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Using a User-centered Cognitive Walkthrough to Evaluate a mHealth Diabetes Self-management System Including a Case Study and External Validity Test
Blekinge Institute of Technology, Faculty of Computing, Department of Creative Technologies.ORCID iD: 0000-0002-9854-7690
University of Utah, Department of Biomedical Informatics, USA.
The Norwegian Centre for E-health Research, University Hospital of North Norway, NOR.
University of Victoria, School of Health Information Science, CAN.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Self-management of chronic diseases with mHealth systems is becoming common. With the move toward patient-centered care, it is vital to incorporate patients in the development and evaluation of these systems. Current methods for usability evaluation such as formal usability testing can be very costly and time-consuming. Other methods may be more efficient but lack a user focus (e.g., Heuristic Evaluation (HE) and Cognitive Walkthrough (CW)). We propose a modified method to address identified deficiencies in the original CW technique and then assess its effectiveness efficiency and user acceptance. In this case study we use the modified, user-centered CW (UC-CW) method with diabetes patient users of a mHealth self-management system and validate it against the “golden-standard” user test with Think Aloud (TA) on the number, types and severity of usability problems, as well as the consumed time, and user experience of the cognitive load.

Materials and methods: A total of 12 diabetes patients were included: 6 in the UC-CW group evaluation session, and 6 in the individual user tests with TA. The setting for the assessments was the Diabetes and Endocrinology Center in Salt Lake City, Utah.  The modified UC-CW method consisted of: making the user the main evaluation contributor in finding the usability problems, a dual domain facilitator with the role of guiding the evaluation session and in rating found usability problems, a task development process resulting in validated tasks, a focus on higher level tasks in evaluation and in streamlining the evaluation in terms of time and resources. Users interacted with the mHealth application for both the modified method and user test with TA. Participants also filled in a pre-test questionnaire of demographic questions and one on their experience, knowledge and perception about information technology. Post-evaluation assessments included the NASA RTLX instrument and a set of brief interview questions about the different methods.

Results: Participants in both methods were a similar mix of males and females with similar types of diabetes. They were equally knowledgeable and experienced in using mobile phones. A total of 26 usability problems were found with the UC-CW and 20 problems with the TA. Participants in both methods gave the application similar severity ratings for all views (UC-CW= 2.7 and TA= 2.6) and a similarly high number of  problems in similar views (Main view [UC-CW=11, TA=10], Carbohydrate Entry view [UC-CW=4, TA= 3] and List view [UC-CW=3, TA=3] and with  similar heuristic violations (Match Between the System and Real World [UC-CW=19, TA=16], Consistency and Standards [UC-CW= 17, TA=15], and Recognition Rather than Recall [UC-CW=13, TA=10]). Both methods converged on 8 usability problems. When comparing the severity of the problems, the UC-CW detected 5 critical issues (severity level 4) while the TA detected two. The distinct issues in the UC-CW compared to the TA were personalized features required for patients’ individual disease needs. In terms of efficiency, the whole evaluation procedure took less time to perform for the TA than the UC-CW. However, when the number of usability problems is considered, the UC-CW was faster. The UC-CW was also faster for the evaluation process. The NASA RTLX scores indicated that participants experienced the UC-CW as half as demanding in terms of cognitive load. Common themes were that the UC-CW was perceived as easy to perform and enjoyable while the TA was considered somewhat awkward and more cognitively demanding.

Conclusions: The modified method proved useful for finding severe and recurring usability issues for users and highlighted the need for personalized user features. The UC-CW also proved efficient with a high user acceptance. These results indicate that the UC-CW can be a useful method to evaluate a mHealth self-management system for diabetes. The external validation that compared the method outcomes provided beginning evidence of the UC-CW’s utility as an effective, as well as efficient and acceptable method.

Keywords [en]
Chronic Disease, Cognitive Walkthrough, Diabetes, Mobile Health, Self-management, Think Aloud, Usability, User Test, User-centered Design
National Category
Computer Sciences
Identifiers
URN: urn:nbn:se:bth-15830OAI: oai:DiVA.org:bth-15830DiVA, id: diva2:1177979
Available from: 2018-01-26 Created: 2018-01-26 Last updated: 2018-01-29Bibliographically approved
In thesis
1. Toward Patient-centered, Standardized, and Reproducible Approaches of Evaluating the Usability of mHealth Chronic Disease Self-management Systems for Diabetes
Open this publication in new window or tab >>Toward Patient-centered, Standardized, and Reproducible Approaches of Evaluating the Usability of mHealth Chronic Disease Self-management Systems for Diabetes
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Diabetes is a chronic disease affecting 422 million patients worldwide according to World Health Organization data with 30.3 million in the United States and 64 million in Europe. The prevalence speaks to the need for improved ways to support patients in disease self-management. mHealth solutions are increasingly used for this; however, usability is a current challenge affecting patients’ mHealth use. Recent literature emphasizes an increased focus on patient-centeredness in diabetes care, user-centeredness in chronic disease mHealth system design and standardized, systematic approaches for usability evaluation. The aim of this thesis and its individual studies was to incorporate these foci into the evaluation of two mobile health self-management systems for diabetes.

Study I used ISO standard 9241-11 to examine the relationship between selected group characteristics of diabetes patients on specific interaction outcomes to quantitatively identify needed system modifications. Study II utilized a multi-method design to assess diabetes patients’ mHealth usage and combined two novel analytic methods to structure and analyze results. Study III used a modified, user-oriented heuristic evaluation (HE) method, validated tasks and in-depth severity factor ratings to identify critical problems from patients’ point of view. By developing and employing a modified, user-centered cognitive walkthrough method (UC-CW), study IV assessed its effectiveness and efficiency in finding relevant usability problems for users as well as patients’ acceptance. The modified CW was validated against the golden-standard user test with Think Aloud.

Study I emphasized the importance of considering user characteristics in mHealth performance as these influenced interaction outcomes. All patients had difficulties with multiple-step tasks. Patients more recently diagnosed were able to perform tasks more successfully, with fewer errors and at faster times and had higher satisfaction scores; similar outcomes to the more experienced users. Educational level did not, however, seem to influence performance. In study II, the usability test with Think-Aloud (TA), in-depth interviews and questionnaires contributed to 19 consolidated issues, and triangulated on 5 critical usability problems for users. The combined analysis methods resulted in structured, categorized descriptions to aid in problem-solving. In Study III, the disease-related, critical information deficiencies found by expert evaluators using the modified, structured method also converged on and highlighted potentially adverse user concerns. Study IV demonstrated that the UC-CW found more critical user problems compared to the user test with TA despite both methods producing similar major average severity ratings and violations of heuristic categories. The modified method was more efficient per detected problem and experienced as less cognitively demanding and with a higher ease of use.

These studies offer different approaches that include patient-centered, efficient and user-acceptable methods and method modifications to detect critical usability issues for users. Importantly, improved mHealth designs for users could mean improvement in interactions, interaction performance, increased adoption, and long-term perhaps even increased adherence to interventions for chronic conditions.

Place, publisher, year, edition, pages
Karlskrona: Blekinge Tekniska Högskola, 2018. p. 165
Series
Blekinge Institute of Technology Doctoral Dissertation Series, ISSN 1653-2090 ; 03
Keywords
Chronic Disease, Diabetes, Mobile Health, mHealth, Self-management, Usability Evaluation, User-centered Design
National Category
Computer Sciences
Identifiers
urn:nbn:se:bth-15140 (URN)978-91-7295-349-9 (ISBN)
Public defence
2018-02-23, J1650, BTH, Valhallavägen 1, 37179, Karlskrona, 09:30 (Swedish)
Opponent
Supervisors
Note

Tillämpad Hälsoteknik

Applied Health Technology

Available from: 2018-01-29 Created: 2018-01-26 Last updated: 2018-04-06Bibliographically approved

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