Overcoming Challenges to Inclusive User-based Testing of Health Information Technology with Vulnerable Older Adults: Recommendations from a Human Factors Engineering Expert Inquiry

Objectives: Involving representative users in usability testing of health information technology (HIT) is central to user-centered design. However, (vulnerable) older adults as representative users have unique requirements. Aging processes may affect physical capabilities and cognitive skills, which can hamper testing with this demographic and may require special attention and revised protocols. This study was performed to provide expert-based recommendations for HIT user-testing with (vulnerable) older adults to support inclusive HIT design and evaluation. Methods: First, we conducted a structured workshop with ten experts in HIT implementation and research, recruited through purposeful sampling, to generate insights into how characteristics of older adults may influence user-testing. Next, five Human Factor researchers experienced in HIT user-testing with (vulnerable) older adults validated the results and provided additional textual insights to gain consensus on the most important recommendations. A thematic analysis was performed on the resulting inquiries. Applied codes were based on the User-Centered Design framework. Results: The analysis resulted in nine recommendations for user-testing of HIT with older adults, divided into three main themes: (1) empathetic approach and trust-building, (2) new requirements for testing and study design, and (3) adjustments to usability evaluation methods. For each theme a checklist of relevant items to follow-up on the recommendation is provided. Conclusions: The recommendations generated through expert inquiry contribute to more effective usability testing of HIT with older adults. This provides an important step towards improved accessibility of HIT amongst older adults through inclusive user-centered design

Aging barriers influencing mobile health usability for older adults: A literature based framework (MOLD-US)

Background: With the growing population of older adults as a potential user group of mHealth, the need increases for mHealth interventions to address specific aging characteristics of older adults. The existence of aging barriers to computer use is widely acknowledged. Yet, usability studies show that mHealth still fails to be appropriately designed for older adults and their expectations. To enhance designs of mHealth aimed at older adult populations, it is essential to gain insight into aging barriers that impact the usability of mHealth as experienced by these adults. Objectives: This study aims to synthesize literature on aging barriers to digital (health) computer use, and explain, map and visualize these barriers in relation to the usability of mHealth by means of a framework. Methods: We performed a scoping review to synthesize and summarize reported physical and functional age barriers in relation to digital (mobile) health applications use. Aging barriers reported in the literature were mapped onto usability aspects categorized by Nielsen to explain their influence on user experience of mHealth. A framework (MOLD-US) was developed summarizing the evidence on the influence of aging barriers on mHealth use experienced by older adults. Results: Four key categories of aging barriers influencing usability of mHealth were identified: cognition, motivation, physical ability and perception. Effective and satisfactory use of mHealth by older adults is complicated by cognition and motivation barriers. Physical ability and perceptual barriers further increase the risk of user errors and fail to notice important interaction tasks. Complexities of medical conditions, such as diminished eye sight related to diabetes or deteriorated motor skills as a result of rheumatism, can cause errors in user interaction. Conclusions: This research provides a novel framework for the exploration of aging barriers and their causes influencing mHealth usability in older adults. This framework allows for further systematic empirical testing and analysis of mHealth usability issues, as it enables results to be classified and interpreted based on impediments intrinsic to usability issues experienced by older adults. Importantly, the paper identifies a key need for future research on motivational barriers impeding mhealth use of older adults. More insights are needed in particular to disaggregating normal age related functional changes from specific medical conditions that influence experienced usefulness of mHealth by these adults

A framework for evaluating mHealth tools for Older Patients on Usability

Mobile health (mHealth) apps can play a significant role in supporting older patients. The aging process is yet related to progressive degradation of sensory, physical and cognitive abilities. mHealth apps with touch screen based interfaces thus need to be adapted to the, often impaired, skills and special needs of older patients. However, existing design guidelines for mHealth apps do not address the aging barriers that older users face in working with touch screen based applications. By means of a constructed conceptual framework on cognitive, motivational, physical and visual impairments of older adults, this study revealed possible aging barriers concerning identified usability issues of an mHealth app for older patients. Insights into the aging process barriers that underlie usability issues supports developers in (re)designing mHealth apps that are better attuned to the needs of the older patient populatio

Impact of Patient-centered eHealth Applications on Patient Outcomes: A Review on the Mediating Influence of Human Factor Issues

To examine the evidence of the impact of patient- centered eHealth applications on patient care and to analyze if and how reported human factor issues mediated the outcomes. We searched PubMed (2014-2015) for studies evaluating the impact of patient-centered eHealth applications on patient care (behavior change, self-efficacy, and patient health-related outcomes). The Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model was used as a guidance framework to identify the reported human factors possibly impacting the effectiveness of an eHealth intervention. Of the 348 potentially relevant papers, 10 papers were included for data analysis. None of the 10 papers reported a negative impact of the eHealth intervention. Seven papers involved a randomized controlled trial (RCT) study. Six of these RCTs reported a positive impact of the eHealth intervention on patient care. All 10 papers reported on human factor issues possibly mediating effects of patient-centered eHealth. Human factors involved patient characteristics, perceived social support, and (type of) interaction between patient and provider. While the amount of patient-centered eHealth interventions increases, many questions remain as to whether and to what extent human factors mediate their use and impact. Future research should adopt a formal theory-driven approach towards human factors when investigating those factors' influence on the effectiveness of these interventions. Insights could then be used to better tailor the content and design of eHealth solutions according to patient user profiles, so as to enhance eHealth interventions impact on patient behavior, self-efficacy, and health-related outcome

Mobile health for older adult patients: Using an aging barriers framework to classify usability problems

BACKGROUND: With populations aging, digital health tools and mobile health applications (mHealth) are becoming more common to assist older people in independent living and self-management of (chronic) illnesses. These mHealth services can be beneficial to older patients, provided that they are adjusted to their needs and characteristics, as the current mHealth landscape lacks user-friendly services for this target group. Understanding of intrinsic aging barriers, which cause and impact usability problems older patients encounter, is needed to achieve this. OBJECTIVES: This study set out to assess usability problems older patients encounter in two mHealth apps and aims to show the value of MOLD-US, a recent aging barriers framework, as a classification tool to identify the intrinsic cause of these problems. METHOD: A case-study design, with in-depth analysis of usability issues older adult patients' experience. Data on usability issues were collected using the Think Aloud Protocol for two mHealth apps. The MOLD-US framework and Nielsen's severity rating were used to classify identified issues and their potential impact. RESULTS: In total 28 high severe usability issues of the mHealth apps were identified. Core natures of most issues were related to motivational and cognitive barriers of older adults. Participants had difficulties in understanding the navigation structure of the apps. Important text, buttons and icon elements were overseen. CONCLUSION: Current knowledge on creating interfaces for older target groups is not well applied within the assessed mHealth designs. Specifically, design guidelines should address older adults' diminishing cognition skills, physical ability and motivational barriers. By classifying usability problems with MOLD-US, insights on these barriers can be enhanced to adequately address these issues in new designs. In addition, we propose that future research focuses on investigating suitable usability evaluation methods adapted to older patients' characteristics to ultimately be able to gain unbiased sight on usability issues older patients may experience while interacting with technology