Running head: ACCESSIBILITY NEEDS OF SMARTPHONE APPS 1

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Nov 12, 2013 (3 years and 8 months ago)

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Running head: ACCESSIBILITY NEEDS OF SMARTPHONE APPS

1

The Accessibility Needs of Patients with Dexterity Impairments

to Use mHealth Apps on Smartphone


Daihua
X.
Yu
1
, 3
,

Bambang Parmanto
1, 3
,

Brad E. Dicianno
2
,
3

Background

The overall goal of this study is to explore and
to identify
the accessibility needs
and preferences

of Persons with
D
isabilities (
PwDs
)

to use
mobile health (
mHealth
)
S
martphone

apps.
D
exterity impairment
s
, characterized by problems grasping or
handling small objects, affect

a
bout 4.04 million adults in the US
(
Pleis et. al., 2010)

and
establish

the target population in this study.

M
-
health

is the provision of health services
and information via mobile technologies such as mobile phones and PDAs

(Cipresso et
al., 2012;
Vital Wave Consulting,
2009
;
World Health Organization
)
.
These emerge
nt

technologies with mobile apps have

been popularly utilized as
platforms for health
research and healthcare
service
delivery

(
Boyer et al., 2010; Han et. al., 2010)
.

Smartphone market penetration in the US reached 55% in early 2013

(
comScore
Incorporation, 2013).
T
he expectation
in using a
Smartphone

is

to provide immediate
,
fully reliable
,

personal communication and services in improving safety and quality of
life
(
Abascal et. al., 2000).
Though the
S
martphone is an ideal tool for implementing
wellness programs for

PwDs

(
Holman, 2004)
, i
t also poses accessibility challenges,
including: 1)
l
ack of screen space

(Brewster, 2002)
;

2)
s
mall form factors, low contras
t,
tiny text, and undifferentiated keys

(
Abascal & Civit, 2000; Kane

et. al.,

2009)
;

and 3)



Address correspondence to Daihua

Xie
Yu, School of Health & Rehabilitation Sciences,
University of Pittsburgh, Pittsburgh, PA, USA. Email: dxy1@pitt.edu.

This study is funded
by Grant #1R21HD071810
-
01
-
A1 from the National Institute of
Child Health and Human Development (NICHD), USA.

1

Department of Health Information Management


2

Department of Physical Medicine and Rehabilitation

3

Rehabilitation Engineering Research Center (R
ERC) on Telerehabilitation

ACCESSIBILITY NEEDS OF SMARTPHONE APPS

2

unnecessary
steps

(
Kurniawan et. al., 2006).

Before
people with dexterity impairments
can harness the potential of mHealth
trends,

accessibility
has to be addressed
.


Materials & Method


The material
used in
this study
was
the iMHere
4

system

a novel mHealth
platform that ha
s
been developed to support self
-
care
in the management of chronic and
complex conditions
(Parmanto

et. al., 2013).
The concentration of this
study focuses on
two iMHere

smartphone

apps: MyMed
s

for medication management and Skincare for
skin
monitoring

and reporting of skin breakdown
.

The
Purdue Pegboard Assessment
(Lafayette Instrument, 2002)

was

utilized
for

evaluat
ing

subjects
’ dexterity levels.

As
suggested
by the

Purdue Pegboard assessment, five tests
were

conducted to assess
subjects’ dexterity levels: 1) Right Hand (30 seconds); 2) Left Hand (30 seconds); 3)
Both Hands (30 seconds); 4) Right + Left + Both Hands (a mathematical sum from
calculation); 5) Assembly (60 seconds). Subjects
were

asked to pick up
pins, collars or
washers from the top of
a

board and drop them in
to

peg holes. The score of each test is
based on the total number of pins, collars, or washers
correctly
dropped in the holes.

A lab
-
test with an in
-
depth interview
was

conducted after
a
one
-
week
field trial.
Four tasks
were

included in this

lab
-
test

1) scheduling

a

new medication alert,
which

include
s

searching and finding the correct medication and setting up a medication
schedule; 2) modifying

a

medication reminder; 3) scheduling a skin ch
eckup alert; 4)
responding to
a
skincare reminder that includ
es

taking
a
picture and reporting issues.
Both

t
he number of possible errors and
the

errors a subject
was

able to self
-
correct
were

recorded
.
Weighted scores
were

added to
all

errors:

1

solve the problem without any



4

iMHere:

iM
obile
He
alth and
Re
habilitation

ACCESSIBILITY NEEDS OF SMARTPHONE APPS

3

help
;

2

need help in one sentence
;

3

need help in two to four sentences
;

4

un
able to
solve the problem.

Difficulty
-
on
-
performance

was

calculated as the sum of weighted
score
s
divided by
the
total steps to complete
a

task.

The

Telehealth Usability

Questionnaire
5

(TUQ
)

was
collected
during interview
. Followed by structured questions
,

these
open
-
ended
questions

help us to understa
nd the complexity and effectiveness of
user
-
interface components on mHealth

apps and their impacts on users’ satisfactions.

Results


Nine subjects with various levels of dexterity abilities were included. Ages ranged
from 18
-
55 years, including 4 women and 5 men.
Eight of them are spina bifida (SB)
patients; one is
a

patient
with
a
spinal cord injury (SCI)
.
As shown in
Table

1
, based on
Pegboard scores for

“Right + Left + Both”

hand
s

test
s
6
, subjects can be classified into
three groups.

Table 1: Study Results
(ER: Error Ration; D
P
: Difficulty
-
on
-
Performance
, %)


Group

#

Score
for
R+L+
Both

Task 1:
Schedule
med alert
(
avg.
16
steps)

Task 2:
Modify med
alert (
avg.
8
steps)

Task 3:
Schedule
skincare
alert (
avg.
6
steps)

Task 4:
Response to
skincare alert
(
avg.
9 steps)

Group
Average

D
P

ER

D
P

ER

D
P

ER

D
P

ER

D
P

ER

1:
Mild

5

36.33

25.00

6.25

50.00

12.50

0.00

0.00

40.00

10.00

16.
38

8.8
3

6

35.00

43.75

12.50

37.50

12.50

0.00

0.00

0.00

0.00

7

37.00

25.00

12.50

25.00

25.00

0.00

0.00

37.50

0.13

9

38.
33

6.25

0.00

25.00

25.00

0.00

0.00

12.50

0.13

2:
Mode
-
rate

1

33.00

33.33

13.33

25.00

12.50

0.00

0.00

40.00

0.10

16.
5

9.6
9

3

27.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4

23.
67

25.00

6.25

87.50

37.50

16.67

0.17

20.00

0.20

3:
Severe

2

0.00

23.53

17.65

25.00

25.00

16.67

0.17

37.50

0.38

17.
35

19.
65

8

0.00

16.67

6.25

25.00

25.00

16.67

0.17

12.50

0.13




5

TUQ is a usability questionnaire that designed to evaluate the usefulness, ease of use,
effectiveness, reliability and satisfaction.

6

Score for general factory work: avg.=46.76,
-
1S.D.=42.72,
-
2S.D.=38.68,
-
3S.D.=34.64.

ACCESSIBILITY NEEDS OF SMARTPHONE APPS

4

A s
ignificant
difference in
e
rror ratio
was found among
the
three groups
:
F(2,
33)=3.604, p=0.038
, based on ANOVA
.
Bonferroni's t
-
test revealed that
group 3

subjects

had a significantly higher
error ratio

than
group 1

(p
=
0.0
45
).

A moderately

negative
correlation was
identified

between
subjects’ dexterity levels
(R
+L+Both)
and their error
ratios

by using
a
Pearson product
-
moment correlation
,
r =
-
0.43
4
,
n=36,
p= 0.004
.
Revealing
ly
,
subjects
with
a
lower
number of Pegboard score
s

might experience more
problems
in task completion
.

No significant difference

was identified
among
the
three groups when comparing
the difficulty
-
on
-
performance
,

using
ANOVA
(F(2, 33), p=0.983)
.

A

slightly
negative

correlation was identified
between
subjects’ dexterity levels (R+L+Both) and the
ir

difficulty
-
on
-
performance

based on
a
Pearson

correlation
, (
r =
-
0.046, n=36)
,

but
this
coefficient

wa
s not significant

(
p= 0.
396
)
.
Insignificant correlations were also found
between the number of steps with error ratios
(r=
-
.081, n=36, p=0.32)

and with
difficulty
-
on
-
performance

(r=0.134, n=36, p=0.219)
. However, the result from Pearson correlation
suggests an increas
ing

error ratio mi
ght significantly increase the
difficulty
-
on
-
performance

for
a
user in completing
a
task (r=0.724, n=36, p<0.001).


The average TUQ score
was
5.9 (out of 7). Overall,
subjects
were satisfied with
the iMHere

apps
and
would
consider using

them

in the future (average score: 6.39).
When looking toward
further
improvements, the sections for “ease of use & learnability,”
“interface quality,” and “reliability” received scores lower than 6 (average scores: 5.56,
5.67 & 5.56).

Subjects


suggest
ions in
clude
d
:

1) simplify and reduce the complexity of
these apps; 2) provide longer training time; and 3) provide
more

immediate

feedback
to
inform

users if they are correctly
using

the app.

ACCESSIBILITY NEEDS OF SMARTPHONE APPS

5

Discussion

& Conclusion


U
sers with
a
higher
degree
of dexterity impairments
demonstrate
more problems
in task completion
.
T
he increas
e in

steps for
task completion

may not

expose user
errors,

b
ut

it does
significantly

increase the
difficulty
-
on
-
performance
.

About

51%

of errors
were
self
-
corrected

without any help
,

but other

errors

called for resolution

from
a
researcher

and
received higher
-
weighted

scores

for
difficulty
-
on
-
performance
.


In
-
app dialogs
were utilized for providing directional guidance and preventing
error
s
.

However,
subjects are
more
likely to close the
dialogs without fully
comprehending
the information
.
Streamlining

the cognitive process of tasks and reducing
the
layout complexity

in one screen may help to improve accessibility.
In addition,
providing fewer functions on a small
screen
may help
reduc
e

confusi
on

about what do to
next
.

User f
rustrations were

identified
regarding

text

entry

and access
ing

buttons.
Either having a
large finger or
having a
finger
that
easily slid
es

off
buttons

is a
contributor to user difficulties
.
Two
patients

indicated that they might be more
comfortable with dark text on a white background. Some
patients

would like to try
different background pictures to make the app more personalized.

Subjects

also
highlight
ed

the usefulness of colors to indicate the status of
whether
or not a
medication
is

schedule
d

(green vs. red)
.

The
use of color to separate body part
s

also helps

patients
to correct
ly

specify the location of problem skin

areas
.
A
subject
suggested
using

different color
s

to separate apps because some activities
(e.g.,
scheduling
)

are very similar
across
five
iMHere apps.
Using color to separate apps will
easily let user
s

know
which app they are using
.

ACCESSIBILITY NEEDS OF SMARTPHONE APPS

6

S
ubjects
with severe dexterity impairments

need
ed

hel
p from
a
family member or
clinical staff
to take a photo of their problem skin

area
because they
were
unable to

hold

a
Smartphone
.
Based on subjects’
functional

movements, s
everal of

them

are not very
co
m
fortable using
the
in
-
screen camera button, especially when the skin
problem
is
located
in an

inconvenien
t

area

to access
.

Manufactures are not providing
a
physical
camera button anymore.
Strategies, such as bi
n
ding
the
camera function to
a
physical
button or adding

a

time delay to
the
camera would be appropriate
improve
ments for

accessibility.

In general
,
users

want

to

have simpler apps with easier process
es
.
From
a
developer
’s perspective,

we
could

approach

this

from
two important aspects,

physical
presentation and navigation
. Physical presentation

involv
es

user
-
interface components
such as size, color, contract and the use of images
.
Navigation concentrates on step
-
by
-
step
activities

that control
functions
behind the scenes
.
S
treamline
d

pr
ocedures
could

reduc
e

users’ efforts to memorize steps.
If physical presentation
is
the foundation for
accessibility, navigation
will be a
hi
gher

priority

to improve

accessibility. P
ersonaliz
ation,
however,

with
the
ability to customize physical presentations and to
detect
shortcut
s

with
in

activity flow
s

based on users’ performances

to

eliminate
unneeded steps

would
be the
optimal solution
to
enhance accessibility
.
The development of accessible and
personalized
mHealth
apps will be continued based on
the accessibility model we
have
concluded here.




ACCESSIBILITY NEEDS OF SMARTPHONE APPS

7

References

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-
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8


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