Usability and feasibility of a tablet-based Decision-Support and Integrated Record-keeping (DESIRE) tool in the nurse management of hypertension in rural western Kenya

BACKGROUND Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension. OBJECTIVE To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya. METHODS Usability testing consisted of "think aloud" exercises and "mock patient encounters" with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions. RESULTS Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests. CONCLUSIONS This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions.

[1]  Emmanuelle Daviaud,et al.  Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa , 2012, BMC Medical Informatics and Decision Making.

[2]  William M. Tierney,et al.  An electronic medical record system for ambulatory care of HIV-infected patients in Kenya , 2005, Int. J. Medical Informatics.

[3]  Kimberly A. Neuendorf,et al.  The Content Analysis Guidebook , 2001 .

[4]  Timo Jokela,et al.  The standard of user-centered design and the standard definition of usability: analyzing ISO 13407 against ISO 9241-11 , 2003, CLIHC '03.

[5]  Joseph W Hogan,et al.  Optimizing linkage and retention to hypertension care in rural Kenya (LARK hypertension study): study protocol for a randomized controlled trial , 2014, Trials.

[6]  M. Foran,et al.  mHealth in Sub-Saharan Africa , 2013, International journal of telemedicine and applications.

[7]  Paul G. Biondich,et al.  AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries , 2005, AMIA.

[8]  Paul G. Biondich,et al.  The AMPATH Medical Record System: Creating, Implementing, and Sustaining an Electronic Medical Record System to Support Hiv/AIDS Care in Western Kenya , 2007, MedInfo.

[9]  James D. Carpenter,et al.  A Rapid Assessment Process for Clinical Informatics Interventions , 2008, AMIA.

[10]  J. Kemppainen.  The critical incident technique and nursing care quality research. , 2000, Journal of advanced nursing.

[11]  Bridget B. Kelly,et al.  Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries , 2010 .

[12]  M. Byrne,et al.  Critical incident technique as a qualitative research method. , 2001, AORN journal.

[13]  Krisda H. Chaiyachati,et al.  A Pilot Study of an mHealth Application for Healthcare Workers: Poor Uptake Despite High Reported Acceptability at a Rural South African Community-Based MDR-TB Treatment Program , 2013, PloS one.

[14]  Constance Schultsz,et al.  Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities , 2012, PloS one.

[15]  P. Schulz,et al.  Mapping mHealth Research: A Decade of Evolution , 2013, Journal of medical Internet research.

[16]  Fabian Esamai,et al.  Responding to the HIV pandemic: the power of an academic medical partnership. , 2007, Academic medicine : journal of the Association of American Medical Colleges.

[17]  J. Whitworth,et al.  2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension , 2003, Journal of hypertension.

[18]  Patricia C. Dykes,et al.  Complexity and the science of implementation in health IT - Knowledge gaps and future visions , 2014, Int. J. Medical Informatics.

[19]  Surendra Sarnikar,et al.  A Usability Analysis Framework for Healthcare Information Technology , 2012, Int. J. Technol. Diffusion.

[20]  G. Mensah.  Epidemiology of stroke and high blood pressure in Africa , 2008, Heart.

[21]  J. C. Flanagan.  Psychological Bulletin THE CRITICAL INCIDENT TECHNIQUE , 2022 .

[22]  Todd R. Johnson,et al.  A user-centered framework for redesigning health care interfaces , 2005, J. Biomed. Informatics.

[23]  Lavanya Vasudevan,et al.  Mobile health for non-communicable diseases in Sub-Saharan Africa: a systematic review of the literature and strategic framework for research , 2014, Globalization and Health.

[24]  Daniel W. Jones,et al.  The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. , 2003, JAMA.

[25]  M. Mars.  Telemedicine and advances in urban and rural healthcare delivery in Africa. , 2013, Progress in cardiovascular diseases.

[26]  Dana Chisnell,et al.  Handbook of Usability Testing , 2009 .

[27]  Rajesh Vedanthan,et al.  Urgent need for human resources to promote global cardiovascular health , 2011, Nature Reviews Cardiology.

[28]  Suzanne Bakken,et al.  A usability study of a mobile health application for rural Ghanaian midwives. , 2014, Journal of midwifery & women's health.

[29]  G. Bloomfield,et al.  Chronic noncommunicable cardiovascular and pulmonary disease in sub-Saharan Africa: an academic model for countering the epidemic. , 2011, American heart journal.

[30]  Daniel W. Jones,et al.  Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. , 2003, Hypertension.

[31]  V. Fuster,et al.  Nurse management of hypertension in rural western Kenya: implementation research to optimize delivery. , 2014, Annals of global health.

[33]  David Amadi,et al.  Evaluation of an Android-based mHealth system for population surveillance in developing countries , 2012, J. Am. Medical Informatics Assoc..

[34]  Jakob Nielsen,et al.  Estimating the number of subjects needed for a thinking aloud test , 1994, Int. J. Hum. Comput. Stud..

[35]  A. Bengtson,et al.  The Nurse’s Role and Skills in Hypertension Care: A Review , 2003, Clinical nurse specialist CNS.