Development of a mHealth System for Post-Stroke Upper Limb Rehabilitation in Medically Underserved Populations: An Iterative Usability Study

Stroke is the leading cause of adult disability, with 60% of patients left with some type of permanent physical disability affecting the upper limb. Standard stroke therapy involves frequent one-on-one interactions with therapists over a period of several months, which places a significant burden on physical therapists and clinics in medically underserved areas that struggle with a shortage of health providers and technical resources crucial to the delivery of physical rehabilitation services. In an attempt to improve stroke rehabilitation outcomes in medically underserved areas and populations, we have developed the outREACH system for the delivery of personalized upper extremity stroke assessment and rehabilitation in an individual's home environment. As a part of the outREACH system development, we conducted an iterative usability study based on a mixed-methods approach, using semi-structured cognitive interviews, as well as a demographic and user experience survey. Two iterative usability testing cycles were completed, testing a total of 10 potential users. Thematic analysis and descriptive statistics were used to analyze the think-aloud tasks, interviews, and questionnaires. Two main usability issues in round 1 were identified with the scheduler module and the similarities between the Home screen and the My Care Plan screen. After applying modifications for the second iteration, there was a significant increase in the average usability score (from 43 to 88%), and a reduction in both the number of errors, as well as the time taken to complete each task. The results of the present study will be integrated into the development, integration, and evaluation of the outREACH system that supports stroke tele-rehabilitation in underserved populations.