Mobile Phone-Based Health Application for Women A Singapore Study Lishan Xue
Ching Chiuan Yen
Leanne Chang
National University of Singapore (NUS) Division of Industrial Design 4 Architecture Drive Singapore 117566
NUS, Division of Industrial Design 4 Architecture Drive Singapore 117566
NUS, CNM Programme, 11 Law Link, Block AS6, Room 03-04 Singapore 117589
[email protected]
[email protected]
[email protected] Bee Choo Tai NUS, Dept of Epidemiology & Public Health 16 Medical Drive Singapore 117597
[email protected]
Hock Chuan Chan
Henry Been-Lirn Duh
NUS, Dept of Information Systems 15 Computing Drive ‘COM2’ #04-34 Singapore 117418
NUS, Dept of Electrical & Computer Engineering Block E4, Level 5, Room 45, 4 Engineering Drive 3 Singapore 117576
[email protected] Mahesh Choolani
[email protected]
NUS, Dept of Obstetrics & Gynaecology NUHS Tower Block Level 12 IE Kent Ridge Road Singapore 119228
[email protected] ABSTRACT
The purpose of this paper is illustrate why and how a mobile-phone based application was proposed to explore how women react and their acceptance toward well-being management after interacting with the application. It was organized by considering the Femalefocused Design Strategy (FDS) and designed to have three features: a description of health topics, a self-help diagnosis through step-bystep questions and quizzes about health topics to test general health knowledge. The paper reports the qualitative user feedback and discusses the recommendations and trends for future design and implementation for women’s health.
Keywords
H.5.2. Ibformation interfaces and presentation: User interfaces – Evaluation/methodology J.3. Health
1. INTRODUCTION
Technological advances in the miniaturization of wireless sensors and wearable computing have paved the way for the empowerment of patients to monitor their health and to gain seamless access to health care services anytime and anywhere. This paper focuses on the use of one of the most pervasive wireless devices - the mobile phone - as a commodity tool for personalized health care management by becoming a means of health information computing device. With its
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expanding capabilities and increasing processing power, the mobile phone is becoming an integral part of people’s everyday activities and context awareness [1-2]. The purpose of this study is to understand the acceptance decisions among women of the mobile phone in enabling them to easily access health care information and better manage their well-being as past research that highlighted women’s pragmatic approach to technology had also shown that women would consider adopting it when its use proved effortless and value are properly demonstrated [3]. The motivation to examine the usefulness of well-being management applications on mobile phone platform for the ageing female population is three-fold. Firstly, women regardless of ethnicity live longer than men; they have greater morbidity [4]; are more attuned to take care of their health and are also more likely to seek preventive services over the internet [5,6]. Secondly, mobile device technology, as well as mobile content and application development, is increasingly being adopted by women as they now have more economic power and demand that any new treatment options demonstrate cost-effectiveness. The convergence of these factors has resulted in making well-being management for women a viable design opportunity today. There is a true demand of minimally invasive, cost-effective designs to address the health needs of women [7]. Last but not least, in Singapore where this study is conducted, the mobile network is considered mature, its government is also circumspect about the prospect of the next generation of mobiles and evidence show a penetration rate of 131% among mobile communication usage [8]. This research rides on this fact to detect factors for designing better health informatics via a mobile phonebased intervention for the female population.
2. MATERIAL AND METHOD
A Female-focused Design Strategy (FDS) had been developed to encourage the adoption and continued usage by women incorporating values and attributes women will look for in purchasing and using a
self-care information system [9]. A number of quantitative studies which provide the basis for the FDS have been carried out over a period of 5 years in relation to different studies connected to projects concerning female-centred care. The projects aimed at different age groups of women, ranging from participants aged 20 to 82. Different methods ranging from paper surveys to national telephone interviews were employed. All interviews have been recorded while some were transcribed. Although the studies did not have exact identical research foci, they all focused on collecting user perspectives and acceptance concerning dedicative health IT for women’s health. The FDS explains from grounded comparison that women are more motivated by systems that benefit them with flexible and responsive interaction and appreciate designs that relate to them almost naturally, with empathy. They like details or features which make the system dependable.
2.1 Mobile Web Health Application
The design was a mobile web application consisting of health information reference and educational tools catered to female health needs, which should empower women to monitor and understand their own conditions in their daily activities. The content layout, features and tools were considered based on the attributes from the FDS. It was effectively a website designed to be accessed solely from mobile phones to provide women with an easy grasp of health information and visualization of how information at hand can be useful and reliable at all times. It was not narrowly focused on a specific patient type or disease, wellness tracking, or medication tracking. Users could access a it online via GPRS (General Packet Radio Service) as long as their phones are equipped with a web browser – which all smartphones come with. While still retaining the concept of seeking health information on mobile phones, a mobile web application has two advantages over a smartphone application that is downloaded onto mobile phones. Firstly, whereas a smartphone application designed for the operating system of a particular mobile phone brand would be incompatible with a different brand, a mobile web application does not face such compatibility issues since it is web-based. Thus, all participants used the same version of the application. Secondly, while a smartphone application downloaded onto mobile phones poses significant challenges for usage tracking, the mobile web application facilitates tracking much like the same way webpages could be tracked.
Figure 1. Screenshots of mobile web application. The system provided users the option of answering step-by-step questions to cope with uncertainties with advice generated based on their very own replies and it also provides knowledge to increase activities that promote their well-being. A quantitative survey of how women may be engaged with the system seeking health care knowledge in non-clinical environments was conducted [10]. To
ensure that only health information seeking on mobile phones was being studied, the mobile web was configured such that it could not be accessed from a desktop or laptop. System logs for each registered user could be obtained and the link between behavioural intention and actual use could thus be established. A total of 164 valid replies were collected with the average age of participants being 33.6 years, and the range being 21 to 62 years.
3. RESULT
Comparing the four participant groups – healthy female adults and patients with chronic health conditions, and those who had experience with health services delivered through mobile applications and those who did not – there were predictable differences identified in the acceptance decisions. Due to experiences with long-term illness, some participants with chronic health conditions were motivated to accept such technology. They were familiar with the difficulties in managing their health care services; their personal encounters helped participants recognize the benefits of mobile phone health support more quickly, such as convenience, ease of access, user-friendliness, availability on demand. They also like the idea of a self-diagnosis system in place, and suggestions on how to get further help. However, they also have certain suggestions such as preferring more pictures, diagrams or photographs than text, enlarging font size in tables, knowing the source and reliability of the information provided, having the content in simplified language without too deep without having to decipher medical terms and meanings, being able to have features such as search function to navigate through the application by keywords, having the option to interact with health portals and doctors, to look professional. Furthermore, many patients with chronic health conditions believed it is useful to use digital systems to manage and monitor their health. Therefore, they were excited to learn about this technology. On the other hand, we allowed healthy participants to speak from experience either by identifying that some of their relatives or close friends may have certain illness which required attention, or they were caregivers to someone who has a persistent condition. Most healthy participants replied by focusing on the potential of mobile applications to be helpful should they develop a health condition. Another comparison to be drawn is between participants who had experience with health information delivered through mobile phones and those who did not. Respondents with experience of health applications were generally more open to the technology because of the convenience especially in times of emergencies. Some shared that they would prefer to use the computer as the size of the mobile phone screen is too small. Overall, experience with health conditions and health technologies may lead to greater interest in these matters. Besides enthusiasm for health technology and familiarity with health management, no other pronounced differences were observed among participant groups. Within the four broad categories, participants had diverse opinions and attitudes. Additionally, many subjects held views that aligned more closely to the views of members in other participant groups. The lack of consistent perspectives was also observed among different age groups. For example, there were participants in their late forties early fifties who were enthusiastic for the technology because of the ease and helpfulness, but there were also subjects in the same age group who were uncomfortable with the size of mobile phones or found the language too difficult to use. Overall, few pronounced differences among participant groups were identified, and there was not a typical profile.
Relationships between participants’ perceptions and their acceptance decisions could not be identified. All respondents fell into one category: they all intended to use the application if there were different tweets towards their personal preferences and contextual needs. Similar to a study conducted by Boland in 2007 [11], participants prefer health information and services to be delivered with relevance to personal characteristics and administered in a method that they prefer. By providing tailored options, users’ demands could be met more easily. As a qualitative study, the acceptance of the technology and the enthusiasm for it may be established but drawing comparisons to identify relationships enumerated for quantitative analysis is not possible. For these reasons, no conclusions were made about which group is more inclined to the technology or which decision factors influence the acceptance decision the greatest. Instead, the analysis focused on the usability issues and functional needs to be addressed when designing future mobile phone health applications.
3.1 Positive Feedback 3.1.1 Usefulness and convenience
Participants saw the usefulness of accessing health information through mobile phones indirectly supporting their health management and behavior change. For many, the device is conveniently available throughout the day and across many activities. As with a computer, the programme can advise health plans, provide guidance, and probably maintain a schedule. According to some respondents, even basic information delivery – such as self-help tips or quizzes could be useful to help you start thinking about your usual health behavior or beliefs. For some participants, the act of carrying a mobile phone installed with health applications was a source of motivation. The device would symbolize a commitment to healthy living. Furthermore, respondents believed the application may offer health support for people who do not rely on family or friends for assistance. Participants valued the ability of mobile phone health applications to reduce geographic barriers to health care. Respondents described a sense of convenience when health information is accessible and manageable on the go. For instance, health files and tools stored on mobile phones meant fewer items that need to be physically carried – no more physical items to search for health symptoms especially when it happens in an emergency and no more paper copies of health instructions.
3.1.2 Novelty and Familiarity
Some participants were interested in this intervention because of a sense of novelty while others find this as a familiar tool. It was considered to be the mobile analogue of digital health information available in the past. Additionally, there were participants with chronic health conditions who did not find such technology to be a recent development. In past research of their health condition, they read about phone technologies for health care being available for some time now.
3.2 Negative Feedback 3.2.1 Text size, graphics, interactivity
Participants perceived and related a number of barriers with using their mobile phone to access health information. There were physical limitations such as small screen sizes and keypads on mobile phones which participants found difficult to maneuver. The chief complaint was about screen size. Young and old participants alike found that many mobile phones had screens that were too small for comfortably
reading text or viewing images. Some said they would not bother with health information that is difficult to read. Participants also felt that visual impairment particularly during illness could exasperate this problem. Other criticisms were about difficulties in data entry and screen navigation. Some respondents found it slow and frustrating to type on the small buttons of a mobile phone keypad especially an alphanumeric one. Finally, some participants doubted the mobile phone’s capacity for extensive computing because of limited battery life and spotty network connections. This was also mentioned in Forman and Zahorjan’s research (1994) [12] Because of these concerns, some saw the mobile phone as a secondary tool for health information. Their first choice was the computer because of its greater speed and reliability. There were also motivational barriers. Some participants believed their elderly loved ones such as mothers or aunties would be extremely upset if they were asked to use the technology. Attributing their apprehension to the lack of familiarity with mobile phones, respondents felt that immense motivation and training would be necessary for encouraging adoption. Moreover, this sentiment was not exclusive to older adults. A young participant, aged 23, described she does not like to type much with the mobile phone or access services- she felt this way despite regularly using a mobile phone. Acquiring the skills for mobile phone use could be difficult for some people. Some participants described their mothers’ difficulty with text messaging. They attributed this to their lack of a conceptual model of the technology’s operation. In another case, an elderly respondent discussed her difficulty in remembering mobile phone procedures. She was embarrassed by this problem, especially when her family members were frustrated with her slow pace of learning.
3.2.2 Technological and financial expenses
Some participants believed their mobile phones were not technologically capable of running health services. It was assumed that functionalities like online access, greater memory, a larger display screen, and a touch-screen interface were important to using the health application. Many would rather forgo the cost of upgrading their phone with these improvements. Concerns about expenses raised issues regarding health care inequality. Some respondents believed that only educated and younger individuals could afford the technology and would thus have special access to national health services. Consequently, the health disparity gap with the financially needy would continue to grow. In order to avoid this inequity, a participant strongly advocated for socially conscious and equitable development of the technology, accessing without requiring an Internet connection.
3.2.3 Too much or too little content
Participants believed health information access is beneficial and the present content is sufficient. But if large volumes of health information were delivered through their mobile phones, there were concerns about the organization and navigation of the content. Additionally, respondents worried that too much information could be difficult to process. This would lead to misunderstandings and errors. Others pointed out they would not be able to understand medical terms thus the choice of language should be sufficiently layman. However, at least an equal number of participants, requested for more information either with the delivery of a wider range of health topics or more pictorial elements. Participants wanted options with the types of features they could use (i.e. new updates/ information, quizzes, self-help diagnoses, health tips, search function), the type of information delivered, but were concerned with the way it is represented and the level of depth versus complexity.
4. DISCUSSION
Many of our participants were interested in using the technology while some intended to adopt later. Due to preferences and concerns for privacy and content coverage and reliability, some participants were only willing to use a selection of proposed features. Participants arrived at their acceptance decision by considering three main factors. The first was health context. If participants’ health care system were to provide mobile phone health applications, many would be interested in using them upon the recommendation of their doctor. Another contextual issue was health status – having a health condition that necessitated intensive management or greater accessibility to health professionals would drive the demand for such information-based applications. Furthermore, costs associated with technology use were an issue. Finally, the perceived privacy threats of digital health applications could be a significant consideration and it depended on the participants’ trust in this application to keep personal entries confidential. The second acceptance decision factor was perceived usefulness of the application. Participants hoped the application features would reduce the effort in practicing healthy behaviors. They wanted the application to be easy to use, but they were concerned that the small size of the mobile phone could be an impediment. Safety and privacy were also important issues, and opinions were divided on whether mobile phone health services would improve matters or make them worse. Determining the usefulness of the application meant balancing positive perceptions against negative ones and considering the usability and safety. However, there came a point when participants would overlook the negatives. If health status was poor and the need for assistive technology was great, participants said their views of danger, annoyances and threats diminished in light of the application’s potential benefits. When the stakes were high, more risks might be taken. Thirdly, the acceptance decision was also shaped by the personality of the potential user. Emotional tolerance and affinity for health affairs and health technology could explain one’s openness to the services as well as shape their perceptions about the application. In addition, it is possible that acceptance decisions could be influenced by women’s health awareness, tolerance for health conditions and risks, receptiveness to mobile applications, and demographics – such as income levels, health literacy, education, or technological experience.
5. FUTURE IMPLICATIONS
In order to appeal to women, creating a dedicative mobile health application requires a completely different approach from just moving existing, stationary Internet services to mobile platforms. According to PC world in December 2010, the most popular ones are iOS (Apple), Android OS, and BlackBerry OS [13]. On the technical side, designers are challenged by the competing and incompatible mobile software platforms, e.g., Google Android, Symbian, Java 2 Micro Edition; applications must be customized for each platform and even for different phone models within the same platform. For a near future design, it is attempted to take into account the unique properties of one popular mobile setting which is the iOS and propose a design only to be accessed via it.
5.1 Relevant support
As health professionals are not always available, participants wished for a way to take care of their health in between doctor’s visits.
Well-being management support tools in mobile applications could provide sufficient knowledge to guide health consumers to take health enhancing actions from home and on the go. One service recommendation was for medical calculators. Participants said that medical questions can arise where an informed health response depends on complex calculations. For example, determining medication dosages, estimating high blood pressure, gauging their menstrual cycle were calculations that participants believed could be important tools for use via a mobile phone. In another proposed service, some participants wished to take advantage of the multimedia capability of mobile phones for health education. Video guides could show patients how to perform medical procedures and prescribed activities. For instance, one respondent found it easy to forget exercises her physiotherapist recommended. If she could view an instructional video on her phone, she could follow along so that her phone would be like a personal trainer. In addition, some participants wanted positive health messages or health tips/ alerts sent to their phone throughout the day. They described the difficulty associated with modifying health behaviors – for example, weight loss for problems with obesity. Thus, participants would like a service that could provide supportive messages throughout the day for motivation. Participants imagined that when they have a difficult moment they could rely on their phone for support. All of these proposed services for well-being management revealed the desire of participants to overcome their knowledge, technical, and motivational barriers in health care. They recognized the mobile phone as a tool capable of providing solutions and as a computer that could provide health support. By this outlook, participants would see the potential for mobile health services and were interested in their development. The future design should allow the user to input, edit and store personal health information on the mobile without the need of cellular or Wi-Fi services.
5.2 Keeping things simple
Women would appreciate simple-to-use mobile applications. The design should focus on mobility since powerful and intricate applications would be difficult to use on a small device. Previous respondents preferred that mobile phones be used for short bursts of information and quick procedures, and this would leave personal computers for the delivery of more detailed services. A second suggestion was for automatic features to minimize the effort needed and the distractions of maneuvering with mobile phones. For example, reducing the need for manual data entry could prevent the difficulties of typing on a small keyboard or navigating small menus. Personalization could help manage large amounts of health information. It is important that health information be relevant to the patient’s profile/ characteristics, otherwise the content might go unread or an overload could be anxiety-inducing. To enhance the relevance of health information, services should be adaptive so that health prompts are synchronized to user needs and to their changing conditions. These features will help reduce the effort of using mobile phones for complicated health issues.
5.3 Privacy, choices and user control
The nature of a mobile phone means that any data on it carries a greater risk profile. It is important to execute anonymity with the technology or to have messages delivered via a code that would be incomprehensible to a passerby, especially when accessing health information dealing with sexuality. In addition, the user interface of the application should be designed to accommodate diverse health users who have different capabilities, skills and finances that could limit their access to the application[14].
6. CONCLUSION
To date, data elements and application features of current mobile health applications are often incomplete and not properly secured. A review of health applications and a set of design criteria are conducted at this moment and ongoing research is conducted to how a possible new design for women could be deployed both in realworld situations and proposed as up-to-date mobile health applications. Future development aims to integrate female-focused decision support systems, vocabularies and tactics. The approach to research should inspire industry and the public – to think about how life would be in the future.
7. ACKNOWLEDGMENTS
This study is part of Research Project supported by a AcRF grant (WBS number: R-298-000-001-112) provided by the Ministry of Education (MOE), Singapore and the School of Design and Environment (SDE), National University of Singapore (NUS). We are grateful to all participants who responded to the survey and graciously gave us their time and thoughtful comments.
8. REFERENCES
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