDTs are best used near the onset of illness when viral load is highest and clinical action will be most impactful, which may be achieved by at-home testing. We evaluated the diagnostic accuracy of the QuickVue Influenza A + B RDT in an at-home setting. A convenience sample of 5,229 individuals who were engaged with an on-line health research platform were prospectively recruited throughout the United States. "flu@home" test kits containing a QuickVue RDT and reference sample collection and shipping materials were pre-positioned with participants at the beginning of the study. Participants responded to daily symptom surveys. If they reported experiencing cough along with aches, fever, chills, and/or sweats, they used their flu@home kit following instructions on a mobile app and indicated what lines they saw on the RDT. Of the 976 participants who met criteria to use their self-collection kit and completed study procedures, 202 (20.7%) were positive for influenza by qPCR. The RDT had a sensitivity of 28% (95% CI: 21-36) and specificity of 99% (98-99) for influenza A, and 32% (95% CI: 20-46) and 99% (95% CI: 98-99), for influenza B. Our results support the concept of app-supported, pre-positioned at-home RDT kits using symptom-based triggers, although it cannot be recommended with the RDT used in this study. Further research is needed to determine ways to improve the accuracy and utility of home-based testing for influenza.

A skills-based sero-status HIV disclosure intervention for sexual minority men in South Africa: A protocol for intervention adaptation and pilot randomized controlled trial (Preprint)

Background

Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV have low antiretroviral treatment adherence in South Africa due to limited skills in managing disclosure and prevention behaviors with sexual and romantic partners. As a result, there is a high HIV transmission risk within HIV-discordant partnerships, but an existing intervention may address these outcomes, if adapted effectively. Healthy Relationships (HR) is a behavioral intervention that was originally delivered in groups and in person over 5 sessions to develop coping skills for managing HIV-related stress and sexually risky situations, enhance decision-making skills for HIV disclosure to partners, and establish and maintain safer sex practices with partners. HR effectively improves prevention behaviors but has yet to be tailored to a non-US context.

Objective

We aim to adapt HR into a new culturally grounded intervention entitled Speaking Out & Allying Relationships for GBMSM and then assess its feasibility in Eastern Cape, South Africa.

Methods

The study will have 2 aims. For aim 1—adaptation—we will use a human-centered design approach. Initial intervention tailoring will involve integrating Undetectable=Untransmittable and pre-exposure prophylaxis education, developing intervention content for a videoconference format, and designing role-plays and movies for skill building based on preliminary data. Afterward, interviews and surveys will be administered to GBMSM to assess intervention preferences, and a focus group will be conducted with health care providers and information technology experts to assess the intervention’s design. Finally, a usability test will be performed to determine functionality and content understanding. Participants will be GBMSM living with HIV (n=15) who are in a relationship and health care providers and information technology (n=7) experts working in HIV care and programming with this population. For aim 2, we will examine the feasibility of the adapted intervention by using a pilot randomized control design. There will be 60 individuals per arm. Feasibility surveys and interviews will be conducted with the intervention arm, and behavioral and biomedical assessments for relationship and treatment adherence outcomes will be collected for both arms. All participants will be GBMSM living with HIV who are in a relationship with an HIV-negative or unknown status partner.

Results

Intervention adaptation began in August 2021. Initial tailoring and the refining of GBMSM intervention preferences were completed in December 2021. Usability and feasibility assessments are due to be completed by March 2022 and February 2024, respectively.

Conclusions

GBMSM need efficacious interventions that tackle partnership dynamics, HIV prevention, and treatment outcomes for antiretroviral treatment adherence and viral suppression in South Africa. Harnessing everyday technology use for social networking (eg, videoconferences), Undetectable=Untransmittable education, and pre-exposure prophylaxis to update an existing intervention for South African GBMSM has the potential to strengthen relationship communication about HIV treatment and prevention and, in turn, improve outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36845

Human-Centered Design of Mobile Health Apps for Older Adults: Systematic Review and Narrative Synthesis

BACKGROUND

The world is aging. The number of older patients is on the rise, and along with it comes the burden of noncommunicable diseases, both clinical and economic. Attempts with mobile health (mHealth) have been made to remedy the situation with promising outcomes. Researchers have adopted human-centered design (HCD) in mHealth creation to ensure those promises become a reality.

OBJECTIVE

This systematic review aims to explore existing literature on relevant primary research and case studies to (1) illustrate how HCD can be used to create mHealth solutions for older adults and (2) summarize the overall process with recommendations specific to the older population.

METHODS

We conducted a systematic review to address the study objectives. IEEE Xplore, Medline via Ovid, PubMed, and Scopus were searched for HCD research of mHealth solutions for older adults. Two independent reviewers then included the papers if they (1) were written in English, (2) included participants equal to or older than 60 years old, (3) were primary research, and (4) reported about mHealth apps and their HCD developments from start to finish. The 2 reviewers continued to assess the included studies' qualities using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was then carried out and completed.

RESULTS

Eight studies passed the eligibility criteria: 5 were mixed methods studies and 3 were case studies. Some studies were about the same mHealth projects with a total of 5 mHealth apps. The included studies differed in HCD goals, target groups, and details of their HCD methodologies. The HCD process was explored through narrative synthesis in 4 steps according to the International Standardization Organization (ISO) standard 9241-210: (1) understand and specify the context of use, (2) specify the user requirements, (3) produce design solutions to meet these requirements, and (4) evaluate the designs against requirements. The overall process and recommendations unique to older adults are summarized logically with structural order and time order based on the Minto pyramid principle and ISO 9241-210.

CONCLUSIONS

Findings show that HCD can be used to create mHealth solutions for older adults with positive outcomes. This review has also summarized practical HCD steps and additional suggestions based on existing literature in the subfield. However, evidence-based results are still limited because most included studies lacked details about their sampling methods and did not set objective and quantifiable goals, leading to failure to draw significant conclusions. More studies of HCD application on mHealth for older adults with measurable design goals and rigorous research strategy are warranted.

Design and Development of a Suite of Intimate Partner Violence Screening and Safety Planning Web Apps: User-Centered Approach

Background

The popularity of mobile health (mHealth) technology has resulted in the development of numerous apps for almost every condition and disease management. mHealth and eHealth solutions for increasing awareness about, and safety around, intimate partner violence are no exception. These apps allow women to control access to these resources and provide unlimited, and with the right design features, safe access when these resources are needed. Few apps, however, have been designed in close collaboration with intended users to ensure relevance and effectiveness.

Objective

The objective of this paper is to discuss the design of a suite of evidence-based mHealth and eHealth apps to facilitate early identification of unsafe relationship behaviors and tailored safety planning to reduce harm from violence including the methods by which we collaborated with and sought input from a population of intended users.

Methods

A user-centered approach with aspects of human-centered design was followed to design a suite of 3 app-based safety planning interventions.

Results

This review of the design suite of app-based interventions revealed challenges faced and lessons learned that may inform future efforts to design evidence-based mHealth and eHealth interventions.

Conclusions

Following a user-centered approach can be helpful in designing mHealth and eHealth interventions for marginalized and vulnerable populations, and led to novel insights that improved the design of our interventions.

The multidisciplinary, theory-based co-design of a new digital health intervention supporting the care of oesophageal cancer patients

Objective

Oesophageal cancer patients have complex care needs. Cancer clinical nurse specialists play a key role in coordinating their care but often have heavy workloads. Digital health interventions can improve patient care but there are few examples for oesophageal cancer. This paper aims to describe the multidisciplinary co-design process of a digital health intervention to improve the experience of care and reduce unmet needs among patients with oesophageal cancer.

Methods

A theory-based, multi-disciplinary, co-design approach was used to inform the developmental process of the digital health intervention. Key user needs were elicited using mixed methodology from systematic reviews, focus groups and interviews and holistic need assessments. Overarching decisions were discussed among a core team of patients, carers, health care professionals including oncologists and cancer clinical nurse specialists, researchers and digital health providers. A series of workshops incorporating a summary of findings of key user needs resulted in the development of a minimum viable product. This was further refined after a pilot study based on feedback from end users.

Results

The final digital health intervention consists of a mobile app feature for patients and carers connected to a dashboard with supporting additional features for clinical nurse specialist. It contains a one-way messaging function for clinical nurse specialists to communicate with patients, functions for patients to record weight and holistic need assessment results which could be viewed by their clinical nurse specialists as well as a library of informative articles.

Conclusions

The multidisciplinary co-design of a digital health intervention providing support for oesophageal cancer patients and health care professionals has been described. Future studies to establish its impact on patient outcomes are planned.

The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices

Background

Human-centered design (HCD) approaches to health care strive to support the development of innovative, effective, and person-centered solutions for health care. Although their use is increasing, there is no integral overview describing the details of HCD methods in health innovations.

Objective

This review aims to explore the current practices of HCD approaches for the development of health innovations, with the aim of providing an overview of the applied methods for participatory and HCD processes and highlighting their shortcomings for further research.

Methods

A narrative review of health research was conducted based on systematic electronic searches in the PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, and Sociological Abstracts (2000-2020) databases using keywords related to human-centered design, design thinking (DT), and user-centered design (UCD). Abstracts and full-text articles were screened by 2 reviewers independently based on predefined inclusion criteria. Data extraction focused on the methodology used throughout the research process, the choice of methods in different phases of the innovation cycle, and the level of engagement of end users.

Results

This review summarizes the application of HCD practices across various areas of health innovation. All approaches prioritized the user’s needs and the participatory and iterative nature of the design process. The design processes comprised several design cycles during which multiple qualitative and quantitative methods were used in combination with specific design methods. HCD- and DT-based research primarily targeted understanding the research context and defining the problem, whereas UCD-based work focused mainly on the direct generation of solutions. Although UCD approaches involved end users primarily as testers and informants, HCD and DT approaches involved end users most often as design partners.

Conclusions

We have provided an overview of the currently applied methodologies and HCD guidelines to assist health care professionals and design researchers in their methodological choices. HCD-based techniques are challenging to evaluate using traditional biomedical research methods. Previously proposed reporting guidelines are a step forward but would require a level of detail that is incompatible with the current publishing landscape. Hence, further development is needed in this area. Special focus should be placed on the congruence between the chosen methods, design strategy, and achievable outcomes. Furthermore, power dimensions, agency, and intersectionality need to be considered in co-design sessions with multiple stakeholders, especially when including vulnerable groups.

Mobile health applications for older adults: a systematic review of interface and persuasive feature design

OBJECTIVE

Mobile-based interventions have the potential to promote healthy aging among older adults. However, the adoption and use of mobile health applications are often low due to inappropriate designs. The aim of this systematic review is to identify, synthesize, and report interface and persuasive feature design recommendations of mobile health applications for elderly users to facilitate adoption and improve health-related outcomes.

MATERIALS AND METHODS

We searched PubMed, Embase, PsycINFO, CINAHL, and Scopus databases to identify studies that discussed and evaluated elderly-friendly interface and persuasive feature designs of mobile health applications using an elderly cohort.

RESULTS

We included 74 studies in our analysis. Our analysis revealed a total of 9 elderly-friendly interface design recommendations: 3 recommendations were targeted at perceptual capabilities of elderly users, 2 at motor coordination problems, and 4 at cognitive and memory deterioration. We also compiled and reported 5 categories of persuasive features: reminders, social features, game elements, personalized interventions, and health education.

DISCUSSION

Only 5 studies included design elements that were based on theories. Moreover, the majority of the included studies evaluated the application as a whole without examining end-user perceptions and the effectiveness of each single design feature. Finally, most studies had methodological limitations, and better research designs are needed to quantify the effectiveness of the application designs rigorously.

CONCLUSIONS

This review synthesizes elderly-friendly interface and persuasive feature design recommendations for mobile health applications from the existing literature and provides recommendations for future research in this area and guidelines for designers.

User-centered requirements engineering to manage the fuzzy front-end of open innovation in e-health: A study on support systems for seniors' physical activity

BACKGROUND

Although e-health potentials for improving health systems in their safety, quality and efficiency has been acknowledged, a large gap between the postulated and empirically demonstrated benefits of e-health technologies has been ascertained. E-health development has classically been technology-driven, often resulting in the design of devices and applications that ignore the complexity of the real-world setting, thus leading to slow diffusion of innovations to care. Therefore, e-health innovation needs to consider the mentioned complexity already from the start. The early phases of innovation, fuzzy front-end (FFE) defined as "the period between when an opportunity is first considered and when an idea is judged ready for development" has been identified to have the highest impact on the innovation process and its outcome. The FFE has been recognized as the most difficult stage to manage in the innovation process as it involves a high degree of uncertainty. Such a phase becomes even more difficult when different sectors and organizations are involved. Therefore, effective methods for involving different organizations and user groups in the FFE of innovation are needed.

OBJECTIVE

The aim of this study was to manage the FFE of a collaborative, open innovation (OI) process, to define a software system supporting seniors' physical activity (PA) by applying a framework of methods from software requirements engineering (RE) to elicit and analyze needs and requirements of users and stakeholders, as well as the context in which the system should be used.

METHODS

Needs and requirements of three future user groups were explored through individual- and focus group interviews. Requirements were categorized and analyzed in a workshop with a multidisciplinary team: a system overview was produced by conceptual modelling using elicited functional requirements; high-level non-functional requirements were negotiated and prioritized. Scenario descriptions of system's supportive roles in different phases of a behavioral change process were developed.

RESULTS

User-centered RE methods were successfully used to define a system and a high-level requirements description was developed based on needs and requirements from three identified user groups. The system aimed to support seniors' motivation for PA and contained four complementary sub-systems. The outcome of the study was a Concept of Operations (ConOps) document that specified the high-level system requirements in a way that was understandable for stakeholders. This document was used both to identify and recruit suitable industrial partners for the following open innovation development and to facilitate communication and collaboration in the innovation process.

CONCLUSIONS

Applying software RE methods and involving user groups in the early phases of OI can contribute to the development of new concepts that meet complex real-world requirements. Different user groups can complement each other in conveying needs and requirements from which systems can be designed. Empirical studies applying and exploring different methods used to define new e-health solutions can contribute with valuable knowledge about handling innovation FFE.

Using Medical Device Standards for Design and Risk Management of Immersive Virtual Reality for At-Home Therapy and Remote Patient Monitoring

Numerous virtual reality (VR) systems have received regulatory clearance as therapeutic medical devices for in-clinic and at-home use. These systems enable remote patient monitoring of clinician-prescribed rehabilitation exercises, although most of these systems are nonimmersive. With the expanding availability of affordable and easy-to-use head-mounted display (HMD)-based VR, there is growing interest in immersive VR therapies. However, HMD-based VR presents unique risks. Following standards for medical device development, the objective of this paper is to demonstrate a risk management process for a generic immersive VR system for remote patient monitoring of at-home therapy. Regulations, standards, and guidance documents applicable to therapeutic VR design are reviewed to provide necessary background. Generic requirements for an immersive VR system for home use and remote patient monitoring are identified using predicate analysis and specified for both patients and clinicians using user stories. To analyze risk, failure modes and effects analysis, adapted for medical device risk management, is performed on the generic user stories and a set of risk control measures is proposed. Many therapeutic applications of VR would be regulated as a medical device if they were to be commercially marketed. Understanding relevant standards for design and risk management early in the development process can help expedite the availability of innovative VR therapies that are safe and effective.

"I'll tell you what's important to me…": lessons for women's health screening

Background

Providers face increasing demands to screen for various health issues. Family medicine, primary care, and obstetric providers are encouraged to screen women universally for intimate partner violence, which could be challenging without comprehensive screening tools. The screening expectations and demands motivated providers and staff in south-central Appalachia (U.S.) to engage community members in streamlining women’s health screening tools, and integrating intimate partner violence screening questions, through a Human-Centered Design (HCD) process. The objective of this article is to present participants’ experiences with and perceptions of the HCD process for developing screening tools for women’s health.

Methods

This was a qualitative, phenomenological study conducted with community members (n = 4) and providers and staff (n = 7) who participated in the HCD process. Sampling was purposive and opportunistic. An experienced qualitative researcher conducted open-ended, semi-structured interviews with participants. Interviews were transcribed and coded for thematic analysis.

Results

Community members reported that in the HCD sessions they wanted clinicians to understand the importance of timing and trust in health screening. They focused on the importance of taking time to build trust before asking about intimate partner violence; not over-focusing on body weight as this can preclude trust and disclosure of other issues; and understanding the role of historical oppression and racial discrimination in contributing to healthcare mistrust. Providers and staff reported that they recognized the importance of these concerns during the HCD process.

Conclusions

Community members provided critical feedback for designing appropriate tools for screening for women’s health. The findings suggest that co-designing screening tools for use in clinical settings can facilitate communication of core values. How, when, and how often screening questions are asked are as important as what is asked—especially as related to intimate partner violence and weight.

A Mobile App to Optimize Social Participation for Individuals with Physical Disabilities: Content Validation and Usability Testing

Background: Social participation is beneficial for individuals’ health. However, people with disabilities that may lead to mobility limitations tend to experience lower levels of social participation. Information and communication technologies such as the OnRoule mobile application (app) can help promote social participation. Objectives: To obtain potential users’ perceptions on the usability and content of the OnRoule app for providing information on accessibility, as well as its potential to optimize social participation. Materials and Methods: Cross-sectional user-centered design study. Individuals with physical disabilities (n = 18) were recruited through community organizations and interviewed using a semi-structured guide. Interviews were recorded, transcribed, and analyzed using thematic analysis. Results: Three main themes were identified: (1) “user-friendliness”; (2) “balance between the amount and relevance of information”; and (3) “potential use of the app”. Discussion and Conclusion: Findings from this study indicated that the app was easy to use, had pertinent information, and enabled a positive experience of finding information. However, several areas of improvement were identified, such as the clarity of specific elements, organization and amount of information, optimization of features, and inclusiveness. Apps such as OnRoule could optimize social participation by facilitating the process of finding resources in the community and building a sense of connectedness between users.

Standards, Processes and Tools Used to Evaluate Health Information Systems Quality: A Systematic Literature Review (Preprint)

Background

Evaluating health information system (HIS) quality is strategically advantageous for improving the quality of patient care. Nevertheless, few systematic studies have reported what methods, such as standards, processes, and tools, were proposed to evaluate HIS quality.

Objective

This study aimed to identify and discuss the existing literature that describes standards, processes, and tools used to evaluate HIS quality.

Methods

We conducted a systematic literature review using review guidelines focused on software and systems. We examined seven electronic databases—Scopus, ACM (Association for Computing Machinery), ScienceDirect, Google Scholar, IEEE Xplore, Web of Science, and PubMed—to search for and select primary studies.

Results

Out of 782 papers, we identified 17 (2.2%) primary studies. We found that most of the primary studies addressed quality evaluation from a management perspective. On the other hand, there was little explicit and pragmatic evidence on the processes and tools that allowed for the evaluation of HIS quality.

Conclusions

To promote quality evaluation of HISs, it is necessary to define mechanisms and methods that operationalize the standards in HISs. Additionally, it is necessary to create metrics that measure the quality of the most critical components and processes of HISs.

Implementation of Electronic Informed Consent in Biomedical Research and Stakeholders' Perspectives: Systematic Review

Background

Informed consent is one of the key elements in biomedical research. The introduction of electronic informed consent can be a way to overcome many challenges related to paper-based informed consent; however, its novel opportunities remain largely unfulfilled due to several barriers.

Objective

We aimed to provide an overview of the ethical, legal, regulatory, and user interface perspectives of multiple stakeholder groups in order to assist responsible implementation of electronic informed consent in biomedical research.

Methods

We conducted a systematic literature search using Web of Science (Core collection), PubMed, EMBASE, ACM Digital Library, and PsycARTICLES. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used for reporting this work. We included empirical full-text studies focusing on the concept of electronic informed consent in biomedical research covering the ethical, legal, regulatory, and user interface domains. Studies written in English and published from January 2010 onward were selected. We explored perspectives of different stakeholder groups, in particular researchers, research participants, health authorities, and ethics committees. We critically appraised literature included in the systematic review using the Newcastle-Ottawa scale for cohort and cross-sectional studies, Critical Appraisal Skills Programme for qualitative studies, Mixed Methods Appraisal Tool for mixed methods studies, and Jadad tool for randomized controlled trials.

Results

A total of 40 studies met our inclusion criteria. Overall, the studies were heterogeneous in the type of study design, population, intervention, research context, and the tools used. Most of the studies’ populations were research participants (ie, patients and healthy volunteers). The majority of studies addressed barriers to achieving adequate understanding when using electronic informed consent. Concerns shared by multiple stakeholder groups were related to the security and legal validity of an electronic informed consent platform and usability for specific groups of research participants.

Conclusions

Electronic informed consent has the potential to improve the informed consent process in biomedical research compared to the current paper-based consent. The ethical, legal, regulatory, and user interface perspectives outlined in this review might serve to enhance the future implementation of electronic informed consent.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020158979; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=158979

Smartphone Apps to Support Falls Rehabilitation Exercise: App Development and Usability and Acceptability Study

Background

Falls have implications for older adults’ health and well-being. Strength and balance interventions significantly reduce the risk of falls. However, patients do not always perform the unsupervised home exercise needed for fall reduction.

Objective

This study aims to develop motivational smartphone apps co-designed with health professionals and older adults to support patients to perform exercise proven to aid fall reduction and to explore the apps’ usability and acceptability with both health professionals and patients.

Methods

There were 3 phases of app development that included analysis, design, and implementation. For analysis, we examined the literature to establish key app components and had a consultation with 12 older adults attending a strength and balance class, exercise instructors, and 3 fall services. For design, we created prototype apps and conducted 2 patient and public involvement workshops, one with 5 health professionals and the second with 8 older adults from an exercise group. The apps were revised based on the feedback. For implementation, we tested them with one fall service and their patients for 3 weeks. Participatory evaluation was used through testing, semistructured interviews, and focus groups to explore acceptability and usability. Focus groups were conducted with the service that tested the apps and two other services. Qualitative data were analyzed using the framework approach.

Results

On the basis of findings from the literature and consultations in the analysis phase, we selected Behavior Change Techniques, such as goal setting, action planning, and feedback on behavior, to be key parts of the app. We developed goals using familiar icons for patients to select and add while self-reporting exercise and decided to develop 2 apps, one for patients (My Activity Programme) and one for health professionals (Motivate Me). This enabled health professionals to guide patients through the goal-setting process, making it more accessible to nontechnology users. Storyboards were created during the design phase, leading to prototypes of “Motivate Me” and “My Activity Programme.” Key changes from the workshops included being able to add more details about the patients’ exercise program and a wider selection of goals within “Motivate Me.” The overall app design was acceptable to health professionals and older adults. In total, 7 patients and 3 health professionals participated in testing in the implementation phase, with interviews conducted with 6 patients and focus groups, with 3 teams (11 health professionals). Barriers, facilitators, and further functionality were identified for both apps, with 2 cross-cutting themes around phone usability and confidence.

Conclusions

The motivational apps were found to be acceptable for older adults taking part in the design stage and patients and health professionals testing the apps in a clinical setting. User-led design is important to ensure that the apps are usable and acceptable.

The Importance of User Involvement: A Systematic Review of Involving Older Users in Technology Design

BACKGROUND AND OBJECTIVES

There is a lack of understanding of how older adults' involvement and participation matters in actual design practice. This systematic literature review investigates existing empirical studies involving older users during the design of technologies and explores the nature and consequences of involving older people.

RESEARCH DESIGN AND METHODS

Our literature review is informed by the guidelines of the PRISMA statement. We examined the included studies by means of thematic content analysis to identify the nature of older users' involvement and existing evidence on what consequences it has.

RESULTS

In total, 40 empirical studies published in the period 2014-2018 are included in the review. Most empirical studies involve older people from local networks, with underlying stereotypical images and at lower levels of participation. The results reveal three main consequences of involving older users: learning, adjusted design, and an increased sense of participation. Furthermore, we found that user involvement is a structured process whose outcomes are contingent on a range of premises.

DISCUSSION AND IMPLICATIONS

Synthesizing the results, we develop the concept of user involvement and present an analytical framework. Our results have implications for researchers and policy makers, since they throw into question the widely held assumption that involving older people inevitably yields beneficial outcomes.

Designing an Information and Communications Technology Tool With and for Victims of Violence and Their Case Managers in San Francisco: Human-Centered Design Study

Background

Violence is a public health problem. Hospital-based violence intervention programs such as the San Francisco Wraparound Project (WAP) have been shown to reduce future violent injury. The WAP model employs culturally competent case managers who recruit and enroll violently injured patients as clients. Client acceptance of the WAP intervention is variable, and program success depends on streamlined, timely communication and access to resources. High rates of smartphone usage in populations who are at risk for violent reinjury create an opportunity to design a tailored information and communications technology (ICT) tool to support hospital-based violence intervention programs.

Objective

Current evidence shows that ICT tools developed in the health care space may not be successful in engaging vulnerable populations. The goal of this study was to use human-centered design methodology to identify the unique communication needs of the clients and case managers at WAP to design a mobile ICT.

Methods

We conducted 15 semi-structured interviews with users: clients, their friends and families, case managers, and other stakeholders in violence intervention and prevention. We used a human-centered design and general inductive approach to thematic analysis to identify themes in the qualitative data, which were extrapolated to insight statements and then reframed into design opportunities. Wireframes of potential mobile ICT app screens were developed to depict these opportunities.

Results

Thematic analysis revealed four main insights that were characterized by the opposing needs of our users. (1) A successful relationship is both professional and personal. Clients need this around the clock, but case managers can only support this while on the clock. (2) Communications need to feel personal, but they do not always need to be personalized. (3) Healing is a journey of skill development and lifestyle changes that must be acknowledged, monitored, and rewarded. (4) Social networks need to provide peer support for healing rather than peer pressure to propagate violence. These insights resulted in the following associated design opportunities: (1) Maximize personal connection while controlling access, (2) allow case managers to personalize automated client interactions, (3) hold clients accountable to progress and reward achievements, and (4) build a connected, yet confidential community.

Conclusions

Human-centered design enabled us to identify unique insights and design opportunities that may inform the design of a novel and tailored mobile ICT tool for the WAP community.

Web-based home-hazard modification app for falls prevention: the views of those at risk of falling and their carers

Purpose

The purpose of the study is to assess the usability and acceptability of FallCheck, a Web app that allows users to complete home-hazard assessments within their own home, with a group of people at risk of falling and their carers.

Design/methodology/approach

This mixed method study used an online survey followed by semi-structured telephone interviews to collect both qualitative and quantitative data. A Think-Aloud study was used to test usability of the Web app through structured tasks.

Findings

Findings showed that FallCheck was easy to use with few usability issues. The Web app was deemed appropriate to use by people at risk of falling (young or old) or by carers if appropriate. The depth of knowledge provision and breadth of content was acceptable, and many participants reported subsequently making changes to their home environment to reduce their risk of falling. Overall, the majority of participants reported feelings of improved confidence and safety with an increased awareness of fall risks and a reduction in fear of falling at home.

Practical implications

FallCheck has good acceptability and usability with people at risk of falling and their carers and has the potential to improve access to home-hazard assessment and affect behavioural change regarding fall risk hazards and behaviour.

Originality/value

This study describes successful use of an app that may be helpful in identifying home-hazards and making changes to reduce risk of falls, particularly in the absence of occupational therapy intervention and has the potential for integration into falls care pathways.

The Extent and Coverage of Current Knowledge of Connected Health: Systematic Mapping Study

Background

This study examines the development of the connected health (CH) research landscape with a view to providing an overview of the existing CH research. The research field of CH has experienced rapid growth coinciding with increasing pressure on health care systems to become more proactive and patient centered.

Objective

This study aimed to assess the extent and coverage of the current body of knowledge in CH. In doing so, we sought to identify specific topics that have drawn the attention of CH researchers and to identify research gaps, in particular those offering opportunities for further interdisciplinary research.

Methods

A systematic mapping study that combined scientific contributions from research in the disciplines of medicine, business, computer science, and engineering was used. Overall, seven classification criteria were used to analyze the papers, including publication source, publication year, research type, empirical type, contribution type, research topic, and the medical condition studied.

Results

The search resulted in 208 papers that were analyzed by a multidisciplinary group of researchers. The results indicated a slow start for CH research but showed a more recent steady upswing since 2013. The majority of papers proposed health care solutions (77/208, 37.0%) or evaluated CH approaches (49/208, 23.5%). Case studies (59/208, 28.3%) and experiments (55/208, 26.4%) were the most popular forms of scientific validation used. Diabetes, cancer, multiple sclerosis, and heart conditions were among the most prevalent medical conditions studied.

Conclusions

We conclude that CH research has become an established field of research that has grown over the last five years. The results of this study indicate a focus on technology-driven research with a strong contribution from medicine, whereas the business aspects of CH have received less research attention.

Methods of usability testing in the development of eHealth applications: A scoping review

BACKGROUND

The number of eHealth applications has exponentially increased in recent years, with over 325,000 health apps now available on all major app stores. This is in addition to other eHealth applications available on other platforms such as PC software, web sites and even gaming consoles. As with other digital applications, usability is one of the key factors in the successful implementation of eHealth apps. Reviews of the literature on empirical methods of usability testing in eHealth were last published in 2015. In the context of an exponentially increasing rate of App development year on year, an updated review is warranted.

OBJECTIVE

To identify, explore, and summarize the current methods used in the usability testing of eHealth applications.

METHODS

A scoping review was conducted on literature available from April 2014 up to October 2017. Four databases were searched. Literature was considered for inclusion if it was (1) focused on an eHealth application (which includes websites, PC software, smartphone and tablet applications), (2) provided information about usability of the application, (3) provided empirical results of the usability testing, (4) a full or short paper (not an abstract) published in English after March 2014. We then extracted data pertaining to the usability evaluation processes described in the selected studies.

RESULTS

133 articles met the inclusion criteria. The methods used for usability testing, in decreasing order of frequency were: questionnaires (n = 105), task completion (n = 57), 'Think-Aloud' (n = 45), interviews (n = 37), heuristic testing (n = 18) and focus groups (n = 13). Majority of the studies used one (n = 45) or two (n = 46) methods of testing. The rest used a combination of three (n = 30) or four (n = 12) methods of testing usability. None of the studies used automated mechanisms to test usability. The System Usability Scale (SUS) was the most frequently used questionnaire (n = 44). The ten most frequent health conditions or diseases where eHealth apps were being evaluated for usability were the following: mental health (n = 12), cancer (n = 10), nutrition (n = 10), child health (n = 9), diabetes (n = 9), telemedicine (n = 8), cardiovascular disease (n = 6), HIV (n = 4), health information systems (n = 4) and smoking (n = 4). Further iterations of the app were reported in a minority of the studies (n = 41). The use of the 'Think-Aloud' (Pearson Chi-squared test: χ2 = 11.15, p < 0.05) and heuristic walkthrough (Pearson Chi-squared test: χ2 = 4.48, p < 0.05) were significantly associated with at least one further iteration of the app being developed.

CONCLUSION

Although there has been an exponential increase in the number of eHealth apps, the number of studies that have been published that report the results of usability testing on these apps has not increased at an equivalent rate. The number of digital health applications that publish their usability evaluation results remains only a small fraction. Questionnaires are the most prevalent method of evaluating usability in eHealth applications, which provide an overall measure of usability but do not pinpoint the problems that need to be addressed. Qualitative methods may be more useful in this regard. The use of multiple evaluation methods has increased. Automated methods such as eye tracking have not gained traction in evaluating health apps. Further research is needed into which methods are best suited for the different types of eHealth applications, according to their target users and the health conditions being addressed.

A Technological Review of Wearable Cueing Devices Addressing Freezing of Gait in Parkinson's Disease

Freezing of gait is one of the most debilitating symptoms of Parkinson’s disease and is an important contributor to falls, leading to it being a major cause of hospitalization and nursing home admissions. When the management of freezing episodes cannot be achieved through medication or surgery, non-pharmacological methods such as cueing have received attention in recent years. Novel cueing systems were developed over the last decade and have been evaluated predominantly in laboratory settings. However, to provide benefit to people with Parkinson’s and improve their quality of life, these systems must have the potential to be used at home as a self-administer intervention. This paper aims to provide a technological review of the literature related to wearable cueing systems and it focuses on current auditory, visual and somatosensory cueing systems, which may provide a suitable intervention for use in home-based environments. The paper describes the technical operation and effectiveness of the different cueing systems in overcoming freezing of gait. The “What Works Clearinghouse (WWC)” tool was used to assess the quality of each study described. The paper findings should prove instructive for further researchers looking to enhance the effectiveness of future cueing systems.

Evaluating the Usefulness of Translation Technologies for Emergency Response Communication: A Scenario-Based Study

Background

In the United States, language barriers pose challenges to communication in emergency response and impact emergency care delivery and quality for individuals who are limited English proficient (LEP). There is a growing interest among Emergency Medical Services (EMS) personnel in using automated translation tools to improve communications with LEP individuals in the field. However, little is known about whether automated translation software can be used successfully in EMS settings to improve communication with LEP individuals.

Objective

The objective of this work is to use scenario-based methods with EMS providers and nonnative English-speaking users who identified themselves as LEP (henceforth referred to as LEP participants) to evaluate the potential of two automated translation technologies in improving emergency communication.

Methods

We developed mock emergency scenarios and enacted them in simulation sessions with EMS personnel and Spanish-speaking and Chinese-speaking (Mandarin) LEP participants using two automated language translation tools: an EMS domain-specific fixed-sentence translation tool (QuickSpeak) and a statistical machine translation tool (Google Translate). At the end of the sessions, we gathered feedback from both groups through a postsession questionnaire. EMS participants also completed the System Usability Scale (SUS).

Results

We conducted a total of 5 group sessions (3 Chinese and 2 Spanish) with 12 Chinese-speaking LEP participants, 14 Spanish-speaking LEP participants, and 17 EMS personnel. Overall, communications between EMS and LEP participants remained limited, even with the use of the two translation tools. QuickSpeak had higher mean SUS scores than Google Translate (65.3 vs 48.4; P=.04). Although both tools were deemed less than satisfactory, LEP participants showed preference toward the domain-specific system with fixed questions (QuickSpeak) over the free-text translation tool (Google Translate) in terms of understanding the EMS personnel’s questions (Chinese 11/12, 92% vs 3/12, 25%; Spanish 12/14, 86% vs 4/14, 29%). While both EMS and LEP participants appreciated the flexibility of the free-text tool, multiple translation errors and difficulty responding to questions limited its usefulness.

Conclusions

Technologies are emerging that have the potential to assist with language translation in emergency response; however, improvements in accuracy and usability are needed before these technologies can be used safely in the field.

Advancing Cardiac Surgery Case Planning and Case Review Conferences Using Virtual Reality in Medical Libraries: Evaluation of the Usability of Two Virtual Reality Apps

BACKGROUND

Care providers and surgeons prepare for cardiac surgery using case conferences to review, discuss, and run through the surgical procedure. Surgeons visualize a patient's anatomy to decide the right surgical approach using magnetic resonance imaging and echocardiograms in a presurgical case planning session. Previous studies have shown that surgical errors can be reduced through the effective use of immersive virtual reality (VR) to visualize patient anatomy. However, inconsistent user interfaces, delegation of view control, and insufficient depth information cause user disorientation and interaction difficulties in using VR apps for case planning.

OBJECTIVE

The objective of the study was to evaluate and compare the usability of 2 commercially available VR apps-Bosc (Pyrus Medical systems) and Medical Holodeck (Nooon Web & IT GmbH)-using the Vive VR headset (HTC Corporation) to evaluate ease of use, physician attitudes toward VR technology, and viability for presurgical case planning. The role of medical libraries in advancing case planning is also explored.

METHODS

After screening a convenience sample of surgeons, fellows, and residents, ethnographic interviews were conducted to understand physician attitudes and experience with VR. Gaps in current case planning methods were also examined. We ran a usability study, employing a concurrent think-aloud protocol. To evaluate user satisfaction, we used the system usability scale (SUS) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). A poststudy questionnaire was used to evaluate the VR experience and explore the role of medical libraries in advancing presurgical case planning. Semistructured interview data were analyzed using content analysis with feedback categorization.

RESULTS

Participants were residents, fellows, and surgeons from the University of Washington with a mean age of 41.5 (SD 11.67) years. A total of 8 surgeons participated in the usability study, 3 of whom had prior exposure to VR. Users found Medical Holodeck easier to use than Bosc. Mean adjusted NASA-TLX score for Medical Holodeck was 62.71 (SD 18.25) versus Bosc's 40.87 (SD 13.90). Neither app passed the mean SUS score of 68 for an app to be considered usable, though Medical Holodeck (66.25 [SD 12.87]) scored a higher mean SUS than Bosc (37.19 [SD 22.41]). One user rated the Bosc usable, whereas 3 users rated Medical Holodeck usable.

CONCLUSIONS

Interviews highlighted the importance of precise anatomical conceptualization in presurgical case planning and teaching, identifying it as the top reason for modifying a surgical procedure. The importance of standardized user interaction features such as labeling is justified. The study also sheds light on the new roles medical librarians can play in curating VR content and promoting interdisciplinary collaboration.

Proposing a standardized, step-by-step model for creating post-traumatic stress disorder (PTSD) related mobile mental health apps in a framework based on technical and medical norms

Background: Prevalence of post-traumatic stress disorder (PTSD) is a problem all over the world. There are high barriers for entry into formal psychotherapy, which results in a lack of mental health care for a significant part of the population. Mobile mental Health (mMHealth) applications (apps) seem to be a promising new development for countering this lack of care, building on the success of mHealth (Mobile Health) apps in general. Unfortunately, the overall quality of such apps stands in high contrast to their number. The aim of this manuscript is to propose a standard for creating PTSD-related mMHealth apps incorporating a process for evaluation and assessment of their usability and impact. Methods: This is done by first defining each step of the process and its relation to the other steps. The steps themselves, divided into those concerned with development, evaluation and implementation, are bound to the established medical and technical norms pertaining to them. Existing protocols from recent literature have been integrated into these steps. Results: As a result, a comprehensive model covering the process of creating, assessing and implementing an mMHealth app from start to finish was developed. The model may be adapted to other disorders or specialized for certain symptoms of PTSD. Conclusion: Adopting such a model could result in a 'blueprint' for creating mMHealth apps in a standardized way, thereby facilitating the testing and comparing of such apps.

A Fall Risk mHealth App for Older Adults: Development and Usability Study

BACKGROUND

Falls are the leading cause of injury-related death in older adults. Due to various constraints, objective fall risk screening is seldom performed in clinical settings. Smartphones offer a high potential to provide fall risk screening for older adults in home settings. However, there is limited understanding of whether smartphone technology for falls screening is usable by older adults who present age-related changes in perceptual, cognitive, and motor capabilities.

OBJECTIVE

The aims of this study were to develop a fall risk mobile health (mHealth) app and to determine the usability of the fall risk app in healthy, older adults.

METHODS

A fall risk app was developed that consists of a health history questionnaire and 5 progressively challenging mobility tasks to measure individual fall risk. An iterative design-evaluation process of semistructured interviews was performed to determine the usability of the app on a smartphone and tablet. Participants also completed a Systematic Usability Scale (SUS). In the first round of interviews, 6 older adults participated, and in the second round, 5 older adults participated. Interviews were videotaped and transcribed, and the data were coded to create themes. Average SUS scores were calculated for the smartphone and tablet.

RESULTS

There were 2 themes identified from the first round of interviews, related to perceived ease of use and perceived usefulness. While instructions for the balance tasks were difficult to understand, participants found it beneficial to learn about their risk for falls, found the app easy to follow, and reported confidence in using the app on their own. Modifications were made to the app, and following the second round of interviews, participants reported high ease of use and usefulness in learning about their risk of falling. Few differences were reported between using a smartphone or tablet. Average SUS scores ranged from 79 to 84.

CONCLUSIONS

Our fall risk app was found to be highly usable by older adults as reported from interviews and high scores on the SUS. When designing a mHealth app for older adults, developers should include clear and simple instructions and preventative strategies to improve health. Furthermore, if the design accommodates for age-related sensory changes, smartphones can be as effective as tablets. A mobile app to assess fall risk has the potential to be used in home settings by older adults.

OB Nest: Reimagining Low-Risk Prenatal Care

Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.

VA mobile apps for PTSD and related problems: public health resources for veterans and those who care for them

Many public health agencies, including the U.S. Department of Veterans Affairs (VA), have identified the use of mobile technologies as an essential part of a larger strategy to address major public health challenges. The VA's National Center for PTSD (NCPTSD), in collaboration with VA's Office of Mental Health and Suicide Prevention and the Defense Health Agency inside the U.S. Department of Defense (DoD), has been involved in the development, evaluation, and testing of 15 mobile apps designed specifically to address the needs and concerns of veterans and others experiencing symptoms of posttraumatic stress disorder (PTSD). These applications include seven treatment-companion apps (designed to be used with a provider, in conjunction with an evidence-based therapy) and eight self-management apps (designed to be used independently or as an adjunct or extender of traditional care). There is growing evidence for the efficacy of several of these apps for reducing PTSD and other symptoms, and studies of providers demonstrate that the apps are engaging, easy-to-use, and provide a relative advantage to traditional care without apps. While publicly available apps do not collect or share personal data, VA has created research-enabled versions of many of its mental health apps to enable ongoing product enhancement and continuous measurement of the value of these tools to veterans and frontline providers. VA and DoD are also collaborating on provider-based implementation networks to enable clinicians to optimize implementation of mobile technologies in care. Although there are many challenges to developing and integrating mHealth into care, including cost, privacy, and the need for additional research, mobile mental health technologies are likely here to stay and have the potential to reach large numbers of those with unmet mental health needs, including PTSD-related concerns.